Medical School · Year 3 · Family Medicine · includes a quiz and discussion video

Seminar 07: Respiratory Conditions in Primary Care

Year 3: Family Medicine Clerkship

Learning Objectives

By the end of this seminar, students will be able to:

1. Diagnose and manage asthma in adults and children
2. Evaluate and treat chronic obstructive pulmonary disease
3. Recognize and manage common respiratory infections
4. Interpret pulmonary function testing
5. Apply appropriate inhaler technique education
6. Identify patients needing referral to pulmonology

Seminar Outline

I. Asthma Diagnosis

Asthma presents with characteristic symptoms that vary in frequency and intensity over time. The cardinal manifestations include wheezing, cough that may be dry or productive, chest tightness, and dyspnea occurring in episodes. Symptoms typically follow a variable pattern with periods of relative wellness interrupted by flares often triggered by identifiable factors. Common triggers include environmental allergens such as dust mites, pet dander, and pollens; respiratory infections; exercise, particularly in cold air; strong emotions; and irritants including tobacco smoke and air pollution. Personal or family history of atopic conditions including allergic rhinitis and eczema strengthens diagnostic suspicion in patients with compatible respiratory symptoms.

Spirometry provides objective documentation of the airflow obstruction and reversibility characteristic of asthma. The hallmark finding is reduced forced expiratory volume in one second (FEV1) relative to forced vital capacity (FVC), with the FEV1/FVC ratio below 0.70 or below the lower limit of normal for age. Demonstrating reversibility distinguishes asthma from fixed obstruction: an increase in FEV1 of at least twelve percent and 200 mL following bronchodilator administration confirms variable airflow limitation. Normal spirometry does not exclude asthma, as testing may occur during asymptomatic periods when obstruction has resolved. Serial peak flow monitoring demonstrating variability exceeding twenty percent provides supportive evidence in such cases.

Additional diagnostic testing helps confirm uncertain diagnoses and identify contributing factors. Bronchoprovocation testing with methacholine or exercise challenge may reveal airway hyperresponsiveness when spirometry is normal but asthma remains suspected. Fractional exhaled nitric oxide (FeNO) measures eosinophilic airway inflammation; elevated levels support an asthma diagnosis and predict corticosteroid responsiveness. Allergy testing through skin prick or specific IgE testing identifies relevant triggers that may be amenable to avoidance measures or immunotherapy. Chest radiography excludes alternative diagnoses but typically appears normal in uncomplicated asthma.

The differential diagnosis for asthma symptoms encompasses several conditions requiring consideration. Chronic obstructive pulmonary disease typically affects older patients with substantial smoking history and demonstrates fixed rather than reversible obstruction. Vocal cord dysfunction causes episodic dyspnea and stridor, often mimicking asthma but not responding to bronchodilators; laryngoscopy during symptoms reveals paradoxical vocal cord adduction. Heart failure produces dyspnea with orthopnea and peripheral edema; elevated B-type natriuretic peptide and pulmonary congestion on imaging differentiate this condition. Gastroesophageal reflux may cause chronic cough and can trigger or exacerbate true asthma. Anxiety with hyperventilation produces respiratory symptoms without objective abnormalities.

<image>Panel A: Symptom pattern diagram showing episodic nature of asthma with common triggers identified. Panel B: Spirometry tracing showing obstructive pattern with bronchodilator reversibility demonstrated. Panel C: Decision tree for additional testing based on spirometry results and clinical suspicion. Panel D: Differential diagnosis comparison chart with distinguishing features for each condition.</image>

II. Asthma Classification and Treatment

Asthma severity classification in treatment-naive patients guides initial therapy selection based on symptom frequency and lung function. Intermittent asthma involves symptoms two or fewer days per week, nighttime awakenings two or fewer times per month, and FEV1 above eighty percent predicted. Mild persistent asthma includes symptoms more than twice weekly but not daily, nighttime awakenings three to four times monthly, and FEV1 above eighty percent. Moderate persistent asthma features daily symptoms, weekly nighttime awakenings, and FEV1 between sixty and eighty percent. Severe persistent asthma manifests with symptoms throughout the day, nightly awakenings, and FEV1 below sixty percent predicted.

