At the end of this module you will be able to:
- Recognise symptoms commonly associated with the presence of respiratory disease and the importance of symptoms in obtaining an early, accurate diagnosis
- Evaluate a patient’s breathlessness and cough to determine the most appropriate treatment plan for them
- Assess and address a patient’s symptoms holistically, including obesity and depression or anxiety
- Know how to manage symptoms from childhood to end-of-life palliative care.
Managing a patient’s respiratory symptoms is often a complex matter. Patients may present with one or a number of symptoms, including dyspnoea, abnormal breath sounds (such as wheezing or stridor), hoarseness, cough with or without sputum production, haemoptysis, snoring and chest pain. Each of these symptoms may be intermittent or persistent, acute or chronic, and isolated or combined – and they may be accompanied by more general signs of systemic disease, such as fever or weight loss.
To manage these symptoms, it’s important to first accurately assess their cause. Diagnosis often requires various investigative procedures, which should be applied in an appropriate and cost-effective manner. At all times, it’s important to remember that there may not be a single cause for all a patient’s symptoms; multimorbidity is common, and the effects of common conditions such as depression, anxiety and obesity must not be overlooked.
Taking a careful clinical history is always the first diagnostic step, and is an essential part of managing any patient’s symptoms. The clinical history and physical examination provide essential clues about the possible underlying cause of the symptoms, guiding selection of the appropriate diagnostic investigations and optimal management plan.
Cough is a common presentation for children in primary care. Often this is due to a simple viral upper respiratory tract infection, and resolves spontaneously. However, cough is a common symptom of several conditions including asthma. To make the diagnosis of asthma, clinicians must take a careful history and see how it links to the BTS/SIGN asthma guidelines where patients are categorised into high, intermediate and low probability of asthma.
Kirsty is 5 years old and has come to the surgery with her mother who describes a cough she has had for over six weeks. Kirsty is otherwise well but has a dry cough which is worse at night. Kirsty has seen your colleagues on two occasions and been diagnosed with a virus but her mother is getting increasingly frustrated and feels more should be done. A number of Kirsty’s friends have asthma and the mother is convinced Kirsty has asthma and wants her to have a ‘blue puffer’ (a reliever inhaler).
It is important to look for clues as to the cause of Kirsty’s cough and take a good history. A careful history should lead to the correct diagnosis being made and ultimately the right treatment being prescribed. It’s important to establish the pattern of symptoms, including frequency and timing. Has she been wheezing? It should also be established whether this occurs only when Kirsty has a viral cold, or is unrelated to colds, and whether Kirsty coughs or wheezes at other times, such as when playing or laughing.
Kirsty’s mother explains that the cough started over six weeks ago. It is a dry cough that is worse at night but occurs every day. She is otherwise well and is a happy and active child. She is up to date with all her immunisations and had an uncomplicated birth history. She was at a party last week and one of the other parents commented on how much Kirsty was coughing when she was running around.
Children with a recurrent cough but no wheezing are unlikely to have asthma. The exception to this is a small minority of children with nocturnal coughing, who may have atypical asthma, but this diagnosis should only be made in consultation with a specialist paediatric respiratory physician. In other children with chronic cough but no wheeze, and no abnormalities seen on examination, X-ray or spirometry, likely causes are:
- Protracted bacterial bronchitis
- Post-viral cough/recurrent viral bronchitis
- Exposure to tobacco smoke and other pollutants.
Kirsty has also had a number of episodes of noisy breathing, which her mother is convinced is wheezing as Kirsty’s father has asthma and Kirsty’s noisy breathing sounds like her father’s when he is wheezing. Kirsty has also sometimes complained that her chest hurts when running around with her siblings in the garden.
