Respiratory health

Respiratory diseases are among the most common long-term conditions affecting patients in the UK. As a GP, your role is to: 

• Recognise that the identification, assessment, diagnosis and treatment of most acute and chronic respiratory diseases are a primary care issue 
• Consider how respiratory disease affects patients of all ages. It also brings specific challenges in the diagnosis and treatment of various groups including children, some occupational and ethnic groups, those with social and mental health challenges, and those nearing the end of their life 
• Be aware of your role as a GP in promoting smoking cessation and offering treatment

A wide range of patients with respiratory problems are seen in primary care, which presents challenges for: 

• Diagnosis: such as distinguishing common minor self-limiting conditions from less common but more serious conditions (for example, sepsis). Early diagnosis is a contributory factor to improving outcomes in conditions such as lung cancer. Awareness of the pros and cons of emerging diagnostic tools such as fractional exhaled nitric oxide (FeNO) in asthma.
• Recognition: conditions such as chronic obstructive airways disease are under-recognised and contribute significantly to seasonal admissions to secondary care
• Patient education: self-management of minor conditions and increasing treatment during exacerbations of chronic conditions such as asthma and chronic obstructive airways disease. The applicability of patient centred models of care such as the House of Care model and care planning
• Chronic disease management: such as managing recall systems for asthma and chronic obstructive airways disease, the effect on acute admissions and influenza vaccination 
• Smoking cessation: the value of opportunistic and structured interventions in helping patients stopping smoking and the evolving role of e-cigarettes/vaping in addition to current therapies. Ongoing research into the safety of e-cigarettes and their use for smoking cessation is underway. As a GP you should be aware of the latest evidence and guidance on e-cigarettes, and smoking cessation more generally, and use your clinical judgement on an individual patient basis 

For each problem or disease, consider the following areas within the general context of primary care: 

• The natural history of the untreated condition including whether acute or chronic
• The prevalence and incidence across all ages and any changes over time 
• Typical and atypical presentations
• Recognition of normal variations throughout life 
• Risk factors, including lifestyle, socio-economic and cultural factors 
• Diagnostic features and differential diagnosis 
• Recognition of 'alarm' or 'red flag' features
• Appropriate and relevant investigations 
• Interpretation of test results 
• Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
• Patient information and education including self-care 
• Prognosis  

Symptoms and signs

• Chest pain 
• Clubbing
• Collapse
• Cough, acute and chronic
• Cyanosis 
• Dyspnoea: acute and chronic 
• Fever
• General malaise including weight loss and fatigue
• Haemoptysis
• Lymphadenopathy
• Pleural effusion 
• Signs of respiratory distress in children (for example, recession, nasal flaring) 
• Stridor and hoarseness 
• Tachypnoea 
• Wheeze 

Common and important conditions

• Asthma: acute and chronic in children and adults
• Asthma-COPD overlap 
• Bronchiectasis
• Chronic obstructive pulmonary disease
• Connective tissue diseases affecting the lung, such as rheumatoid arthritis, SLE and sarcoidosis
• Cough including haemoptysis, and non-respiratory causes such as GORD
• Cystic fibrosis
• Emphysema including α1-antitrypsin deficiency
• Immunosuppression affecting the respiratory system including opportunistic infections such as TB, fungal and parasitic Lower respiratory tract infections (for example, bronchiolitis, bronchitis, pertussis and pneumonia (of any cause), atypical pneumonias including Legionnaire's disease and tuberculosis), sepsis
• Lower respiratory tract infections
• Lung fibrosis and associated causes including adverse drug reactions 
• Occupational respiratory diseases such as the pneumoconioses, asthma, extrinsic allergic alveolitis and asbestos related diseas
• Pleural effusion causes including infection, connective tissue diseases and malignancies 
• Pneumothorax including simple and tension
• Pulmonary embolism
• Respiratory failure and methods of ventilation such as CPAP for sleep apnoea
• Respiratory malignancies, including laryngeal, bronchial and pleural such as mesothelioma. Primary and secondary lung malignancies, and related para-neoplastic syndromes
• Stridor and hoarseness: differential diagnosis including assessment of urgency for investigation and management 
• Upper respiratory tract infections including tonsillitis, peri-tonsillar abscess, epiglottitis, laryngitis, pharyngitis and tracheitis

