Remote consulting: adult respiratory conditions

Dr Fiona Mosgrove continues our series on dealing with common presentations remotely, focusing on four potential respiratory diagnoses in adults

Asthma
Key pointers in the history

• Patients may present with episodic cough, wheeze, chest tightness or breathlessness, alone or in combination. Variability is important, with symptoms often worse in the morning than in the evening. 
• Ask if symptoms are triggered by cold air, exercise or allergy – this increases the probability of an asthma diagnosis.
• Personal or family history of hayfever or eczema also makes a diagnosis more likely, as does family history of asthma.  
• Documented evidence of wheeze, and the absence of any alternative explanation, support the diagnosis.

Are investigations needed?

• Spirometry with reversibility and either a raised fractional exhaled nitric oxide (FeNO) level or evidence of peak flow variability is required to confirm diagnosis, under guidelines and the QOF.¹
• If spirometry or FeNO are still not routinely available,² take serial peak flow readings over two to four weeks remotely; patients can be taught how to perform peak flow over video and directed to online resources, such as Asthma UK (asthma.org.uk/advice/diagnosis/tests/).³ Readings should be documented twice daily and when symptomatic; variability of ≥20% supports a diagnosis of asthma.
• Until a diagnosis is confirmed, be careful to code suspected asthma and note spirometry will be performed when available.

Remote management

• Where access to spirometry and FeNO testing is limited, a pragmatic approach is required, as above.³ 
• If probability of asthma is high (recurrent episodes of symptoms, personal and family history of atopy, absence of alternative likely diagnosis, variable peak flow readings) start a six-week trial of inhaled steroids. Demonstrate proper inhaler technique and signpost to resources.
• If asthma is an intermediate probability, with some but not all features present, checking blood eosinophils, total IgE and skin-prick tests can help support the diagnosis.  
• Use an objective measure of disease control such as the Asthma Control Test (ACT) score (asthmacontroltest.com/) at baseline and at review to assess response to treatment.
• Agree a personalised asthma action with patients, detailing their treatment, when to escalate doses and when to call for help. See the Asthma UK website for a template.

Follow-up

• The interval of follow-up should be dictated by symptoms and is typically six to 12 weeks, with safety netting in case symptoms deteriorate. An annual review is required by QOF.
• Re-assess symptoms using the ACT score, check inhaler technique and number of exacerbations and discuss smoking status.
• Discuss and update asthma action plans at every review.

COPD
Key pointers in the history

• Consider COPD in current or former smokers, particularly those over 40 years of age, presenting with cough, breathlessness, wheeze or chest tightness – particularly with a history of frequent chest infections or previous courses of antibiotics or steroids.

What investigations are needed 

• Spirometry is required to confirm the diagnosis,⁴ but if this is unavailable, serial peak flow readings demonstrating lack of variability can be useful.
• Micro-spirometry can also be useful to screen for COPD. 
• Where spirometry is not performed, this should be noted, with appropriate coding, with a plan to perform it when the service becomes available again.
• Sputum should be sent for culture if the patient is expectorating. 
• A chest X-ray at baseline is useful to rule out infection and malignancy.

Remote management

• Give smoking cessation advice and facilitate dialogue about smoking in an open, non-judgmental fashion. Signpost to online support for smoking cessation on the NHS website.
• Counsel patients about the need for immunisations (pneumococcal, influenza and Covid).
• Assess breathlessness using MRC score; refer patients with a score of 3 or more to pulmonary rehabilitation and signpost to local exercise facilities.
• Consider advising use of digital self-management tools, such as
  myCOPD.
• Start short-acting ß-agonist treatment (SABA) in all breathless patients. 
• For patients who remain breathless despite SABA treatment, start a long-acting bronchodilator (LABA), either single or dual, according to local guidelines.
• For patients who are exacerbating, consider a trial of inhaled steroid for three months.

Follow-up

• Review symptoms and inhaler technique, at least three monthly after newly initiated inhaled treatment and annually in stable patients.
• Encourage patients to report exacerbations – explain they are treatable, and that prompt treatment can slow decline in lung function.
• Patients who can identify their exacerbations may be suitable for home rescue packs to allow prompt treatment, but should always then make contact with their primary care clinician for a review.

