Respiratory Medicine for GPs: Your Survival Guide
Major Guideline Update – November 2024:

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

☕ 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

🚨 Red Flags
Don't miss these
📋 Data Gathering
History & examination
🔬 Investigations
When & what to order
🧠 Differentials
Symptom frameworks
🫁 Common Conditions
Your daily bread
💨 Inhalers
Devices & techniques

📁 Downloads

🌐 Web Resources

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

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)

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

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

🧠 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 (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):
Step 1 FeNO and/or blood eosinophil count — Diagnose asthma if FeNO ≥50 ppb OR eosinophil count above local lab reference range
Step 2 Bronchodilator reversibility (BDR) with spirometry — Diagnose if FEV1 increase ≥12% AND ≥200ml (or ≥10% of predicted normal FEV1)
Step 3 Peak flow variability (if spirometry unavailable/delayed) — twice daily for 2 weeks. Diagnose if variability ≥20%
Step 4 Bronchial challenge test (refer if still suspected) — diagnose if bronchial hyper-responsiveness present
Children (5–16): Start with FeNO (≥35 ppb = diagnose). Then BDR spirometry → PEF variability → skin prick test/IgE + eosinophil count (diagnose if sensitised or IgE raised + eosinophils >0.5 × 10⁹/L).

Stepwise Management (BTS/NICE/SIGN NG245, November 2024 — aged ≥12)

⚠️ Major change: SABA monotherapy is no longer recommended. All patients should receive an ICS-containing reliever. Two new treatment approaches replace the old stepwise SABA-first model:
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.
Step 1 — Infrequent symptoms (≤3 days/week):

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.

Step 2 — More frequent symptoms (>3 days/week) or nocturnal waking or recent exacerbation:

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.

Step 3 — Not controlled on low-dose MART:

Offer moderate-dose MART. Review after 8–12 weeks.

Step 4 — Not controlled on moderate-dose MART (good adherence confirmed):

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.

Step 5 — Uncontrolled despite above / raised inflammatory markers:

Refer to specialist asthma care. High-dose ICS, add-on biologics, and other specialist therapies will be considered.

Children (5–11): MART is also an option for escalation. However, MART is not currently licensed for children under 5 in the UK. Children under 12 who cannot use or tolerate MART have an alternative pathway — see NG245 for details.

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
🚩 High-risk features warranting proactive review: FeNO >25 ppb or eosinophils >300 cells/µl, excessive reliever use (>3 canisters/year), or poor ICS adherence.

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
CAT Score:
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:
  1. Remove cap, shake 5 times
  2. Breathe out gently
  3. Seal lips around mouthpiece
  4. Start breathing in slowly and deeply
  5. Press canister down once
  6. Continue breathing in slowly
  7. Hold breath for 10 seconds
  8. 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:
  1. Load dose (varies by device)
  2. Breathe out gently (away from device)
  3. Seal lips around mouthpiece
  4. Breathe in hard and fast
  5. Hold breath for 10 seconds
  6. 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:
  1. Attach inhaler to spacer
  2. Shake and actuate once
  3. Breathe normally 5-6 times
  4. 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 ☕
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