Examinations and procedures

• Appropriate focused clinical examination to identify respiratory disease (for example, clubbing, lymphadenopathy, significance of measuring respiratory rate, chest exam, signs of sepsis) 
• Specific procedures, such as peak expiratory flow rate measurement 
• Demonstrate the correct use of a dry powdered and metered dose inhaler and check that a patient can use their device properly
• Administration of inhaled bronchodilators with spacer or nebuliser, including correct techniques 

Investigations

• Primary care investigations such as peak expiratory flow rates, spirometry, exhaled nitric oxide testing (FeNO), pulse oximetry, blood tests and sputum culture (including indications for, correct technique, interpretation of results, and factors affecting results)
• Disease scoring tools (for example, CURB for community acquired pneumonia) 
• Indications for chest-x-rays, CT and MRI scans, and bronchoscopy  

Service issues

• Local and national guidelines to manage common respiratory diseases (asthma, COPD, lung cancer) in primary care 
• Indications for the use of oxygen in emergency, acute and chronic management including domiciliary oxygen and use in palliative care 
• Patients’ understanding of prescribed inhaled medication, both routinely and in an emergency, including its appropriate use and technique 
• Inhaler devices, including types of devices and their ease of use, prescribing, cost-effectiveness and patient's preference 
• Support available to patients and their carers from health, social services and charities/voluntary sector organisations 

Additional important content

• History-taking key points with respect to specific respiratory diseases (for example, in relation to occupation, smoking, 'red flag' symptoms, family history)
• The importance of lifestyle changes, particularly smoking cessation and pulmonary rehabilitation 
• The impact of co-morbidity such as muscle wasting, osteoporosis, cardiovascular disease or mental health problems in people with long-term respiratory conditions such as asthma and COPD, and the effect of these on morbidity and mortality
• The potential for financial compensation for those diagnosed with mesothelioma and other occupational lung diseases. Appropriate signposting to specialist services, and appropriate death certification for these conditions.  

Mr Davies is a 55-year-old man who first presented to you a year ago complaining of increasing breathlessness over the past year. Further discussion revealed repeated winter chest infections with mucopurulent sputum needing antibiotics. He is a smoker, having started smoking age 15 . He usually smokes one pack of cigarettes per day. He is a self-employed plumber. His mother has COPD. 

He has a BMI of 31. On the basis of an examination and investigations, you diagnosed chronic obstructive pulmonary disease (COPD) and prescribed appropriate inhaler devices. You also offered support to stop smoking, follow-up with the practice nurse, and a referral for pulmonary rehabilitation at the local community centre. 

It is now the following winter and Mr Davies attends an emergency GP appointment. He is distressed, breathless, cyanosed and tachycardic, with an SpO2 of 89%, having been unwell for the previous five days. Although he has stopped smoking his wife continues to do so. He tells you he didn't want to bother anyone and can't afford to take time off work. He'd hoped he could ride out this episode using more inhalers.   

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive. 

