2.2 Chose diagnostics as appropriate and when required.

2.2.1 asthma control questionnaire, exercise capacity. Rule out Thrombo embolic disease

2.2.3 Alpha 1 antitrypsin (young aged smokers, family history). Skin prick test to guide treatment and environmental factors.

2.2.4 Physiological Measurement, simple exercise test and full lung function, oxygen Assessment. Spirometry must be done to ARTP/BTS guidelines and be quality assured.
Blood gases & CT can be part of direct access services available to GPs, for severity assessment, if carried out in appropriate location with expert reporting. The location will usually be in secondary care.

3.2.1 asthma control questionnaire, exercise capacity. Rule out Thrombo embolic disease

3.2.3 other tests to include: diabetes, U's and E's, immunology, CRP, serum, pro-BNP, arteial blood gas analysis, skin prick

3.2.4 other tests to include: flight assess, exercise, oximetry, oxygen assessment, exercise tests, mouth pressure tests, challenge non specific BHR,sleep studies, allergy testing (e.g. aspirin allergy) bronchial challenge.

All investigations should be carried out in an appropriate environment, with appropriate skills for interpretation.

Acute Asthma i.e. inability to talk

Other causes of breathlessness may be pneumothorax, pulmonary embolism, cardiac causes.

Chest x-ray would be mandatory.

Excess or persistent purulent sputum

Sleep Disorder would be complex sleep disorder more appropriate for management on Sleep Pathway

COPD Prevalence
2006/07: COPD prevalence among all patients registered with a GP in England was 1.43% (765,806); 671,410 of these patients had their COPD confirmed by spirometry (source: QOF).
2005/06: COPD prevalence ranged in GP practices from 0-17.5% (average 1.4%)
Extrapolation from Health Survey for England (Shahab et al, 2006: use of spirometry with a representative sample of people aged 35+): 13.3% of those aged 35 and over (3.7million people)
GP consultations
2006/07: there were 2,328,438 primary care consultations where COPD recorded as the reason for consultation (extrapolated data from Information Centre sample average 2.76 consults per person due to COPD), at a total cost of 81,509,688 (DH analytical team)
2006/07: there were 5,930,768 primary care consultations for people with COPD (extrapolated data from Information Centre sample average 7.03 consults per person with COPD for any reason)
Hospital admissions
2006/07: 179,460 inpatient admissions for England where COPD was the primary cause of treatment (source: HES); total costs approximately 276m (DH analytical team)
Mortality
2006: there were 21,811 deaths in England where COPD was the underlying cause (ONS)
Direct Healthcare costs
2006/07: 733.5 million for primary care, pharmaceuticals, secondary care, community services oxygen therapy, and prevention vaccination (DH analytical team)
Lost days of work
COPD is responsible for 24 million lost working days per year (source: previous DH presentation)

Asthma Prevalence
2007/8: Asthma prevalence was approximately 5.8% of the population (approx. 3 million people), based on QOF and ONS population data.
This population had between 14.5m and 18.7m consultations in 2006 (Based on Information Centre Data and Gupta et al. (2004) (http://www3.interscience.wiley.com/journal/118792371/abstract?CRETRY=1&SRETRY=0
))
2006/07: 88,766 hospital admissions (ONS data and DH calculations)
2006: there were 1,012 deaths in England where Asthma was the underlying cause (ONS)
Direct Healthcare costs: Approx 1bn according to MRC-Asthma UK centre estimate (http://www.asthma.org.uk/how_we_help/funding_research/mrcasthma_uk.html)
Lost days of work
Asthma is responsible for 12.7 million lost working days per year according to MRC-Asthma UK estimate (http://www.asthma.org.uk/how_we_help/funding_research/mrcasthma_uk.html)

Avoidance of triggers for obstructive lung disease (allergic and occupational exposures), environmental advice.

Smoking cessation important as 95% of COPD due to smoking.
Limiting occupational exposure important - e.g. welding fumes increase risk of COPD & reduced exposure to sensitisers such as car paint spray in asthma

This pathway may apply to patients with either COPD or Asthma.

Breathlessness can be caused by other factors. Use spirometry to differentiate restrictive and obstructive lung disease.

