Diagnosis of the cause of chronic dyspnoea in primary and tertiary care: characterizing diagnostic confidence

Management of chronic breathlessness in primary care: what do GPs, non-GP specialists, and allied health professionals think?

BACKGROUND

To explore the perspectives of GPs, non-GP specialists, and allied health professionals on the role of primary care in diagnosing and managing chronic breathlessness, the barriers faced, and the resources needed to optimise care of patients with chronic breathlessness.

METHODS

This was a qualitative study involving focus group discussions that included 35GPs, non-GP specialists, and allied health professionals. Topics explored included: (1) views on the role of primary care in diagnosing and managing chronic breathlessness; (2) barriers to optimal assessment in primary care; and (3) facilitators to further optimise the care of patients with chronic breathlessness.

RESULTS

All participants considered that primary care has a central role to play in the assessment and management of chronic breathlessness, but greater access to referral services, suitable funding structures, and upskilling on the use of diagnostic tests such as spirometry and electrocardiography are required for this to be realised. Both GPs and non-GP specialists described great potential for developing better linkages, including new ways of referral and online consultations, greater ease of referral to allied health services, even if conducted virtually, for patients with functional causes of breathlessness. Participants identified a need to develop integrated breathlessness clinics for patients referred by GPs, which would ensure patients receive optimal care in the shortest possible time frame.

CONCLUSIONS

GPs are crucial to achieving optimal care for breathless patients, especially given the multifactorial and multimorbid nature of breathlessness; however, there are significant gaps in services and resources at present that limit their ability to perform this role.

A systematic review on the effectiveness and impact of clinical decision support systems for breathlessness

Breathlessness is a common presenting symptom in practice. This systematic review aimed to evaluate the impact of CDSS on breathlessness and associated diseases in real-world clinical settings. Studies published between 1 January 2000 to 10 September 2021 were systematically obtained from 14 electronic research databases including CENTRAL, Embase, Pubmed, and clinical trial registries. Main outcomes of interest were patient health outcomes, provider use, diagnostic concordance, economic evaluation, and unintended consequences. The review protocol was prospectively registered in PROSPERO (CRD42020163141). A total of 4294 records were screened and 37 studies included of which 30 were RCTs. Twenty studies were in primary care, 13 in hospital outpatient/emergency department (ED), and the remainder mixed. Study duration ranged from 2 weeks to 5 years. Most were adults (58%). Five CDSS were focused on assessment, one on assessment and management, and the rest on disease-specific management. Most studies were disease-specific, predominantly focused on asthma (17 studies), COPD (2 studies), or asthma and COPD (3 studies). CDSS for COPD, heart failure, and asthma in adults reported clinical benefits such as reduced exacerbations, improved quality of life, improved patient-reported outcomes or reduced mortality. Studies identified low usage as the main barrier to effectiveness. Clinicians identified dissonance between CDSS recommendations and real-world practice as a major barrier. This review identified potential benefits of CDSS implementation in primary care and outpatient services for adults with heart failure, COPD, and asthma in improving diagnosis, compliance with guideline recommendations, promotion of non-pharmacological interventions, and improved clinical outcomes including mortality.

Management of Refractory Breathlessness: a Review for General Internists

Internists frequently care for patients who suffer from breathlessness in both the inpatient and the outpatient settings. Patients may experience chronic refractory breathlessness despite thorough evaluation and management of their underlying medical illnesses. Left unmanaged, chronic breathlessness is associated with worsened quality of life, more frequent visits to the emergency room, and decreased activity levels, as well as increased levels of depression and anxiety. This narrative review summarizes recent research on interventions for the relief of breathlessness, including both non-pharmacologic and pharmacologic options.

Diagnostic approach to chronic dyspnoea in adults

Chronic dyspnoea, or breathlessness for more than four weeks duration, is a common symptom in adults presenting to primary and tertiary care. It often presents a diagnostic challenge due to the wide spectrum of underlying disease, which is multifactorial in approximately one third of cases. Challenges in diagnosis include an often non-diagnostic clinical assessment, difficulty in selecting the most appropriate investigations and correct speciality referral for further diagnostic assessment. In patients presenting with chronic dyspnoea, history and physical examination are often non-specific with key findings more useful as negative predictive factors. There is a broad range of simple to specialised investigations that may be utilised in the diagnostic workup. Several diagnostic algorithms incorporating different tiers of investigations have been tested in studies of chronic dyspnoea patients but there is currently very limited data that test a diagnostic algorithm against standard clinical care. In this review we propose a diagnostic pathway with primary, secondary and tertiary level investigations for patients with chronic dyspnoea. This pathway is based on the combination of previously tested diagnostic algorithms in the literature, to assist clinicians in their diagnostic workup of chronic dyspnoea patients. Further research is needed to further evaluate diagnostic algorithms in this setting and to test this diagnostic pathway in clinical practice.