Summary
Definition
History and exam
Key diagnostic factors
- dyspnoea
- cough
- increased sputum purulence and volume
- wheeze
- chest tightness/chest pain
- tachypnoea
- tachycardia
- risk factors
- cor pulmonale
Other diagnostic factors
- signs of respiratory failure
- fever
- gastro-oesophageal reflux and/or swallowing dysfunction
Risk factors
- bacterial infection
- gastro-oesophageal reflux and/or swallowing dysfunction
- viral infection
- pollutants
- atypical bacterial infection
- change in weather
Diagnostic investigations
1st investigations to order
- arterial blood gas (in hospital)
- pulse oximetry (in hospital and in the community)
- ECG (in hospital and in the community if available)
- FBC with platelets (in hospital)
- urea, electrolytes, and creatinine (in hospital)
- CRP (in hospital)
- CXR (in hospital)
- sputum microscopy, culture, and Gram stain (in hospital)
- vitamin D (in hospital or in the community)
Investigations to consider
- blood cultures
- respiratory virus diagnostics
- cardiac troponin
- serum theophylline level
- pro-brain natriuretic peptide (BNP)
- CT scan of chest
- spirometry
Treatment algorithm
Contributors
Expert advisers
Jonathan Bennett, MD
Honorary Professor of Respiratory Sciences
University of Leicester
Respiratory Consultant
Glenfield Hospital
Leicester
UK
Biography
JB is Chair of the British Thoracic Society (BTS). He is also deputy medical director RCP Invited service Reviews, and speaker at National Society (eg., BTS), Primary Care respiratory Society, Society Cardiothoracic Surgeons meetings.
Disclosures
JB declares that he has no competing interests.
Richard Russell
Specialty Registrar in Respiratory Medicine
Glenfield Hospital
Leicester
UK
Disclosures
RJR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Carolyn L. Rochester MD
Associate Professor
Yale University School of Medicine
New Haven
VA Connecticut Healthcare System
West Haven
CT
Richard A. Martinello MD
Associate Professor
Yale University School of Medicine
New Haven
Veterans Health Administration
Office of Public Health
West Haven
CT
Disclosures
CLR serves on the COPD scientific advisory board for GlaxoSmithKline Pharmaceuticals but has no competing interests pertaining to this publication. RAM declares that he has no competing interests.
Peer reviewers
Carlos Echevarria
Consultant Respiratory Physician
Royal Victoria Infirmary
Newcastle upon Tyne
UK
Disclosures
CE declares that he has no competing interests.
Editors
Emma Quigley
Section Editor, BMJ Best Practice
Disclosures
EQ declares that she has no competing interests.
Tannaz Aliabadi-Oglesby
Lead Section Editor, BMJ Best Practice
Disclosures
TAO declares that she has no competing interests.
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Expert advisers: comorbidities
Martyn Patel, BMBcH, FRCP, MA
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee.
Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP
Consultant Renal Physician
Honorary Associate Professor
Nephrology Department
Leeds Teaching Hospitals NHS Trust
Head of MBChB
School of Medicine
University of Leeds
Leeds
UK
Disclosures
AL has been the principal applicant/co-applicant for a number of grants including: Engineering and Physical Sciences Research Council Research - Multiplexed AKI biomarker detection with a single molecule biosensor; Leeds Cares - A novel, non-invasive diagnostic approach to assess kidney transplant health through the targeted measurement of biomarkers of kidney injury and immune response in kidney transplant recipients at the Leeds Teaching Hospitals NHS Trust; Kidney Research Yorkshire - Use of enhanced technology to characterise haemodialysis treatment for acute kidney injury (AKI); Bringing It Home - Validation of a micro-sampling technique for measuring tacrolimus and creatinine remotely; and to fund a research nurse; British Renal Society - Renal function assessment with point of care creatinine in diverse populations (RAPID), and several NIHR grants including on a) Improving the quality of post-discharge care following AKI b) An investigation into the use of remote blood sample collection to reduce health inequalities in patients with mental health disorders c) A comparison of remote blood collection devices: a human factor use study d) Defining the characteristics for a novel automatic device to monitor urine output in catheterized patients e) Leeds Medtech and In-vitro Diagnostic Cooperative Grant Extension f) Surgical MedTech Co-operative for the 2019/20 proof-of-principle funding stream g) A pilot investigation into the use of beta-trace protein for residual renal function estimation in haemodialysis h) Application of functional MRI to improve assessment of chronic kidney disease (AFiRM study) i) SuperResPath-Renal: Quantitative super-resolution technology for a fast, decentralised clinical diagnosis of renal pathologies. AL is the co-author of a number of manuscripts including on extracorporeal treatments, AKI, kidney function testing prior to contrast-enhanced CT, plasma exchange and glucocorticoids in severe ANCA-associated vasculitis, COVID-19 rapid diagnostics, multimodal image-guided ablation on management of renal cancer in Von-Hippel-Lindau syndrome, and on a summary of NICE guidance on CKD. AL is the author of several book chapters on nephrology and AKI. AL has received expenses for accommodation and travel for conferences at which he has given lectures, other than those delivered virtually. AL was a member of the AKI Scientific Program Committee for the ISN World Congress of Nephrology 2020-2021 and Chair of this same committee in 2021-2022.
Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC
Professor of Cardiology
Imperial College London (Royal Brompton Hospital)
London
UK
Disclosures
MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, & Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.
Rachael Evans, MBChB, FRCP (UK), PhD
Associate Professor (Clinical)
University of Leicester
Honorary Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
RAE has given lectures for non-promotional industry-led sessions on long COVID and provided consultancy for GSK, AstraZenica, Boehringer, and Chiesi, for individual payment and travel expenses totalling <£4000.
Gerry Rayman, MD, FRCP
Consultant Physician and Head of Service
Diabetes and Endocrine Centre and the Diabetes Research Unit
Ipswich Hospitals NHS Trust
Ipswich
UK
Disclosures
GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.
Sotiris Posporelis, MD, MRCPsych
Consultant Liaison Neuropsychiatrist
King’s College Hospital
South London and Maudsley NHS Foundation Trust
Honorary Senior Clinical Lecturer
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
London
UK
Disclosures
SP declares that he has no competing interests.
Hamish McAuley, MBBS, BSc, MRCP
Clinical Research Fellow
Specialist Registrar (ST5)
Department of Respiratory Sciences
University of Leicester
Respiratory Biomedical Research Unit
Glenfield Hospital
Leicester
UK
Disclosures
HM declares that he has no competing interests.
Asangaedem Akpan, MPH, FRC
Consultant Geriatrician
Liverpool University Hospitals NHS Foundation Trust
Visiting Professor
University of Cumbria
Carlisle
Honorary Clinical Associate Professor
University of Liverpool
Liverpool
UK
Disclosures
AA has received honorariums for giving lectures on behalf of Profile Pharma in 2021. AA is an expert committee member of the National Institute for Health and Care Excellence (NICE) quality standards committee on urinary tract infections in adults and Deputy chair of the British Geriatrics Society England Council and Ageing Specialty Research Lead CRN NWC. AA sits on advisory committees for the following research studies: VOICE2 (development and testing of communication skills training for hospital healthcare practitioners caring for people living with dementia), SWOP (social work in older people) and CFIN (cognitive frailty interdisciplinary network). AA has received research funding from the Liverpool CCG and Applied Research Collaborative. He is contributing to developing a heart failure pathway tool for the British Society for Heart Failure and has been invited to contribute to the European Union Geriatric Medicine conference (free conference registration) and British Society for Heart Failure conference (accommodation and travel expenses covered).
Acknowledgement: Professor Sanjay Agrawal
BMJ Best Practice would like to gratefully acknowledge Professor Sanjay Agrawal, National Speciality Advisor for tobacco dependency at NHS England and Chair of Royal College of Physicians tobacco advisory group, for his advice on the comorbidity content for 'current smoker'.
Professor Sanjay Agrawal, MBChB, FRCP
Consultant in Respiratory and Intensive Care Medicine
University Hospitals of Leicester NHS Trust
Leicester
UK
Disclosures
SA declares that he has no competing interests.
Peer reviewers: comorbidities
Martyn Patel, BMBcH, FRCP, MA
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee.
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