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Koshy K, Limb C et al. International Journal of Surgical Oncology. 2017 2:e20
Respiratory medicine - Special interest
Symposium: Respiratory medicine
|Diagnosing asthma in school-age children can prove challenging
20 Dec 2022
Asthma is the most common chronic respiratory condition affecting children in the UK. There is no single gold standard test to confirm the diagnosis and both overdiagnosis and underdiagnosis are common. Asthma should be suspected in any child presenting with episodes of wheeze, especially recurrent episodes of wheeze. Clinical diagnosis alone often results in misdiagnosis; all children from the age of five years under investigation for asthma in primary care should have access to spirometry, bronchodilator reversibility and FeNO testing.
|Early diagnosis the main driver to improving outcomes in lung cancer
20 Dec 2022
Earlier diagnosis of lung cancer improves outcomes for two main reasons. First, the disease stage may be earlier allowing more chance of curative-intent treatment. Second, patients may be fitter at presentation. Functional status is one of the most important independent predictors of survival. Lung cancer is caused by smoking in 80-85% of cases. Patients who do not have smoking-attributable lung cancer are often diagnosed late. So it is important to refer patients who have persistent symptoms either for chest X-ray, or when symptoms persist and no alternative diagnosis is found, refer for consideration of CT.
COPD related articles
|Improving COPD outcomes in primary care
24 Oct 2019
Diagnosis of COPD is based on the presence of airflow obstruction after the administration of a bronchodilator i.e. post-bronchodilator spirometry. However, the National COPD Audit report for 2017-18 found that 59.5% of people hospitalised with a COPD exacerbation in England and Wales had no spirometry result available and in 12% of those who had undergone spirometry the test showed no airflow obstruction. Patients with COPD should be reviewed annually. It is advisable to repeat spirometry if there is a significant change in symptoms. It is important to determine objective measures of breathlessness (MRC dyspnoea score), quality of life (CAT questionnaire) and exacerbations (annual exacerbation and hospitalisation rate) as part of this review.
|Optimising the management of patients with COPD
25 Mar 2019
COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) who presents with symptoms such as breathlessness, wheeze, cough and sputum production and has one or more risk factors, typically current, or a past history of, cigarette smoking. A diagnosis should also be suspected when an individual with a risk factor develops a lower respiratory tract infection requiring treatment. COPD is far more common in smokers of heroin and crack cocaine, in whom it occurs at a younger age.
|Smoking duration the best indicator of COPD progression
22 May 2018
The number of years that an individual has been smoking is closely linked to the degree of structural lung disease, airflow obstruction and functional outcomes in chronic obstructive pulmonary disease (COPD). It is a better measure than pack-years or the number of cigarettes smoked per day, a large study from the USA has shown.
|Pulmonary rehabilitation improves exercise capacity and quality of life
23 Jan 2018
Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management. Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.
|Improving outcomes in COPD
23 Nov 2017
Cigarette smoking is overwhelmingly the most important risk factor for COPD. In some cases, other factors such as occupation, passive exposure to inhalants and fetal nutrition/low birthweight are also important. The diagnosis should be suspected in symptomatic patients with risk factors, usually cigarette smoking, aged 40 years or above, albeit a majority of people with COPD present when considerably older. The 2017 GOLD guideline recommends that management should be focused on two objectives. First, to relieve symptoms of breathlessness (assessed using the MRC dyspnoea scale) and improve quality of life (assessed by the COPD Assessment Test). Second, to reduce risk assessed by the number of exacerbations and hospitalisations in the previous year.
Asthma in adults
|Managing mild to moderate asthma in adults
22 Nov 2018
The National Review of Asthma Deaths found that most patients who died were actually considered to have mild to moderate asthma, with 57% of fatal cases not under specialist care at the time of their death. In cases of fatal asthma there was widespread underuse of inhaled corticosteroids and an overreliance on short-acting beta-agonists. Referral to secondary care should take place when there is diagnostic uncertainty or atypical features, the possibility of hypersensitivity to inhaled material or concerns over treatment or exacerbations. Patients who have suffered even a single life-threatening asthma attack should be under specialist supervision.
|GPs have key role in improving outcomes in acute asthma
24 Nov 2016
Features which indicate a high risk of severe attacks include: previous admission to intensive care, particularly if requiring mechanical ventilation; previous admission with asthma especially in the past year or repeated emergency admissions; history of worsening asthma in January or February; use of three or more classes of asthma medication; heavy use of beta-2 agonists; anxiety traits; and marital stress.
Other respiratory diseases
|Detecting and managing pulmonary hypertension
20 Dec 2019
Pulmonary hypertension (PH) is a haemodynamic state where the mean pulmonary artery pressure measured at cardiac catheterisation is 25 mmHg or more. Precapillary PH arises from increased resistance to blood flow in the pulmonary arterioles and postcapillary PH from elevated left atrial pressure. In postcapillary PH the cause is left heart disease whereas precapillary PH may be caused by any other form of PH. Patients develop symptoms only when the disease is advanced. Symptoms at presentation are non specific. Adults almost always present with breathlessness and may also complain of exercise-induced dizziness or syncope and angina. An echocardiogram is the best investigation to ascertain the probability of PH.
