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PCP Toolkit for Treating Patients With Respiratory Diseases
Primary care physicians (PCPs) regularly encounter respiratory issues, from the common cold to asthma, chronic obstructive pulmonary disease ( COPD), and more. These conditions can, at times, be diagnosed fairly quickly and easily. But sometimes, ubiquitous symptoms can make differentiating diagnoses difficult.
Lung diseases can range from very minor to critical, so you don't want to waste any time in the diagnostic process. It's important, then, to know what tools PCPs have at hand and how to best apply them.
This is especially true as many lung diseases also have comorbidities.
'Patients with COPD often also have high blood pressure, high cholesterol, and left-sided heart disease,' said Jeffrey Marshall, MD, pulmonologist at University of Maryland Baltimore Washington Medical Center in Glen Burnie, Maryland.
It's also common for patients with respiratory diseases to experience concomitant mental health struggles, according to Marshall. For instance, high rates of anxiety are often found in patients with advanced lung disease. 'All these comorbid conditions can both exacerbate the patient's underlying pulmonary disease or be confused as an exacerbation of that pulmonary disease,' he said.
Respiratory complaints — like difficulty breathing and chest pain — are among the most common reasons patients visit the emergency room.
While these complaints may fall within respiratory illnesses, there are often other explanations for a patient's symptoms. Learning to discern these differences can be an important skill set as a PCP.
That said, it's also important to know when to refer to a specialist.
'Early recognition and timely referral can significantly improve patient outcomes,' said Tejaswini Kulkarni, MD, associate professor of medicine and director of the Interstitial Lung Disease Program at The University of Alabama at Birmingham.
Here's what you need to know to treat and guide your patients presenting with respiratory issues.
PCP Toolkit
The first step to having a handle on respiratory issues with your patients is taking a comprehensive medical history. For patients who have been already diagnosed with a respiratory condition, 'it's important to reinforce proper disease management and medication adherence,' said Marshall.
'Exposures, triggers, prior personal history, and a detailed family history are all important components of understanding a patient's pulmonary condition.'
Tobacco use is a primary example of this — patients who currently smoke or have smoked in the past are going to be more susceptible to respiratory conditions of all kinds.
'Though cigarette use has declined in most places across the country, tobacco use still has a significant impact on our nation's health,' said Marshall. 'Tobacco use contributes to many diseases, including asthma, COPD, heart disease, and, of course, cancer. Current and former smokers are also at a significantly increased risk of infections, namely the development of pneumonia.'
In addition, patients with a history of smoking are more likely to be hospitalized and die from pneumonia, he said.
Physicians should also consider their patients' work history, hobbies, and current occupation. Patients who work in certain occupations, like construction, for instance, may have exposure to harmful substances, like asbestos or certain paints.
Chronic exposure may lead to complications and can be a good starting point for diagnosis. Even living in an area with high pollution and poor air quality can be a contributing factor.
Patients will present with both acute and chronic symptoms, ranging from cough to shortness of breath, exercise-induced asthma, allergies, and sleep apnea. After taking a comprehensive history, physicians can utilize a variety of tools for further diagnosis — one of which could include pulse oximetry.
'Though patients typically present with symptoms prior to ever becoming hypoxemic, it may be helpful to get a walking pulse oximetry to understand the degree of changes in SpO2 and heart rate with exertion,' said Marshall. 'Simply walking a patient with a pulse oximeter can provide helpful information regarding exercise tolerance and whether that patient needs oxygen.'
Physicians might also want to try a handheld spirometer, which is simple to use and provides a good deal of information regarding patients' pulmonary and respiratory health.
'Spirometers can provide you with a basic set of numbers right in the office,' said Orlando Ruiz-Rodriguez, MD, a pulmonologist at Orlando Health in Orlando, Florida.
A basic stethoscope can also help in diagnosing pulmonary issues. 'Listening to lungs is part of the standard of care,' said Ruiz-Rodriguez. 'Make sure there are no abnormal sounds, like wheezing, crackling, or decreased breathing. Today's generation of stethoscopes are electronic and a much-improved tool at the primary care level.'
There are other tests PCPs can explore before deciding it's time to seek out a specialist. 'To expedite workup and management of patients with lung diseases, pulmonologists typically prefer certain baseline tests before a referral,' said Kulkarni. 'These commonly include pulmonary function tests to assess airflow obstruction or restriction, chest imaging (chest x-ray or high-resolution CT if interstitial lung disease is suspected), and basic lab work such as CBC [complete blood count], CMP [comprehensive metabolic panel], and BNP [B-type natriuretic peptide test].'
To help reduce diagnostic delays and improve patient outcomes, it's best to move with caution when considering a pulmonary fibrosis diagnosis, said Kulkarni.
Pulmonary fibrosis is often challenging to diagnose because clinical presentation mimics common conditions like coronary artery disease and COPD, 'but it has worse clinical outcomes with delays in treatment,' she said.
Beyond diagnostics, one consideration to keep in your toolkit, said Marshall, is vaccines. 'Patients with underlying respiratory or pulmonary conditions are at a higher risk of developing and becoming sick from respiratory illnesses,' he said. 'We now have several extraordinary vaccines available to our patients to help reduce the burden of infectious respiratory disease.'
When to Refer
While PCPs can treat respiratory issues in office to the best of their ability, there are times when referring to a pulmonologist is essential.
'Your local neighborhood pulmonologist is your friend,' said Marshall. 'Referrals to a pulmonologist should be considered whenever there is diagnostic uncertainty, when initial therapeutics are not working, or when more complex interventions or therapeutics are necessary in the workup and management of your patient.'
A few common reasons to refer to a pulmonologist include treating or diagnosing unremitting cough or chronic refractory, he said.
There are certain times when immediate referral is appropriate, according to Kulkarni. These include rapidly progressive dyspnea, hypoxia, hypercapnia, hemoptysis, suspected lung cancer, and large pleural effusions. For cases of symptom progression, she recommends referring with chronic coughs lasting over 8 weeks, unexplained or worsening dyspnea, frequent asthma or COPD exacerbations despite treatment, recurrent pneumonia, and signs of pulmonary hypertension.
Referring should not be considered a last resort, either, said Ruiz-Rodriguez.
'Some primary care doctors want to do as much as possible before referring,' he said. 'But know the limitations of what you have available to you. If your patient has symptoms, abnormal test results, or even a complicated medical history, send them to us. Even sleep apnea with a complicated history is a cue to move on to a specialist.'
