Most patients presenting with breathlessness should have a diagnosis and comprehensive plan in place with six months, a support tool published by NHS England to reduce variation in care says.
Breathlessness is associated with high use of healthcare services accounting for 4% of GP consultations and 5% of emergency department attendances, NHS England said.
Yet despite the burden to the patient and the NHS, delays to diagnosis and misdiagnosis are common, the toolkit notes.
This includes 58% of patients with COPD who present with respiratory symptoms for over five years before diagnosed as well as 41% of patients with heart failure.
Patients with chronic breathlessness are likely to need multiple investigations and should be provided with self-management advice, have lifestyle issues addressed and support for mental health from the first presentation, the guidance states.
Timeliness is key with a proactive approach to reassessment rather than waiting for patients to keep highlighting their breathlessness, it says, and in a third of patients the cause will be multifactorial.
The guidance sets out diagnostic pathway for initial investigations of chronic breathlessness lasting more than eight weeks including ECG, spirometry and FeNO with suggestions for further tests should be diagnosis be unclear.
Referral to respiratory physician or cardiologist is the third step should other investigations provide no explanation, the pathway says.
‘If there is no obvious cause(s) for breathlessness after robust investigation, fitness and lifestyle factors should be addressed,’ the toolkit continues.
‘Consider referral for therapeutic interventions for alcohol reduction, weight management, physical activity improvement and psychosocial support.’
It notes the guidance is not intended to override clinical judgment in individual cases.
The toolkit follows calls for breathlessness hubs to be set up to improve the speed and accuracy of diagnosis for COPD.
In its annual report on COPD care, Asthma and Lung UK said almost a quarter of patients wait five year or more before their condition is diagnosed and 12% of 6,500 patients surveyed had waited more than a decade.
Some community diagnostic centres have been piloting the use of a pre-diagnosis breathlessness pathway, the charity said, but this approach now needs to be rolled out nationally as a matter of urgency.
The goal would be for any patients presenting with breathlessness with no obvious diagnosis to be referred to a diagnostic hub to have an assessment by heart, respiratory and mental health experts before onward specialist referral and treatment where necessary.
Dr Daryl Freeman, Primary Care Respiratory Society committee member and associate clinical director at Norfolk Community Health & Care said: ‘The NHSE breathlessness pathway is an opportunity to fine tune primary care diagnosis of breathlessness and look at how they can develop their PCN hublets or refer into community based diagnostic hubs if they exist.
‘The algorithm is useful I feel and is particularly useful for allied health professionals looking after patients with new onset breathlessness.’
READERS' COMMENTS [8]
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Pie in the sky thinking . Feno not available except in private sector. All referrals will be rejected unless all 50 boxes are ticketed including serum rhubarb and full body high resolution ct scan. Pathways made by people who don’t work in general practice.
An excellent and streamlined breathlessness pathway to getting an accurate diagnosis in patients with serious heart or lung problems. GP clinics can do most of the tests and history/examination in step ONE; 80-85% of cases will not need onward referral to the breathing hubs is our experience. GP clinics need to restart spirometry if they have not been doing this essential service as you cant diagnosis COPD and many adult asthmatics without this. FeNO is used in some GP practices but would be ideal to be based at PCN hub/lead practice and can be rented now at less than 800 pounds per year. Many areas have schemes to get FeNO via AHSN too. Practices who are using it have found it really excellent and transforms care of asthma.
Spirometry has been regulated and contracted to death in my patch, talk about own goal.
No money for primary care FeNO
Commonest respiratory diagnostic tool: try this inhaler, let me know if it helps.
But to be honest, I would first target the money on lifestyle interventions for diet, smoking, drugs and alcohol.
Reversing T2 diabetes with diet really does feel like making people 10y younger and happier.
Weird how loads of tests, which are not part of the primary care contract are listed before referral to secondary care in the pathway.
We must recognise that there is no more capacity in the GP system. And all new pathways must move away from the automatic assumption that work up in primary care is efficient and cost effective – as all it does is prevent new undifferentiated patients from getting an appointment, of which some will have serious urgent illness.
The pathway should be breathlessness with no obvious cause – refer to respiratory team without work up. They work up by doing bloods, spirometry, feNO and ecg, bnp, echo or whatever. And respiratory nurses can refer on to cardiology, gastro/ haematology or wherever as needed.
“all it does is prevent new undifferentiated patients from getting an appointment, of which some will have serious urgent illness.”
These patients are now being squeezed out of our service, yet it’s a core remit. It’s also the only part of the job I truly enjoy.
And even after you’ve got all the ‘tests’ done and ‘ticked’ all the boxes, the routine wait to seen a specialty around here is still 9-12months!
There continues to be an embarrassing lack of the grown up conversation about what GP can do /we as a society want it to do/getting enough space/people/skill in place to do it.
I’m knackered shuffling deckchairs and have never been closer to jumping ship because of how childishly we are being “led”.
Agree with BB. This sort of guidance needs to be properly resourced if it is to happen. Expecting GPs to perform tests that they are being regulated out of providing, and weren’t funded anyway largely is short sighted.