Respiratory Hot Topics

For your SCA revision, here is a list of topics to make sure you have covered from respiratory medicine. You can print this list and ensure you have practiced cases from each and that you are familiar with the NICE CKS guidelines for each of them. There are plenty of cases to practice from on our SCA Roleplays page or you can generate your own SCA cases here.

Asthma: New Diagnosis and Management

Understand the diagnostic criteria for asthma, including the use of objective tests such as spirometry with reversibility testing and FeNO (fractional exhaled nitric oxide). The new BTS/NICE/SIGN guidelines emphasise the importance of objective testing rather than relying solely on clinical diagnosis.

Key management areas include understanding the stepwise approach to treatment, now incorporating SABA-free pathways using low-dose ICS/formoterol combination inhalers for newly diagnosed patients aged 12 and over. Be familiar with MART (Maintenance and Reliever Therapy) regimens.

Focus on inhaler technique – this should be checked at every review. Poor technique is a common cause of uncontrolled asthma. Ensure you can demonstrate proper use of MDIs, spacers, and breath-actuated devices.

All patients must have a personalised asthma action plan which includes their treatment regime, triggers, warning signs, and who to contact when they need help. Regular annual reviews should be conducted by appropriately trained healthcare professionals.

Safety netting: Red flags include use of more than 3 SABA inhalers per year (indicating poor control), symptoms waking them at night, increasing breathlessness despite treatment, or signs of acute severe asthma (unable to complete sentences, respiratory rate >25, heart rate >110, PEFR <50% predicted).

Acute Asthma Exacerbation

Be able to assess severity using PEFR or FEV1 measurements. Know the difference between moderate, acute severe, and life-threatening asthma.

Moderate: PEFR 50-75% best/predicted, no features of acute severe.

Acute severe: Any of – PEFR 33-50% best/predicted, respiratory rate ≥25/min, heart rate ≥110/min, inability to complete sentences in one breath.

Life-threatening: PEFR <33% best/predicted, SpO2 <92%, silent chest, cyanosis, exhaustion, altered consciousness, or arrhythmia.

Management involves high-flow oxygen (target 94-98%), nebulised salbutamol (back-to-back if needed), nebulised ipratropium bromide for severe cases, and oral prednisolone 40-50mg (or IV hydrocortisone 100mg if unable to swallow). IV magnesium sulphate 2g over 20 minutes should be given for patients not responding to initial treatment.

Safety netting: All patients need safety netting about when to call 999, and follow-up within 2 days with their GP or asthma nurse. Peak flow should be checked at arrival, during admission, and pre-discharge. Ensure patients have supply of inhalers and prednisolone 40mg for 5 days for adults and adjusted doses for paediatrics. Check BNF to confirm the right dose as often a weight is required.

Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management

Focus on spirometry for diagnosis – post-bronchodilator FEV1/FVC ratio <0.7 confirms airflow obstruction. Ensure you understand the difference between COPD and asthma, though they can coexist.

Management fundamentals include smoking cessation (the only intervention proven to slow disease progression), pneumococcal and annual influenza vaccinations, and pulmonary rehabilitation for patients with MRC dyspnoea score ≥2 or those who have had hospital-treated exacerbations.

Know the stepwise approach to inhaled therapy. Avoid over-prescribing inhaled corticosteroids – these should only be added if there are asthmatic features, high eosinophil count, or frequent exacerbations.

First-line: if few symptoms and low risk of exacerbations with MRC score of 0-1: SABA or SAMA as required.
Persistent breathlessness: Add LABA or LAMA.
Further symptoms: LABA + LAMA combination e.g. Umeclidinium/vilanterol, glycopyrronium/formoterol, tiotropium/olodaterol, and aclidinium/formoterol
Frequent exacerbations: Consider adding ICS to LABA/LAMA (triple therapy).

First Line: MRC Score 2+: Note that in the case of persistent/ moderate/ high symptoms at initial presentation, a LABA + LAMA combination becomes FIRST line instead of SABA/ SAMA.

