Breathlessness Algorithm

Safety

Red Flags — Exclude Life-Threatening Causes Immediately

Done

Assess these FIRST before any structured history. If present, act immediately — do not complete the algorithm.

Numbers support the decision; they do not make it. SpO₂, RR, pulse, BP and NEWS2 are warning signs, not diagnostic requirements or destination rules. Severe asthma, PE, pulmonary oedema and ACS can all be critical before a score rises. Read every threshold below against the patient's own baseline, their trajectory and the suspected diagnosis — and an ECG belongs in the initial assessment of any unexplained new breathlessness.

Severe or new hypoxia Judge SpO₂ against the patient's usual/individualised target: most acutely ill adults 94–98%, 88–92% if at risk of hypercapnic respiratory failure — so 91% can sit within their target, but does not exclude acute deterioration (more work of breathing, drowsiness, rising oxygen need, falling trend). Severe hypoxia, a fall below their target, a falling trend, cyanosis, exhaustion, altered consciousness or inability to speak in sentences → 999. SpO₂ alone does not determine destination

Increased work of breathing Rising RR, accessory muscle use, unable to complete sentences, breathlessness at rest that is new → urgent escalation. RR ≥25 is a severity trigger; the destination depends on trajectory, diagnosis and context

Haemodynamic compromise marked tachycardia (e.g. HR >130 — local threshold, not national), BP <90 systolic, mottled peripheries, altered consciousness → 999

Suspected PE Pleuritic chest pain + tachycardia + unilateral leg swelling + DVT risk factors. Unstable — hypotension, severe hypoxia, syncope → 999. Stable but suspected → same-day acute assessment for imaging, not routine primary-care testing

Cardiac cause without chest pain Breathlessness can be the ACS equivalent (diabetes, age over 75, women); also tachy- or bradyarrhythmia, valvular disease, myocarditis, pericardial disease, pulmonary hypertension. ECG in the initial assessment; suspected ACS or malignant arrhythmia → 999

Tension pneumothorax Sudden onset, tracheal deviation, absent breath sounds, hypotension → 999

Acute severe / life-threatening asthma Life-threatening: PEF <33%, silent chest, cyanosis, poor respiratory effort, exhaustion, bradycardia, confusion — a normal or rising PaCO₂ in a deteriorating patient signals fatigue / near-fatal asthma. Acute severe: PEF 33–50%, RR ≥25, pulse ≥110, cannot complete sentences (BTS/SIGN 158 — NG245 excludes acute attacks). Treat immediately. Life-threatening features → 999, immediate admission; acute severe → admit if any feature persists after initial treatment (999 if deteriorating, exhausted, hypoxic or unable to speak)

Acute pulmonary oedema Orthopnoea, pink frothy sputum, bilateral crackles, elevated JVP → 999

Anaphylaxis Acute onset dyspnoea + urticaria/angioedema/hypotension after trigger → 999 + IM adrenaline 0.5 mg

Stridor / upper airway Inspiratory noise, drooling, unable to swallow, epiglottitis features → 999

Haemoptysis Unexplained haemoptysis aged 40 and over → suspected cancer pathway referral (NICE NG12). At any age it needs prompt clinical assessment and targeted investigation (CXR, FBC, clotting, examination) — not a wait-and-see

Suspected SVC obstruction Facial or arm swelling, distended neck veins, facial plethora, headache. Stridor, airway compromise, cerebral symptoms or severe deterioration → 999; otherwise urgent same-day oncology / respiratory assessment — urgency also depends on the underlying malignancy, progression of facial/neck swelling, suspected thrombosis and ability to lie flat

Breathlessness is a common presentation in UK general practice and carries a broad differential from trivial to immediately life-threatening. Missed acute asthma and PE remain causes of avoidable death. A low or falling SpO₂ matters because compensatory mechanisms are near-exhausted — but it must be read against the patient's own target, since a person with chronic hypercapnic respiratory failure may live at 88–92%. Unexplained haemoptysis at 40 and over meets NICE NG12 criteria for a suspected cancer pathway referral, where the positive predictive value passes the 3% referral threshold; at any age it still needs prompt assessment.

Diagnose

Confirm Onset, Pattern & Severity — Structured History

Done

Use SOCRATES + targeted questions to narrow the differential. One key question separates most diagnoses.

