Master CPS - Respiratory
for MSRA

Core Concepts

Respiratory Common Presentations (CPS) primarily encompasses acute and chronic conditions managed in primary care. Key conditions include Asthma (reversible airway inflammation), Chronic Obstructive Pulmonary Disease (COPD - irreversible airflow limitation, often smoking-related), Acute Bronchitis (usually viral lower respiratory tract infection), Pneumonia (lung parenchymal infection), Upper Respiratory Tract Infections (URTIs - common cold, pharyngitis), and non-infectious causes of cough like post-nasal drip, GERD, or medication-induced (e.g., ACE inhibitors). Distinguishing acute vs. chronic, infectious vs. inflammatory, and self-limiting vs. progressive disease is crucial for initial assessment.

Clinical Presentation

• Cough: Most common symptom.
  • Acute (<3 weeks): Typically URTI, acute bronchitis, early pneumonia.
  • Subacute (3-8 weeks): Post-viral, pertussis, sinusitis.
  • Chronic (>8 weeks): Asthma, COPD, GERD, post-nasal drip, ACE inhibitor, lung cancer, ILD.
  • Productive (sputum) vs. Non-productive (dry).
• Dyspnoea (Shortness of Breath):
  • Acute: PE, pneumothorax, acute asthma exacerbation, severe pneumonia.
  • Chronic/Progressive: COPD, heart failure, interstitial lung disease, obesity, anaemia.
• Wheeze: High-pitched whistling sound, usually expiratory. Suggests airway narrowing (asthma, COPD). Unilateral wheeze is concerning for foreign body or endobronchial lesion.
• Chest Pain:
  • Pleuritic: Sharp, localised, worse with deep breath/cough (pleurisy, pneumonia, PE).
  • Non-pleuritic: Cardiac, musculoskeletal, oesophageal.
• Sputum: Colour (clear, white, yellow, green, rusty), volume. Purulent sputum suggests bacterial infection.
• Fever/Chills/Rigors: Common in infectious processes (pneumonia, acute bronchitis).
• Hoarseness: Laryngitis (viral), persistent hoarseness may indicate malignancy or reflux.
• Haemoptysis: Coughing up blood. Always a red flag.

Diagnosis (Gold Standard)

In primary care, diagnosis relies heavily on comprehensive history and physical examination.

• Asthma: Clinical picture (recurrent wheeze, cough, SOB worse at night/exercise) + spirometry with bronchodilator reversibility (FEV1 increase >12% and >200ml post-bronchodilator).
• COPD: Clinical picture (chronic cough, sputum, dyspnoea, smoking history) + spirometry (post-bronchodilator FEV1/FVC ratio < 0.7).
• Pneumonia: Clinical (fever, cough, dyspnoea, signs of consolidation) + Chest X-ray (confirms consolidation). Sputum culture for resistant/severe cases.
• Acute Bronchitis/URTI: Clinical diagnosis based on symptoms. Investigations usually not required.
• Pulmonary Embolism (PE): Clinical suspicion (Wells' score), D-dimer (if low risk), then CT Pulmonary Angiogram (CTPA) for confirmation.
• Lung Cancer: Clinical suspicion (red flags) + Chest X-ray (initial), CT Chest, biopsy for definitive diagnosis.

Management (First Line)

• Asthma:
  • Reliever: Short-Acting Beta-Agonist (SABA) e.g., Salbutamol.
  • Preventer: Inhaled Corticosteroid (ICS) e.g., Beclomethasone, Fluticasone. Stepped approach per BTS/SIGN or NICE guidelines.
• COPD:
  • Smoking cessation (most critical intervention).
  • Bronchodilators: Short-Acting Muscarinic Antagonist (SAMA) e.g., Ipratropium; Short-Acting Beta-Agonist (SABA) e.g., Salbutamol.
  • Long-Acting Bronchodilators (LABA/LAMA) for persistent symptoms. ICS in severe disease/frequent exacerbations.
  • Pulmonary rehabilitation, annual flu/pneumococcal vaccines.
• Acute Bronchitis (viral): Symptomatic management (paracetamol, fluids). Antibiotics not recommended unless complications or specific indications (e.g., pertussis).
• Pneumonia:
  • Assess severity (CURB-65 score).
  • Antibiotics: Amoxicillin or Doxycycline/Clarithromycin (macrolide) as first-line depending on local guidelines and patient factors.
  • Supportive care: Oxygen if hypoxic, fluids, paracetamol.
• URTIs: Symptomatic relief (analgesia, decongestants, fluids).
• Persistent Cough (non-infectious): Address underlying cause (e.g., PPIs for GERD, intranasal steroids/antihistamines for post-nasal drip, consider ACE inhibitor cessation).
• Smoking Cessation: Offer behavioural support, Nicotine Replacement Therapy (NRT), Varenicline, Bupropion.

Exam Red Flags