Kirsty is showing some classic symptoms linked to a possible diagnosis of asthma – cough, tight chest and wheeze. The GP highlights to her mother, however, that it is not always easy to make a diagnosis of asthma – the process can take weeks and sometimes months. The GP asks whether anyone in the home smokes or has pets, and whether Kirsty or anyone in her family have a history of atopy. Kirsty’s mother confirms that nobody smokes, and the only pets are two goldfish. Kirsty’s father was diagnosed with asthma as a child and currently uses an inhaler before playing sport, and her elder brother suffers from eczema and hay fever.
The GP conducts a thorough physical examination, assessing Kirsty’s height, weight, chest (looking for any deformity or abnormal breath sounds), signs of allergic rhinitis or polyps, and presence of any other atopic conditions such as eczema or features of allergy (e.g. transverse nasal crease or ‘allergic shiners’).
- Onset of symptoms/signs from birth or early in life: Suggests cystic fibrosis, chronic lung disease of prematurity, primary ciliary dyskinesia, bronchopulmonary dysplasia or congenital abnormality
- Crepitations (crackles) that do not clear on coughing: Suggests a lower respiratory tract condition e.g. pneumonia, atelectasis, bronchiectasis
- Unilateral wheeze: Suggests inhaled foreign body
- Systemic symptoms (e.g. fever, weight loss, failure to thrive): Suggests an alternative systemic disorder
- Feeding difficulties (e.g. vomiting or choking): Suggests aspiration
- Inspiratory upper airway noise (e.g. stridor or snoring): Suggests croup
- Localised lung sounds: Suggests pneumonia
Other ‘red flag’ findings that need further investigation include a family history of unusual chest disease, severe upper respiratory tract disease (e.g. severe allergic rhinitis or nasal polyps), persistent voice abnormality, finger clubbing, chronic productive cough, nasal polyps in a child under 5 years old, and severe chest abnormality.
Kirsty’s history and examination did not reveal any worrying features but the GP does hear a wheeze, and clearly documents this in the notes. Kirsty is displaying the key features of asthma and there is a strong family history of atopic disease, including asthma in her father and atopy in her brother, which increases the probability of asthma even more. Using the BTS/SIGN asthma guidelines Kirsty has a high probability that she has asthma, and so the GP codes in her notes that she has ‘suspected asthma’.
In line with the BTS/SIGN asthma guidelines Kirsty should be started on a trial of treatment and clear guidelines given to her mother about the two inhalers she is prescribed (a low-dose corticosteroid for twice-daily use and a bronchodilator for use as needed). The GP explains the difference between her inhalers to her mother, including how the two different inhalers work on Kirsty’s airways, when they need to be taken, and how to use them with the spacer she’s been given. The GP also explains that if this is asthma, over the next 6–8 weeks Kirsty’s symptoms should resolve – but that she should come back for a follow-up appointment in two weeks with her inhalers, to assess her progress and check her inhaler technique.
Robert is 54 years old and was admitted to hospital six weeks ago, via the accident and emergency department, with severe breathing problems. At the hospital, he was diagnosed with COPD, and his spell of severe breathing problems attributed to an exacerbation. He has now been discharged and referred to his GP for ongoing management of his condition.
A person with undiagnosed COPD may seek medical attention either because of chronic symptoms or a first acute exacerbation. COPD should be diagnosed based on a combination of symptoms, history and spirometry results indicating airflow limitation. A full clinical assessment should be carried out in a new patient with COPD; this includes those with diagnoses made in the emergency department. Diagnostic spirometry should be carried out at least six weeks after an exacerbation.
The GP measures Robert’s airflow with a spirometer and records a low forced expiratory volume (FEV)1/forced vital capacity (FVC) ratio (FEV1 58% pred; FEV1/FVC: 0.61), indicating an obstructive pattern. Robert had a chest X-ray in the emergency department, which showed decreased lung markings but no other findings of concern. Robert says that over the past year he’s noticed himself becoming out of breath more quickly while playing golf, and also has developed a productive cough, which he put down to his 25-pack year smoking history. The cough is not bloody but he estimates he produces about a teaspoon of sputum per day, mostly first thing in the morning.
