Bradford VTS · MRCGP SCA · High-yield revision
Respiratory Medicine — SCA Must-Know
The clinical knowledge to have straight in your head before the SCA. Patient safety, practical GP management, and the traps that cost marks.
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30-minute revision
NICE-verified
Checked against NICE NG245 (asthma, November 2024, replacing NG80), NG115 and NG114 (COPD), NG138, NG120, NG12, NG234 (September 2023, replacing CG75), NG158, NG33, NG128, NG18, CG184 and NICE CKS. Where NICE does not cover a point, the fallback source is named on the page: BTS clinical statement on pulmonary sarcoidosis, ATS 2020 sarcoidosis guideline, RCP concise guidance on occupational asthma, BTS patient information on pulmonary embolism, the BNF and product literature, and RIDDOR 2013.
Before you start Asthma 12+ Children Occupational COPD End of life PE Lung cancer TB Sarcoidosis Cough Not the lungs Flying Genetics 60-second check
Before you start — what could sink you?
Where a candidate misses serious disease, prescribes dangerously, falsely reassures, or fails to refer.
Never prescribe a short-acting reliever on its own to anyone with asthma. SABA monotherapy is out, at every age.
Never confirm asthma without a supporting objective test. Breathlessness with a normal peak flow and clear chest is not asthma.
Unexplained haemoptysis at 40 or over goes down the lung cancer pathway — not ENT, and not "it's the anticoagulant".
Normal observations do not exclude a PE. Crackles do not exclude it either — infarction and atelectasis both cause them.
Never continue a previous clinician's working diagnosis unexamined. "The paramedic thought it was a chest infection" is where the missed PE lives.
Back pain plus respiratory red flags in a smoker is malignancy until proven otherwise, not a pulled muscle.
Persistent thrombocytosis after an infection has resolved is a lung cancer marker, not a leftover.
Cough unresponsive to three antibiotic courses in someone immunosuppressed is TB until excluded.
Long-term oxygen is not a treatment for breathlessness. In a normoxic patient it does nothing and carries real risk.
Aspirin does not prevent flight-related VTE. Don't recommend it.
Deep sighing breathing with a clear chest in a vomiting child is DKA until glucose and ketones say otherwise.
Keep a suspected acute stroke nil by mouth until swallowing has been formally screened.
The nub of it
Respiratory SCA cases are rarely about picking the right inhaler. They are about whether you noticed that the breathlessness in front of you is not coming from the airways at all — and whether you gave the reliever a preventer to travel with.
Asthma in people aged 12 and over
✅ Must know
Newly diagnosed at 12 and over: offer a low-dose ICS/formoterol inhaler taken as needed — as-needed AIR therapy. This is the first step, not regular ICS plus a SABA.
If they present highly symptomatic (for example regular nocturnal waking) or with a severe exacerbation, start low-dose MART instead, treating the acute episode as well. Step down to as-needed AIR later if control is good.
Not controlled on as-needed AIR → low-dose MART. Not controlled on low-dose MART → moderate-dose MART.
Do not prescribe a SABA to anyone with asthma of any age without a concomitant ICS prescription.
Do not confirm asthma without both a suggestive history and a supporting objective test. Code as suspected asthma until confirmed.
NICE NG245, recommendations 1.1.2, 1.6.3, 1.7.1 to 1.7.5.
⚠ Don't miss — the reliever-only patient
A blue inhaler used several times a week with no preventer is not "mild". NICE's risk-stratification triggers: more than 2 SABA inhalers a year, 2 or more oral steroid courses a year, 2 or more emergency department visits or any admission for asthma.
NICE NG245, recommendation 1.15.1.
🎯 SCA trap
Escalating the inhaler before doing the groundwork. NICE requires you to address the reasons for poor control first: alternative diagnoses, adherence, inhaler technique, smoking or vaping, occupational exposure, psychosocial factors, seasonal and environmental factors including damp and mould. Reciting that list out loud earns marks. Reaching for a bigger dose does not.
NICE NG245, recommendation 1.6.1.
📋 Source check — what "first line" now means
The original notes describe the move from SABA monotherapy to as-needed ICS/formoterol, which is right for adults and young people. But the pathway is age-banded, and the SCA tests the band, not the slogan.
12 and over: as-needed AIR, then low-dose MART, then moderate-dose MART.
5 to 11: twice-daily paediatric low-dose ICS with SABA as needed is the initial treatment. AIR is not first line here.
Under 5: an 8 to 12 week trial of twice-daily paediatric low-dose ICS, as part of the diagnostic process.
NICE NG245, recommendations 1.7.1, 1.8.1, 1.9.1.
💡 Clinical pearl
In November 2024 only certain budesonide/formoterol inhalers were licensed for as-needed AIR in mild asthma, and no inhaler was licensed for MART under 12. The evidence for both rests on dry powder devices. "I'd check the licence and document the discussion" is a mark, not a hedge.
NICE NG245, prescribing notes to recommendations 1.7.1 and 1.8.2.
Diagnosing asthma — the objective test sequence
Step | Adults | Children 5 to 16 |
|---|---|---|
First test | Blood eosinophils or FeNO. Diagnose if eosinophils above the lab reference range, or FeNO 50 ppb or more | FeNO. Diagnose if 35 ppb or more |
Second test | Bronchodilator reversibility: FEV1 rise 12% or more and 200 ml or more (or 10% or more of predicted) | Bronchodilator reversibility: FEV1 rise 12% or more (or 10% or more of predicted) |
Spirometry unavailable or delayed | Twice-daily PEF for 2 weeks; diagnose if variability 20% or more | Twice-daily PEF for 2 weeks; diagnose if variability 20% or more |
Still uncertain | Refer for a bronchial challenge test | Skin prick testing to house dust mite, or total IgE with eosinophil count, then paediatric referral |
Under 5 there is no reliable objective test; NICE manages these children on symptoms and signs with a treatment trial.