Onset & speed

Sudden (<minutes) → PE, pneumothorax, anaphylaxis, acute pulmonary oedema
Hours–days → Pneumonia, asthma exacerbation, acute HF
Weeks–months → COPD, malignancy, anaemia, pleural effusion, anxiety

Triggering factors

Exercise → cardiac / COPD / deconditioning · Rest → severe cardiorespiratory disease · Allergen → asthma / anaphylaxis · Position (flat) → HF, phrenic palsy · Night symptoms → asthma

Associated symptoms

Wheeze → asthma / COPD · Pleuritic pain → PE / pneumonia / pleurisy · Ankle swelling + orthopnoea → HF · Productive cough → infection · Haemoptysis → PE / TB / malignancy · Palpitations → arrhythmia · Stridor → upper airway

Functional severity

Use MRC Dyspnoea Scale: Grade 1 (strenuous exercise only) to Grade 5 (too breathless to leave home). Document baseline vs change.

Background history

Smoking (pack-years) · Prior asthma / COPD / HF / PE / malignancy · Recent immobility / long-haul flight / surgery (DVT/PE risk) · Medications (β-blockers worsen asthma; ACEi cause cough)

DVT/PE risk

Apply Wells PE score if PE suspected: ≤4 → D-dimer — if the result will take over 4 hours, give interim therapeutic anticoagulation (NG158); >4 → immediate CTPA (or V/Q) via the acute route — no D-dimer, and interim therapeutic anticoagulation if imaging will be delayed. Do not apply Wells if already sending to 999, and neither Wells nor D-dimer is validated in pregnancy or up to 6 weeks postpartum.

Occupational / environmental

Asbestos (mesothelioma) · Farming / birds (extrinsic allergic alveolitis) · Silica (silicosis) · Always ask about pets and hobbies

The MRC Dyspnoea Scale is validated, reproducible, and tracks treatment response over time — document grade at every consultation. Wells score is a validated clinical decision rule that stratifies pre-test probability for PE; using it reduces unnecessary imaging without missing significant PE (NICE NG158). Occupational history is frequently omitted and can reveal treatable, compensable diagnoses.

Diagnose

Classify the Working Diagnosis — Phenotyping by Pattern

Done

Classify by acuity and mechanism. Treatment diverges sharply between these groups.

Obstructive airway
(Asthma / COPD)

Variable wheeze · Diurnal variation · Atopy / smoking history · Reversibility on spirometry (FEV₁/FVC <0.7 in COPD). Spirometry is diagnostic gold standard — not peak flow alone.

Cardiac dyspnoea
(HF / arrhythmia)

Orthopnoea, PND, ankle oedema, elevated JVP, S3 gallop. NT-proBNP + ECG, then the local HF pathway (NG106). A low NT-proBNP makes heart failure unlikely but does not exclude all cardiac disease, and is lowered by obesity and by treatment. Echo defines phenotype (HFrEF/HFpEF) — treatment follows the diagnosis, not the symptom.

Thromboembolic
(PE / DVT)

Wells score. D-dimer only if Wells ≤4 (interim anticoagulation if the result will take over 4 hours — NG158); an age-adjusted threshold (age × 10) applies only where the assay's units are stated. Wells >4 → imaging, not D-dimer.

Infective / inflammatory
(Pneumonia / pleuritis)

Fever, productive cough, crackles, consolidation on CXR. CRB65 is a mortality-risk tool used with clinical judgement: 0 low risk — community management if observations, comorbidity and social circumstances are safe; 1 — shared decision on GP-led care, virtual ward, SDEC, hospital-at-home or hospital; ≥2 — consider hospital referral (NICE NG250 1.2.3). Sepsis, cardiorespiratory failure, inability to take oral medicines or major concern → hospital assessment.

Pleural disease
(Effusion / pneumothorax)

Reduced breath sounds, stony dull (effusion) or hyper-resonant (pneumothorax). CXR first-line. Exudate vs transudate → Light's criteria at aspiration.

Haematological
(Anaemia / metHb)

Pallor, tachycardia, fatigue, exertional dyspnoea disproportionate to exam. FBC + haematinics. SpO₂ unreliable in methaemoglobinaemia — co-oximetry needed.

Psychogenic / deconditioning

Diagnosis of exclusion. Breathing pattern disorder features: sighing, hyperventilation, tingling, inconsistency. Consider Nijmegen questionnaire. Do not diagnose anxiety until all organic causes excluded.