Stepwise treatment guidelines match therapy intensity to disease severity and control level. Step 1 for intermittent asthma involves short-acting beta-agonist (SABA) as needed or low-dose inhaled corticosteroid with formoterol as needed. Step 2 for mild persistent asthma adds scheduled low-dose inhaled corticosteroid (ICS) with as-needed SABA. Step 3 introduces low-dose ICS combined with long-acting beta-agonist (LABA). Step 4 increases to medium-dose ICS-LABA combinations. Step 5 escalates to high-dose ICS-LABA. Step 6 adds additional therapies including long-acting muscarinic antagonists, biologics for appropriate phenotypes, or oral corticosteroids as last resort. Treatment steps up when control is inadequate and steps down when well-controlled for three or more months.

Controller medications form the foundation of persistent asthma management. Inhaled corticosteroids including fluticasone, budesonide, and beclomethasone remain the most effective controllers, reducing inflammation, symptoms, exacerbations, and airway remodeling. Long-acting beta-agonists such as salmeterol and formoterol provide sustained bronchodilation and are always used in combination with ICS, never as monotherapy. ICS-LABA combination inhalers including fluticasone-salmeterol and budesonide-formoterol simplify regimens and ensure concomitant use. Long-acting muscarinic antagonists, particularly tiotropium, add benefit for patients inadequately controlled on ICS-LABA. Leukotriene receptor antagonists such as montelukast serve as alternatives to ICS in mild persistent asthma, though less effective; FDA boxed warnings regarding neuropsychiatric events now limit their role.

Single Maintenance and Reliever Therapy (SMART) represents an emerging approach using ICS-formoterol combinations for both daily maintenance and symptom relief. Formoterol's rapid onset enables reliever function while the corticosteroid component addresses underlying inflammation with each use. This approach reduces exacerbations compared to traditional ICS plus as-needed SABA regimens. Global Initiative for Asthma guidelines now recommend ICS-formoterol as an option from step one through step four. Benefits include simplified treatment, automatic corticosteroid intensification during symptomatic periods, and reduced reliance on SABA alone for symptom relief.

<image>Panel A: Severity classification table showing symptom frequency, nighttime awakening, and FEV1 thresholds for each category. Panel B: Stepwise treatment ladder showing medications at each step with step-up and step-down arrows. Panel C: Controller medication profiles comparing ICS, LABA, ICS-LABA, LAMA, and LTRA options. Panel D: SMART therapy protocol diagram showing single inhaler use for maintenance and relief.</image>

III. Asthma Control and Management

Assessing asthma control guides treatment adjustments based on symptom burden and risk factors. Well-controlled asthma involves daytime symptoms two or fewer days weekly, nighttime symptoms two or fewer times monthly, no activity limitations, SABA use two or fewer days weekly for symptoms, FEV1 above eighty percent of personal best, and zero to one exacerbation requiring oral corticosteroids per year. Not well-controlled asthma exceeds any of these thresholds. Very poorly controlled asthma involves symptoms throughout the day, nightly awakenings, extreme activity limitation, or multiple exacerbations. Regular assessment using standardized tools such as the Asthma Control Test quantifies control objectively.

Treatment adjustment decisions follow control assessment findings. Patients well-controlled for at least three months may be candidates for step-down to the minimum effective therapy, reducing cost, complexity, and medication side effects while confirming that current treatment is not excessive. Patients not well-controlled should first have adherence and inhaler technique assessed before stepping up treatment. Identifying and addressing modifiable factors including trigger exposure, comorbidities such as allergic rhinitis or GERD, and medication adherence may improve control without adding medications. Stepping up therapy adds the next level of treatment intensity when optimization fails to achieve control.

Written asthma action plans empower patients to self-manage symptoms using a traffic light system. The green zone indicates doing well with maintained controller medications and absence of concerning symptoms. The yellow zone signals worsening requiring increased controller medication and addition of SABA; specific instructions guide medication adjustments and monitoring. The red zone constitutes a medical alert requiring immediate SABA, often oral corticosteroid initiation, and prompt medical contact or emergency care. Every patient with asthma should receive a personalized written action plan developed collaboratively with their healthcare provider.

Environmental control measures reduce trigger exposure and complement pharmacotherapy. Dust mite avoidance involves allergen-impermeable mattress and pillow encasements and washing bedding weekly in hot water. Pet allergen management includes keeping pets out of bedrooms and ideally out of the home, though many patients resist this recommendation. Mold prevention requires fixing water leaks, reducing indoor humidity, and addressing visible mold growth. Tobacco smoke avoidance encompasses both personal smoking cessation and eliminating secondhand smoke exposure. Occupational exposures require identification and workplace modification or job change when possible.