NICE NG245, recommendations 1.2.1 to 1.2.9 and 1.3.1.
Exercise-induced symptoms and the teenager who won't use a spacer
Exercise-induced symptoms usually mark asthma that is not controlled, so review control, adherence and technique before adding a pre-exercise ritual. A dry powder ICS/formoterol inhaler removes the spacer from the equation, which addresses a real adherence barrier for adolescents.
Loses marks
"You do need to use the spacer, I'm afraid — it's how the medicine gets into your lungs properly."
Gains marks
"It sounds like the spacer is the bit that puts you off, and I get that. There's a type of inhaler that's breath-activated, so there's no spacer at all — shall we look at whether that would suit you better?"
⚠ Don't miss — the under-12 exception
For children under 12 who may not manage a dry powder device when acutely breathless, NICE says consider providing an additional metered dose SABA inhaler plus a spacer for emergency use. Switching a younger child to a dry powder inhaler does not remove the need for a spacer in an attack.
NICE NG245, recommendations 1.6.5 and 1.6.8.
📋 Source check — allergy testing referral
The original notes advise avoiding referral for allergy testing in a poorly controlled teenager. NICE makes no such recommendation; it is a clinical judgement, not guidance. NICE does require you to work through adherence, technique, smoking and vaping, environment and psychosocial factors before changing treatment. Frame it as "let's fix what we know is wrong first", not a rule against referral.
NICE NG245, recommendation 1.6.1.
Asthma in pregnancy
Continue short-acting and long-acting beta2 agonists, inhaled corticosteroids and oral theophyllines as normal.
Offer oral corticosteroids if needed for an exacerbation — benefits outweigh risks, and that is worth saying out loud.
Do not stop an LTRA or LAMA if it is needed to maintain control.
Arrange an asthma review in early pregnancy and again postpartum.
Say this
"The risk to your baby from an asthma attack is far greater than any risk from your inhalers. The safest thing you can do for both of you is keep taking them exactly as you do now."
NICE NG245, recommendations 1.12.1 to 1.12.5.
Asthma and wheeze in children
✅ Must know
Under 5: consider an 8 to 12 week trial of twice-daily paediatric low-dose ICS with SABA as reliever, where there are interval symptoms suggesting the need for maintenance therapy, or severe acute episodes.
If symptoms resolve on the trial, consider stopping and reviewing 3 months later. Recurrence after stopping is what points to asthma.
Refer any preschool child with a hospital admission, or 2 or more emergency department attendances with wheeze in 12 months, to a specialist respiratory paediatrician.
5 to 11: initial treatment is twice-daily paediatric low-dose ICS plus SABA as needed, stepping up to paediatric low-dose MART if the child can manage that regimen.
Everyone aged 5 and over gets a written personalised asthma action plan, reviewed at every admission, acute consultation and annual review.
NICE NG245, recommendations 1.3.3, 1.8.1 to 1.8.3, 1.9.1 to 1.9.4, 1.14.1 and 1.14.2.
Trial
8 to 12 weeks
Twice-daily paediatric low-dose ICS via a spacer, with SABA as needed
→
Symptoms resolved
Stop and watch
Consider stopping ICS and SABA; review symptoms after a further 3 months
→
Symptoms return
Restart
Restart regular ICS; consider a further trial off treatment within 12 months
→
No response
Check, then refer
Technique, adherence, environment (mould, cold housing, smoke), alternative diagnosis — then refer
📋 Source check — how a diagnosis is made under 5
The original notes state that diagnosis under 5 rests on two or more wheezing episodes. That is not a NICE criterion. No diagnostic test is reliable in this age group, so children with recurrent wheeze and features suggesting asthma are treated empirically, and the diagnosis comes from the pattern of response and relapse. The trigger for the trial is interval symptoms needing maintenance therapy, or severe acute episodes such as admission or two or more oral corticosteroid courses — not a count of episodes.
NICE NG245, recommendations 1.3.1 and 1.9.1.
⚠ Don't miss — the preventer used only during flares
A parent describing "we give the brown one when she's bad" is telling you the preventer is being used as a reliever. This is the commonest reason for uncontrolled childhood asthma and it will not be fixed by a dose increase.
💡 Clinical pearl
Where a child moves between two households, a single prescription solves nothing. Prescribe a preventer and spacer for both homes, arrange an emergency inhaler kit at school, give one written action plan that both parents hold, and check height and weight annually to monitor growth on inhaled steroids.
Stepping up in 5 to 11 year olds
Not controlled on paediatric low-dose ICS plus SABA → consider paediatric low-dose MART, if the child can manage the regimen. Off-label under 12.
Not controlled on paediatric low-dose MART → consider paediatric moderate-dose MART.
Child unable to manage MART → consider adding an LTRA for 8 to 12 weeks, stopping it if ineffective; then twice-daily paediatric low-dose ICS/LABA plus SABA; then moderate-dose ICS/LABA.
Not controlled on paediatric moderate-dose MART or moderate-dose ICS/LABA → refer to a specialist in asthma care.
Follow the MHRA safety advice on neuropsychiatric reactions whenever montelukast is prescribed.
NICE NG245, recommendations 1.8.2 to 1.8.7.