Classifying the mechanism determines the entire management pathway. Treating presumed asthma with bronchodilators in undiagnosed HF delays definitive care and may cause harm. NT-proBNP has a high negative predictive value, so a low result makes heart failure unlikely — but it does not exclude other cardiac disease, and obesity and HF drugs lower it. CRB65 is validated for community-acquired pneumonia mortality risk and informs, rather than replaces, the admission decision (NICE NG250). Psychogenic breathlessness is common but cannot be diagnosed until organic causes are excluded — never anchor on this diagnosis prematurely.

Diagnose

Targeted Examination — Focused Clinical Assessment

Done

Examine in order of urgency. Each finding should confirm or refute your working hypothesis.

Vital signs first

RR over a full minute — RR ≥25 is a severity trigger, not by itself a destination. SpO₂ on air, against the patient's usual/individualised target (mandatory). HR, BP, temperature, GCS. NEWS2 supports escalation and prompts urgent clinical review; it does not replace judgement or decide 999 — physiology, suspected diagnosis, trajectory and the local escalation protocol do. Repeat the observations after treatment.

General inspection

Position (sitting forward → severe obstruction) · Pursed-lip breathing → COPD · Accessory muscle use · Cyanosis (central vs peripheral) · Cachexia → malignancy · Clubbing → fibrosis, malignancy, bronchiectasis

Respiratory

Expansion (symmetry → pneumothorax if asymmetric) · Percussion (dull → effusion / consolidation; hyperresonant → pneumothorax) · Auscultation: wheeze (expiratory = obstruction), crackles (fine = fibrosis / HF, coarse = infection), bronchial breathing (consolidation), absent sounds (effusion / pneumothorax)

Cardiovascular

JVP elevation → HF / SVCO / COPD cor pulmonale · Apex beat position · Heave (RV overload) · Heart sounds: S3 gallop (HF), loud P2 (pulmonary hypertension) · Peripheral oedema (bilateral → HF; unilateral → DVT)

Peak flow (if asthma suspected)

Compare to predicted and personal best. <50% personal best = acute severe. <33% = life-threatening. Measure in acute asthma unless too ill to perform; never let it delay treatment or transfer. SpO₂ <92% is itself a life-threatening feature.

Legs

Clinical signs of DVT (leg swelling and tenderness along the deep veins) → scores 3 in the Wells PE score. Bilateral pitting oedema → cardiac / hypoalbuminaemia / venous insufficiency.

ENT / upper airway

Inspiratory stridor → laryngeal or tracheal obstruction. Uvular deviation → peritonsillar abscess / epiglottitis. Do NOT examine throat if epiglottitis suspected (risk of complete obstruction).

NEWS2 is the NHS-mandated early warning score for acute deterioration; a score ≥5 should trigger senior review or hospital transfer discussion. SpO₂ monitoring often changes management. Percussion is underutilised in primary care but helps detect a moderate–large pleural effusion. Clubbing should always prompt investigation as it is often associated with significant underlying disease (malignancy, ILD, bronchiectasis).

Diagnose

Investigations — Targeted Testing to Confirm Diagnosis

Done

Investigate based on working diagnosis. Avoid blanket requesting — every test should answer a specific question.

Initial assessment

SpO₂ (point-of-care) and full observations · ECG for any unexplained new breathlessness — AF and other arrhythmia, RV strain, LVH, ischaemia. CXR is targeted: it is part of the initial assessment for newly suspected COPD (with post-bronchodilator spirometry, FBC and BMI — NG115); otherwise request it for suspected pneumonia, pulmonary oedema, pneumothorax, pleural disease, malignancy, interstitial lung disease or another thoracic cause — not for an uncomplicated asthma exacerbation unless an alternative diagnosis or complication is suspected.

Suspected HF

NT-proBNP + ECG (NICE NG106): <400 ng/L — heart failure less likely in an untreated person, investigate alternatives; 400–2000 ng/L — specialist assessment and echocardiography within 6 weeks; >2000 ng/L — urgent specialist assessment and echocardiography within 2 weeks. A low value does not exclude all cardiac disease and is lowered by obesity (BMI >35), African or African-Caribbean family background, and by diuretics, ACEi/ARB, beta-blockers and MRAs; it is raised by age over 70, left ventricular hypertrophy, myocardial ischaemia, tachycardia (including AF), right ventricular overload, hypoxaemia (including PE), eGFR <60, sepsis, COPD, diabetes and cirrhosis (NG106). In acute pulmonary oedema or severe decompensation, do not wait for NT-proBNP or echo. Add U&Es, eGFR, LFTs, TFTs, FBC

