News & Comment

Obstructive airways diseases, including asthma and COPD as the most commonly encountered respiratory diseases in primary care, are both diagnosed by lung function testing using spirometry as the gold standard. However, this test is not always available in primary care practices and if it is, it is a difficult test to perform, requiring extensive operator training and patient co-operation with multiple forced manoeuvres. These barriers can lead to underdiagnosis and misdiagnosis, which further contributes to increased suffering and mortality associated with asthma and COPD. Oscillometry uses oscillating pressure waves to measure airflow obstruction and provides an alternative diagnostic test which is quicker and simpler than spirometry, requiring little training and no forced manoeuvres. Moreover, it provides additional aspects of lung function measurement which are not obtained by spirometry, making it a valuable option in primary care for diagnosing asthma and COPD.

The British BTS/NICE/SIGN Asthma Guideline was launched in November 2024 and represents a major shift in asthma diagnosis and management in the United Kingdom. The British Guideline places emphasis on markers of eosinophilic inflammation as initial key diagnostic tests whereas GINA places emphasis on test of reversible airflow limitation. Both documents acknowledge that there is no one “gold-standard” test and, especially in areas of the world where the is limited or delayed access to tests, the IPCRG “jigsaw puzzle” approach to asthma diagnosis may he particularly useful. The BTS/NICE/SIGN guideline provides strong economic evidence to support the GINA strategy approach of single anti-inflammatory-reliever (AIR) and Maintenance and Reliever (MART) therapies as the cornerstone of asthma management in people age 12 and over.

It is likely that the burden of breathlessness in low and middle-income countries (LMICs) is much higher than has been estimated using calculations of disease burden and expected prevalence of the symptom. However, most breathlessness research has been conducted in high-income countries and may not be relevant to LMICs. To address this issue, we convened an international breathlessness and global health workshop. Our multidisciplinary team of experts (global palliative care, respiratory medicine, epidemiology, palliative medicine, psychiatry, sport science, global public health and health economics) met at the University of Hull for a two-day workshop in May 2024. We had 8 presentations on key issues relevant to global breathlessness research. Our discussions focussed on unexplored questions and links between breathlessness and other health and social issues, in order to develop an agenda for global breathlessness research. Our discussions highlighted (1) the global burden of breathlessness generated by a range of lifestyle, environmental, disease and poverty-related factors, (2) the need for a global healthcare workforce that can address modifiable causes and the symptoms of breathlessness together using an integrated approach, (3) the value of information over clinical effectiveness when considering implementation of breathlessness self-management interventions, (4) Addressing non-clinical outcomes which are meaningful to individuals and families and (5) Developing a language for global breathlessness research which does not assume that the cause of breathlessness is diagnosed or treated. We present our discussions and recommendations for new approaches and paradigms for global breathlessness research to generate discussion—not to provide empirical evidence.

Allergic rhinitis (AR), a condition characterized by sensitivity to allergens leading to poor quality of life, including disrupted sleep, reduced vitality, lowered mood, changes in blood pressure limited frustration tolerance, impaired focus, decreased performance in academic and professional settings, and millions of missed work and school days every year. Approximately 20–40% of individuals in the United States are affected by AR, which carries notable clinical and financial burdens. Interestingly, there is a strong link between AR and asthma to the extent that countries with a high prevalence of rhinitis have asthma rates ranging from 10% to 25%. Research has indicated that Allergen Immunotherapy (AIT) is associated with improved AR symptoms, a potential to resolve the AR over time, a decreased likelihood of asthma exacerbations and incidence of pneumonia in individuals with concurrent asthma, which are advantages that persist for years even after the cessation of treatment. Although patients presenting with allergies are first seen and treated in the primary care setting, gaps in training and the lack of available guidance for primary care practitioners have significantly impacted the quality of care for these patients with persistent AR symptoms, resulting in inefficient use of healthcare resources. To complicate matters, there is an insufficiency of allergists and immunologists, impacting the capacity to provide next-level care to the number of AR patients who could benefit from AIT. Hence, there is a critical need to equip primary care providers with educational experiences on essential concepts related to immune responses in allergies and asthma, recognizing the significance of the common airway in treating these entities and familiarization with the scientific evidence supporting various options for AIT. The development and implementation of medical education and algorithms designed to assess diverse patients’ symptoms, pharmacotherapy approaches, and situations where AIT can be initiated or sustained are warranted. The present commentary proposes a workflow model of the critical steps for managing and treating mild to moderate respiratory allergies via AIT in primary care settings. In addition, the initial development of medical education programs to minimize the burden on allergy-specialized care while, importantly, actively improving patient outcomes will be discussed.