Regular inhaler technique review is essential – ensure correct device selection based on patient’s inspiratory effort and ability. A personalised COPD management plan should enable patients to recognise early symptoms of exacerbation.

These review appointments can be done by a GP or clinical pharmacist etc.

COPD Exacerbations

Recognise the cardinal symptoms: increased breathlessness, increased sputum volume, and change in sputum colour (purulence). Additional features include increased cough, wheeze, and feeling generally unwell.

Most mild-moderate exacerbations can be managed in primary care with face-to-face assessment to determine severity.

Management: Increase frequency of SABA/SAMA use (1-2 puffs hourly initially via spacer, then every 2-4 hours based on response). If no improvement, add prednisolone 30-40mg for 5 days.

Antibiotics should only be prescribed if sputum is purulent AND increased in volume with breathlessness. Course length is typically 5 days (14 days if patient has bronchiectasis). Follow local microbiology guidelines.

Consider issuing rescue packs for appropriate patients – those with previous exacerbations, clear self-management plans, confidence to start treatment, and who know to inform healthcare professional within 48 hours. Ensure rescue packs are NOT on repeat prescription.

Post-exacerbation review is vital to identify possible causes, reinforce education, assess comorbidities (check heart rate, BP, BMI for AF, heart failure, cor pulmonale), review treatment, check inhaler technique, offer smoking cessation, and check vaccinations.

Community-Acquired Pneumonia

Understand the use of CRB-65 score in primary care for risk stratification (Confusion, Respiratory rate ≥30, Blood pressure <90 systolic or ≤60 diastolic, age ≥65). Each scores 1 point.

CRB-65 score 0: Consider home-based care.
CRB-65 score 1: Discuss options – shared decision about hospital vs supported home-based care.
CRB-65 score ≥2: Consider hospital assessment.

If managing at home, consider using C-reactive protein (CRP) point-of-care testing: CRP <20mg/L – no antibiotics or consider delayed prescription; CRP 20-100mg/L – consider delayed prescription; CRP >100mg/L – offer antibiotics.

First-line antibiotic is usually amoxicillin. Diagnosis should be confirmed by chest radiography before commencing antibiotics in most patients, though those with life-threatening disease should be treated based on presumptive clinical diagnosis.

Offer antibiotic therapy as soon as possible after diagnosis. Safety net about worsening symptoms requiring urgent medical review. Follow-up chest X-rays are NOT routinely needed after successful treatment unless risk factors present.

Pulmonary Embolism (PE)

Have a high index of suspicion in patients presenting with breathlessness, chest pain (often pleuritic), haemoptysis, or syncope, particularly with risk factors (recent surgery, immobilisation, long-haul travel, malignancy, previous VTE, pregnancy/postpartum, hormone therapy).

Use the Wells score to assess probability:

• Clinical signs of DVT: 3 points
• PE most likely diagnosis: 3 points
• Heart rate >100: 1.5 points
• Immobilisation/surgery in past 4 weeks: 1.5 points
• Previous PE/DVT: 1.5 points
• Haemoptysis: 1 point
• Malignancy: 1 point

Wells score ≤4 + negative D-dimer: PE can be safely excluded in primary care. A Wells score <2 is even safer.
Wells score >4 OR positive D-dimer: Urgent referral for CT pulmonary angiogram (CTPA).

The Wells rule combined with point-of-care D-dimer testing can safely exclude PE in about 45% of patients in primary care, with a failure rate of less than 2%.

Always ask about leg pain (possible DVT) and consider this as first presentation of malignancy – enquire about constitutional symptoms and other red flags.

Lung Cancer: Red Flag Symptoms and Urgent Referrals

Be alert to symptoms and know when to refer urgently or request urgent chest X-ray. Lung cancer is more common in smokers/ex-smokers but can occur in never-smokers.

Urgent suspected cancer pathway referral (2-week wait):

• Chest X-ray findings suggestive of lung cancer (including pleural effusion, pleural mass, or slowly resolving consolidation)
• Aged ≥40 with unexplained haemoptysis (persistent in smokers/ex-smokers).

