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Respiratory health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Respiratory presentations contribute greatly to the burden of disease and are common presentations in Australian general practice. For children aged 0–14 years, the most common presentation to general practice is acute upper respiratory tract infections (URTIs). Eleven per cent of the population live with asthma, and 33% or these people use daily medication to manage their symptoms.1 A further 2.5% of the Australian population have chronic obstructive pulmonary disease (COPD)2 and lung cancer is the fifth most common cancer in Australia and a leading cause of cancer death.3 Early diagnosis of lung cancer leads to better survival outcomes.4 In addition, pandemic influenza and COVID-195 have added to the burden6 of respiratory presentations.

There are many factors that influence respiratory disease, these include the social and environmental determinants of health and geographical location, with rural and remote people having higher rates of prevalence than those living in urban areas.7 As such, general practitioners (GPs) in rural and remote communities may choose to undertake additional training relevant for their location. Those at increased risk of respiratory conditions include people with compromised immunity, pregnant women and Aboriginal and Torres Strait Islander peoples who have a higher burden of morbidity/mortality from respiratory disease.8

Respiratory illness outbreaks are common and can occur seasonally as happens with respiratory syncytial virus (RSV) and influenza. Climate change has impacted respiratory health through conditions such as bushfire smoke inhalation disease and thunderstorm asthma. Bushfire smoke inhalation disease leads to a significant increase in hospital presentations.9 Environmental sustainability initiatives in healthcare can have positive impacts, including the development of chlorofluorocarbon (CFC) free inhalers.10

Managing acute respiratory presentations requires skills in recognising the patient who needs hospital admission or those who can be managed at home. Discerning this can be challenging, especially in children. The COVID-19 pandemic has highlighted the public health considerations in managing acute respiratory illness. It has influenced practices with the increased use of telehealth, the added challenge of managing large-scale vaccination programs, screening for illnesses with a focus on prevention of spread, as well as the safe use of personal protective equipment and considerations about how best to protect clinic staff.

Chronic respiratory conditions, including asthma, COPD, bronchiectasis, cystic fibrosis and lung cancer, require management that considers physical, social and psychological impacts of illness. Asthma, COPD and bronchiectasis management guidelines and asthma action plans are advances in best practice management. Demonstration of correct use of inhaler devices and spacers is essential to the management of asthma and COPD. Ninety per cent of asthma patients use their inhaler devices and spacers incorrectly, increasing their risk of hospitalisation by 50%.11 The ability to interpret spirometry is important for GPs in the diagnosis of respiratory illness.

Public health approaches to respiratory disease management include disease exclusion times and vaccination schedules. Vaccination may be a consideration for groups beyond the individual, for example, the vaccination of adults in contact with babies to reduce the risk of pertussis.

In the prevention of respiratory disease, attention to factors such as smoking, consideration of current/past occupation and vaccinations are important. The GP requires skills in communication and motivational interviewing to avoid being judgemental and to provide compassionate support.