Occupational asthma
✅ Must know
Screen every adult with new-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma for an occupational cause.
NICE asks two questions: are symptoms the same, better or worse on days away from work? And the same, better or worse on holiday, at weekends or between shifts? Record the answers for later review.
Refer people with suspected occupational asthma to an occupational asthma specialist. This is a specialist diagnosis, not a primary care one.
Once occupational asthma is confirmed in writing, the employer must report it to the HSE under RIDDOR. The duty sits with the employer, not the patient.
NICE NG245, recommendations 1.4.1 and 1.4.2. RIDDOR 2013, Schedule 1.
⚠ Don't miss — the Friday pattern
Chest tightness and cough that worsen across the working week and clear on a fortnight's holiday is occupational asthma until proven otherwise. Isocyanates in spray paint are among the most potent respiratory sensitisers in UK industry. Once sensitisation has occurred, exposure at any level can provoke attacks — not a dose problem that better ventilation will fix.
⚠ Inconsistency in the source notes
The supplied material says to arrange a 4-week serial peak flow diary and, in the same breath, not to withhold steroid treatment while it runs. These pull against each other: a serial PEF record is only interpretable if treatment is held constant throughout, because a mid-record change in inhaled steroid produces exactly the work-versus-rest gradient the test looks for. NICE does not cover serial PEF protocols, so it cannot settle this.
The transferable SCA point: do not leave the patient untreated while investigating, and do not change treatment during the recording period. Start appropriate ICS/formoterol, keep it stable for the whole record, and say so out loud. The specialist referral is the part NICE actually asks of you.
NICE NG245 recommendation 1.4.2 for the referral. Serial PEF practice from RCP concise guidance on occupational asthma and the Oasys serial PEF standard.
What the serial peak flow record actually requires
Minimum standard: at least 4 readings a day for at least 2 weeks, covering work and rest periods, with start and stop times of work recorded each day and treatment kept constant.
Better records: 2-hourly readings during waking hours over 4 weeks, covering at least two work periods and two rest periods.
Records are analysed against work and rest days, commonly with Oasys software, by the specialist service.
The diagnosis has real consequences for employment and for any claim, so it should not rest on a symptom pattern alone.
RCP concise guidance on occupational asthma; Oasys serial PEF recording standard. Not covered by NICE.
Explaining RIDDOR without alarming them
"If the specialist confirms this is caused by something at work, your employer has a legal duty to report it. That isn't a complaint against you or against them — it's how workplaces get made safer, and it's what protects your position if you need adjustments."
COPD and acute exacerbations
✅ Must know
Offer 30 mg oral prednisolone once daily for 5 days for an exacerbation with a significant increase in breathlessness that interferes with daily activities.
Only add antibiotics if the sputum has changed colour and increased in volume or thickness beyond the patient's normal day-to-day variation.
First-choice oral antibiotics: amoxicillin 500 mg three times a day for 5 days; doxycycline 200 mg on day 1 then 100 mg once daily, 5 days in total; or clarithromycin 500 mg twice a day for 5 days. Check allergies first.
There is no single saturation cut-off for admission. NICE gives a table of factors to weigh together.
NICE NG115, recommendations 1.2.130, 1.3.1 and 1.3.16. NICE NG114, table 1.
📋 Source check — the admission threshold
The original notes give saturations below 90% on air as "the core criterion" for emergency admission, and above 92% as safe at home. That leaves 90 to 92% undefined and overstates NICE. The verified position:
NICE lists 16 factors. SaO2 below 90% is one and favours hospital — but so do inability to cope at home, severe breathlessness, poor or deteriorating general condition, being confined to bed, cyanosis, worsening peripheral oedema, impaired consciousness, acute confusion, already being on long-term oxygen, living alone or not coping, rapid onset, and significant comorbidity, particularly cardiac disease and insulin-treated diabetes.
There is no threshold above which NICE declares home management safe. A well-looking patient at 93% who lives alone and is deteriorating rapidly may still need admission.
In primary care, pulse oximetry is of value if there are clinical features of a severe exacerbation, and routine sputum culture is not recommended.
NICE NG115, recommendations 1.3.1 to 1.3.2 and table 7.
⚠ Don't miss — the social criteria
Half of NICE's admission factors are not physiological. Living alone, not coping, and a rapid rate of onset all push towards hospital independently of the numbers. In the SCA, "who's at home with you?" is a clinical question, not small talk.
Rescue packs — who should have one, and the safeguards
NICE supports keeping a short course of oral corticosteroids and antibiotics at home, but only where all of the following apply:
They have had an exacerbation within the last year and remain at risk of exacerbations.
They understand and are confident about when and how to take the medicines, and about the benefits and harms.
They know to tell a healthcare professional when they have used them, and to ask for replacements.
Check understanding at every review. If someone has used 3 or more courses of oral corticosteroids or antibiotics in the last year, investigate why.
📋 Source check — rescue packs and vulnerable patients
The original notes present rescue packs mainly as a workaround for patients who struggle to access care, such as people who are homeless. That is not how NICE frames it, and the safeguards above are not optional. A pack given to someone who cannot judge when to start it, or who will not report using it, creates steroid and antibiotic exposure nobody is monitoring. Meet the access problem with an action plan the person can follow, plus social prescribing and housing support alongside — not instead of — the NICE criteria.
NICE NG115, recommendations 1.2.125 to 1.2.130.