Common COPD symptoms include:
- Chronic cough (may be intermittent or continuous, and productive or non-productive)
- Sputum production (difficult to evaluate)
- Chest tightness
*Marked weight loss may indicate severe COPD or an alternative diagnosis such as lung cancer.
Having confirmed the diagnosis, the GP refers Robert to the nurse-led COPD clinic at the surgery. Robert tells the nurse the symptom that’s been bothering him the most is the breathlessness. He has found it difficult to keep up with his friends while walking between holes on the golf course, although he feels okay when he is walking by himself at his own pace. He thought it was just due to getting older, but his golf friends are similar ages to himself.
It is important to note that the mMRC score is not the same as the original MRC score, which runs from 1–5 rather than from 0–4. (Robert’s MRC score would be 3.) Both scores are valid, but different local authorities may prefer the use of one over the other. The GOLD guidelines for COPD use mMRC.
Although breathlessness is the symptom most troubling Robert, the nurse recognises the need to carry out a full assessment and address any other symptoms that are bothering him. The objectives of treating COPD fall into two categories: relieving immediate symptoms, and reducing the risk of future adverse health events (such as exacerbations), hence requiring clinicians to think about both the short- and long-term impact of COPD on a patient. It’s also important to assess the possibility of comorbidities.
Robert does not have any chest pain, haemoptysis, ankle swelling or weight loss. He does however admit to feeling drowsy throughout the day, and often falling asleep in the armchair while watching television (his Epworth Sleepiness score is 16); his wife has told him that he snores loudly, and sometimes his breathing pauses during the night. He has a BMI of 28 kg/m2, but has been actively trying to lose weight since his hospital admission. He also says that he has cut down his smoking, from 15 cigarettes a day to only 2 a day, although he does still enjoy drinking half a bottle of wine most evenings. He finds his cough is worse after eating or drinking, and his Hull Airway Reflux Questionnaire (HARQ) score is 8 out of a maximum of 70 points.
The nurse enquires about symptoms of depression and anxiety. Robert denies any such symptoms, but he does say that he occasionally feels frustrated when he realises that his symptoms are limiting his ability to do things he enjoys, and that his productive cough sometimes makes him feel embarrassed in public.
Robert has just been prescribed a long-acting muscarinic antagonist (LAMA) by the GP, and has an appointment in a week to review it, but the nurse contemplates what other treatment options are available.
There are several treatment options recommended for all patients with COPD, described by GOLD as ‘non-pharmacologic treatment’. These include smoking cessation support for all current smokers (which may, in fact, include the use of medications such as varenicline), and influenza and pneumococcal pneumonia vaccination. Approaching the subject of weight loss with a patient may be sensitive, but obese COPD patients have been shown to have increased dyspnoea at rest and poorer health status compared with normal-weight patients. Particularly since Robert is actively trying to lose weight, advice on how to do this sensibly while maintaining a balanced nutritional intake could be helpful, but may require referral to a dietician.
GOLD guidelines recommend patients like Robert with an mMRC score of 2 or above be referred for pulmonary rehabilitation. His symptoms also suggest sleep apnoea, which should prompt a referral for further investigation. Patients with both COPD and sleep apnoea have a worse prognosis than those with either condition alone, and there are “clear benefits” to using continuous positive airway pressure (CPAP), a form of NIV, in these patients – but the diagnosis of sleep apnoea should be confirmed first. Some patients also find CPAP difficult to tolerate so specialist assessment is necessary before beginning treatment.
Robert’s HARQ score is 8; the upper limit of normal is 13, so acid reflux is unlikely. He does not have symptoms of depression or anxiety, so counselling is unlikely to be required; his feelings of frustration and embarrassment could likely be controlled by effective management of his COPD symptoms.
Alfonso is 84 years old, and was diagnosed with COPD 20 years ago and heart failure 4 years ago. He has suffered three exacerbations requiring hospital admission in the past 6 months – the most recent was 6 weeks ago. Since returning home he has spent all his time either in bed or sitting in an armchair in his living room; he is only able now to walk very short distances.
