Updated Guidelines 2024:
NICE guidelines updated for COPD management (NG115) and asthma diagnosis (NG80). New FeNO testing recommendations and revised inhaler prescribing guidance included.
Respiratory Medicine for GPs: Your Survival Guide
Breathe easy - we've got your back when patients can't catch theirs
☕ Tea-Friendly Learning
⏰ For GP Trainees Short on Time
🚨 Red Flag Focused
Date Updated: November 2025
Executive Summary: What You'll Master Today
Because you have 47 other things to do before lunch, and that's just the morning list
What This Page Covers:
- • Red flags that'll keep you awake at night (in a good way)
- • Data gathering that actually matters
- • Differential diagnosis frameworks
- • Common conditions you'll see daily
- • When to panic vs when to prescribe paracetamol
- • Inhaler techniques (because we all need reminding)
Quick Facts at a Glance:
15%
of GP consultations are respiratory
1 in 5
adults have asthma or COPD
90%
of COPD is smoking-related
3 weeks
chronic cough threshold
Quick Navigation
📁 Downloads
path: RESPIRATORY
- asthma - in children.doc
- asthma - pace guidelines.pdf
- asthma - the 3 questions to assess impact on patients
- asthma acute in children over 5 years.doc
- asthma acute in children under 5 years.doc
- asthma and lung function tests.pdf
- asthma and wheeze in children.doc
- asthma copd and the evidence.rtf
- asthma practice protocol detailed.doc
- asthma through case scenarios.ppt
- asthma.ppt
- chest infections.ppt
- copd - the gold initiative.ppt
- copd -definition, symptoms and guidelines.doc
- copd guidelines bradford.pdf
- copd.ppt
- epworth sleep apnoea scale.pdf
- inhaled steroids in adults - comparison chart.doc
- inhaled steroids in adults - equivalence.doc
- inhaled steroids in children - equivalence.doc
- osce - inhaler use.doc
- osce cases - respiratory.ppt
- oxygen equipment guide.pdf
- PEFR - adults.pdf
- PEFR - paeds.pdf
- respiratory triage in primary care - a starting point.docx
- spirometry - basic interpretation.pdf
- spirometry - doing and interpreting.pdf
- spirometry - volume time curves.pdf
- spirometry and lung function.doc
- spirometry course.ppt
- spirometry handbook.pdf
- spirometry hinters.doc
- spirometry interpretation.pdf
- wells score for pulmonary embolism risk.doc
Brainy Bites: Essential Respiratory Wisdom
Key Questions for Data Gathering
"When did this start?" - Acute vs chronic changes everything
"What makes it worse?" - Triggers tell the story
"Any blood?" - Haemoptysis needs urgent attention
"Ever smoked?" - Even 5 pack-years matters
Red Flags – What Not to Miss!
🚨 SpO₂ <92%
Needs urgent assessment
🩸 Any haemoptysis
2WW referral territory
🤐 Silent chest in asthma
Life-threatening attack
📉 Unexplained weight loss
Think malignancy
📉 Isolated unexplained hyponatraemia
Think lung malignancy. 15% will have lung Ca. small-cell Ca produce ADH. order CXR
🚨 Red Flags / Conditions Not to Miss
Classic Triad (but often incomplete):
- Sudden breathlessness
- Pleuritic chest pain
- Haemoptysis
Action: Wells score, D-dimer if low risk, CTPA if high risk. Don't delay anticoagulation if high suspicion.
Key Features:
- Acute pleuritic pain (usually unilateral)
- Hyperresonance on percussion
- Decreased breath sounds
- Young tall males at higher risk
Action: CXR urgently. If >50% or breathless, needs chest drain. Tension pneumothorax = immediate needle decompression.
Suspicious Features:
- Persistent cough >3 weeks (especially smokers >40)
- Any haemoptysis
- Unexplained weight loss
- Voice change (recurrent laryngeal nerve)
- Finger clubbing
Action: CXR within 2 weeks. 2WW referral for any haemoptysis or suspicious CXR. Don't wait for "typical" presentation.