Long-term oxygen therapy — assessment and criteria
Assess the need for oxygen in people with very severe airflow obstruction (FEV1 below 30% predicted), cyanosis, polycythaemia, peripheral oedema, raised JVP, or saturations of 92% or less breathing air. Also consider assessment at FEV1 30 to 49% predicted.
Assess with arterial blood gases on 2 occasions at least 3 weeks apart, when stable and optimally treated.
Consider LTOT if PaO2 is below 7.3 kPa when stable, or 7.3 to below 8 kPa with secondary polycythaemia, peripheral oedema or pulmonary hypertension.
At least 15 hours a day, with a structured risk assessment covering falls, burns and fire.
Do not offer LTOT to people who continue to smoke after being offered cessation support and specialist referral, and do not offer it for isolated nocturnal hypoxaemia.
NICE NG115, recommendations 1.2.56 to 1.2.63.
Inhaled therapy in stable COPD
Short-acting bronchodilators as needed are the initial empirical treatment.
No asthmatic features or features suggesting steroid responsiveness → offer LAMA plus LABA, once tobacco dependence, non-pharmacological management and vaccinations have been addressed.
Asthmatic features or features suggesting steroid responsiveness → consider LABA plus ICS.
On LABA plus ICS with continuing day-to-day symptoms, a severe exacerbation needing hospitalisation, or 2 moderate exacerbations in a year → offer LAMA plus LABA plus ICS.
On LAMA plus LABA with day-to-day symptoms affecting quality of life → consider a 3-month trial only of triple therapy, switching back if symptoms have not improved. Document the reason for continuing ICS and review at least annually.
"Asthmatic features" means a previous secure diagnosis of asthma or atopy, a higher blood eosinophil count, FEV1 variation of at least 400 ml, or diurnal PEF variation of at least 20%.
NICE NG115, recommendations 1.2.11 to 1.2.18.
A 68-year-old with COPD phones with 3 days of increasing breathlessness and a cough. Sputum is unchanged in colour and volume. She is eating and drinking, saturations are 94% on air, and her husband is with her. What is the most appropriate management?
Amoxicillin 500 mg three times a day for 5 days and prednisolone 30 mg for 5 days
Prednisolone 30 mg once daily for 5 days, increased bronchodilator use, and safety-netting, without an antibiotic
Doxycycline 100 mg once daily for 7 days with no steroid
Emergency admission, because any increase in breathlessness in COPD requires hospital assessment
Antibiotics are added only when sputum changes colour and increases in volume or thickness beyond her normal variation, which has not happened. Oral corticosteroids are appropriate because the breathlessness interferes with daily activities — 30 mg daily for 5 days. Doxycycline, when indicated, is 200 mg day 1 then 100 mg daily, 5 days in total. Nothing here pushes towards admission on NICE's factor list, but the safety-netting is where the marks are. (NG115 1.2.130, 1.3.16; NG114 table 1.)
End-stage COPD and refractory breathlessness
✅ Must know
Do not offer ambulatory oxygen or short-burst oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. "Mild or no hypoxaemia" means a PaO2 above 7.3 kPa in someone not on long-term oxygen.
When appropriate, use opioids to relieve breathlessness in end-stage COPD that is unresponsive to other medical therapy.
Ask directly whether the breathlessness frightens them. If it does, consider a cognitive behavioural component in the self-management plan.
Ensure access to the full range of multidisciplinary palliative care, including hospice admission and 24-hour community palliative telephone support, and explain what to expect if they are hospitalised — non-invasive ventilation, ceilings of care and resuscitation. Complete a ReSPECT form and DNACPR decision where appropriate, and be alert for anxiety and depression.
NICE NG115, recommendations 1.2.67, 1.2.73, 1.2.106 to 1.2.110, 1.2.131 and 1.2.132.
⚠ Don't miss — the oxygen request
A patient with severe COPD, resting saturations in the low 90s and disabling breathlessness will often ask for home oxygen, and the family will often ask on their behalf. It will not help and it carries a real burns and fire risk. Refusing without offering something better is the failure; the answer is opioids, a handheld fan, breathing technique, positioning and palliative care input.
📋 Source check — the morphine dose
The original notes give immediate-release oral morphine 2 to 2.5 mg every 4 hours as required. This dose is not stated by NICE. NG115 recommends opioids for refractory breathlessness in end-stage COPD but specifies no drug, dose or route, cross-referring to CG140 for starting and titrating strong opioids and NG46 for controlled drugs. A low starting dose of immediate-release oral morphine is standard palliative practice, but the number must come from your local palliative care formulary and the current BNF. In the SCA: "I'd start a low dose of immediate-release morphine and check the starting dose against our palliative care guideline".
NICE NG115 recommendation 1.2.106; NICE CG140 and NG46 for opioid initiation and controlled drugs. Dose not specified by NICE.
💡 Clinical pearl
A handheld fan directing cool air across the face is one of the most effective and least appreciated interventions in refractory breathlessness. It costs nothing, works within minutes, and gives the patient something to do at the moment of panic. Standard palliative practice rather than a NICE recommendation, so present it as such.
The morphine conversation with an anxious family
"I know morphine sounds like a big step, and I want to be clear about what it does. At this dose it isn't sedating him and it isn't shortening his life — it works on the part of the brain that creates the feeling of not getting enough air. We're treating the distress, not the lungs."
Pulmonary embolism
✅ Must know
Use the 2-level PE Wells score. More than 4 points means PE is likely; 4 or fewer means unlikely.
Wells more than 4: arrange an immediate CTPA — in practice, immediate hospital transfer from primary care.
Wells 4 or fewer: a D-dimer with the result available within 4 hours. If it cannot be obtained within 4 hours, offer interim therapeutic anticoagulation while waiting.