When the practice nurse visits him, Alfonso seems unusually curt and irritable. The nurse recognises that depression may present as irritability, and is a common comorbidity in COPD patients. She asks the ‘2 Whooley questions’ (see box below) and Alfonso’s responds in the affirmative, indicating the possibility of depression.
Because of Alfonso’s positive answers to the two questions, the practice nurse uses the PHQ-9 tool. Alfonso’s score is 7, which represents moderate depression.
The exact mechanisms of association between depression and COPD have not been identified. The relationship between COPD and depression or anxiety appears to be bidirectional, however; depression and anxiety adversely affect COPD prognosis and are associated with an increased risk of exacerbation, and the presence of COPD increases the risk of developing depression. Additionally, smoking increases the risk and severity of COPD and makes daily activities require more effort, increasing the risk of depression. There is also some evidence to suggest chronic inflammation mediates both pulmonary function and depressive symptoms, with inflammatory markers found to be increased in both depression and COPD.
Less than a third of COPD patients with comorbid depression or anxiety are receiving adequate treatment. Barriers may include:
- Patient reluctance to disclose symptoms
- Lack of standardised diagnosis approach for anxiety and depression
- Short consultation time
- Low physician confidence in assessing patients for depression or anxiety
- Poor communication links between primary care and community mental health teams
- Inadequate resources for providing mental health treatment.
Anxiety and depression in COPD are associated with a poor prognosis, younger age, female gender, smoking, lower FEV1, cough, higher SGRQ score, and a history of cardiovascular disease.
Although there are no screening tools specifically validated in COPD, tools such as the Geriatric Depression Scale and the Hospital Anxiety and Depression Scale have been validated for use in patients with somatic conditions.
During a visit from the GP a few weeks later, Alfonso seems to be coughing more than usual. Initially, he says that he feels the same as normal; however, he later admits that he has felt more breathless over the last day or two, but didn’t want to say anything out of fear of being admitted to hospital again. He says he recognises he’s on his “last legs”, but that he’s frustrated at having to go to hospital so much over the last few months. He feels he has no control over his health or his treatment any more, and is concerned about the effects of going back and forth to the hospital on his wife, who is 75 years old.
The disease trajectory in COPD is usually marked by a gradual decline in health status and increasing symptoms, punctuated by acute exacerbations. Palliative care encompasses approaches to symptom control as well as management of terminal patients close to death. The aim of palliative care is to prevent suffering, relieve symptoms and support the best possible quality of life for patients and their families.
Patients who may be approaching the end of their life can be proactively identified using the ‘surprise question’ – would you be surprised if the patient were to die within the next year? If the answer is “no”, it may be time to begin the discussion around end-of-life care. The Gold Standards Framework provides ‘Proactive Identification Guidance’, including an algorithm to support this process (Figure 1).
Figure 1: The Proactive Identification Guidance flowchart
Note: GSF: Gold Standards Framework
At least three acute exacerbations is not a specific indicator of decline, unless all three required hospital admission. NIV at home is not a listed criterion but patients who require NIV at home are likely to meet one of the other criteria – e.g. “Fulfils long-term oxygen therapy criteria (Pa)2 <7.3 kPa)”. BMI is also not mentioned as an indicator, although malnutrition is certainly something that must be addressed in patients nearing the end of life, and weight loss of more than 10% over the past 6 months is considered a general indicator of decline.
Hospitalisation may trigger discussion of advance care planning. Primary care clinicians may also initiate end-of-life care discussions based on their knowledge of the patient, and scoring systems such as BODE or DOSE are available to support this (see tables below). Whatever the trigger, advance care planning should take place while the patient is still well enough to participate in discussions and before the loss of mental capacity. Good advance care planning can reduce anxiety for patients and families by offering emotional support and avoiding unnecessary, unwanted and invasive approaches. Patients with an advance care plan are also more likely to receive end-of-life care that is in line with their wishes; in one study, patients who had completed an advance care plan spent significantly less time in hospital during their last year of life than those without such a plan.