Life-threatening features:
- Silent chest (no wheeze = very bad)
- Exhaustion, confusion
- SpO₂ <92%
- Peak flow <33% predicted
- Can't complete sentences
Action: 999 ambulance. High-flow oxygen, nebulised salbutamol + ipratropium, prednisolone 40mg. IV magnesium if severe.
📋 Data-Gathering & Examination Tips
Symptom Timing & Character
Timing Questions:
- • Onset: sudden vs gradual
- • Duration: acute (<3 weeks) vs chronic
- • Pattern: constant vs intermittent
- • Triggers: exertion, allergens, infection
Character Details:
- • Cough: dry vs productive
- • Sputum: colour, volume, blood
- • Breathlessness: at rest vs exertion
- • Chest pain: pleuritic vs central
Essential Background
Smoking History:
- • Pack-years calculation
- • Vaping/e-cigarettes
- • Passive smoking
Occupational:
- • Asbestos exposure
- • Dusts, fumes, chemicals
- • Farming, mining
Past Medical:
- • Previous pneumonia/TB
- • Asthma, COPD, allergies
- • Heart disease, reflux
Systematic Approach
General Inspection:
- • Respiratory rate (normal 12-20)
- • Accessory muscle use
- • Cyanosis (central vs peripheral)
- • Finger clubbing
- • Pursed lip breathing
Chest Examination:
- • Symmetry of expansion
- • Tracheal deviation
- • Percussion: dull vs hyperresonant
- • Auscultation: wheeze, crackles
- • Vocal resonance
Key Measurements
SpO₂
Normal >95%
Room air essential
Peak Flow
% predicted
Best of 3 attempts
Temp
Infection marker
Don't forget!
🔬 Diagnostic Approach & Investigations
First-Line Investigations
Spirometry
Gold standard for COPD diagnosis. Post-bronchodilator FEV1/FVC <0.7
Peak Flow
Diurnal variation >20% suggests asthma. Serial measurements more useful than single reading
FeNO Testing
Fractional exhaled nitric oxide. >40ppb suggests asthma (if available)
Supporting Tests
Chest X-ray
Chronic cough, haemoptysis, suspected pneumonia or malignancy
Blood Tests
FBC, CRP, eosinophils. ABG if acute breathlessness
Sputum Culture
Persistent productive cough, suspected TB, bronchiectasis
Urgent Referral (2WW)
- • Any haemoptysis (especially >40 years + smoking history)
- • Suspicious CXR findings
- • Persistent cough >3 weeks with high-risk features
- • Unexplained weight loss + respiratory symptoms
Urgent Hospital Admission
- • SpO₂ <92% on room air
- • Signs of sepsis (CURB-65 ≥2)
- • Suspected PE with high Wells score
- • Life-threatening asthma
Routine Specialist Referral
- • Persistent cough with normal CXR
- • Suspected occupational lung disease
- • Unexplained pulmonary fibrosis
- • Difficult-to-control asthma
CURB-65 Score (Pneumonia)
C
Confusion (new)
U
Urea >7 mmol/L
R
Respiratory rate ≥30
B
Blood pressure <90/60
65
Age ≥65 years
Score 0-1: Home treatment
Score 2: Hospital assessment
Score ≥3: Urgent admission
Score 2: Hospital assessment
Score ≥3: Urgent admission
Wells Score (PE)
Clinical signs of DVT (3 points)
PE most likely diagnosis (3 points)
Heart rate >100 (1.5 points)
Immobilisation/surgery (1.5 points)
Previous PE/DVT (1.5 points)
Haemoptysis (1 point)
Malignancy (1 point)
Score ≤4: D-dimer first
Score >4: CTPA or interim anticoagulation
Score >4: CTPA or interim anticoagulation
🧠 Differential Diagnosis Frameworks
🩸
Cough (Acute/Chronic)
• Viral URTI (most common)
• Pneumonia
