Respiratory Health

Respiratory conditions are a major AKT topic. Asthma and COPD are the most heavily tested, but you also need to know about pneumonia, lung cancer recognition, and sleep apnoea.

Asthma diagnosis in adults requires demonstration of variable airflow obstruction. NICE recommends spirometry (FEV1/FVC ratio below 0.7 supports obstruction), bronchodilator reversibility (improvement of 12% and 200ml in FEV1), FeNO (above 40 ppb supports eosinophilic inflammation), and peak flow variability (more than 20% variation). Treatment follows a stepwise approach: SABA reliever as needed (step 1), add low-dose ICS (step 2), add LTRA or LABA (step 3), increase ICS to medium dose (step 4), refer to specialist (step 5). NICE and BTS/SIGN guidelines differ slightly: NICE recommends LTRA before LABA at step 3, while BTS/SIGN recommends LABA first. Check which guideline the question references.

COPD is diagnosed with post-bronchodilator spirometry showing FEV1/FVC below 0.7 in a patient with appropriate symptoms and exposure history (typically smoking). Severity is graded by FEV1: mild (above 80%), moderate (50-79%), severe (30-49%), very severe (below 30%). Management: smoking cessation (most important intervention), inhaled bronchodilators (SABA or SAMA as needed), long-acting bronchodilators (LAMA or LABA), ICS added if asthmatic features or repeated exacerbations despite dual bronchodilator therapy. Pulmonary rehabilitation is offered if MRC breathlessness grade 3 or above.

Pneumonia in primary care is assessed using CRB-65 score: Confusion, Respiratory rate above 30, Blood pressure (systolic below 90 or diastolic below 60), and age 65 or over. Score 0: treat at home with amoxicillin. Score 1-2: consider hospital assessment. Score 3-4: urgent hospital admission.

Lung cancer recognition: NICE recommends urgent CXR if aged 40 or over with unexplained haemoptysis, or if aged 40 or over with two or more unexplained symptoms including cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss. Refer via 2WW if CXR suggests lung cancer.

Obstructive sleep apnoea presents with daytime somnolence, loud snoring, and witnessed apnoeas. Screen with the Epworth Sleepiness Scale. Refer to sleep services for home sleep study. Treatment is CPAP for moderate to severe OSA. Patients must inform the DVLA.

Inhaler technique assessment is essential at every review. Poor technique is the most common cause of poor asthma and COPD control. Check technique before stepping up treatment.