Pragmatic Guides

Antibiotics are crucial for managing infectious diseases and preventing complications like pneumonia or sepsis. However, antimicrobial resistance (AMR) poses a growing global health threat, contributing to over 3 million deaths annually. While resistance can occur naturally, the misuse and overuse of antibiotics significantly accelerate this process, rendering treatments less effective or ineffective. 

2024 marked a pivotal change in the management of asthma in the UK with the publication of a joint British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guideline. This guideline, ‘Asthma: diagnosis, monitoring and chronic asthma management’, has the potential to be the paradigm shift that is needed to improve asthma care in the UK. 

The UK has the largest market for vapes in Western Europe. There has been a rapid increase in use over the last decade and, whilst this has now been stabilised in adults, there has been a sharp rise in usage in 18-24-year-olds from 2020, coinciding with the introduction of disposable and flavoured vapes into the UK, which have been popular and attractive to children and young people. In this position statement we outline the background, key issues and PCRS position on CYP and vaping. As part of this, the Primary Care Respiratory Society (PCRS) advocates that:

PCRS welcomes the opportunity that digital respiratory healthcare and the collection and analysis of respiratory data could bring. However, new technology for use in primary care must be interoperable with current patient consultation and management systems, should not be mandated for patients and should be an option as part of shared decision making. New respiratory digital health interventions must, as well as being clinically and cost effective also preferentially attend to the factors that currently maintain respiratory health inequality.

There is a strong commitment from the British Thoracic Society (BTS) and Primary Care Respiratory Society (PCRS) to identify opportunities to support those delivering integrated respiratory care and showcase that planned, properly funded, and evaluated integrated solutions can be used to drive improvements in the care of patients.We value the importance of:• integration between primary, community and secondary care.• integration of respiratory care with other long-term conditions.• integration of both physical and mental health, housing, and social care.

Tackling smoking, reducing air pollution, improving access to healthcare for those experiencing health inequality and an improved focus on research and development to fit the needs of people experiencing health inequality should be the priorities for systems wanting to make respiratory health outcomes equal. Whilst primary care is in an ideal position to screen for, recognise, and treat the effects of poverty on respiratory health, the evidence for prevention interventions that have a direct effect on poverty are limited and do not have strong evidence to support them.

Spirometry is a component of the diagnosis and management of respiratory conditions in primary care and should ideally be performed via referral to a primary care network respiratory diagnostic service or community diagnostics centre (CDC) with expertise in the diagnosis of the most common respiratory conditions and of less common diagnoses. Where limited resources create a challenge for testing everyone with a new suspected diagnosis of asthma, those with an intermediate probability should be prioritised for spirometry and also FENO where available.

Primary care should seek to identify and provide proactive support to older people living with frailty. An extended consultation should be considered that should ideally include the patient’s usual carer to enable a comprehensive review, confirmation of current diagnoses, and review of all medications. Appropriateness of self-administered medication should be considered if dexterity or cognitive issues are present. Patients should have a clear, concise management plan that is available to and understood by all those providing care.

PCRS believe that it is the responsibility of every healthcare professional to treat tobacco dependency systematically and effectively. PCRS advocate that people wishing to quit using tobacco should be offered the most effective but also the least harmful methods first to support a quit attempt. Delivery of stop smoking treatment is challenging due to reduced stop smoking services and a current lack of licensed pharmacotherapies. Prescribed NRT, combining short and long acting versions, along with behavioural support is currently the primary treatment choice.

PCRS recognises a need for improvement in the timely diagnosis of people living with chronic breathlessness and generally welcomes the NHS England diagnostic pathway support tool. PCRS has some concerns that a diagnostic algorithm can communicate an oversimplification of diagnosis. We are disappointed that this pathway will not be accompanied by the long awaited and hoped for, but now deprioritised, NICE Breathlessness guideline.

Concerns about the environmental impact of the propellant gases used in pressurised metered dose inhalers (pMDIs) and the plastics used in all single-use inhaler devices have made them an important focus for efforts to reduce the environmental impact of the NHS. Patients themselves may also be concerned about the environmental impact of their inhalers and express a preference for alternatives. PCRS do not support ‘blanket switching’ of patients from one inhaler type to another.

PCRS advocate a pragmatic approach to the pharmacological management of patients with COPD guided by the predominance of breathlessness and/or exacerbations and the presence or absence of comorbid asthma. Clinicians must undertake a holistic evaluation for alternative causes of persistent daily symptoms or repeated exacerbations and consider seeking advice from a respiratory specialist before escalating to triple therapy (a respiratory specialist may be a GP/nurse/consultant).

Point-of-care testing of C-reactive protein (CRP) for the acute assessment of worsening symptoms in people known to have COPD can safely reduce the use of antibiotics and could help improve the diagnostic approach towards someone presenting in such a crisis. New high-quality evidence has emerged since the last NICE COPD update and we encourage re-opening and review of the current guideline to enable clinicians and system leaders to understand whether and how to implement this promising diagnostic aid.

PCRS support initiatives to improve air quality and minimise short- and long-term damage to the environment, particularly those with an impact on climate change resulting from greenhouse gases.

PCRS supports the UK National Screening Committee’s recommendation that people at high risk of lung cancer have screening and encourage the committee to ensure that the screening programme maximises opportunities for diagnosis of lung disease beyond lung cancer and to ensure ongoing provision of smoking cessation services.

PCRS believe that it is the responsibility of every healthcare professional to treat tobacco dependency systematically and effectively. PCRS advocate that people wishing to quit using tobacco should be offered the most effective but also the least harmful methods first to support a quit attempt. People wishing to use nicotine e-cigarettes to quit should be encouraged to use the support offered by NHS stop smoking services including the ‘swap to stop’ scheme in England. A tobacco quit attempt should be followed ultimately by stopping e-cigarette use as well due to safety concerns.