• Asthma exacerbation
• Covid-19
• Pertussis (whooping cough)
• Asthma
• COPD
• GORD (often nocturnal)
• Post-nasal drip
• ACE inhibitor
• Lung cancer ⚠️
• Bronchiectasis
😮
Dyspnoea/Breathlessness
Respiratory: Asthma, COPD, PE, pneumonia
Cardiac: Heart failure, angina, arrhythmia
Other: Anaemia, obesity, anxiety
Systemic: Thyrotoxicosis, acidosis
🔥
Chest Pain
Pleuritic: PE, pneumonia, pneumothorax
Central: Angina, ACS, aortic dissection
Burning: GORD, oesophageal spasm
Localised: Costochondritis, muscle strain
💨
Wheeze
Asthma - Variable, reversible
COPD - Fixed, progressive
Anaphylaxis - Acute, with other features
Heart failure - "Cardiac asthma"
Vocal cord dysfunction - Inspiratory stridor
🫁 Common Conditions in Primary Care
Diagnostic Criteria
Clinical Features:
- • Variable wheeze, cough, breathlessness
- • Worse at night/early morning
- • Triggered by allergens, exercise, cold
- • Family history of atopy
Objective Tests:
- • FeNO >40ppb (if available)
- • Peak flow variability >20%
- • Spirometry: reversibility >12% + 200ml
- • Bronchial challenge test
Stepwise Management (BTS/SIGN)
Step 1: SABA as required (salbutamol)
Step 2: + Low-dose ICS (beclometasone 200-400mcg/day)
Step 3: + LABA (salmeterol/formoterol) or LTRA (montelukast)
Step 4: Medium-dose ICS + LABA + LTRA
Step 5: High-dose ICS or add-on therapy (specialist)
Regular Review
Assess Control:
- • Daytime symptoms <2/week
- • Night waking <1/week
- • SABA use <2/week
- • No activity limitation
Action Points:
- • Check inhaler technique
- • Review adherence
- • Identify triggers
- • Update action plan
Acute Exacerbation Management
Mild-Moderate:
- • Salbutamol 2-10 puffs via spacer
- • Prednisolone 40mg for 5 days
- • Review in 24-48 hours
Severe/Life-threatening:
- • 999 ambulance
- • High-flow oxygen
- • Nebulised salbutamol + ipratropium
- • IV magnesium if severe
Diagnostic Criteria
Essential: Post-bronchodilator FEV1/FVC <0.7
Clinical Features:
- • Progressive breathlessness
- • Chronic cough ± sputum
- • Smoking history (usually >20 pack-years)
- • Age >40 years
Exclude Asthma:
- • No significant reversibility
- • No childhood/family history
- • No atopy/allergies
- • Symptoms not variable
GOLD Classification
Airflow Limitation:
GOLD 1 (Mild): FEV1 ≥80% predicted
GOLD 2 (Moderate): 50-79% predicted
GOLD 3 (Severe): 30-49% predicted
GOLD 4 (Very Severe): <30% predicted
Symptom Assessment:
mMRC Dyspnoea Scale:
0 = Only breathless with strenuous exercise
4 = Too breathless to leave house
0 = Only breathless with strenuous exercise
4 = Too breathless to leave house
CAT Score:
COPD Assessment Test
0-10 = Low impact
>30 = Very high impact
COPD Assessment Test
0-10 = Low impact
>30 = Very high impact
Stepwise Management
All patients: SABA or SAMA as required + smoking cessation
Group A (Low risk, few symptoms): Bronchodilator PRN
Group B (Low risk, more symptoms): LABA or LAMA
Group C (High risk, few symptoms): LAMA
Group D (High risk, more symptoms): LAMA + LABA ± ICS
COPD Acute Exacerbation Management
1 Patient NOT on Prophylactic Antibiotics
1
Antibiotics: Amoxicillin, Doxycycline, or Clarithromycin - usually 5 days
2
Steroids: Prednisolone 30mg OD for 5 days (Remember: 40mg for asthma!)