Urgent chest X-ray (within 2 weeks) for patients aged ≥40:

• 2 or more of: cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss
• Ever-smokers with 1 or more of the above unexplained symptoms
• Persistent or recurrent chest infection
• Finger clubbing (new or not previously documented)
• Cervical/supraclavicular lymphadenopathy
• Chest signs
• Hoarseness >3 weeks
• Thrombocytosis (platelets >450 × 10⁹/L).

Consider urgent CXR for:

• Unexplained haemoptysis
• Persistent cough >3 weeks
• Unexplained chest/shoulder pain
• Underlying chronic respiratory problems with unexplained changes.

Early detection significantly improves outcomes. A normal chest X-ray does not exclude lung cancer – if high suspicion persists or symptoms continue for >6 weeks despite normal CXR, refer via urgent cancer pathway.

Bronchiectasis

Bronchiectasis is characterised by permanent dilation of the bronchi, leading to chronic productive cough with daily sputum production, recurrent chest infections, and breathlessness.

Diagnosis requires high-resolution CT chest (HRCT). Once suspected, all patients should be assessed initially by a specialist respiratory team to investigate underlying causes (post-infective, ABPA, primary ciliary dyskinesia, immune deficiency, inflammatory bowel disease, rheumatoid arthritis) and formulate a shared management plan.

Primary care management focuses on:

• Chest physiotherapy – cornerstone of treatment. All patients should see a specialist respiratory physiotherapist and be taught airway clearance techniques (active cycle of breathing, postural drainage). Aim for at least 10 minutes three times daily.
• Prompt treatment of acute exacerbations – ideally obtain sputum for culture before starting antibiotics. Most patients need 14 days of antibiotics (unlike 5-7 days for pneumonia). In mild bronchiectasis, 7-day course may suffice.
• Standby antibiotics – suitable patients should have home sputum pots and rescue antibiotics for future exacerbations.

Common organisms: Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae. Pseudomonas requires specialist management and 14-day courses.

Refer back to secondary care if: ≥3 exacerbations per year, chronic colonisation with Pseudomonas or MRSA, allergic bronchopulmonary aspergillosis, associated inflammatory bowel disease or rheumatoid arthritis, deteriorating lung function, or advanced disease.

Annual influenza and pneumococcal vaccinations are essential. Smoking cessation must be encouraged.

Pleural Effusion

Recognise the typical presentation: breathlessness, dull percussion note, reduced breath sounds, and reduced tactile vocal fremitus on the affected side.

Chest X-ray shows water-dense shadow with concave-upwards upper border. Approximately 200ml of pleural fluid produces an abnormal PA chest X-ray, while 50ml will produce detectable blunting on lateral film. Ultrasound is more sensitive for detecting smaller effusions.

Determine whether effusion is likely transudative or exudative based on clinical context:

Transudative causes: Heart failure, cirrhosis, nephrotic syndrome, hypoalbuminaemia.

Exudative causes: Pneumonia (parapneumonic effusion), malignancy, pulmonary embolism, tuberculosis.

Primary care investigations: PA chest X-ray, blood tests (FBC, U&Es, LFTs, CRP), NT-proBNP if heart failure suspected.

If bilateral effusions in context of heart failure, a trial of diuresis is appropriate. However, unilateral effusions or those not responding to treatment require diagnostic pleural aspiration.

Most patients require referral to respiratory team for pleural aspiration/drainage and further investigation. Patients who are clinically stable may be seen in ambulatory clinic. Empyema (infected pleural fluid with pH <7.2, frank pus, or positive culture) requires urgent chest drain insertion.

Interstitial Lung Disease (ILD)

ILD encompasses diverse conditions causing lung inflammation and fibrosis. Common causes include idiopathic pulmonary fibrosis (IPF), hypersensitivity pneumonitis, drug-induced (methotrexate, nitrofurantoin, amiodarone, statins), connective tissue disease-associated ILD, and sarcoidosis.