Suspected asthma

FeNO ≥50 ppb (adults 17+) or ≥35 ppb (ages 5–16) = diagnostic of asthma per NG245 (the older 40 ppb figure was NG80) · Spirometry + bronchodilator reversibility (>12% AND >200 mL improvement = positive) · Bronchial challenge if equivocal · Peak flow diary (2-week record). Tests can be temporarily normal after treatment — code as suspected asthma until objectively confirmed

Suspected COPD

Post-bronchodilator spirometry (FEV₁/FVC <0.7 confirms) · FBC (polycythaemia), α₁-antitrypsin (if early onset / minimal smoking)

Suspected PE

Wells ≤4: D-dimer — interim anticoagulation if the result will take over 4 hours (NG158) (age-adjusted threshold only where the assay's units are specified). Raised → imaging. Wells >4: immediate CTPA or V/Q — no D-dimer; if imaging will be delayed, interim therapeutic anticoagulation with baseline FBC, renal and hepatic function, PT and APTT — do not delay anticoagulation for results — and document bleeding risk, active bleeding, recent surgery, weight and interacting medicines (NG158). Pregnant or up to 6 weeks postpartum: no Wells, no D-dimer — urgent objective testing must still be arranged: ECG and CXR, compression ultrasound first if DVT symptoms, V/Q or CTPA if PE remains suspected, and LMWH while awaiting exclusion unless strongly contraindicated (RCOG Green-top 37b). This is more than a maternity referral.

Suspected pneumonia

CXR · CRP (only if LRTI diagnosis is uncertain — never overrides clinical assessment or CRB65) · If admitted: urine pneumococcal antigen, blood cultures, legionella antigen

Suspected malignancy

CXR (mass, collapse, effusion, pleural thickening) · CT chest via the lung suspected cancer pathway · FBC, LFTs, calcium, albumin

Suspected anaemia

FBC + film · Ferritin, B12, folate · Reticulocyte count if haemolysis suspected · Ferritin can be low before anaemia and is raised by inflammation — consider transferrin saturation if equivocal

Do NOT investigate

D-dimer if Wells >4 (go direct to imaging) · Spirometry during an acute exacerbation (inaccurate) · Routine ECHO without clinical/NT-proBNP indication (low yield, long wait) · Routine CXR for every breathlessness presentation, or for an uncomplicated asthma exacerbation · A blanket blood panel — each test should answer a question you have asked

NT-proBNP has a high negative predictive value for HF — it is the single most efficient test for ruling out cardiac dyspnoea in primary care. FeNO is the recommended first objective test for suspected asthma (BTS/SIGN/NICE NG245): ≥50 ppb in adults 17 and over, or ≥35 ppb at ages 5–16, confirms asthma. Smoking lowers FeNO, so a normal result does not exclude it — move on to spirometry with reversibility, then PEF variability. Age-adjusted D-dimer (age × 10 µg/L for patients >50) increases specificity without sacrificing sensitivity, avoiding unnecessary CTPA in older patients. A normal CXR is common in PE and should not be used to exclude it.

Refer

Referral Criteria — When to Escalate & to Whom

Done

Match urgency to clinical risk. When in doubt, refer more urgently, not less.

999 Emergency

Severe hypoxia or a fall below the patient's individualised target · exhaustion, cyanosis, inability to speak in sentences, altered consciousness · haemodynamic instability · life-threatening asthma (PEF <33%, silent chest, poor effort, bradycardia, confusion) · suspected tension pneumothorax · anaphylaxis · suspected ACS or malignant arrhythmia with dyspnoea · stridor or airway compromise. A high NEWS2 demands urgent clinical review — it does not by itself decide 999; physiology, suspected diagnosis, trajectory and the local escalation protocol do

Same-day hospital

New hypoxia or breathlessness at rest without life-threatening features · suspected PE, stable (Wells >4, or Wells ≤4 with a positive or unobtainable D-dimer) · acute severe asthma with any feature persisting after initial treatment — admit (BTS/SIGN 158) · community pneumonia CRB65 ≥2 (consider hospital referral, NICE NG250 1.2.3), or CRB65 1 with hypoxia, frailty, major comorbidity or poor support · suspected spontaneous pneumothorax of any size (BTS 2023 manages by symptoms and stability, not CXR size) · suspected cardiac tamponade · acute heart failure or pulmonary oedema · suspected SVC obstruction without instability (oncology/respiratory)

