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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.

Red flags

Patients with any of the following symptoms should be referred for an urgent chest X-ray.9 Those with symptoms persisting for six weeks should have an urgent suspected cancer referral (except for persistent lymphadenopathy or isolated thrombocytosis). Persistent haemoptysis in smokers, or ex-smokers aged over 40 years, should be co-referred for urgent chest X-ray and urgent suspected lung cancer.

  • Haemoptysis
  • ≥ 3 weeks of:
    – New cough or change in cough
    – Shortness of breath
    – Otherwise unexplained chest or shoulder pain
    – Loss of appetite
    – Weight loss
    – Hoarseness
    – Fatigue in smoker >40
  • Clubbing
  • Recurrent chest infections
  • Persistent cervical or supraclavicular lymphadenopathy
  • Thrombocytosis (platelets above 400)

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. 

When is face-to-face examination required?

  • If the diagnosis is unclear, despite repeated phone or video assessment.
  • In a patient with new onset of breathlessness, to help stratify the differential diagnosis. 
  • In patients with complex needs, sight or hearing problems, or who cannot use technology or who lack the privacy to conduct a confidential consultation

When video assessment might be helpful

  • To assess general condition, work of breathing and vital signs in patients suspected of having pneumonia or exacerbations of chronic lung conditions, particularly where they may need admission to hospital. Patients with access to a blood pressure monitor and oxygen saturation probe can be talked through how to use these via video consult. 
  • Assessment of exercise tolerance.  Asking the patient to sit and stand repeatedly for 1 minute, using an oxygen saturation probe if available, can provide useful information and identify silent hypoxia.
  • Assessment of cognition. The Abbreviated Mental Test can help identify patients who are confused and may need inpatient management.
  • Assessment of home situation. Seeing a patient’s home setting can help clinch the diagnosis or provide insight into management (for example, unused inhalers or medication in the background).
  • To teach and assess inhaler technique and peak flow monitoring, which can highlight critical errors, allowing correction and signposting to other resources. 
  • For further information see the International Primary Care Respiratory Group Desktop Helper No. 11 on remote consultations (https://www.ipcrg.org/desktophelpers) 

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