Respiratory

In the following video, Dr Rod Lawson, Consultant in respiratory medicine, discusses chronic cough and its management in primary care:

1. Causes of chronic cough include Asthma, post-nasal drip, GORD and iatrogenic causes (including ACE inhibitors).) Exclude Red Flags (haemoptysis, wt loss, fever) Refer if these are present. Exclude above conditions or if suspected give trial of treatment before referral. If these conditions are not considered relevant and the patient has normal CXR, spirometry and examination then laryngeal hypersensitivity remains the most probable cause and it is reasonable to reassure the patient but repeat CXR and spirometry after 6 months to exclude new developments.
2. Causes of chronic wheeze. Look for specific respiratory causes of wheeze first using serial PEFR and spirometry. Reflux is a common cause of wheeze. Where a respiratory cause is not identified give a trial of treatment of GORD with Lansoprazole 30mg bd, Ranitidine 300 mg nocte and alginate qid for 2-3/12.
3. When stopping ACE inhibitors for persistent cough it can take up to 2/12 for the cough to resolve.
4. Do not refer stable asymptomatic pleural plaques. Refer if respiratory symptoms (pain, breathlessness, symptoms suggesting neoplasia or pulmonary restriction found on spirometry.) Asbestos related pleural plaques have no functional consequences and are not predictive of future complications. They confirm asbestos exposure. However, they don’t predict future asbestos related lung disease (asbestosis, mesothelioma and lung cancer). In other words if you have been exposed to asbestos then you are as likely to get any of these clinically important diseases whether you have or have not got pleural plaques.
5. Snoring – for suspicion of OSA confirm symptoms are suggestive and Epworth Score >11, baseline bloods have been checked and patient has been advised not to drive if they are an HGV/PCV driver or their condition affects their ability to drive safely. Use the referral template on PRESS portal to distinguish whether an ENT or Respiratory referral is appropriate.
6. Community clinics. Patients with a COPD diagnosis resistant to recognized primary care guidelines can be referred to a community clinic (internally triaged to consultant or nurse led clinics) for further assessment. These will confirm the diagnosis, and give holistic advice including education and a management plan and are useful for patients needing additional input from that which can be achieved in primary care. The consultant clinic will address additional issues of differential diagnosis and complex management. Refer via SPA for Pulmonary Rehabilitation, which includes patient education, smoking cessation, diet/exercise and vaccinations advice. The COPD nurses will also visit at home if required. )
7. Poorly controlled asthma may be due to poor inhaler technique. Check that the appliance is appropriate for the patient. MDI inhalers require less respiratory effort (but better co-ordination unless used with a spacer) than DPI inhalers, which need fast inhalation. Useful information can be obtained from spirometry with reversibility and peak flow diary for up to 4 weeks along with baseline bloods and CXR in the last year. If there is a suspicion of Occupational asthma, request serial peak flows on 3 consecutive days at work and also on 3 periods way from work, each for 3 consecutive days.
8. Breathlessness: consider cardiac, haematological, thyroid and other non-respiratory causes. Ideally check ECG, CXR, spirometry and blood tests, O2 SATS and NTproBNP before considering referral.
9. Sputum culture and sensitivity should be obtained for patients with productive coughs to accompany referrals as part of the routine suggested investigations on PRESS portal i.e. CXR, spirometry, O2 SATS, FBC, U+Es.
10. Refer to secondary care the following findings which can cause uncertainty:

• Restrictive disease found on spirometry.
• A new diagnosis of bronchiectasis or known bronchiectasis with new symptoms or new concern. In particular isolation of pseudomonas in sputum culture should always result in referral
• Pulmonary nodules <3cm have multiple causes.
• Incidental finding of pulmonary hypertension can be referred to the Pulmonary Vascular Disease clinic. Refer unexplained or disproportionate pulmonary hypertension. Severe COPD will always be associated with some pulmonary hypertension. Left sided heart disease (especially mitral valve disease) will also cause secondary pulmonary hypertension. In all these cases treatment is of the primary cause and there is no need for further investigation or treatment of the pulmonary hypertension itself.

1. ALWAYS CONSIDER RADIATION RISK WHEN REQUESTING CT SCANS

• Lifetime additional risk of fatal cancer per examination =

○ 1 in several million for CXR

○ 1 in 2000-2500 for CT scan.

