Top ten advice and guidance requests in respiratory medicine

Continuing our series sharing expert insights on common advice and guidance (A&G) requests in key specialties, consultant in respiratory medicine Dr Himender Makker highlights ten typical examples of requests to a respiratory A&G service and explains how these should be managed

Note all requests are hypothetical cases developed for illustrative purposes

1. This 68-year-old male who has smoked for many years was sent by the local lung cancer screening team because of CT evidence of emphysema. But he is completely asymptomatic. Other than supporting him to stop smoking, is there anything else we should be doing? And should he be coded as COPD?

A CT finding of emphysema in a smoker or ex-smoker is not uncommon. It is important to review the full CT report to establish the extent and distribution of emphysematous changes (lower zone predominance can be due to alpha-1 antitrypsin [ATT] deficiency), type of emphysematous changes (panacinar and centriacinar changes in upper zones are typical in smokers) and associated bullous changes. Breathlessness on exertion is the main symptom of emphysema. This may be missed or underestimated in a sedentary patient.

The clinician can evaluate breathlessness further by asking about:

• ability to manage strenuous exertional activity;
• number of flights of stairs the patient can manage;
• capacity for brisk walking and distance walking at own pace;
• breathlessness at night or on lying down.

The MRC breathlessness score may be helpful.

Unless the patient is symptomatic, spirometry is not necessary as the diagnosis of COPD requires persistent respiratory symptoms such as breathlessness, in combination with airflow obstruction.

Isolated findings of emphysema on CT should not be labelled or coded as COPD – it is a diagnosis based on the characteristic spirometric findings in a symptomatic patient.

2. This 78-year-old lady has shortness of breath on exertion, slowly progressing over the last year or so. She recently had an echocardiogram which showed normal ventricular function and heart valves but evidence of pulmonary hypertension. How should I proceed?

The main concern is diffuse interstitial lung disease (ILD). However, isolated exertional breathlessness associated with pulmonary hypertension can be due to marked obesity associated with obstructive sleep apnoea/obesity hypoventilation syndrome. The remote possibility of chronic pulmonary thrombo-embolism should be excluded if the patient has a history of DVT/PE.

Ask about a history of exposure to avian dust, mouldy hay, jacuzzi or asbestos, associated rheumatological conditions (rheumatoid arthritis, lupus, scleroderma) or drugs (eg, amiodarone) known to cause ILD. If any of these are present, ILD is more likely.

Request chest radiograph and spirometry. If the chest X-ray demonstrates fibrotic/ground glass changes and spirometry shows restrictive pattern, request an urgent referral to respiratory clinic (ILD clinic if available) for further detailed evaluation with CT chest and full lung functions. If chest X-ray and spirometry are normal, consider routine respiratory referral.   

3. This 52-year-old man has a previous history of asbestos exposure and on recent chest X-ray for persistent cough (now resolved) was found to have pleural plaques. He is extremely anxious about them. Can he be reassured? Should I be doing anything else? Do the plaques increase his risk of mesothelioma and does this warrant any form of screening?

Incidental pleural plaques on chest radiograph indicates known or unknown exposure to asbestos, but can be due to other causes. It is harmless by itself and not a precursor of mesothelioma. However, it should alert the radiologist to look for other asbestos related respiratory problems such as fibrotic lung changes and pleural effusion.

Smokers with asbestos related pleural plaques are at higher risk of lung cancer than from smoking alone. If the patient is a smoker, he should be advised to stop smoking and encouraged to take up the offer of lung cancer screening if possible.

Be mindful of this increased risk and have a low threshold for referral for low-dose CT or on the urgent suspected cancer pathway if the patient develops persistent symptoms.

4. This 83-year-old man with very severe COPD on maximal treatment has had many recent admissions and is reluctant to attend hospital in future. I’m wondering whether to convert his care to a palliative approach. Are there any pointers you can give to confirm he should be managed in this way and which treatments might be of palliative benefit to him?

Patients with severe COPD are extremely limited and disabled by breathlessness and experience frequent exacerbations requiring antibiotics, steroids and hospital admission. Breathlessness is an extremely distressing symptom and referral to a dedicated breathlessness clinic can be helpful, if one is available. However, referral should be not a knee jerk reaction.