References
  1. Australian Bureau of Statistics. Asthma. Canberra, ACT; ABS, 2018 [Accessed 31 August 2021].
  2. Australian Bureau of Statistics. National Health Survey - First Results. Canberra, ACT: ABS 2018 [Accessed 31 August 2021].
  3. Cancer Council. Lung Cancer. Sydney, NSW: Cancer Council Australia, 2020 [Accessed 5 October 2021].
  4. Australian Government Cancer Australia. Evidence Report for Investigating symptoms of lung cancer: A guide for all health professionals. Canberra, ACT: Cancer Australia, 2020 [Accessed 30 November 2021].
  5. NPS MedicineWise. MedicineInsight: General Practice Insights Report. Sydney, NSW: NPS MedicineWise, 2020 [Accessed 5 October 2021].
  6. Australian Bureau of Statistics. COVID-19 Mortality. Canberra, ACT: ABS, 2020 [Accessed 31 August 2021].
  7. Australian Institute of Health and Welfare. Rural & remote health. Canberra, ACT: AIHW, 2019
  8. Kirov E, Thompson N. Summary of Indigenous health: Respiratory disease. Aborig Isl Health Work J 2004;28(2):15–18.
  9. Pendrey C, Beaton L, Kneebone J. General practice in the era of planetary health: Responding to the climate health emergency. Aust J Gen Pract 2020;49(8):520–23. doi:10.31128/AJGP-01-20-5207.
  10. Janson C, Henderson R, Lofdahl M, Hedberg M, Sharma R, Wilkinson AJ. Carbon footprint impact of the choice of inhalers for asthma and COPD. Thorax 2020;75(1):82–84. doi: 10.1136/thoraxjnl-2019-214381.
  11. National Asthma Council. Ninety per cent of Australians with asthma use their inhalers incorrectly. South Melbourne, Vic: National Asthma Council, 2017 [Accessed 31 August 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • engage the patient or carer to gather detailed information about their respiratory presentation and the impact of their illness in their lives
 1.1.5, 1.4.1, 1.4.3, 1.4.4, 1.4.5, AH1.4.1, RH1.4.1
  • assess patient understanding of common terminology as it relates to their respiratory illness considering cultural and language differences
 1.1.5, 1.1.6, 1.2.1
  • demonstrate effective communication skills in the delivery of respiratory diagnoses that are chronic or terminal
 1.1.2, 1.1.5
  • discuss the principles of ensuring safe and effective consultations conducted remotely, such as via telehealth, in the context of respiratory illness
 1.1.5
  • incorporate the principles of motivational interviewing in managing patients with health behaviours that contribute to chronic respiratory illness
 1.2.1, 1.2.2, 1.2.3, 1.3.2
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • interpret and analyse the history and examination findings of a respiratory presentation to arrive at a working diagnosis that considers red flags
 2.1.4, 2.1.7, 2.1.10
  • demonstrate the use of diagnostic equipment, including spirometry, inhaler devices and spacer technique to patients and those who care for respiratory patients
 2.1.2, 2.1.5
  • select and interpret appropriate investigations in the diagnosis and management of respiratory disease
 2.1.4, 2.1.5, 2.1.6, 2.1.7, 2.1.8, 2.3.1
  • prescribe evidence-based non-pharmacological and pharmacological interventions to manage respiratory presentations
 2.1.9
  • recognise and manage the acutely unwell patient with respiratory illness
 2.1.3, 2.1.4, AH2.1.2, 2.3.3, AH2.3.1, RH2.4.1
  • coordinate the care of patients with chronic respiratory conditions
 2.1.3, 2.1.5, RH2.4.1, AH2.1.2, AH2.3.2
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • advise on and administer vaccinations for preventable respiratory illnesses
 3.1.1, 3.1.3, 3.1.4, AH3.2.1, RH3.2.1
  • discuss the impact of environment and climate change on the presentation and management of respiratory presentations
 3.1.1, 3.1.3, 3.1.4, 3.2.3
  • undertake screening and health promotion activities for the prevention of respiratory disease suited to the local community
 3.1.1, 3.1.2, 3.1.3, 3.1.4, 3.2.2
  • explain the link between the social determinants of health on respiratory disease epidemiology, its presentation and management
 3.2.1, 3.2.2, 3.2.3, AH3.2.2, RH3.2.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • engage in self-reflection regarding personal values or beliefs that may impact on their ability to deliver patient-centred care in the context of ongoing health risk behaviours that may impact respiratory health
 4.1.2, 4.1.4, 4.2.2, AH4.2.2, 4.2.4
 
  • reflect on current knowledge and skills related to respiratory presentations and enhance these by critically analysing new and emerging research information
 4.4.1, AH4.4.1, AH4.4.2
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify appropriate Medicare item numbers that assist in the management of chronic respiratory disease
 5.2.3, 5.2.4, AH5.1.1, AH5.1.2, AH5.1.3, AH5.2.1
  • incorporate the use of management plans for chronic respiratory conditions in digital note-keeping
 5.2.1, 5.2.3
  • explain the role of practice software recall systems to support ongoing monitoring of chronic respiratory conditions
 5.1.1, AH5.1.1, AH5.1.2, AH5.1.3, RH5.1.1, 5.2.3, 5.2.4
  • conduct practice audits to review respiratory illness-related vaccination rates
 5.1.1, AH5.1.1, AH5.1.2, 5.2.1, 5.2.3
  • describe the role of medico-legal principles in the management of chronic respiratory disease, including reporting of notifiable diseases and assessing fitness to drive
 5.1.1, 5.2.1, 5.2.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Understanding a patient’s health literacy is important when prescribing treatment plans for chronic conditions such as asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis. Diagrams and timetables can be useful for patients to refer to and share with their significant others. For example, include times for their salbutamol inhaler doses, number of breaths per puff in spacer, and the dates when they should reduce their corticosteroid dosage. This will improve compliance with your treatment plan, including prophylaxis and management of flare-ups.
  2. Consider the involvement of workers compensation insurance to fund healthcare for patients with occupational exposure lung diseases such as silicosis, asbestosis, pneumoconiosis and some types of lung cancer.
  3. Good GPs will realise parents of children who present with respiratory illness know their child best. Young children who sit quietly in your consulting room are usually more seriously unwell than those who are active, eating, drinking and playing. It is important to look under their shirts for signs of respiratory distress.
  4. When approaching patients with chronic respiratory disease, it is important to look at all available resources and support options, including the role of multidisciplinary team care and pulmonary rehabilitation to provide a wholistic approach. Consider the coexistence of multiple respiratory diagnoses, such as asthma, allergic rhinitis, COPD and obstructive sleep apnoea; multimorbidity such as cardiac disease which may be compounding the respiratory presentation; and the impact of factors such as smoking and weight gain, which may be adding to respiratory illness burden.
  5. An important pitfall to avoid is to assume that patients, even those with long-term asthma or COPD, are using their inhaler devices and spacers correctly. Mismanagement can sometimes go on for years.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Respiratory health