Lung suspected cancer pathway
NICE NG12

Unexplained haemoptysis aged ≥40 · Age ≥40 + ≥2 unexplained symptoms of: cough, fatigue, breathlessness, chest pain, weight loss, appetite loss — or one of those in an ever-smoker → urgent direct-access CXR within 2 weeks · unexplained breathlessness aged ≥40 with a smoking history, asbestos exposure or a relevant symptom combination → urgent CXR · CXR suspicious for malignancy → suspected cancer pathway. Hoarseness is a separate pathway: persistent unexplained hoarseness (≥3 weeks) aged 45 and over → suspected head and neck cancer referral, not a lung rule

Urgent respiratory
(Within 2 weeks)

New pleural effusion (undiagnosed) · Suspected ILD (bilateral crackles, clubbing, CXR changes) · Haemoptysis under 40 (outside the suspected cancer pathway criteria) that stays unexplained or recurs after prompt assessment (CXR, FBC, clotting) · Suspected malignant pleural mesothelioma (asbestos exposure)

Routine respiratory

Confirmed COPD requiring specialist spirometry · Difficult / uncontrolled asthma despite step 3 treatment · Bronchiectasis (confirmed or suspected) · Suspected pulmonary hypertension (echo referral)

Urgent cardiology

NT-proBNP 400–2000 ng/L → specialist assessment and echo within 6 weeks; >2000 ng/L → within 2 weeks (NICE NG106) · New AF with dyspnoea → rate/rhythm and anticoagulation assessment · Decompensated chronic HF not responding to treatment · Suspected valvular disease, myocarditis, pericardial disease or pulmonary hypertension

Manage in primary care

Mild COPD with good symptom control · Well-controlled asthma (NG245 step 1–2) · Deconditioning / obesity-related dyspnoea · Anxiety / breathing pattern disorder (after exclusion) · Mild anaemia with identified cause

The lung suspected cancer pathway detects lung cancer at an earlier stage and improves 5-year survival; BNP-guided referral for echocardiography is the NICE NG106 recommended pathway — it is cost-effective and reduces unnecessary echocardiography. New undiagnosed pleural effusions require urgent respiratory referral as a substantial proportion have an underlying malignant aetiology. Suspected spontaneous pneumothorax of any size needs same-day acute assessment: BTS 2023 bases management on symptoms and stability rather than CXR size, and tension features need 999.

Treat

Treatment Pathway — Condition-Specific Management

Done

First-line treatment depends on confirmed diagnosis. Each pathway below follows the numbered guideline named in its heading (NICE NG245, NG115, NG106, NG250) and the BTS guidance listed under Sources.

This is a diagnostic pathway. Only the immediately required treatment lives here — full asthma, COPD, heart-failure and PE regimens belong to their own maintained pathways. Check doses in the SPC and your local formulary. Treat acute bronchospasm immediately when the patient is unwell; confirm a chronic diagnosis objectively afterwards — objective testing must never delay acute treatment.

First-line initial therapy by diagnosis

Asthma (newly diagnosed)

AIR — ICS/formoterol PRN NG245 Step 1

Low-dose combined ICS/formoterol, 1 puff as needed — the anti-inflammatory reliever. NG245: never start SABA alone. Use the local formulary's preparation and check the product-specific dose. Check inhaler technique at every visit.

COPD (newly diagnosed)

Short-acting bronchodilator Step 1

Confirm COPD with post-bronchodilator spirometry first. Salbutamol (or ipratropium) PRN for symptom relief, then assess the response. If symptoms persist, choose maintenance therapy on breathlessness, exacerbation history, inhaler technique, comorbidity and the presence or absence of asthma features — not a fixed LABA/LAMA pathway applied to everyone.

Heart failure (suspected)

Diagnose first NT-proBNP + ECG

Follow the local HF diagnostic pathway (NG106); acute pulmonary oedema is an emergency. A loop diuretic only where there is clinical fluid overload, per local guidance — never for breathlessness of uncertain cause. Start disease-modifying treatment (ACEi/ARNI, beta-blocker, MRA, SGLT2 inhibitor) only after diagnosis, echo phenotype and clinical review; do not start or up-titrate a beta-blocker during acute decompensation. Check renal function, potassium and BP before and after any change.