Bronchiectasis
Key pointers in the history

• Bronchiectasis is a complex, heterogeneous disease. Maintain a high index of suspicion, particularly in patients with chronic cough, or who regularly expectorate purulent or mucopurulent sputum or with recurrent chest infections.⁵
• History of inflammatory conditions such as rheumatoid arthritis and inflammatory bowel disease increase the risk of bronchiectasis.
• Patients, particularly those with COPD, whose sputum culture shows Pseudomonas aeruginosa growth should be investigated for bronchiectasis.

What investigations are needed 

• Send sputum samples for microbiology, including fungal and mycobacterial culture.
• Chest X-ray should be performed to rule out infection and malignancy.
• Spirometry is useful in a general work-up but is not diagnostic – patients may have obstructive, restrictive or normal spirometry.

Remote management

• Refer to secondary care for high resolution computed tomography scan, investigation of the underlying cause and ongoing management.⁵
• In the interim, treat patient-reported breathlessness with LABAs.
• Exacerbations should be treated promptly with a two-week course of antibiotics; send sputum sample before starting antibiotics. 

Follow-up

• Review if there is a change, such as an increase in exacerbation, or a new isolation of P. aeruginosa.

Pneumonia
Key pointers in history

• Patients classically present with acute fever and productive cough, often associated with breathlessness, malaise, lethargy, anorexia and myalgia and sometimes chest pain.
• Atypical presentations such as headache, general malaise and diarrhoea are common in the elderly and immunocompromised; maintain a high index of suspicion in these patients as they may present without fever or cough.
• Risk factors include age over 64, alcohol misuse, exposure to cigarette smoke and use of acid-reducing medication. 

What investigations are needed

• Consider a chest X-ray and blood tests, depending on the patient’s condition.

Remote management

• The CRB-65 score⁷ can be used to guide management with one point for each of: new confusion (8 or less on abbreviated mental test score or new disorientation to person, time or place); respiratory rate over 30; blood pressure of 60mmHg or less diastolic, 90mmHg or less systolic; and age 65 years or over. The score predicts mortality, with a score of 0 associated with less than 1% risk, 1-2 with a risk of up to 10% and 3 or more with mortality of more than 10%.
• Confusion is often evident when talking to the patient on the phone, or may be reported by a relative or neighbour.
• Respiratory rate can be assessed by phone, perhaps asking a relative to count the patient’s breaths for a minute, or by video assessment.
• A home visit may be needed to check blood pressure if it is impossible to access a monitor at home.
• All patients should start an antibiotic within four hours of diagnosis.⁸
• Patients scoring 0 on the CRB-65 can usually be managed at home with five days of oral antibiotics. Patients scoring 1-2 should be considered for inpatient assessment. Patients scoring 3 or more should be admitted urgently. 
• Other factors influencing admission are social support, ability to take oral medications, co-morbidities and frailty.

Follow-up

• Patients should have a chest X-ray repeated six weeks after diagnosis to confirm resolution and check for underlying pathology. 

Dr Fiona Mosgrove is a GPSI in respiratory medicine and senior clinical lecturer at the University of Aberdeen

References

1. NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: NICE, 2017
2. Primary Care Respiratory Society. Update on Spirometry Guidance. West Midlands: PCRS, 2021
3. SIGN 158: British guideline on the management of asthma. Edinburgh: Health Improvement Scotland, 2019
4. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: NICE, 2018
5. Hill A, Sullivan A, Chalmers J et al. British Thoracic Society Guideline for bronchiectasis in adults. Thorax 2019;74 (Suppl 1): 1-69
6. NICE. CKS: Chest infections – adult: Diagnosis, assessment. London: NICE, 2021 
7. NICE. CKS: Chest infections – adult: Scenario: Community-acquired pneumonia. London: NICE, 2021 
8. NICE. Pneumonia, community acquired: antimicrobial prescribing. NG138. London: NICE, 2019
9. NICE. Suspected cancer: rcognition and referral. NG12. London: NICE, 2015