If imaging cannot be done immediately, offer interim therapeutic anticoagulation. Apixaban or rivaroxaban are first line for confirmed PE.
NICE NG158, recommendations 1.1.17 to 1.1.21 and the section on interim therapeutic anticoagulation.
⚠ Don't miss — PE dressed as a chest infection
Sudden-onset unilateral upper back or chest pain with mild breathlessness and a cough, in an older patient with normal or near-normal observations, is the classic missed PE. Crackles do not exclude it — pulmonary infarction and local atelectasis both produce them, which is exactly how these patients end up with amoxicillin.
🎯 SCA trap
Inheriting someone else's diagnosis. If a paramedic or out-of-hours doctor has already written "chest infection", the marks are in re-taking the history from scratch — particularly the speed of onset, the most discriminating feature and the one that gets lost in a handover.
Feature | Points towards PE | Points towards chest infection |
|---|---|---|
Onset | Sudden, often to the minute | Gradual over days |
Pain | Pleuritic, may be posterior or in the flank | Pleuritic or absent, usually with the cough |
Fever and sputum | Often absent; sputum clear or absent | Fever and purulent sputum common |
Crackles | May be present from infarction or atelectasis | Present, usually focal with dullness |
Risk factors | Long-haul travel, combined hormonal contraception or HRT, immobility, malignancy, obesity, previous VTE, pregnancy and postpartum | Recent viral illness, COPD, aspiration risk |
💡 Clinical pearl
Where clinical suspicion is low on the overall impression and other diagnoses are feasible, NICE allows you to consider the PE rule-out criteria (PERC) to decide whether any further investigation for PE is needed at all. That is a different move from scoring Wells, and it is worth knowing it exists.
NICE NG158, recommendation 1.1.16.
Suspected lung cancer and serious pathology
✅ Must know
Refer using a suspected cancer pathway referral (appointment within 2 weeks) if chest X-ray findings suggest lung cancer, or the person is aged 40 or over with unexplained haemoptysis.
Offer an urgent chest X-ray within 2 weeks in people aged 40 and over with 2 or more of: cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss — or just 1 of those if they have ever smoked.
Consider an urgent chest X-ray within 2 weeks in people aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis.
Consider a suspected cancer pathway referral for laryngeal cancer at 45 and over with persistent unexplained hoarseness or an unexplained lump in the neck.
NICE NG12, recommendations 1.1.1 to 1.1.3 and 1.8.1.
📋 Source check — haemoptysis on an anticoagulant
The original notes route a patient on apixaban with new haemoptysis and weight loss down a 2-week-wait ENT pathway. That is the wrong pathway. Under NG12, unexplained haemoptysis at 40 or over is a suspected cancer pathway referral for lung cancer, alongside a chest X-ray. The head and neck route applies to persistent unexplained hoarseness or an unexplained neck lump at 45 and over — different symptoms, different pathway.
Elsewhere the notes say streaks of blood on apixaban do not warrant stopping the drug, and also refer via 2-week-wait. Both instincts are right; only the destination was wrong. The anticoagulant is not the explanation until cancer has been excluded, and the anticoagulation decision is separate from the pathway decision.
NICE NG12, recommendations 1.1.1 and 1.8.1.
⚠ Don't miss — persistent thrombocytosis
A platelet count still above the reference range weeks after a chest infection has resolved is a recognised marker of occult lung cancer, and is on NICE's list of triggers for an urgent chest X-ray at 40 and over. Repeated chest infections reinforce it. Occupational silica exposure — stonemasonry, quarrying, granite work — is a Group 1 carcinogen and raises the pre-test probability further.
⚠ Don't miss — back pain as a presentation of lung cancer
Acute thoracic or lumbar back pain in a smoker with an unresolving cough, haemoptysis or weight loss is not a pulled muscle. The characteristics that point to spinal metastases: severe unremitting or progressive pain, night pain disturbing sleep, or pain aggravated by coughing or straining.
📋 Source check — where to send the back pain
The original notes send this patient straight to A&E for spinal imaging. The guideline behind that has been replaced: NICE NG234 superseded CG75 in September 2023, and it makes a distinction the notes do not.
Past or current cancer plus symptoms or signs of cord compression — limb weakness, sensory change, gait disturbance, bladder or bowel dysfunction, radicular pain — is an oncological emergency: contact the MSCC coordinator immediately.
Past or current cancer with the pain characteristics but no cord signs — seek advice through the MSCC coordinator within 24 hours.
No past or current cancer, pain characteristics present and cancer suspected — the situation in the original case — refer for urgent oncology assessment, alongside the NG12 route and the urgent chest X-ray. Emergency admission is right if there are neurological signs of cord compression.
Do not use plain X-ray of the spine to diagnose or rule out spinal metastases or cord compression. MRI is the test, within 24 hours where cord compression is suspected.
Dexamethasone 16 mg orally (or equivalent parenteral dose) is for people with neurological symptoms or signs of MSCC, and follows discussion with the MSCC service — not a primary care first move.
NICE NG234, recommendations 1.3.1 to 1.3.5, 1.5.2, 1.5.9 and 1.8.1; box 1.
🎯 SCA trap
Arranging the chest X-ray and stopping there. In an unwell patient with weight loss and a possible pathological fracture, the X-ray is the slowest part of your plan. Say what you are doing today, what you are doing this week, and what would make the patient call 999 before either happens.