Suspect COPD if: over 35, smokers / ex smokers. no variation of symptoms and signs in time
Suspect Asthma if variable or noctural symptons or family history of Atopic disease. See British Asthma Guidelines

Diagnostic difficulties can include co-existing conditions or excess persistent sputum production.These may include complex or severe disease, sub-optimal response, risk of death including referral for end of life planning
Disproportionate symptoms may indicate red flag.
May also be referred due to severity of disease.

Should be single point of access. Referral for respiratory failure.
Occupational or difficult asthma.
Early ass. for surgical intervention for respiratory failure
Advice and guidance could be delivered remotely (e.g.email or phone)

4.2.3 specialist microbiology, thyroid function, U&E, specialist sputum examination

4.2.4 specific BHR, transcutaneous gas exchange measurements, full CP exercise test

Review of exacerbation frequency for Asthma and COPD (number of exacerbations in previous year including RCP score)
Cardio-respiratory & general examination (upper airway, blood pressure, pulse, respitratory rate, BMI)
Review of dyspnoea severity and progression(sputum production and colour, cough, ankle oedema, nightime symptoms and associated atopic disease & RCP score), smoking status, BMI and diet, exercise tolerance and daily activities, recognition of any symptoms of depression or anxiety.
Review of the presence of co-morbidities (cardiovascular disease, diabetes, allergies) and any familial tendency to airways disease
Blood pressure check
Symptom variability, exclude hayfever
Differential diagnosis of heart failure, lung disease, obesity, hyperthyroidism
medication review
Psychological assessment

Remember breathlessness (even in those with an existing diagnosis) may be due to:
- Heart disease
- Lung disease
- Pulmonary vascular disease
- Diaphragm weakness
- Systemic disease (obesity, anaemia & hyperthyroidism

Specialist assessment reacting to suboptimal response to initial therapy / disproportionate breathlessness

Respiratory specialist assessment that is multidisciplinary with close links to primary care and social services access to other services if required.
Assessment as above for the primary assessment including full assessment of current therapy for COPD, exacerbation frequency, severity of exacerbations and hospitalisations, presence of any respiratory failure or its complications such as oedema, pulmonary hypertension, secondary polycythaemia.
Access to specialist psychological assessment and End of Life services. Evaluate rather than review as at 2.0, define specialist assessment e.g. secondary care, specialist elective primary care services, outpatients, polyclinic

Assessment of symptom and disease progression with full medication review.
Facilities for more complex respiratory investigations, eg CT scanning and sleep studies. Facilities for direct referral to cardiology services and investigations.
Access required to facilities for ventilatory support, both for acute therapy (non-invasive (NIV) and invasive), home NIV and for surgical interventions for COPD.
Links with early discharge and out of hospital services. services required.
Access to specialist psychological assessment and end of life services.
Brochial reactivity testing

This is a pathway for patients who are breathless due to obstructive lung disease (the main diseases of which are COPD and Asthma).

It is intended to stimulate discussion between PCTs and providers to achieve seamless integrated care.

2.4.1 Lifestyle actions to enable better self-management. Information pack to include information about COPD, LTCs in general and locally available services.

2.4.2 Pulmonary rehabilitation ("A healthier lung course"), Psychological support

2.4.3 Standby antibiotics and steroids. Concordance and smoking cessation.

2.4.4 Contact and support from designated health professional. Possible use of standby steroids and antibiotics, increased inhaler medication for asthma

Smoking cessation advice can be counted as advice and pharmacological treatment

2.4.5 including details of local services and self help

3.4.2 speech therapy, CBT, physiotherapy

3.4.4. In action plan may need referral as part of exacerbation managment to acute NIV (non-invasive, or non-intubated, ventilation)

3.4.6 occupational and vocational guidance

4.4.2 CBT, speech Tx, physio Tx

4.4.3 Anxiety management also important

4.4.6 endobronchial valves, airway bypass, specialist O&G support for pre-menstrual and pregnancy

End of life care best done in conjunction with & after specialist discussion. Advance planning to include advance directives

Management of exacerbation including acute admission

Management of exacerbation including acute admission