Note maximal treatment does not necessarily mean maximum dose of inhaled triple combination. The patient should be comprehensively reviewed by a COPD MDT clinic to establish whether treatment options have been fully explored, before palliative care referral. For example, a patient with poor inhaler technique with once-a-day triple combination may miss out on effective dose delivery. Changing to a metered dose inhaler via spacer device twice a day may help. Provision of rescue antibiotics and steroids, with access to a community COPD or respiratory nurse, can be extremely helpful. Similarly, assessment and provision of ambulatory or long-term oxygen treatment and pulmonary rehabilitation is important.

Patients with severe COPD should have up-to-date vaccinations against influenza, Covid-19, RSV and pneumonia.

The main pharmacological interventions for palliation of breathlessness would be opioids, ie, oromorph and benzodiazepines such as lorazepam. Although there is limited evidence of their effectiveness in randomized trials, clinical experiences suggest that these can help.

Nebulised morphine, lignocaine and saline are not effective and should be avoided. Hyoscine may reduce distress from excessive secretion in the terminally ill.

Non-pharmacological measures such as occupational therapy assessment adjustment, home help and improving nutritional status could make an immense difference.  

Breathing techniques and exercises, and blowing cool air on the face are worth attempting. Acupuncture has been shown to offer some subjective benefit but requires prolonged treatment.

5. This 32-year-old with severe asthma is convinced that his work in a bakery aggravates his asthma, but doesn’t want to leave because of the money and security. How can we confirm whether his problems have an occupational element? How much could this adversely affect his prognosis? Could there be an alternative diagnosis?

It is important to confirm the aggravation of asthma due to occupational exposure (occupational asthma), even in occupations known to cause, trigger and worsen asthma.

Clues to occupational involvement include:

• history of onset or worsening of asthma on starting new occupation;
• symptoms worse during work days and better on non-work days/holidays

Peak expiratory flow rate (PEFR) measurement four times a day for four to six weeks may demonstrate typical peak flow pattern associated with occupational asthma.  However, a patient with long standing poorly controlled asthma may lose typical peak flow variability. They should be referred to a respiratory clinic, preferably an occupational lung disease clinic.

Evidence indicates that by ceasing exposure, a significant proportion of people – 25-30% – can expect a full recovery over 3-5 years.

Ask your patient to record peak flows four times a day for four to six weeks and send these recordings to the respiratory clinic.

6. I would appreciate your advice about this 80-year-old man undergoing palliative care for inoperable lung cancer. He’s had a couple of admissions to hospital and found the administration of oxygen helped his breathlessness. He is asking for oxygen at home. Would this be appropriate? How can I arrange it?

Yes, it could be appropriate but he should be formally assessed in a lung function laboratory to confirm that his breathlessness improves with oxygen. This is to reduce any unnecessary burden of treatment on the patient, and conserve NHS resources. Often, the improvement with oxygen reported by patients is due to air blowing on their face. The same benefit can achieved by a portable fan. Other measures such as opiates are far more effective in reducing breathless than oxygen or air.

However, if assessment for oxygen for relief of breathlessness does confirm a benefit, oxygen can then be arranged by the lung function laboratory or palliative care team.

7. This 28-year-old girl with asthma and on a lot of treatment frequently presents with poor control, often with apparent exacerbations. I’ve wondered if she might actually be hyperventilating or experiencing some other form of dysfunctional breathing. How can I confirm this, and how should it be managed?

Listen to chest for wheeze and measure PEFR and SaO₂ during an apparent episode – a normal PEFR and SaO2 would help to rule out acute asthma exacerbation as the cause and point to hyperventilation/dysfunctional breathing.

Hyperventilation itself can trigger asthma and precipitate an acute attack. There are formal lung function tests for confirming hyperventilation and scoring systems for dysfunctional breathing, specifically the hyperventilation provocation test and Breathing Pattern Assessment Tool (BPAT).

Note however that some near-fatal asthma episodes in young asthmatics have occurred due to misinterpretation of an acute asthma attack as hyperventilation or dysfunctional breathing. Use extreme caution, even in someone with confirmed hyperventilation or dysfunctional breathing.