Tuberculosis
✅ Must know
Suspect pulmonary TB with a persistent cough, weight loss, drenching night sweats and fever, particularly with upper-lobe signs, immunosuppression, or a link to a high-incidence country.
Investigations are a chest X-ray plus 3 respiratory samples — preferably spontaneously produced deep-cough sputum, ideally including one early morning sample — for microscopy, culture and nucleic acid amplification testing.
Refer urgently to the TB or respiratory service. Diagnosis and treatment are specialist; the GP role is recognition, initial investigation and referral.
TB is a notifiable disease. Notification is a statutory duty on the registered medical practitioner.
NICE NG33, recommendations 1.3.1 to 1.3.4 and table 1. Health Protection (Notification) Regulations 2010.
⚠ Don't miss — the third failed antibiotic course
A cough that has not responded to three courses of standard antibiotics is a diagnostic finding in its own right. With weight loss, night sweats, upper-lobe crepitations, immunosuppressive therapy and travel to or from a high-incidence country, TB moves from a differential to the working diagnosis. Prescribing a fourth antibiotic is the error the case is built around.
📋 Source check — stopping the immunosuppressant
The original notes instruct you to hold the methotrexate immediately. NICE does not make this recommendation and it is not a unilateral primary care decision. Immunosuppression does worsen active TB and does need addressing, but stopping a disease-modifying drug abruptly has consequences for the underlying condition, and TB treatment interacts with several of these drugs. The defensible position: refer urgently to the TB service, and discuss the immunosuppressive therapy urgently with both the TB team and the prescribing specialist rather than stopping it yourself.
Not covered by NICE NG33 as a primary care action. Framed here as a specialist decision.
💡 Clinical pearl
TB is not only pulmonary. Progressive back pain with night sweats, weight loss and evolving leg weakness in someone from a high-incidence setting is spinal TB until excluded. It needs urgent spinal MRI and TB screening, and it is one of the few causes of back pain where the neurological deficit and the systemic history matter more than the mechanical history.
Practical steps in the consultation
Travel and country-of-origin history, known TB contacts, BCG, previous TB treatment or latent TB screening.
HIV risk, and any immunosuppressive medication including biologics and steroids.
Give household infection control advice while awaiting results, and explain that the TB service handles contact tracing.
Do not carry out aerosol-generating procedures such as nebulisation in a possible TB patient in an ordinary consulting room.
NICE NG33, recommendations on diagnosis and infection control.
Sarcoidosis
✅ Must know
The picture: persistent dry cough, progressive exertional breathlessness and fatigue, often with hypercalcaemia on routine bloods.
Bilateral hilar lymphadenopathy on chest X-ray is the classic early radiological sign, and defines Scadding stage I.
Refer to a respiratory specialist. Do not start empirical asthma treatment on a dry cough and breathlessness without objective evidence of variable airflow obstruction.
Sarcoidosis is multi-system. Cardiac involvement causes conduction block, arrhythmia and sudden death; ocular involvement causes uveitis.
NICE does not cover sarcoidosis. Source: BTS clinical statement on pulmonary sarcoidosis (Thorax, 2021).
📋 Source check — what cardiac screening is recommended
The original notes say to always request an ECG and an ophthalmic review to screen for extra-pulmonary sarcoidosis. It is more nuanced, and over-investigation also loses marks:
A baseline ECG forms part of standard initial assessment and is a reasonable primary care investigation.
Routine baseline echocardiography or 24-hour ambulatory ECG monitoring is not recommended in people with extracardiac sarcoidosis who have no cardiac symptoms or signs.
Cardiac sarcoidosis should be actively considered where there is breathlessness out of proportion to the degree of lung function impairment, or symptoms such as palpitations or syncope.
Baseline assessment for extrapulmonary involvement, including ocular assessment, sits with the specialist service rather than being a primary care checklist.
ATS clinical practice guideline on the diagnosis and detection of sarcoidosis (2020); BTS clinical statement on pulmonary sarcoidosis (2021). Not covered by NICE.
💡 Clinical pearl
Hypercalcaemia in a breathless patient is a genuinely useful pointer. In sarcoidosis it arises from granuloma-derived activation of vitamin D, and it is one of the few situations where a routine bone profile changes the respiratory differential.
Cough, chest infection and antibiotic stewardship
✅ Must know
Do not offer an antibiotic for acute cough with an upper respiratory tract infection, and do not routinely offer one for acute bronchitis, in people who are not systemically very unwell or at higher risk of complications.
Offer an immediate antibiotic if the person is systemically very unwell, ideally identified at face-to-face examination.
Low-severity community-acquired pneumonia: amoxicillin 500 mg three times a day for 5 days is first choice; doxycycline 200 mg on day 1 then 100 mg daily, or clarithromycin 500 mg twice daily, for penicillin allergy or where atypicals are suspected.
Use CRB65 with clinical judgement — confusion, respiratory rate 30 or more, systolic BP under 90 or diastolic 60 or less, age 65 or over.
Do not offer bronchodilators, corticosteroids or mucolytics for an acute cough unless there is underlying airways disease.
NICE NG120, recommendations 1.1.8 to 1.1.12; NICE NG138, table 1 and the section on CRB65.