Community pneumonia (CRB65 0, or 1 assessed as safe for primary care)

Amoxicillin 500 mg TDS 5 days

If penicillin allergic: doxycycline 200 mg then 100 mg OD for 5 days. Atypical cover: add clarithromycin 500 mg BD if atypical features (dry cough, bilateral infiltrates). Follow the current local antimicrobial guideline.

PE (confirmed, stable)

DOAC Anticoagulant

Apixaban 10 mg BD for 7 days then 5 mg BD, or rivaroxaban 15 mg BD for 21 days then 20 mg OD (NG158 — neither is universally "preferred"). Before starting: FBC, renal (Cockcroft–Gault CrCl) and hepatic function, PT/APTT, weight, bleeding risk, pregnancy/breastfeeding, active cancer, antiphospholipid syndrome (triple-positive: DOACs unsuitable) and interacting drugs — do not delay anticoagulation for results; follow the local VTE pathway. Confirmed PE needs at least 3 months; continuation beyond 3 months is individualised, not a fixed provoked-3/unprovoked-6 rule. Community treatment only through a validated low-risk PE pathway with reliable follow-up.

Iron deficiency anaemia

Ferrous sulfate 1st line

200 mg OD (one tablet OD, on alternate days if tolerated). Recheck Hb at about 2–4 weeks per the local anaemia pathway. Do not delay cancer referral or investigation while awaiting response. Treat for 3 months after Hb normalised to replenish stores. Investigate cause simultaneously.

Asthma escalation ladder (BTS/SIGN/NICE NG245, 2024)

Step 1AIR — low-dose ICS/formoterol PRN (1 puff as needed; use the local formulary preparation and its own dose). No SABA-only therapy at any step. Counsel that every reliever puff now also delivers the steroid.

Step 2Low-dose MART — same ICS/formoterol inhaler 1 puff BD maintenance + PRN relief. One inhaler for prevention and rescue.

Step 3Moderate-dose MART — increase the maintenance dose (product-specific: typically 2 puffs BD + PRN). Confirm technique + adherence before stepping up.

Step 4Before stepping up check adherence, inhaler technique, exposures, smoking, comorbidity and the diagnosis. Refer if uncontrolled on moderate-dose MART, diagnostic uncertainty, frequent exacerbations or high-risk features (NG245); FeNO and eosinophils support specialist assessment and treatment choice rather than acting as a binary rule.

COPD escalation ladder (NICE NG115)

Step 1Short-acting bronchodilator PRN — salbutamol (or ipratropium). NICE NG115's actual first step; assess response before any maintenance inhaler.

Step 2Maintenance therapy chosen on assessment — once short-acting treatment is insufficient, NG115 offers LABA + LAMA where there are no asthmatic/steroid-responsive features, or LABA + ICS where there are. Choose on breathlessness, exacerbation history, technique, adherence and comorbidity, and review the response; LAMA alone is for the patient who cannot tolerate a LABA.

Step 3ICS-containing (triple) therapy: LAMA + LABA + ICS — consider where there are asthma features or persistent exacerbations despite appropriate bronchodilator treatment, guided by blood eosinophils, local criteria and NICE NG115. FEV₁ <50% is not a universal prerequisite. Weigh the pneumonia and other ICS risks, and review whether it helped.

Step 4Specialist review — Consider theophylline (monitor levels), azithromycin prophylaxis (for frequent exacerbators, check QTc, NTM), roflumilast, long-term oxygen therapy (LTOT) assessment only with resting hypoxaemia — breathlessness alone is not an indication.

⚠ Acute exacerbation — asthma and COPD are separate, do not merge the boxes:
Acute asthma: salbutamol 4–10 puffs via spacer, one puff at a time, every 10–20 minutes, or 5 mg nebulised · prednisolone 40–50 mg daily until recovery, for at least 5 days (BTS/SIGN) · titrate oxygen to 94–98%, avoiding unnecessary high-concentration oxygen · no routine antibiotic · nebulise with oxygen if hypoxic · do not let PEF measurement delay treatment or transfer · repeat PEF and SpO₂ after treatment where the patient is not deteriorating. Life-threatening features → 999 and immediate admission; acute severe features persisting after initial treatment → admit (BTS/SIGN 158).
COPD exacerbation: increase the short-acting bronchodilator via spacer or air-driven nebuliser · prednisolone 30 mg daily for 5 days · antibiotic only when clinically indicated, particularly more purulent sputum or other features suggesting bacterial infection · oxygen to the individualised target, generally 88–92% if at risk of hypercapnia · titrate oxygen, never withhold it · air-driven nebulisers where hypercapnia is a concern, with oxygen given separately if needed · drowsiness or headache suggests CO₂ retention but only blood gases confirm it — suspected hypercapnic respiratory failure is a transfer, not more nebulisers.