<image>Panel A: Asthma Control Test with scoring interpretation showing well-controlled, not well-controlled, and very poorly controlled ranges. Panel B: Treatment adjustment algorithm based on control assessment with adherence and technique checks included. Panel C: Traffic light asthma action plan template with green, yellow, and red zone instructions. Panel D: Environmental trigger control strategies organized by common allergen and irritant categories.</image>

IV. COPD Diagnosis

Chronic obstructive pulmonary disease develops in susceptible individuals exposed to noxious particles or gases, with cigarette smoking representing the dominant risk factor responsible for approximately eighty-five percent of cases. Alpha-1 antitrypsin deficiency accounts for a small proportion of cases and should be considered in younger patients or those without smoking history. Symptoms develop gradually, typically in adults over age forty, and include progressive dyspnea that initially occurs only with exertion but eventually limits daily activities. Chronic cough and sputum production may precede dyspnea by years. Physical examination may reveal barrel chest configuration, decreased breath sounds, prolonged expiratory phase, and wheezing.

Spirometry is required for COPD diagnosis, demonstrating persistent airflow limitation. The diagnostic criterion is post-bronchodilator FEV1/FVC ratio below 0.70, confirming obstruction that persists despite bronchodilator administration. Unlike asthma's characteristic reversibility, COPD shows fixed or minimally reversible obstruction, though some patients demonstrate partial bronchodilator response. GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging classifies severity based on FEV1 percent predicted after bronchodilator: GOLD 1 (mild) with FEV1 at or above eighty percent, GOLD 2 (moderate) with FEV1 fifty to seventy-nine percent, GOLD 3 (severe) with FEV1 thirty to forty-nine percent, and GOLD 4 (very severe) with FEV1 below thirty percent.

Assessment extends beyond spirometry to include symptoms and exacerbation risk for comprehensive disease characterization. Symptom severity measurement uses validated instruments including the modified Medical Research Council (mMRC) dyspnea scale and the COPD Assessment Test (CAT). The mMRC grades dyspnea from zero (only with strenuous exercise) to four (too breathless to leave house or dress). The CAT provides an eight-item questionnaire with scores from zero to forty assessing multiple symptom dimensions. Exacerbation history considers the number of events in the prior year and whether any required hospitalization, as exacerbation frequency predicts future risk.

The differential diagnosis for COPD includes several conditions with overlapping presentations. Asthma may coexist with COPD (asthma-COPD overlap) or cause diagnostic confusion; features favoring asthma include younger age, atopy, more complete reversibility, and greater symptom variability. Heart failure produces dyspnea and may coexist with COPD; orthopnea, paroxysmal nocturnal dyspnea, and response to diuretics suggest cardiac contribution. Bronchiectasis causes chronic productive cough with recurrent infections; high-resolution CT demonstrates characteristic airway dilation. Lung cancer should be considered in patients with hemoptysis, weight loss, or new imaging abnormalities. Interstitial lung disease produces dyspnea with restrictive rather than obstructive spirometry pattern.

<image>Panel A: COPD risk factors and natural history diagram showing progression from exposure through symptom development. Panel B: Spirometry criteria and GOLD staging classification with FEV1 thresholds. Panel C: mMRC dyspnea scale and CAT questionnaire summary with scoring interpretation. Panel D: Differential diagnosis comparison highlighting distinguishing features for COPD mimics.</image>

V. COPD Treatment

Non-pharmacological interventions form the essential foundation of COPD management regardless of disease severity. Smoking cessation represents the single most important intervention, being the only treatment proven to alter disease progression and improve survival. Combination pharmacotherapy with varenicline, bupropion, or nicotine replacement plus behavioral counseling maximizes quit rates. Vaccinations prevent infection-related morbidity: annual influenza vaccination, pneumococcal vaccination per guidelines, and COVID-19 vaccination protect against common precipitants of exacerbations and complications. Pulmonary rehabilitation programs combining exercise training, education, and self-management support improve functional capacity, symptoms, and quality of life in patients with moderate to severe disease. Supplemental oxygen therapy provides survival benefit for patients with severe resting hypoxemia defined as PaO2 at or below 55 mmHg or oxygen saturation at or below 88 percent.

Maintenance pharmacotherapy is guided by symptom burden and exacerbation risk using the GOLD ABCD assessment framework. Group A patients with fewer symptoms and low exacerbation risk may use any bronchodilator based on effect and preference. Group B patients with more symptoms but low exacerbation risk benefit from a LABA plus LAMA combination as preferred initial therapy. Group E patients (the new designation combining former groups C and D, indicating exacerbation history) should receive LABA plus LAMA combination, with consideration of ICS addition if blood eosinophils are elevated at or above 300 cells per microliter. The goal is matching treatment intensity to disease impact while minimizing unnecessary medication burden.