Feature | Acute bronchitis | Pneumonia |
|---|---|---|
Chest signs | None focal; may be wheeze | Focal crackles, bronchial breathing, dullness |
Systemic features | Usually absent | Fever, tachycardia, tachypnoea, confusion |
Antibiotics | Not routinely — usually viral | Yes, guided by severity |
What to tell them | Cough may last 3 to 4 weeks; seek help if it worsens rapidly, does not settle by 3 to 4 weeks, or they become very unwell | Review if not improving; explain what deterioration looks like |
⚠ Don't miss — the cough that has outlasted its welcome
A cough persisting beyond a few weeks in a current or former smoker is a chest X-ray decision before it is a treatment decision. At 40 and over, a cough plus one other symptom in an ever-smoker meets NICE's threshold for an urgent chest X-ray within 2 weeks. Do the X-ray and treat the likely benign cause — they are not alternatives.
Reflux-related cough and silent laryngopharyngeal reflux
Morning cough, throat clearing, globus sensation, stringy phlegm and morning hoarseness, worse after meals and on lying flat, point to reflux rather than the airways. In a person with a smoking history, exclude malignancy first.
Offer a full-dose PPI for 4 or 8 weeks — omeprazole 20 mg daily is a full dose. If symptoms recur, use the lowest dose that controls them.
Review contributing medicines. NSAIDs and some antidepressants aggravate reflux symptoms.
Positional measures: raise the head of the bed, avoid late meals, avoid eating within 3 hours of lying down.
Consider an alginate at night alongside the PPI.
In a non-verbal adult with a learning disability, reflux presents instead as nocturnal waking and distress, back arching, throat clearing and morning hoarseness. Assess choking and aspiration risk explicitly, take the history from people who know the baseline, treat a change in behaviour as a symptom, and make reasonable adjustments.
NICE CG184 and appendix A on PPI dosing. Extra-oesophageal reflux presentations are not specifically covered by NICE.
Breathless, but not the lungs
✅ Must know
Deep sighing breathing with a clear chest in a child with abdominal pain and vomiting is DKA. Measure capillary blood glucose immediately.
Glucose above 11 mmol/L with symptoms suggesting DKA: suspect DKA and send immediately to a hospital with acute paediatric facilities.
Episodic breathlessness with a completely normal peak flow and clear chest is not asthma. Do not confirm the diagnosis without a supporting objective test, and do not prescribe a reliever on the story alone.
In suspected acute stroke, keep the patient nil by mouth until swallowing has been screened by a specially trained healthcare professional — before any food, fluid or oral medication.
NICE NG18, recommendations 1.2.1, 1.2.5 and 1.4.1. NICE NG245, recommendations 1.1.2 and 1.6.3. NICE NG128, swallowing screening.
⚠ Don't miss — Kussmaul breathing mistaken for a chest problem
The child has no cough, no wheeze and a clear chest, and the breathing is deep and rapid rather than laboured. That combination should stop you reaching for the respiratory examination and send you to the glucose meter. Blue-light transfer, not a same-day appointment.
🎯 SCA trap
Giving the anxious patient the inhaler they came for. An older patient with episodic breathlessness, normal peak flows and a clear chest asking firmly for a blue inhaler is testing whether you can hold a boundary kindly. Refusing without offering anything is also a fail — give an explanation, an objective test if there is genuine doubt, and a real plan for the anxiety including talking therapy and social isolation.
Declining the inhaler without dismissing the symptom
"What you're describing is real and it's frightening — I'm not doubting that. But your breathing tests are normal, which means the airways aren't narrowing. An inhaler wouldn't help, and I'd rather treat what's actually causing it. Can I tell you what I think is going on?"
💡 Clinical pearl
Nil by mouth after a suspected stroke means no oral medication either, and the family need telling explicitly — including "no sips of tea", the instruction most often undone in the ambulance bay. The swallow screen happens in hospital, not in the surgery.
Flying, travel and VTE prevention
✅ Must know
Do not recommend aspirin to prevent travel-related DVT or PE. It is not effective for venous thrombosis and carries gastrointestinal risk.
For people at moderate or high risk, advise correctly fitted compression stockings for long-distance flights.
For people at low risk, advise staying mobile and avoiding dehydration.
Combined hormonal contraception plus obesity plus a long-haul flight is a stacked risk — count the factors rather than treating each in isolation.
NICE CKS, DVT prevention for travellers. SIGN does not routinely recommend compression stockings for long-haul travel, so name the source you are using.
📋 Source check — how long before flying after a PE
The original notes state that patients must not fly for at least 4 weeks after a PE. This is not a NICE recommendation, and there is no single UK figure. Patient information hosted by the British Thoracic Society advises that flying, particularly long-haul, is generally not advised in the first 4 weeks, and that travel becomes reasonable once symptoms settle and anticoagulation is tolerated. Other sources give shorter intervals for a stable, anticoagulated patient.
In the SCA, "in general we'd advise avoiding flying for around 4 weeks, and I'd want the respiratory or haematology team's view on your case" is both accurate and safe. Advise them to inform their travel insurer and the airline.
BTS pulmonary embolism patient information. Not covered by NICE.
💡 Clinical pearl
Aircrew and long-distance drivers have both an occupational VTE risk and a professional interest in your answer. A PE has implications for fitness to work beyond the clinical picture, so ask what their role involves and be clear that the return-to-work decision sits with occupational health.
Genetics, cystic fibrosis and pre-conception counselling
✅ Must know
Cystic fibrosis is autosomal recessive. An unaffected sibling of an affected person has a 2 in 3 chance of being a carrier.
Refer for formal genetic carrier testing rather than calculating a risk and leaving it there. Partner testing is what changes the couple's options.
CFTR modulator therapy has substantially changed the outlook in eligible genotypes — but quote the direction of travel, not a specific life expectancy figure.
Address the grief before the arithmetic. A patient asking about carrier risk after losing a sibling is not primarily asking a maths question.
