BTS/NICE/SIGN Guideline NG245 (November 2024) represents a major shift in asthma care. Blood eosinophil count and FeNO are now first-line diagnostic tests (replacing spirometry as the starting point). SABA monotherapy is no longer recommended — AIR (Anti-Inflammatory Reliever) and MART (Maintenance and Reliever Therapy) using ICS/formoterol are now the cornerstone of management in those aged ≥12. COPD: NICE NG115 guidance remains current.
Respiratory Medicine for GPs: Your Survival Guide
Breathe easy - we've got your back when patients can't catch theirs
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:
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
Red Flags – What Not to Miss!
Needs urgent assessment
2WW referral territory
Life-threatening attack
Think malignancy
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
Key Features:
- Acute pleuritic pain (usually unilateral)
- Hyperresonance on percussion
- Decreased breath sounds
- Young tall males at higher risk
Suspicious Features:
- Persistent cough >3 weeks (especially smokers >40)
- Any haemoptysis
- Unexplained weight loss
- Voice change (recurrent laryngeal nerve)
- Finger clubbing
Life-threatening features:
- Silent chest (no wheeze = very bad)
- Exhaustion, confusion
- SpO₂ <92%
- Peak flow <33% predicted
- Can't complete sentences
📋 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
🔬 Diagnostic Approach & Investigations
First-Line Investigations
FeNO Testing NG245 2024 – 1st line
Fractional exhaled nitric oxide. First-line test for suspected asthma (adults & children ≥5). Diagnose asthma if FeNO ≥50 ppb (adults) or ≥35 ppb (children 5–16). Note: sensitivity is reduced in smokers.
Blood Eosinophil Count NG245 2024 – 1st line adults
Alternative first-line test in adults alongside FeNO. Diagnose asthma if count is above the local laboratory reference range (often >0.5 × 10⁹/L). Can be done at same appointment as FeNO.
Spirometry + BDR 2nd line
If FeNO/eosinophils inconclusive. Diagnose asthma if FEV1 increase ≥12% AND ≥200ml from pre-bronchodilator (or ≥10% of predicted normal FEV1). Still gold standard for COPD diagnosis (post-BD FEV1/FVC <0.7).
Peak Flow Variability 3rd line / if spirometry delayed
Twice daily for 2 weeks if spirometry unavailable or delayed. Diagnose asthma if variability (amplitude % mean) ≥20%.
Supporting Tests
Chest X-ray
Chronic cough, haemoptysis, suspected pneumonia or malignancy
Blood Tests
FBC, CRP, eosinophils (also useful for asthma diagnosis in adults). ABG if acute breathlessness.
Sputum Culture
Persistent productive cough, suspected TB, bronchiectasis
Bronchial Challenge Test 4th line / refer
If asthma not confirmed by FeNO, eosinophils, BDR or PEF variability but still clinically suspected. Diagnose if bronchial hyper-responsiveness present.
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)
Score 2: Hospital assessment
Score ≥3: Urgent admission
Wells Score (PE)
Score >4: CTPA or interim anticoagulation
🧠 Differential Diagnosis Frameworks
🫁 Common Conditions in Primary Care
Diagnostic Criteria (BTS/NICE/SIGN NG245, November 2024)
Diagnosis requires a suggestive clinical history PLUS at least one positive objective test. Work through tests in sequence — stop when a test is positive.
Clinical Features (history first):
- • Variable wheeze, cough, breathlessness
- • Worse at night/early morning
- • Triggered by allergens, exercise, cold
- • Family history of atopy
⚠️ Cautions:
- • ICS treatment makes FeNO and spirometry less likely to be positive
- • FeNO sensitivity reduced in smokers and obese individuals
- • All tests have limited sensitivity — a negative result does not exclude asthma
Objective Tests – Sequential Approach (Adults >16):
Stepwise Management (BTS/NICE/SIGN NG245, November 2024 — aged ≥12)
AIR = Anti-Inflammatory Reliever (ICS/formoterol used as reliever only, no regular maintenance inhaler)
MART = Maintenance And Reliever Therapy (same ICS/formoterol inhaler used for both daily maintenance AND as reliever)
Only certain ICS/formoterol inhalers are licensed for reliever use — check local formulary.
Consider AIR therapy: low-dose ICS/formoterol inhaler used as reliever only (as needed), with no separate maintenance inhaler. Alternatively, low-dose ICS twice daily + SABA as needed if AIR not suitable.
Offer low-dose MART: low-dose ICS/formoterol as regular maintenance (e.g. twice daily) AND as reliever as needed. One inhaler does both jobs.
Offer moderate-dose MART. Review after 8–12 weeks.
Check FeNO and blood eosinophil count. If either raised → refer to specialist. If neither raised → trial LTRA (montelukast) OR LAMA added to moderate-dose MART for 8–12 weeks. If partial improvement, continue and trial the other agent. If no improvement, stop and try the alternative.
Refer to specialist asthma care. High-dose ICS, add-on biologics, and other specialist therapies will be considered.
Regular Review
Assess Control:
- • Daytime symptoms <2/week
- • Night waking <1/week
- • Reliever use <2/week (AIR/MART or SABA)
- • No activity limitation
Action Points:
- • Check inhaler technique
- • Review adherence
- • Identify triggers
- • Update action plan
- • Consider FeNO if control uncertain or adherence questioned
Acute Exacerbation Management
- • Salbutamol 2-10 puffs via spacer
- • Prednisolone 40mg for 5 days
- • Review in 24-48 hours
- • 999 ambulance
- • High-flow oxygen
- • Nebulised salbutamol + ipratropium
- • IV magnesium if severe
Diagnostic Criteria
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:
Symptom Assessment:
0 = Only breathless with strenuous exercise
4 = Too breathless to leave house
COPD Assessment Test
0-10 = Low impact
>30 = Very high impact
Stepwise Management
COPD Acute Exacerbation Management
1 Patient NOT on Prophylactic Antibiotics
2 Patient IS on Prophylactic Antibiotics
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!
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
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)
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
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
- • 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.