2. AIM FOR GOOD QUALITY CLINICAL INFO ON IMAGING REQUESTS

• This will improve the quality of the report you receive – to include more accurate advice on diagnosis & further management.
• For CT, the clinical information helps guide which CT imaging protocol is used. CT scans are done differently to investigate PE, parenchymal lung disease etc. The wrong type of CT study can lead to relevant pathology being missed.
• Give updated clinical info on requests for follow-up imaging – changes in symptoms/signs etc are much more useful than “Test as req by Radiology” etc
• Radiology suggestions re possible follow-up tests are not compulsory – use your knowledge of the patient to determine whether they are justified

3. FOLLOW-UP IMAGING IS NOT NEEDED IN THESE SCENARIOS :

• Patients <40 yrs with a single episode of pneumonia whose symptoms have resolved.
• bronchial wall thickening
• minor linear atelectasis
• long standing pleural thickening
• pleural plaques
• calcified granulomas

4. IMAGING IN CHRONIC DRY COUGH

• Do not routinely request a chest CT scan in patients with chronic dry cough who have a normal CXR and physical examination.
• In the presence of a normal CXR, a non-smoker with a dry cough & no other symptoms is extremely unlikely to have malignancy (<0.05%).
• Dr Rod Lawson’s video is very helpful : https://youtu.be/xYSGgQdKNxc

5. FOLLOW-UP IMAGING IN SUSPECTED CANCER / INFECTION

• In smokers with multiple red flag symptoms & a high suspicion of lung cancer, but a normal CXR, consider CT chest.
• Many pneumonias appear rounded and mimic the appearance of cancer. In the setting of infective symptoms, radiology advice to perform repeat CXR (rather than CT) is preferred, UNLESS there are RED FLAG symptoms.

6. LUNG NODULE FOLLOW-UP

• Nodules less than 5 mm don’t require follow up.
• Other nodules – rpt as advised in report OR refer to dedicated weekly Lung Nodule MDT
• For more detail, see Appendix 1

7. IMAGING FOR SUSPECTED BRONCHIECTASIS

• CXR indicated.
• HRCT should be requested (at the time of referral) in those referred to Chest Clinic for further management. Mention clinic referral in clinical info for HRCT request
• In premenopausal women, Chest Clinic review prior to requesting HRCT is recommended due to the radiation risk.

8. PULMONARY FIBROSIS

• This finding is frequently detected on CXR.
• An HRCT scan and referral to the Interstitial Lung Disease (ILD) Clinic is warranted if the patient is fit for further treatment.
• Relevant clinical information required on the Radiology request includes : occupational history, pets (especially birds), drugs, connective tissue disorders, smoking history.

9. CT IS NOT A SCREENING TEST IN SOB

• In the presence of a normal CXR, the absence of any other symptoms and normal PFTs, consider non-respiratory causes or referral, rather than a chest CT.

Appendix 1: Outline of CT investigation of Lung Nodules:

Full details on nodule follow up are in the BTS 2015 guidelines:

British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Callister ME, Baldwin DR, Akram AR et al. Thorax 2015; 70 Suppl 2: ii1 – ii54.

Nodule follow up should be conducted in those suitable for treatment ONLY.

Clinicians assign a risk score (BROCK SCORE) which is used to guide management. This is affected by the radiological appearance and location of the nodule and clinical factors such as age and smoking history.

• No nodule less than 5 mm requires follow up.

Solid nodules:
• Followed up for 2 years to confirm stability
• More than 95% of solid nodules under follow up are benign.
• The frequency of follow up depends on the nodule size.
• Most nodules are followed up at 3, 12 and 24 months from baseline scan.

Subsolid nodules:
• Followed up for 4 years to confirm stability
• Ground glass nodules have a significant malignant risk and are usually adenocarcinoma in situ. BUT , this type of cancer is low risk and usually grows very slowly. Most elderly people will die WITH this rather than FROM this. Therefore, follow up of this type of nodule is frequently not indicated.
• Subsolid nodules are followed up at 3 months, 1 year, 2 years and 4 years from baseline.
• An increase in size of the solid component or less dense ground glass component will prompt referral to the Lung Cancer MDT.

1)  The Primary Care Respiratory Society UK (PCRS-UK) is the UK-wide professional society supporting primary care to deliver high value patient centred respiratory care. It produces several resources to support healthcare professionals in the delivery of respiratory disease management in primary care.

2)  The British Lung Foundation has published a new booklet, endorsed by the RCGP, to help guide and support people living with chronic obstructive pulmonary disease (COPD).

3)  The PRESS PORTAL on the CCG’s website has got extensive updates on COPD and other long term respiratory conditions.

4) Gastro/ Respiratory newsletter February 2023