This paper described the use of photovoice within design thinking to empathise with patients’ challenges and co-create ideas on asthma management in Singapore. A one-day workshop was organised and conducted in Singapore by SingHealth Polyclinics to discuss the challenges and enablers of good asthma care and ideate innovations to address the issues discussed. The workshop was conceptualised based on the Stanford’s d: school Design Thinking Process: 1. empathise, 2. define, 3. ideate, 4. prototype, and 5. test, focussing on the first three stages. Empathise stage was executed by having two patients share their challenges and enablers of good asthma care using photovoice. Define and ideate stage were accomplished through the multidisciplinary team discussion, with the patient going to every group to allow them to seek clarifications and opinions on ideas. The study findings were summarised based on the Empathise, Define and Ideate stages. Thirty-seven healthcare providers attended—9 doctors, 14 nurses, 4 pharmacists, 3 clinical service, 3 medical students and 4 research staff. Participants’ feedback was collected via an online feedback form to evaluate the effectiveness of an innovation workshop. More than 90% of participants strongly agreed or agreed that they could generate ideas to improving asthma care, the workshop helped drive innovation, and the use of photovoice helped them empathise with patients challenges. A design thinking framework can be used for innovation workshops. Photovoice is a useful method for understanding the problems faced by patients. A multidisciplinary team format with patient involvement was highly favoured.

The Covid-19 pandemic has significantly disrupted all aspects of healthcare, and while the worst may be over, its broader impact on health services, such as cancer diagnosis and treatment, is likely to be profound. We examine, in this paper, how our response to Covid-19 impacted on the recognition, referral, and diagnosis of individuals with lung cancer in primary care. The overlapping nature of symptoms of Covid-19 and lung cancer posed a particular challenge, and lung cancer referrals have been slow to return to pre-pandemic levels. Strategies need to be implemented to ensure the impact of future variants does not derail the precarious recovery we are now witnessing in many countries—it is vital that the gains we have made in earlier diagnosis are not lost. The pandemic has underlined the importance of improving early diagnosis through public awareness raising of symptoms, rapid diagnostic facilities, reduced primary care diagnostic intervals and, potentially, the introduction of screening in high-risk groups.

As evidence continues to emerge, our understanding of the relationship between smoking and COVID-19 prognosis is steadily growing. An early outlook from World Health Organisation (WHO) indicates that smokers are more vulnerable to severe COVID-19 disease and are also more likely to be infected, as frequent motions from hand to mouth and sharing of tobacco products such as waterpipes increased the possibility of being infected. In this commentary, we discuss some of the latest evidence on smoking and COVID-19 and emphasise the need to promote the personal and public advantages of smoking cessation during the COVID-19 pandemic.

A number of recent studies have found low percentages of smokers among COVID-19 patients, causing scientists to conclude that smokers may be protected against SARS-CoV-2 infection. National and international media were interested in this story and we soon began receiving questions about this topic in general practice. In this article, we shed light on the process that resulted in the misinterpretation of observational research by scientists and the media. We also point out the methodological flaws of various studies on which hasty conclusions were based. Finally, we address the role of primary healthcare providers in mitigating the consequences of erroneous claims about a protective effect of smoking.

COVID-19 is wreaking havoc around the world, which is a serious challenge to all our health systems. China reacted quickly in the early stage of the pandemic, and accumulated a lot of experiences, especially in the prevention and control of COVID-19 at the primary care level. Here, we would like to share how the Chinese Alliance for Respiratory Diseases in Primary Care (CARDPC) played a role in the pandemic, hoping to provide guidance and hope for effective control of the outbreak worldwide, for future public health emergencies and for systematic management of chronic respiratory diseases in the community.

COVID-19 is presenting novel challenges for global primary care, and its response has been inspiring, varied, and also troubling.