Implementation of a clinical pathway for guideline-based assessment and diagnosis of adult breathlessness: Cardio-LungHealth and Everton in the Community (EiTC)

Project overview, including who was involved in the project
Breathlessness is a common symptom heralding serious underlying cardiopulmonary disease. The early and accurate diagnosis of the breathlessness patient is therefore essential in order to reduce emergency healthcare utilisation and improve patient outcomes. Healthcare inequality is also a primary driver to delayed presentation of cardiorespiratory disease. Football is a gateway to accessing healthcare services as breathlessness and cardiorespiratory conditions often affect patients from groups who were often harder to engage with from primary care services. In Merseyside, an initiative launched by Everton Football Club (Everton in the Community) addresses this challenge by the implementing a ‘Beat Breathlessness Clinic’ based on the NHS England (NHSE) Adult Breathlessness pathway.

Subjects aged >=40 years were invited to attend a ’Walk-in’ clinic if they have been experiencing Chronic Breathlessness for >=4 weeks and undergo an assessment by a nurse using clinical decision support software i.e. a Clinical Guided Consultation (CGC; Cardio-LungHealth; LungHealth Ltd). The CGC is programmed in line with the NHS England Adult Breathlessness pathway. This intelligently integrates a structured history, physical examination with results from key investigations thus generating a final diagnosis or alerting the operator to the possibility a significant cardio-respiratory condition. The CGC interprets spirometry and stages COPD also integrating Heart Failure symptom screening. All patients undergo spirometry, ECG, point of care testing for HbA1c, NT-Pro BNP and FeNO. Each patient report generated from the CGC review along with key investigations was sent electronically and securely by the CGC from the clinic hub direct to the patient’s GP practice.

Who was involved in this work/project?
- Patient reviews were conducted by Nursing staff employed by Everton in the Community and National Services for Health Improvement (NSHI). The project was funded by AstraZeneca. The Cardio-LungHealth software is owned by LungHealth Ltd.
Project outcomes/impact
261 patients (mean age 61 (SD 18) years; 55% Female; mean BMI 27.58 (SD 8.62)) attended the ‘Beat Breathlessness clinic’ from 16/4/24 to 19/3/25.
112 patients complained of breathlessness (96 reporting mMRC2 or higher) and spirometry was performed in 61 of these all of whom had no previous respiratory diagnosis. Of these, 38% (23/61) had spirometry consistent with COPD (GOLD staging by CGC software: 5=1A, 6=1B, 1=1E, 3=2A, 6=2B, 2=2E).
CGC review revealed one case of haemoptysis. 7 patients displayed low oxygen saturations (<=93%) with the CGC alerting the operator and recommending urgent medical review in all cases.
168 patients had point of care NT-Pro BNP levels checked and of these, 30 (18%) were elevated including 5 patients>2000png/L (all these patients underwent echocardiography and specialist assessment).
CGC review determined that 32 subjects were current smokers, 76 ex-smokers and 152 were never smokers with the software prompting the operator to administer smoking cessation support and offer community referral in all tobacco users. 38% (12/32) of smokers accepted community smoking cessation service referral.
CGC review determined 37% (97/261) to be clinically obese highlighting all for weight management advice and following the launch of the pathway, targeted Hba1c checking has been introduced.
Medical oversight is provided by a GP with access to a Consultant Respiratory Physician and Cardiologist with the CGC linked to an electronic dashboard.

The implementation of this clinical pathway thus provides a scalable solution for the assessment and diagnosis of breathlessness as per the NHS England pathway.
If you were to run the project again, what would you do differently?
The project is continuing at present as the work highlighted was part of the initial implementation and “feasibility” phase. As clinicians in LungHealth, we wished to validate the Cardio-LungHealth technology and the wider pathway prior to further implementation. This phase has now provided us with the necessary foundation to continue this work. A key learning point with such projects is the need to undertake the assessment and required tests in a truly “one stop” manner given the target population and the unique setting and circumstances.
Advice you would have for others undertaking the same type of project.
It is important to clinically validate one’s approach and pathway in a feasibility phase, and this should be reported ideally in the form of peer reviewed publication. Some projects struggle beyond an initial “pilot” phase as insufficient consideration is given to scalability and wider adoption which is crucial if one is to truly address healthcare inequality. Consideration should also be given to the implementation of robust governance structures behind any digital pathway as well as to the methods of communication with the patient’s GP and this is where technology may play a role.