Advance care planning might involve:
- Advance statement of wishes
- This is a statement of the patient’s preferences and priorities for their care. It may include their faith, next of kin and details of where they would like to be cared for and/or die
- Advance decision to refuse treatment (ADRT)
- This is a legally binding document allowing the patient to refuse specified life-sustaining treatments. It is important that patients understand an ADRT does not prevent basic nursing care from being administered, such as repositioning in bed.
- Lasting power of attorney
- This allows patients to nominate a person to make decisions on their behalf, should they lose capacity.
- Do not attempt cardiopulmonary resuscitation (DNACPR)
- This may form part of an ADRT; if the DNACPR is recorded on its own and not as part of an ADRT, it is not considered legally binding, but will be used to inform healthcare professionals’ decisions.
- Practical issues (eg wills, funeral provisions)
The GP and Alfonso discuss how he’d like to be cared for. Alfonso’s BMI is 19 kg/m2 and his PaO2 is 7.6 kPa, so the GP offers advice on relieving breathlessness through posture and using a hand-held fan. He also refers him to the home oxygen service for assessment of suitability of oxygen therapy, and prescribes some oral nutritional supplements (noting in the records that Alfonso is at high risk for malnutrition according to his MUST score (Figure 2), and his nutritional status should be reviewed in 6 weeks). Alfonso doesn’t want to go to hospital, so the GP also prescribes a course of oral steroids to manage his current exacerbation, and a ‘rescue pack’ of steroids and antibiotics to use in case of future exacerbations. The GP advises that he contacts the surgery within 24 hours of starting his rescue pack and gives him specific instructions as to how he should take the medication as part of his self-management plan. He also puts in a referral for social services to assess what support they can offer Alfonso and his wife, and agrees to come back in a week to discuss Alfonso’s end-of-life wishes, as Alfonso wants some time to think through exactly what he wants before making any plans.
Figure 2: Managing malnutrition according to risk category using the MUST score.
Patients approaching the end of life should receive the same standard of guideline-driven COPD treatment as any other patient. Additional therapies that might be of use in palliative care include:
- Palliative treatment of dyspnoea – opiates, a fan blowing air on the face, neuromuscular electrical stimulation and/or chest wall vibration (the last two are recommended by GOLD and by Canadian Thoracic Society guidelines, but may be more difficult to access in primary care)
- Non-invasive ventilation can be useful in severe cases, but may cause distress in patients very near the end of their life so caution is advised
- Benzodiazepines may have some use here, although the evidence to support their use in relieving dyspnoea is mixed. Some patients may benefit from a preloaded syringe to administer at home when they are very short of breath
- Nutritional support for patients losing weight: the website Managing Adult Malnutrition in the Community offers guidance and resources on assessing and managing malnutrition in patients with COPD
- Tailored self-management education
- Mind–body interventions to manage panic, anxiety, depression and fatigue
- Referral to hospice services.
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- British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. 2016.
- Global Initiative for Chronic Obstructive Lung Disease, Global strategy for the diagnosis, management, and prevention of Chronic Obstructive Pulmonary Disease: 2017 report. 2017.
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- Gold Standards Framework. Proactive Identification Guidance (GSF-PIG), 6th Edition. 2016.
- Medscape. BODE Index for COPD Survival Prediction. 2011; Available from: http://reference.medscape.com/calculator/bode-index-copd.
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- Sundh J, et al. The Dyspnoea, Obstruction, Smoking, Exacerbation (DOSE) index is predictive of mortality in COPD. Prim Care Respir J 2012;21(3):295-301.
- British Medical Association, Resuscitation Council (UK) and Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation (3rd edition). 2016.
- Malnutrition Pathway. Managing Malnutrition in COPD. 2016.
- Marciniuk DD, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011;18(2):69-78.
- Simon ST, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev, 2016;10:CD007354.
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