Next steps: see Asthma · COPD · Heart failure · Pulmonary embolism · Acute cough and chest infections · Iron deficiency anaemia · Atrial fibrillation

ICS in asthma reduces exacerbations and asthma deaths — which is why NG245 (2024) abolished SABA-only therapy: every reliever is now ICS/formoterol (AIR/MART), so treating symptoms automatically treats inflammation. Triple therapy in COPD reduces exacerbations compared with dual bronchodilation but increases pneumonia risk — hence reserving ICS for asthma features or persistent exacerbations, guided by eosinophils. DOACs are preferred over LMWH/warfarin for most confirmed PE; apixaban and rivaroxaban are both first-line options in NG158, chosen on renal and hepatic function, weight, bleeding risk and interactions rather than a blanket preference. Titrate oxygen to the individualised target — generally 88–92% where there is hypercapnic risk, because in a CO₂ retainer high-flow oxygen risks worsening hypercapnia.

Lifestyle

Non-Pharmacological Interventions — Essential Adjuncts

Done

Lifestyle modifications are treatments, not optional extras. Prescribe them with the same specificity as drugs.

Smoking cessation Single most impactful intervention for COPD, asthma, lung cancer and cardiovascular disease. Refer to the NHS Stop Smoking Service and offer licensed pharmacotherapy through it. Every consultation is an opportunity — brief intervention takes 30 seconds.

Pulmonary rehabilitation (PR) 6–8 week supervised exercise and education programme. Offer to COPD patients functionally limited by breathlessness (MRC ≥3) and after a hospital admission for an exacerbation (NG115). Improves exercise capacity, symptoms and quality of life (NG115). Refer via respiratory or the local PR service.

Vaccinations Influenza, pneumococcal, COVID-19 and RSV vaccination according to the current UK immunisation schedule (Green Book) — products and eligibility change each season, so check rather than working from a remembered regimen.

Weight management Obesity (BMI >30) independently worsens dyspnoea via reduced chest wall compliance and increased O₂ demand. Weight loss improves breathlessness, exercise tolerance, and CPAP compliance in OSA. Refer to NHS Tier 2/3 weight management services if BMI >35.

Breathing retraining Diaphragmatic and pursed-lip breathing (COPD) · physiotherapy-led breathing pattern disorder programme for hyperventilation and inducible laryngeal obstruction. The Nijmegen questionnaire is supportive, not diagnostic — interpret it with the history once cardiopulmonary disease is excluded. Deliver it through a physiotherapist rather than recommending a named proprietary technique.

Exercise and physical activity Deconditioning is reversible. Prescribe structured exercise: 150 minutes moderate-intensity/week (UK Chief Medical Officers' physical activity guidelines, 2019; brief advice per NICE PH44). Cardiac rehab for HF patients. Social prescribing to community walking groups / BHF programmes.

Trigger avoidance (asthma) Avoid identified triggers — NSAIDs in NSAID-sensitive asthma, beta-blockers, occupational exposures, and known animal or mould exposure where the history fits. Physical measures against house dust mite (mattress covers, filters) are not recommended as general advice: no consistent clinical benefit.

Home environment COPD and asthma: damp, mould, wood-burning stoves and gas cooking worsen symptoms. Refer to the housing team where poor housing contributes, and address the source rather than recommending a device.

Mental health support Anxiety and depression are common in COPD and HF — breathlessness generates fear, which worsens breathlessness (hyperventilation cycle). Offer NHS Talking Therapies referral. CBT has evidence for both asthma and COPD self-management.

Advance care planning (COPD / HF) For MRC Grade 4–5 or advanced HF: sensitive ACP discussion about resuscitation preferences, preferred place of care, and goals. Refer to specialist respiratory or palliative services for refractory breathlessness (fan, breathing techniques; opioids only in selected advanced disease — not for unexplained breathlessness or stable COPD).

