Patient assessment
Do not use spirometry values obtained during an infection/exacerbation as the only source to make a diagnosis of asthma or COPD.
During an exacerbation of asthma or COPD, airflow obstruction is bound to be present and will skew the results of spirometry.
Some people will be incorrectly diagnosed at that time and some alternative diagnoses may be missed. Diagnostic spirometry should be carried out when a patient has returned to their baseline. They will usually need six weeks for everything to settle.
Do not make a diagnosis of COPD in a patient where the diagnostic spirometry shows an FEV1/FVC ratio greater than 0.7 unless the patient has been assessed in the chest clinic.
An FEV1/FVC ratio greater than 0.7 indicates either normal spirometry or a restrictive disorder. All restrictive spirometry should be evaluated further in the chest clinic. Other possible diagnoses, such as interstitial lung disease, may be present.
Do not diagnose late-onset asthma in people with a smoking history of more than 10 pack years unless you have carried out spirometry and taken a thorough respiratory history.
Asthma will usually present by the second and third decades of life. Question all diagnoses of asthma made in people after the age of 40. Make sure the history points to a high likelihood of asthma before making the diagnosis. Were they smokers? Is there some other cause for the breathlessness, such as cardiac factors or obesity?
Investigations
Do not send routine sputum samples for culture in COPD patients who have their exacerbation managed in primary care.
The sending of routine sputum samples is highly unlikely to change management in patients with established COPD. Use local guidelines (if available) to help with the choice of antibiotic prescribed during an exacerbation. First line will usually be a penicillin or tetracycline. Send sputum samples where there is suspicion of an alternative diagnosis, or where there is a higher index of suspicion of an atypical infection. Sputum samples should be reserved to help guide antibiotic treatment where the causative organism may be in doubt – for instance, after foreign travel, where there is co-existing bronchiectasis, or if you want to rule out tuberculosis.
Do not use oral steroid reversibility tests to identify which patients should be prescribed inhaled steroid.
Oral steroid reversibility tests don’t predict response to inhaled steroid therapy. Asthma has always been, and still is, a clinical diagnosis. The decision on when to prescribe inhaled steroids should be governed by a combination of the following: the symptoms the patient experiences, the impact these have on the patient’s life and the peak flow.
Treatment
Do not give antibiotic therapy to patients with exacerbations without more purulent sputum unless there is consolidation on a chest radiograph or clinical signs of pneumonia.
Consider antibiotics carefully, even in groups of patients with respiratory illness. Have the lowest threshold of use in bronchiectasis and a lower than normal threshold of use in patients with COPD. However, patients with COPD will also get the common viruses and will not necessarily need antibiotics. Do not prescribe antibiotics for simple uncomplicated upper respiratory tract infection – you may wish to give a delayed antibiotic prescription in those cases.
Do not give a course of steroid treatment longer than 14 days, as there is no advantage in prolonged therapy.
In patients who seem to be having refractory breathlessness or prolonged exacerbations of asthma or COPD, consider providing a slow-reducing course of prednisolone after they have completed a course at maximum dose. Do not provide extra steroid for prolonged cough only. If they are unable to tolerate a slow reduction in prednisolone due to refractory breathlessness, then consider other causes of their persistent need for the steroid – occupational exposure, poor inhaler technique and other diagnoses. If they remain acutely breathless, consider the need for hospital admission or urgent outpatient clinic assessment.
Do not use high-dose inhaled steroids (beclometasone equivalent >800µg) unless they are really necessary.
High-dose inhaled steroids should be reserved for patients with severe asthma at step 3 and above in the BTS/SIGN guidelines, and severe COPD patients at NICE stage 3 and above.1 Many patients are prematurely put on high doses of inhaled steroids, for instance, Seretide 500 and Symbicort 400, where the side-effects of the high steroid dose may outweigh the anti-inflammatory benefit.2 Consult local and national guidelines before starting these inhalers.
Do not withhold ß-blocker treatment just on the basis of a diagnosis of asthma or COPD.
ß-blockers should generally be avoided in asthma patients, especially those with difficult (brittle) asthma, but can be used with caution in COPD, keeping in mind the small risks of bronchospasm in COPD patients. If their indication is strongly beneficial – for instance post-MI or in heart failure – then consider a benefits/risk assessment in patients with asthma. In those with well-controlled asthma, it is fair to trial a low-dose cardioselective ß-blocker. In COPD patients, it is quite unlikely that cardioselective ß-blockers will cause any problems.3
Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD.
Mucolytics confer no additional benefit in terms of mortality or the natural history of illness. They are for symptomatic control and benefit only. They have side-effects, like any other medication, so reserve them for use where patients have significant problems with excess mucus production.
Do not use anti-tussive therapy in the management of stable COPD.
There is little evidence that cough medicines actually reduce cough symptoms significantly in any illness, whether it is asthma, COPD or respiratory tract infections.4 Many trials have shown that these medicines, at best, perform as well as simple home remedies, such as steam inhalation and honey.5 They may provide a small amount of symptomatic benefit and should be reserved only for patients who have specifically found benefit with them.
Referral
Pleural plaques on a chest X-ray (CXR) do not necessarily need referring.
Patients with incidental finding of pleural plaques do not need specific follow-up or investigation in the chest clinic. Pleural plaques will not necessarily lead to mesothelioma or other pleural disease. Chest clinic referral becomes indicated if a patient has persistent respiratory symptoms or there is significant interval change on a CXR.
Dr Azhar Saleem is a GP in London and is clinical respiratory lead for Lambeth CCG
References
1 Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Edinburgh: SIGN; 2008
2 Calverley PMA, Anderson JA, Celli B et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. New England Journal of Medicine, 2007; 356 (8): 775-789
3 British National Formulary. Section 2.4 – beta blockers. London: Royal Pharmaceutical Society; 2014
4 Schroeder K. Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults. BMJ, 2002; 324: 329.1
5 Raeessi MA, Aslani J, Raeessi N, Gharaie H, Karimi Zarchi AA, Raeessi F. Honey plus coffee versus systemic steroid in the treatment of persistent post-infectious cough: a randomised controlled trial. Primary Care Respiratory Journal, 2013; 22 (3): 325-330