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|Time to diagnosis key in improving lung cancer outcomes
25 Nov 2019
NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.
Allergy and anaphylaxis
|Improving outcomes in allergic rhinitis in children
24 Jun 2019
Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone.
|History taking the key to diagnosing food allergy in children
25 Jul 2018
Allergy to milk and egg are the two most prevalent food allergies in children. They are typically diagnosed in infancy and carry a good prognosis with the majority of cases resolving before the child reaches school age. Other allergies may present later in childhood and are more likely to persist. There is evidence of a causal link between early onset severe and widespread eczema that is unresponsive to moderate topical steroids and development of IgE mediated food allergy, in particular peanut allergy. The EAT study showed that infants who were weaned early and exposed to egg and peanut had a significant reduction in allergy to both foods.
Asthma in children
|Improving the management of chronic asthma in children
21 Dec 2020
There is no gold standard test to diagnose asthma. As a result, overdiagnosis and underdiagnosis are common especially when relying on history and clinical examination alone. Spirometry and bronchodilator reversibility testing are particularly useful when a child aged 5 years or older is brought to the practice with symptoms. The validated Asthma Control Test for children aged 12 years and over and the Children’s Asthma Control Test for children aged 4-11 years should be used to assess current asthma control based on four-week recall. Asthma control test scores correlate poorly with lung function and measures of airway inflammation such as FeNO in children and should not be used in isolation.
|Managing acute asthma in children
25 Jun 2018
The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring.
Research reviews
Azithromycin beneficial in nonsmoking COPD patients who suffer exacerbations
20 Dec 2022
Long-term azithromycin confers a net benefit in COPD patients who are former smokers with a recent history of exacerbations, a model-based benefit-harm analysis has shown. The benefit is likely to be larger in those patients who suffer frequent exacerbations, the study found.
How do genetic factors influence lung cancer risk in smokers and non-smokers?
26 Sep 2022
The presence of genetic risk factors significantly increases the probability of developing lung cancer in smokers, particularly heavy smokers. However, even with a high genetic risk for lung cancer, individuals who never smoke do not have a significantly increased risk of developing the condition, a prospective cohort study has found.
Novel model predicts risk factors for mortality in COPD
27 Jul 2022
Heart failure and current smoking were the strongest risk factors for predicting ten-year mortality in COPD patients, a risk prediction model based on primary care data has found.
Why do patients with COPD delay seeking medical care for exacerbations?
24 Jun 2022
Reluctance to seek care is a common response to exacerbations in patients with COPD. Excessive self-reliance, not wanting to bother healthcare professionals and waiting for a tipping point when the exacerbation became more severe were reasons cited by COPD patients for not seeking medical care sooner, in a qualitative study from the USA.
Asthma education reduces hospitalisations in children
25 Apr 2022
Asthma education reduces the frequency of hospitalisation and visits to emergency departments and clinics in children, a meta-analysis has found. Education involving both children and parents/guardians was more effective than that involving only children.
Changes in health-related quality of life scores in COPD predict prognosis
25 Mar 2022
Impairment of health-related quality of life is a marker for risk of hospitalisation and death in patients with chronic obstructive pulmonary disease (COPD), a study from Spain has found.
Early life factors associated with spirometric restriction in adulthood
24 Jan 2022
Poor growth and nutritional deficits in utero and in childhood are associated with spirometric restriction in adult life, a longitudinal, multicohort population-based study has shown.
Asthma admissions in under 5s fall following smoking ban in vehicles
24 Sep 2021
Hospitalisation rates for asthma in preschool children have significantly declined since the ban on smoking in vehicles carrying children in Scotland, a study has found.
|Corticosteroid therapy for asthma raises risk of osteoporosis and fragility fractures
27 Oct 2020
Use of oral or inhaled corticosteroids appears to be an independent risk factor for osteoporosis and fragility fractures in patients with asthma, a UK population-based study has found.
Is air pollution associated with onset of asthma in childhood?
24 Sep 2020
A nationwide case-control study from Denmark has strengthened the evidence that parental asthma and smoking in pregnancy are risk factors for onset of asthma and persistent wheezing in children. The results also suggest that exposure to ambient small particles < 2.5 µm (PM2.5) may be a potential risk factor. However, this finding needs to be substantiated in future studies, the authors say.
Asthma - research reviews
|Temporary quadrupling of inhaled steroids can reduce severe asthma exacerbations
23 Apr 2018
A temporary four-fold increase in inhaled steroids for deteriorating asthma control reduced the incidence of severe exacerbations, in a UK study.
Breathing self-management programme improves quality of life in asthma
23 Jan 2018
A breathing retraining exercise programme, incorporating a training DVD and accompanying booklet, achieved similar improvements in quality of life scores as conventional face to face training in patients with asthma, in a UK study.
Wheeze in children
Risk factors for wheezing in early childhood across Europe
22 Nov 2018
Lower respiratory tract infections (LRTIs), maternal smoking, day care attendance and male gender are important risk factors for wheezing in infants, a panEuropean study has confirmed. Food allergy and infant feeding practices were not associated with wheeze. The prevalence of wheezing varied widely between different European countries.
|Optimising the management of wheeze in preschool children
23 Jun 2016
One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy.