Inhaled bronchodilators provide the cornerstone of COPD pharmacotherapy. Short-acting agents including albuterol (SABA) and ipratropium (SAMA) offer rapid symptom relief but require frequent dosing. Long-acting beta-agonists such as salmeterol, formoterol, and indacaterol provide twelve to twenty-four hour bronchodilation with once or twice daily administration. Long-acting muscarinic antagonists including tiotropium and umeclidinium offer sustained bronchodilation through anticholinergic mechanisms. Combination LABA-LAMA inhalers provide complementary bronchodilation through different pathways and represent preferred therapy for most patients with persistent symptoms beyond Group A. Triple therapy combining LABA-LAMA-ICS is available in single inhalers for appropriate patients.

Inhaled corticosteroids play a more limited role in COPD than asthma but benefit selected patients. ICS addition is most appropriate for patients with frequent exacerbations despite LABA-LAMA therapy and blood eosinophil counts at or above 300 cells per microliter. Patients with history of asthma-COPD overlap similarly benefit from ICS-containing regimens. Pneumonia risk increases with ICS use in COPD, requiring careful patient selection and monitoring. For patients without these features, LABA-LAMA dual bronchodilator therapy without ICS is preferred. Withdrawal of ICS may be appropriate for patients originally prescribed triple therapy who have stable disease and lower eosinophil counts.

<image>Panel A: Smoking cessation pharmacotherapy options with efficacy and combination strategies. Panel B: GOLD ABCD assessment framework showing symptom-exacerbation matrix with treatment recommendations. Panel C: Bronchodilator class comparison showing SABA, SAMA, LABA, LAMA, and combinations with durations and dosing. Panel D: ICS decision algorithm for COPD based on exacerbation frequency and eosinophil count.</image>

VI. COPD Exacerbations

COPD exacerbations represent acute worsening events requiring additional treatment beyond usual maintenance therapy. The clinical definition encompasses sustained increase in dyspnea, cough, and/or sputum beyond normal day-to-day variation. Severity classification guides management setting: mild exacerbations require only increased short-acting bronchodilator use, moderate exacerbations require treatment with systemic corticosteroids and/or antibiotics but can be managed outpatient, and severe exacerbations require hospitalization due to respiratory distress, hypoxemia, or failure of initial treatment.

Infectious triggers predominate in COPD exacerbations, with both viral and bacterial pathogens implicated. Viral respiratory infections including rhinovirus, influenza, and respiratory syncytial virus account for fifty to seventy percent of exacerbations. Bacterial infections, often superimposed on viral illness, contribute to twenty-five to fifty percent of events, with Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis most commonly isolated. Air pollution exposure precipitates some exacerbations, particularly in urban environments with elevated particulate matter. A substantial proportion of exacerbations lack identifiable triggers despite investigation.

Outpatient exacerbation treatment combines increased bronchodilators, systemic corticosteroids, and selective antibiotic use. Bronchodilator frequency should increase, with short-acting agents used every four to six hours during symptomatic periods. Oral corticosteroids, typically prednisone 40 mg daily for five days, reduce inflammation and hasten recovery. Antibiotics are indicated when patients have increased dyspnea accompanied by increased sputum purulence or volume suggesting bacterial infection. Appropriate antibiotic choices include azithromycin, doxycycline, or amoxicillin-clavulanate, with respiratory fluoroquinolones reserved for treatment failures or patients at higher risk of resistant organisms.

Hospitalization criteria identify patients requiring inpatient management due to severity or failure of outpatient treatment. Severe dyspnea unresponsive to initial therapy indicates need for more intensive intervention. Hypoxemia with oxygen saturation below ninety percent on room air requires supplemental oxygen and close monitoring. Altered mental status suggests hypercapnic respiratory failure requiring possible ventilatory support. Failure to improve with outpatient treatment warrants escalation to inpatient care. Significant comorbidities including heart failure, renal disease, or frailty lower the threshold for admission given reduced physiologic reserve. Inadequate social support limiting ability to adhere to treatment or respond to deterioration may necessitate admission for supervised care.