James is a 40-year-old business executive who presents with a cough. His cough started with a sore throat and rhinorrhoea one month ago and has persisted since then.

James is feeling breathless on exertion. He has smoked for 30 years intermittently. He does not drink alcohol. He works long hours and has little time for exercise. His history includes seasonal hay fever, childhood asthma, appendicectomy and treated hypertension. His chest sounds are reduced with some wheezing. He has reduced chest expansion. There is no dullness to percussion.

 
Questions for you to consider Clinical exam assessment area Domains

What communication strategies would you use to empower James to take control of his current and pre-existing medical conditions?

How would this be different if James were an Aboriginal or Torres Strait Islander?

What if you were talking to a parent or guardian of a three-year-old child with a persistent cough?
  1. Communication and consultation skills
 1,2,5

What further history, examination and investigation findings are necessary to formulate a diagnosis and management plan for James?

How would this be different if James were an Aboriginal or Torres Strait Islander?

What if this were a three-year-old child with a persistent cough?
  1. Clinical information gathering and interpretation
 2   

What is your approach to a persistent cough presentation for an adult? How would this be different for a child?

What would your approach be if James were a non-smoker or lived in rural northern Australia rather than urban southern Australia, or had an occupation that may have contributed to this presentation?
  1. Making a diagnosis, decision making and reasoning
 2

What is your problem list for James, in order of priority?

What non-pharmacological treatments and pharmacological treatments need to be considered for James?

How would this problem list and treatments be different for a three-year-old with a persistent cough?
  1. Clinical management and therapeutic reasoning
 2   

What community resources are available to James for his respiratory health and wellbeing?

Would these resources be different if James were an Aboriginal or Torres Strait Islander?

Would these resources be different if you were practising in rural Australia?
  1. Preventive and population health 
 1,2,3

What personal biases and limitations may influence your management of James, especially if he continues to smoke?

How would you work in a culturally safe way with James if he were an Aboriginal or Torres Strait Islander?
  1. Professionalism
 4   

How would you use general practice software to develop a management plan, including ongoing monitoring, and what Medicare items are available to manage James?

Are there different Medicare items available if James were an Aboriginal or Torres Strait Islander?

What are the PBS restrictions for the pharmacological treatments?

What are your legal obligations if James had untreated obstructive sleep apnoea and continued to drive?
  1. General practice systems and regulatory requirement
 5   

What procedural skills would be useful in this scenario?

How might you instruct James in the use of an inhaler device and spacer?

What procedural skill would be useful if you were practising in rural Australia?
  1. Procedural skills
 2   

How would you manage James if the diagnosis was not yet clear?

How would this be different for a three-year-old child?
  1. Managing uncertainty
 2   

What presenting features would lead you to refer James to the emergency department?

How would this be different for a three-year-old child?

What presenting features would lead you to refer James for review by a respiratory specialist?

How would this be different for a three-year-old child?
  1. Identifying and managing the significantly ill patient
 2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Use practice software to carry out an audit of eight of your patients with respiratory presentations: a) acute cough in an adult and a child; b) persistent cough in an adult and a child; c) dyspnoea in an adult and a child; d) chest pain in an adult and a child. Compare your management notes for your provisional diagnoses to guidelines such as the Therapeutic Guidelines.

  • What were the differences between your approach and the guidelines you identified?
  • What would you change in your management of these conditions next time?

Ask for feedback from two of the of the above audited patients, including a child with a parent/guardian at a follow-up consultation. Ask them if they understood what the management plan was and if they were able to implement this.

  • What communication skills would help you improve the patient’s or parent/carer’s understanding?

Carry out a nasopharyngeal swab.

  • How would you practise infection control when you do this?
  • Where could you find a video that demonstrates how to do a swab? What could you learn from this video?
With a supervisor

Create your own case example based on a patient seen in your practice with a respiratory presentation that is different to the case consultation example above.

  • Consider questions for each of the 10 assessment areas (see case consultation example section) and discuss your answers to these questions with your supervisor.

Do a review of your patients to see if they have action plans for asthma and/or COPD, and if their respiratory disease vaccinations are up to date.