2 Patient IS on Prophylactic Antibiotics
1
Continue azithromycin - do not stop
2
Add acute antibiotics: Amoxicillin or Doxycycline for 5 days
⚠️ AVOID: Clarithromycin or Erythromycin (QT prolongation risk with azithromycin)
3
Steroids: Prednisolone 30mg OD for 5 days
CURB-65 Assessment & Management
Score 0-1 (Low Risk)
- • Home treatment
- • Amoxicillin 500mg TDS 5 days
- • If penicillin allergic: clarithromycin
- • Safety net advice
Score 2 (Moderate Risk)
- • Consider hospital assessment
- • May treat at home if stable
- • Amoxicillin + clarithromycin
- • Close follow-up essential
Score ≥3 (High Risk)
- • Urgent hospital admission
- • IV antibiotics
- • Consider ITU if score 4-5
- • Mortality risk 15-40%
💨 Inhaler Devices & Technique
💡 Golden Rule
Poor inhaler technique is the #1 reason for poor asthma/COPD control. Check technique at EVERY appointment!
pMDI (Pressurised Metered Dose Inhaler)
Most common but hardest to use correctly
Correct Technique:
- Remove cap, shake 5 times
- Breathe out gently
- Seal lips around mouthpiece
- Start breathing in slowly and deeply
- Press canister down once
- Continue breathing in slowly
- Hold breath for 10 seconds
- Wait 30 seconds before next dose
Common Errors:
- • Breathing too fast
- • Poor coordination
- • Not shaking inhaler
- • Multiple actuations
DPI (Dry Powder Inhaler)
Easier coordination, needs good inspiratory flow
Correct Technique:
- Load dose (varies by device)
- Breathe out gently (away from device)
- Seal lips around mouthpiece
- Breathe in hard and fast
- Hold breath for 10 seconds
- Rinse mouth if steroid
Device Types:
- • Turbohaler (twist and click)
- • Accuhaler (slide and click)
- • Breezhaler (pierce capsule)
- • Ellipta (slide cover)
Spacer Devices
Improve drug delivery and reduce side effects
Benefits:
- • Removes need for coordination
- • Reduces oral thrush risk
- • Increases lung deposition
- • Essential for children <5 years
Technique with Spacer:
- Attach inhaler to spacer
- Shake and actuate once
- Breathe normally 5-6 times
- Or single deep breath
🌍 SABA Over-reliance & Environmental Impact
Reframe the Conversation
The GTN Analogy:
A GTN spray has up to 200 puffs - the same as many SABA inhalers. Are we happy with patients having 200 puffs of GTN for 'just a bit of chest pain'? Probably not.
How have we become so comfortable with asthma patients having 200 puffs a month for 'just a bit of breathlessness'?
💡 Start a conversation today - see the Asthma Right Care Slide Rule
Environmental Impact of Inhalers
- • Inhalers are essential for asthma control - this is the priority
- • Some inhalers have a bigger carbon footprint than others
- • Patient choice should consider both clinical effectiveness and environmental impact
- • Poor asthma control leads to higher carbon footprint (more SABA use, more healthcare visits)
Remember: Never stop inhalers without healthcare professional discussion. Good asthma control is both clinically and environmentally important.
You've Got This! 💪
Remember: You don't need to be a respiratory physician to provide excellent respiratory care. You just need to know when to worry, when to treat, and when to refer.
Trust your clinical instincts, use your safety nets, and remember that most respiratory problems in primary care are common things being common. When in doubt, a good history and examination will get you 80% of the way there.
Now go reward yourself with that well-deserved coffee ☕