Core Competence	Questions
Fitness to practise   This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients.	What are my personal feelings about smoking-related illnesses and how do I ensure these don’t adversely affect the care I provide?  Maintaining an ethical approach  This addresses the importance of practising ethically, with integrity and a respect for diversity.  Is Mr Davies responsible for his own illness?  What are the challenges facing me as a GP in delivering effective care in this case?  How does patient autonomy influence my joint decision-making (considering occupation, smoking or illicit drug use, which affect respiratory illness and its treatment)?
Communication and consultation This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters.	On what occasions in Mr Davies' case could his worries have been addressed, and by whom?  What is the role of self-management in respiratory disease?
Data gathering and interpretation  This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations.	What investigations are appropriate to diagnose COPD?  How confident am I at interpreting spirometry?  How do I grade the severity of symptoms/ functionality?
Clinical Examination and Procedural Skills This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.	What clinical skills do I need to assess different patients with respiratory disease including children, the elderly and those with mental health problems?  What is the correct technique for recording a peak flow and for using a metered dose inhaler with spacer? How would I instruct my patient to apply these techniques?  What are the signs of respiratory distress in a child?
Making decisions This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice.	What elements of the primary care assessment and treatment of patients with respiratory disease are unique to this group of patients?
Clinical management This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches.	What management options are available for Mr Davies in the acute setting?  What are the specific indications for the various treatments for COPD and how can I monitor their effectiveness?
Managing medical complexity   This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation.	What are the common co-morbidities associated with respiratory disease?  How do co-morbidities or systemic problems impact on respiratory illness or its treatment?   What impact does the patient's lifestyle, ethnicity, education and occupation have on their respiratory health and their future treatment?
Working with colleagues and in teams This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development.	Are there any local protocols for managing COPD?   How are COPD patients looked after in my practice? What role do nurses and other PHCT members play in their management?  What is the role of the generalist and the specialist in diagnosis and management?
Improving performance, learning and teaching  This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity.	What is the evidence base for the early identification of patients with chronic lung disease and subsequent health education or therapeutic interventions?   Do I know when to introduce additional treatment?   How many unidentified patients with COPD are there in our practice? How might we identify such patients?
Organisational management and leadership This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills.	What templates should I use during consultation with patients with asthma and COPD?  How would I monitor quality of care for COPD patients?
Practising holistically, safeguarding and promoting health This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers.	What is the impact of respiratory disease on patients, physically, psychologically and socially (including occupation and employability)?   What impact does respiratory disease have on families?  How do I assess suitability for smoking cessation options?
Community orientation This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare.	What is the impact of health and social inequality on respiratory disease prevalence, diagnosis, prognosis and treatment?   What support services might be available to Mr Davies and his family?   How relevant are social, ethnic and gender issues in the prevention and treatment of respiratory disease, in particular smoking and inhaler use?  How does Mr Davies smoking impact on the services he needs, and where they are provided?

Work-based learning

As a GP specialty trainee, the principal component of your work-based learning around respiratory disease involves meeting, assessing and helping to manage patients with respiratory disease. Learning from the training team, and specifically from the respiratory lead GP and practice nurse, as well as colleagues within the practice is also important.

Specific learning around the performance and interpretation of lung function testing, as commonly performed in general practice, should reflect the needs and responsibilities of the generalist, and should cover: 

• patient selection and preparation
• health and safety
• infection control 
• equipment selection and calibration 
• interpretation of results for validity and clinical patterns 
• the role of bronchodilators in lung function testing 
• the limits of lung function assessment in patient management, and the value of other available patient-related outcome measures

With respect to patients with respiratory disease, a GP should be aware of the roles and responsibilities of the primary care team, in its widest sense, including community staff and secondary care outreach, charities and self-help groups, physiotherapists and exercise trainers. You should also look for opportunities to learn from local respiratory consultants, physiotherapists and multidisciplinary groups.    

Self-directed learning

You can find e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare. 
Other organisations offering education and support include: Asthma UK, British Lung Foundation, British Society of Allergy and Clinical Immunology, British Thoracic Society and the Primary Care Respiratory Society UK.   

Applied Knowledge Test (AKT)

• Interpretation of spirometry results 
• Symptoms of lung cancer
• Aetiology of community-acquired pneumonia 

Clinical Skills Assessment (CSA)

• Blind woman has recently been diagnosed with asthma and was prescribed salbutamol, but she is still symptomatic
• Carer requests a house visit to an elderly man who has a dry cough and become slightly confused over the past few days 
• Man with COPD has been stable on three inhaled medications but is now complaining of increasing cough and dyspnoea. Examination expected.  

Workplace-based Assessment (WPBA)

• Log entry about your involvement in the asthma clinic and the indications for the different asthma inhalers available 
• Consultation Observation Tool (COT) about a woman with a persistent cough whose chest x-ray suggests sarcoidosis 
• Audit on the use of high-dose steroid inhalers against current national guidelines