8. A 44-year-old female school teacher has had persistent cough for last six months. She is a non-smoker and has no history of significant respiratory illness. Her investigations (routine blood tests, chest radiograph, peak flow records and spirometry) were normal. She had a trial of PPI, SABA and ICS inhaler with a little response. Does she need any further investigations?

In the absence of any red flag signs such as haemoptysis, chest pain, fever, night sweat, it is unlikely that any further investigation is required at this stage.

Check her inhaler technique – for some patients with poorly controlled asthma, even the inhalation of the ICS (with aerosol or as dry powder) can trigger cough, reducing delivery and deposition of the particles with reduction or loss of efficacy.

If the cough was preceded by viral respiratory tract illness, consider a short course of oral corticosteroid – prednisolone 30mg once a day

 for five days followed by ICS for four weeks for post-viral bronchial hyperreactivity.

Reconsider gastro-oesophageal reflux (silent or symptomatic) and treat with double dose of PPI and antacids. Treat associated symptoms of rhinitis with a nasal steroid. Consider referring to ENT surgeons to establish extra pulmonary causes of cough such as GORD and naso-sinusitis.

It is also worth checking if the patient is on an ACE inhibitor as these commonly induce cough

If all above fails to help, consider a CT chest scan to rule out the remote possibility of bronchiectasis and tracheomalacia.

9. This 63-year-old female patient with a history of bronchiectasis feels unwell, with persistent cough and copious amount of yellow green sputum. She has had four courses of antibiotics over the past 12 months. Please advise if she will benefit from prophylactic antibiotics.

Yes, she should be considered for prophylactic antibiotics – provided she also meets certain other criteria, in line with NICE recommendations for prophylactic antibiotic therapy (check local guidelines in case of any divergence from these criteria).

Provided the patient does not smoke, is up to date with relevant vaccinations, is receiving optimal therapy and (if appropriate) has been referred for pulmonary rehabilitation, anyone with more than three exacerbations a year requiring antibiotics can be considered for prophylactic azithromycin 500mg three times a week or 250mg daily. There is very good evidence that prophylactic antibiotics reduce exacerbations and sputum volume and improve lung function.

However, first check sputum for MC&S. Frequent exacerbations could be caused by bacteria resistant to commonly prescribed antibiotics. Tests should rule out colonisation with Pseudomonas aeruginosa. Similarly, exclude mycobacterium infection, typical and atypical, by checking three early morning sputum specimens for acid alcohol fast bacteria (AAFB) and MC&S.

If it is clear that the patient meets the above criteria for prophylactic antibiotic therapy, and you have checked MC&S and ruled out AAFB, refer to the respiratory clinic.

Other considerations before starting long-term prophylactic azithromycin are:

1. Check if QTc interval is normal (<450ms) on ECG.
2. Warn patient that it could affect their hearing and balance.

10. This 33-year-old male known asthmatic is symptomatic with chest tightness limiting his exercise tolerance despite treatment with combination inhaler (ICS+LABA). He has had frequent exacerbations requiring antibiotics and oral steroids and A&E attendances over the past year. Please advise on further management.

Re-check inhaler technique and compliance with treatment.

Confirm if current dose of inhaler combination is effective in reducing airway inflammation. Check fractional exhaled nitric oxide (FeNO) and consider maximum treatment and MART regimen.

Check reduction/elimination of asthma triggers or irritants such as cigarette smoke, pollutants and allergens. This should be done at home (dust mite, moulds, animal hair) and explore whether the patient’s role suggests potential occupational exposure (eg, hairdresser, baker). Consider extrapulmonary triggers such as GORD and rhinosinusitis.

If spirometry shows partially reversible airflow obstruction, consider asthma/COPD overlap and use triple combination therapy.

Consider associated ABPA and test for total IgE, specific IgE aspergillus and aspergillus precipitins. If results are positive, refer to respiratory clinic.

If the patient remains poorly controlled despite these measures and has evidence of atopy and raised eosinophil count, he can be assessed for treatment with biological agents.

Dr Himender Makker is a consultant physician in respiratory and sleep medicine, formerly at University College London Hospitals NHS Foundation Trust, now working full-time in private practice