Typical presentation:

• Progressive breathlessness on exertion
• Persistent dry cough
• Non-specific fatigue
• Fine bilateral inspiratory crackles on auscultation (Velcro-like crackles)
• Finger clubbing suggests IPF
• Weight loss (in some cases).

Spirometry may show restrictive pattern (reduced FVC) or normal findings. Sometimes shows obstructive pattern as IPF may coexist with emphysema/COPD. Consider heart failure and bronchiectasis in differential diagnosis.

Important history: Detailed occupational and environmental exposure (birds, mould, asbestos), drug history, family history. Ask about symptoms of connective tissue disease (joint pain, morning stiffness, dry eyes/mouth, Raynaud’s phenomenon, skin changes, photosensitivity).

A lack of response to treatments for infection or pulmonary oedema should prompt consideration of ILD diagnosis.

Refer to respiratory specialist for high-resolution CT chest and specialist assessment. HRCT is standard investigation and may be diagnostic in some cases. Early diagnosis and treatment can slow progression in some forms of ILD.

Tuberculosis (TB): When to Suspect and Refer

Maintain high index of suspicion, particularly in high-risk groups: recent immigrants from high-prevalence countries, homeless individuals, immunosuppressed patients (HIV, biologics, long-term steroids), healthcare workers, and close contacts of active TB cases.

Classical pulmonary TB symptoms:

• Persistent cough >3 weeks (often productive)
• Haemoptysis
• Fever, night sweats
• Weight loss
• Lymphadenopathy
• Chest pain.

However, presentation can be atypical or subtle, particularly in immunosuppressed or elderly patients. Chest X-ray may show upper lobe infiltrates, cavitation, or miliary pattern.

If TB suspected, arrange urgent same-day referral to TB clinic or respiratory team. Patients with suspected pulmonary TB should be isolated pending investigation. Sputum samples (3 early morning samples) should be sent for microscopy and culture.

Do not start empirical antibiotic treatment for presumed bacterial infection if TB is possible – this can delay diagnosis and has implications for public health contact tracing.

Sarcoidosis

Multi-system granulomatous disease most commonly affecting lungs and lymph nodes. Highest incidence in Black and Scandinavian populations. Peak age 20-40 years.

Pulmonary manifestations: Dry cough, breathlessness, chest discomfort, wheeze. May be asymptomatic with incidental finding of bilateral hilar lymphadenopathy on chest X-ray.

Extrapulmonary features: Erythema nodosum, uveitis, arthralgia, hypercalcaemia, cardiac involvement (heart block, arrhythmias), neurosarcoidosis (cranial nerve palsies, particularly facial nerve), skin lesions.

Löfgren’s syndrome (acute sarcoidosis): Triad of bilateral hilar lymphadenopathy, erythema nodosum, and arthralgia. Good prognosis with often spontaneous resolution.

Diagnosis requires compatible clinical/radiological picture plus histological confirmation of non-caseating granulomas. Differential includes tuberculosis, lymphoma, and other granulomatous diseases. Most patients managed by respiratory specialists.

Smoking Cessation

Offering smoking cessation advice is one of the most effective interventions for respiratory health. Should be offered at every opportunity, particularly to patients with respiratory conditions.

Brief interventions using “Ask, Advise, Act” approach take only 30 seconds but significantly increase quit rates.

Ask: Document smoking status at every consultation.
Advise: Clearly state benefits of quitting and offer support.
Act: Refer to stop smoking services or prescribe pharmacotherapy.

Pharmacotherapy options:

• Nicotine replacement therapy (NRT): Patches, gum, lozenges, inhalator, nasal spray. Can combine short-acting with long-acting formulations.
• Varenicline: Most effective pharmacotherapy. 12-week course.
• Bupropion: Contraindicated in seizure disorders.

E-cigarettes/vaping: Current evidence suggests substantially less harmful than smoking. Can be used as quitting aid. Complete cessation of tobacco smoking is the goal.

Smoking cessation is the only intervention proven to slow progression of COPD and reduce risk of lung cancer, cardiovascular disease, and other smoking-related conditions