  • Ask your supervisor how they approach this.

Identify a patient who would benefit from pre- and post-spirometry. Carry this out with the assistance of your practice nurse.

  • Did you feel confident explaining the process to the patient? How could you improve this?
  • Discuss the results with the nurse or your supervisor.
In a small group

Research the various inhaler devices that are currently available in the market. Do a role play explaining how to use each of these devices correctly. Ask the group for feedback.

  • What did you learn from this feedback?
  • How can you incorporate this into your practice?

Research accurate information about vaccinations, such as influenza, pneumococcal and COVID-19, and role-play explaining the pros and cons of vaccination to a vaccine-hesitant patient.

  • What information did you find? Did you find information that is easy for patients to understand?
  • What did you find helpful or unhelpful during this role-play consultation? How does this change the way you approach these consultations in future?
With a friend or family member

Find a friend or family member who has asthma (or has a relative with asthma) and show them an asthma action plan from the Asthma Council of Australia or practice software.

  • How would you use this as a tool to explain how they should manage their asthma?
  • Did you check their understanding by asking them to explain it back to you?

Role-play your respiratory presentation case consultation that you created (‘With a supervisor’ section above) and video record this with permission from your friend. Review the recording.

  • What did you do well and what could you improve on?

Read patient information handouts on respiratory presentations from practice software, John Murtagh Patient Education Handouts, and The Royal Children’s Hospital Melbourne Kids Health Information fact sheets.

  • How would you use one of these handouts to explain the condition to a friend?
  • Which of these sources of handouts did you find most useful?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Understand the common presentations, aetiologies and management of acute infections of the upper respiratory tract including:
    • acute sinusitis
    • tonsillitis
    • pharyngitis
    • laryngitis
    • epiglottitis
    • croup.
  • Understand the common presentations, aetiologies and management of acute infections of the lower respiratory tract including:
    • typical and atypical pneumonias
    • acute bronchitis
    • acute exacerbation of asthma and chronic obstructive pulmonary disease (COPD)
    • pleurisy
    • tuberculosis (TB)
    • lung abscess
    • bronchiolitis.
  • Understand the common presentations, aetiologies and management of chronic respiratory diseases including:
    • asthma
    • COPD
    • occupational lung disorders, for example, asbestosis, silicosis, pneumoconiosis
    • cystic fibrosis
    • bronchiectasis
    • interstitial lung disease.
  • Understand the common presentations and management of respiratory illness resulting from exposure to climate factors:
    • air pollution, including bushfire smoke
    • thunderstorm asthma.
  • Understand the presentation, aetiologies and management of upper respiratory tract and lower respiratory tract malignancies.
  • Understand the presentations and management of obstructive sleep apnoea, including fitness to drive implications.
  • Understand the presentations and management of respiratory trauma, including:
    • inhaled foreign body
    • pneumothorax.
  • Be able to perform procedures specific to the respiratory unit, including:
    • correct spirometry performance and interpretation
    • demonstration of inhaler devices and spacer technique, including a face mask for young children
    • collection of sputum and nasopharyngeal swabs for pathology
    • chest X-ray interpretation.
  • Consider certification implications for fitness to drive for conditions such as untreated obstructive sleep apnoea.
  • Consider certification implications for work and capacity to work as it relates to occupationally acquired respiratory diseases.
  • Consider public health notification requirements related to respiratory diseases, such as TB.
  • Consider epidemiology, preventive health screening and interventions in groups at increased risk of respiratory disease, including Aboriginal and Torres Strait Islander peoples.
  • Consider guidelines for oxygen therapies in acute presentations and in the management of chronic respiratory diseases.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
A concise article on asthma and COPD assessment. A useful decision tree for the management of wheezing as a respiratory presentation in children. A summary of management of pulmonary embolism.

This article is useful for addressing lifestyle factors when managing obstructive sleep apnoea.

Online resources
An outline of the knowledge required to manage COPD. An outline of the knowledge required to manage asthma. Guidelines on how to manage children with bronchiolitis. Clinical guidelines for other respiratory conditions such as croup are also available here. Advice on supporting smoking cessation. Asthma Australia has a range of YouTube videos, including on using inhaler devices and spacer techniques.
Learning activities
eLearning activities related to the topic of respiratory health.
  • The Royal Australian College of General Practitioners. gplearning:
    • Identifying and managing the risk factors for thunderstorm asthma
    • check, unit 575, September 2020: Chronic conditions: A case related to the management of bronchiectasis
    • check, unit 558, March 2019: Interstitial lung disease
    • AJGP Clinical Challenge, April 2019: Respiratory tract and sleep disorders
A free, accredited eLearning course for primary care health professionals.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/respiratory-health 9/10/2024