Clinical update

Diagnosis of respiratory symptoms

New guidance offers pragmatic advice on the safest and most appropriate approach during the pandemic

New guidance offers pragmatic advice on the safest and most appropriate approach during the pandemic

Picture: iStock

Essential information

According to NHS England, respiratory disease affects one in five people and is the third-biggest cause of death in England, after cancer and cardiovascular disease.

Respiratory diseases are a major factor in winter pressures faced by the NHS, with most admissions being non-elective and doubling during the winter months.

COVID-19 has introduced many challenges for primary care practitioners, including being able to carry out a comprehensive evaluation that allows accurate diagnosis, while minimising the risks of cross infection.

New guidance offers pragmatic advice on the safest and most appropriate approach during the pandemic

Picture: iStock

Essential information

According to NHS England, respiratory disease affects one in five people and is the third-biggest cause of death in England, after cancer and cardiovascular disease.

Respiratory diseases are a major factor in winter pressures faced by the NHS, with most admissions being non-elective and doubling during the winter months.

COVID-19 has introduced many challenges for primary care practitioners, including being able to carry out a comprehensive evaluation that allows accurate diagnosis, while minimising the risks of cross infection.

In particular, testing procedures, including spirometry, have the potential to increase the risk of transmission of viral infections, through droplet or aerosol formation.

What’s new?

In June, the Primary Care Respiratory Society (PCRS) agreed new guidance for clinicians to help diagnose patients who have respiratory symptoms during the pandemic, taking the safest and most appropriate approach.

The recommendations recognise that certain procedures with the potential for droplet or aerosol formation may not be possible under current circumstances.

This includes spirometry, fractional exhaled nitric oxide (FeNO) and peak expiratory flow rate (PEFR). Instead the society offers pragmatic advice on diagnosis, based on a patient’s history, a physical examination and their presenting symptoms.

Key recommendations

For patients presenting with undifferentiated respiratory symptoms, where diagnosis is unclear and the possibility of asthma is intermediate or low, the PCRS recommends a structured, logical and context-based approach.

Ideally this should be carried out via a primary care-based respiratory diagnostic service, avoiding the need for hospital referral.

Where asthma is suspected, a structured clinical assessment should be carried out, reviewing the patient’s clinical records, including the results of any completed investigations, such as PEFR, spirometry or blood eosinophils.

Patients with a high probability of asthma can then be managed with a trial of treatment with peak flow monitoring in their home.

Only patients with an intermediate probability of asthma should be considered for further investigations, says the PCRS.

For patients with suspected chronic obstructive pulmonary disease, while history is crucial, they cannot be formally diagnosed unless fixed airway obstruction is demonstrated.

If a PEFR test is considered necessary it can be carried out using the patient’s own PEF meter and disposable mouthpiece in a room with an open window or outside the building, says the PCRS.

If investigations such as spirometry are deferred, this should be clearly marked in the patient’s notes, with confirmation that the test will happen when it is safe.

How you can help your patient

Nurses should understand that patients may have had to build up their courage to seek help for their breathlessness, so their symptoms should not be dismissed – instead they should be reassured that they have done the right thing.

Patients who are only offered a virtual or remote consultation may feel brushed aside, so nurses should try to see them face-to-face if it is safe to do so.

Expert comment

Carol Stonham

Carol Stonham is a Queen’s Nurse and Primary Care Respiratory Society executive chair

‘The guidance reminds us how to make a good clinical diagnosis of ongoing respiratory symptoms, without relying on spirometry. Spirometry is important in clarifying and confirming diagnosis, but it isn’t the single thing that makes it.

‘Remember there are lots of other things we can do. This includes detailed histories, asking the right questions, examination when it’s safe, chest X-rays and taking bloods.

Nurses play a key role in diagnosis, so seek training as needed

‘As professionals, we shouldn’t have tunnel vision and assume a patient who is breathless has chronic obstructive pulmonary disease, but instead rule out other possible causes.

‘As nurses often play such a key role in diagnosis, it’s a good time to ensure they feel competent and confident in their role, seeking training as necessary.’


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