Pulmonary rehabilitation is one of the most cost-effective interventions in all of medicine — UK economic evaluations put its cost per QALY gained in COPD far below the usual £20,000–30,000 per QALY threshold. Smoking cessation slows FEV₁ decline in COPD towards the normal rate — no pharmacological intervention comes close. Influenza vaccination reduces COPD exacerbations. The breathlessness-anxiety cycle is a key driver of functional impairment; treating only the physiological component without addressing the psychological response leads to persistent disability. Prescribe rehabilitation as you would a drug — with dose, frequency, and duration.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

Every breathless patient needs a clear follow-up plan and explicit safety-netting before leaving. Document both in the records.

Acute presentation
(Infection / exacerbation)

48–72 hours: Phone or in-person review if not improving or worsening. Confirm treatment response. If still febrile or SpO₂ falling below target → same-day hospital assessment. Re-examine and repeat the observations. After an acute asthma attack treated in primary care or OOH: review within about 2–7 days — UK standards specify within 2 working days of an exacerbation treated in hospital or out of hours (NICE QS25). Routine asthma review is separate — at least annually.

New diagnosis
(Asthma / COPD / HF)

2 weeks: Confirm diagnosis, review investigation results (spirometry, BNP, echo request). Assess inhaler technique. Check adherence and tolerability of new medications. Smoking cessation referral confirmed?

Medication titration

1–2 weeks: renal function and electrolytes 1–2 weeks after starting and 1–2 weeks after each dose increase of ACEi, ARNI, ARB or MRA in heart failure, then periodically (NG106). Hb response at about 2–4 weeks of iron therapy, per the local anaemia pathway. BP and renal function if starting a diuretic. Theophylline level (target 10–20 mg/L) at steady state (3–5 days).

Stable chronic disease
(COPD / Asthma / HF)

3 months: Annual structured review minimum. COPD: CAT score, exacerbation frequency, smoking status, inhaler technique, PR attendance, vaccinations, spirometry. Asthma: PAAP in place, symptom control (ACQ/RCP 3 questions), PEFR. HF: symptoms, function, volume status, BP, renal function, potassium and medication tolerance; repeat echo or NT-proBNP only when clinically indicated or per the local HF pathway.

Anticoagulation for PE

3 months: review anticoagulation and individualise continuation — recurrence risk, bleeding risk, cancer status, patient preference and the specialist/local protocol, not a fixed provoked-3/unprovoked-6 rule. Reduced-dose apixaban 2.5 mg BD is one extended-treatment option. Thrombophilia testing only per local haematology criteria. Cancer-associated PE → DOAC or LMWH with oncology input.

Post-referral monitoring

Confirm suspected cancer pathway referral acknowledged within 2 working days. Chase echo result if not received within 6 weeks (HF pathway). Ensure patient has specialist contact if condition deteriorates before appointment.

Safety-net: Call 999

Sudden severe worsening of breathlessness at rest · oxygen saturation falling below the patient's target · cannot complete a sentence · cyanosis · collapse or altered consciousness · chest pain with breathlessness (possible ACS / PE) · stridor develops

Safety-net: Same-day GP

Breathlessness not improving after 48 hours of treatment · Fever returning after initial improvement (secondary infection / empyema) · Increasing wheeze not responding to reliever · New ankle swelling · Haemoptysis develops · Cough productive of green / brown sputum after 5 days

Personalised action plan

All asthma patients must leave with a written Personalised Asthma Action Plan (PAAP) — a core NG245 requirement and the intervention most consistently linked to fewer attacks. COPD patients: self-management plan (NG115); a rescue pack only if they can recognise an exacerbation, understand when to use it and its harms, agree to tell the practice after use and are reviewed — antibiotic only when indicated, no repeated unsupervised courses.

Safety-netting is a medicolegally critical part of any breathlessness consultation and should be documented verbatim in the patient record. Written instructions are recalled better than verbal advice alone. Renal function monitoring after starting an ACEi in HF detects acute kidney injury; this is a key prescribing safety competency assessed in the RCGP SCA. Personalised asthma action plans are among the most evidence-based interventions for reducing asthma attacks, yet a minority of UK asthma patients have one. The 48-hour safety-net is particularly important in pneumonia: failure to improve by 48 hours suggests a resistant organism, a complication (empyema, abscess), or a missed diagnosis. Good safety-netting is not optional — it is the standard of care.