📋 Source check — the survival figures
The original notes state that elexacaftor/tezacaftor/ivacaftor has extended median lifespan to 71.6 to 82.5 years. Those figures come from a single industry-funded microsimulation of people homozygous for F508del aged 12 and over. They are modelled projections, not observed survival, and 82.5 applies only where treatment starts between ages 12 and 17 — published without a credible interval, and followed by a commentary in the same journal cautioning against over-emphasising the point estimates.
Quoting them as a patient's life expectancy would be a significant overstatement. The defensible version: "CFTR modulators have transformed the outlook, and outcomes now are very different from even ten years ago — the specialist team can talk you through what that means for a particular genotype." Observed UK data come from the UK Cystic Fibrosis Registry.
Lopez et al., Journal of Cystic Fibrosis, 2023, and the accompanying commentary. Modelled data, not NICE guidance.
🎯 SCA trap
Delivering the genetics accurately and missing the person. The consultation is about a bereaved sibling deciding whether to have children. Ideas, concerns and expectations are the case; the referral to clinical genetics is the plan.
📋 Source check — desmopressin and asthma
The original notes state that desmopressin for nocturnal enuresis must be used with caution in asthmatics because fluid retention risks bronchospasm. This could not be verified from any primary source. Asthma is not a listed caution or contraindication in the UK product literature or the BNF. The cautions are conditions associated with fluid and electrolyte imbalance — renal impairment, cardiovascular disease and cystic fibrosis — very likely where the confusion arose in a respiratory context.
The genuine safety points: restrict fluid from 1 hour before until 8 hours after each dose; stop the drug during vomiting, diarrhoea or any intercurrent illness disturbing fluid balance until the patient is back to normal; warn against swallowing water while swimming; and counsel for hyponatraemia.
Desmopressin summary of product characteristics and the BNF. The asthma caution is not supported by either.
60-second check before your SCA
Scan this, and nothing else, on the way in.
New asthma at 12+ = as-needed low-dose ICS/formoterol (AIR). Highly symptomatic at presentation = start low-dose MART.
Not controlled on AIR → low-dose MART → moderate-dose MART → FeNO and eosinophils, then LTRA or LAMA, then refer.
Ages 5 to 11 start on twice-daily paediatric low-dose ICS plus SABA, not AIR.
Under 5 = 8 to 12 week ICS trial, stop, review at 3 months, restart if symptoms return.
Never a SABA without an ICS. Never asthma without an objective test.
COPD exacerbation = prednisolone 30 mg for 5 days. Antibiotics only if sputum changes colour and increases in volume or thickness.
Doxycycline = 200 mg day 1, then 100 mg daily, 5 days in total.
COPD admission is a 16-factor judgement, not a saturation number. Living alone and not coping counts.
LTOT assessment at 92% or less on air. LTOT if PaO2 below 7.3 kPa, or 7.3 to 8 with polycythaemia, oedema or pulmonary hypertension.
No oxygen for breathlessness in a normoxic patient. Opioids, a fan, positioning, palliative care.
Wells more than 4 = PE likely = immediate CTPA. 4 or fewer = D-dimer within 4 hours, or interim anticoagulation if delayed.
Haemoptysis at 40 and over = suspected cancer pathway for lung, not ENT.
Urgent CXR at 40+ with 2 symptoms, or 1 if they have ever smoked. Consider it for thrombocytosis, clubbing, recurrent chest infection.
Back pain plus cancer suspicion, no known cancer = urgent oncology assessment (NG234). Cord signs = emergency.
Cough unresponsive to 3 antibiotic courses in someone immunosuppressed = TB. CXR plus 3 sputum samples, refer, notify.
Bilateral hilar lymphadenopathy plus hypercalcaemia = sarcoidosis. Refer; baseline ECG; no routine echo or Holter if asymptomatic.
Acute bronchitis = no routine antibiotic. Low-severity pneumonia = amoxicillin 500 mg TDS for 5 days.
Deep sighing breathing, clear chest, vomiting child = DKA. Glucose now, hospital now.
Suspected stroke = nil by mouth until swallowing is screened.
No aspirin for flight VTE. Compression stockings for moderate and high risk; mobility and hydration for all.
Tap to test yourself
First-line treatment for newly diagnosed asthma at 12 and over?
A low-dose ICS/formoterol combination inhaler taken as needed — as-needed AIR therapy.
Oral corticosteroid dose and duration for a COPD exacerbation?
Prednisolone 30 mg once daily for 5 days.
Doxycycline regimen for a COPD exacerbation?
200 mg on the first day, then 100 mg once daily — 5 days in total.
Two-level PE Wells score that makes PE likely?
More than 4 points. Offer a CTPA immediately.
How quickly must the D-dimer result be available before you anticoagulate anyway?
Within 4 hours. If it cannot be, offer interim therapeutic anticoagulation while waiting.
FeNO levels that diagnose asthma?
50 ppb or more in adults; 35 ppb or more in children aged 5 to 16.
Age threshold for an urgent chest X-ray under the suspected cancer guideline?
40 and over — with 2 unexplained symptoms, or 1 if they have ever smoked.
Oxygen saturation that should trigger assessment for long-term oxygen therapy?
92% or less breathing air, alongside the other clinical triggers.
Bradford VTS · Respiratory Medicine · SCA must-know clinical knowledge
© Bradford VTS. Last updated 5 September 2026.
Teaching material for GP training use. Clinical content is condensed for exam recall and is not a substitute for the full guidelines. Verify all prescribing against the current BNF and NICE guidance before clinical use.