<image>Panel A: Exacerbation definition and severity classification with management setting implications. Panel B: Infectious etiology breakdown showing viral, bacterial, and unidentified proportions with common pathogens. Panel C: Outpatient treatment protocol including bronchodilators, corticosteroids, and antibiotics with specific agents and durations. Panel D: Hospitalization decision criteria organized by clinical severity, treatment response, and social factors.</image>

VII. Inhaler Technique

Poor inhaler technique represents a common and correctable cause of suboptimal respiratory disease control. Studies consistently demonstrate that most patients make at least one critical error that substantially reduces lung deposition of medication. Common mistakes include failure to prime new or unused inhalers, inadequate coordination between actuation and inhalation for metered-dose inhalers, breathing too rapidly causing medication impaction in the oropharynx, failure to hold breath after inhalation allowing drug exhalation before deposition, and incorrect device handling specific to various inhaler types. Regular technique assessment and retraining at each encounter is essential because skills deteriorate over time.

Metered-dose inhaler (MDI) technique requires specific sequential steps for optimal drug delivery. The patient should first remove the cap, shake the inhaler to disperse the medication, and exhale completely away from the inhaler. Placing the mouthpiece in the mouth with lips sealed around it, the patient should begin a slow deep inhalation while simultaneously pressing the canister to release medication. Inhalation should continue slowly over three to five seconds until lungs are full. Breath holding for approximately ten seconds allows particle deposition before exhaling. When multiple puffs are prescribed, waiting at least one minute between actuations allows aerosol to settle. Rinsing the mouth and spitting after inhaled corticosteroid use reduces oral candidiasis and dysphonia risk.

Dry powder inhaler (DPI) technique differs importantly from MDI technique due to the different drug delivery mechanism. Each device type has specific loading steps that must be followed to prepare the dose, whether rotating a grip, sliding a lever, or opening a chamber. Exhaling away from the device is critical, as breathing into the DPI causes clumping of the powder. Unlike MDIs requiring slow inhalation, DPIs require a quick deep breath to generate sufficient inspiratory flow to disperse the powder. Shaking is unnecessary and contraindicated for DPIs, as it may dislodge already-prepared doses. Patients with poor inspiratory flow, such as during exacerbations or with very severe disease, may be unable to generate adequate flow for effective DPI use.

Spacer devices paired with MDIs improve drug delivery while reducing technique dependence. Spacers hold the aerosolized medication in a chamber, eliminating the need for precise coordination between actuation and inhalation. Larger particles deposit in the spacer rather than the oropharynx, reducing local side effects from inhaled corticosteroids. Children, elderly patients, and anyone with coordination difficulties benefit particularly from spacer use. Spacers should be recommended for most MDI users, especially those on inhaled corticosteroids. Proper spacer use involves actuating the MDI into the spacer, then taking one to two slow deep breaths through the mouthpiece, with minimal delay between actuation and inhalation to prevent particle settling.

<image>Panel A: Common inhaler technique errors with their impact on drug delivery and clinical outcomes. Panel B: MDI technique step-by-step with illustrations and timing notes for each phase. Panel C: DPI technique comparison across device types with key differences from MDI technique highlighted. Panel D: Spacer benefits and proper use instructions including coordination elimination and local side effect reduction.</image>

VIII. Respiratory Infections

Community-acquired pneumonia diagnosis integrates clinical presentation with radiographic confirmation. Symptoms include cough, fever, dyspnea, and pleuritic chest pain; physical examination may reveal tachypnea, diminished breath sounds, crackles, or dullness to percussion. Chest radiograph demonstrating new infiltrate confirms the diagnosis and helps exclude alternative diagnoses. Severity assessment guides management setting; the CURB-65 score awards one point each for Confusion, Urea above 7 mmol/L (BUN above 20), Respiratory rate at or above 30, Blood pressure below 90 systolic or 60 diastolic, and age 65 or older. Scores of zero to one generally indicate outpatient management, score of two warrants hospital consideration, and three or higher indicates hospitalization with intensive care consideration for higher scores.

Outpatient pneumonia treatment targets the most likely pathogens with appropriate antibiotic selection. For healthy adults without comorbidities or recent antibiotic use, amoxicillin or doxycycline or a macrolide (where local resistance permits) provides appropriate coverage for Streptococcus pneumoniae and atypical organisms. Patients with comorbidities including heart, lung, liver, or renal disease, diabetes, alcoholism, immunosuppression, or recent antibiotic use require broader coverage. Options include amoxicillin-clavulanate or a cephalosporin plus a macrolide, or a respiratory fluoroquinolone as monotherapy. Minimum treatment duration is five days, with continuation until afebrile for 48 to 72 hours and clinically stable.

Influenza warrants specific consideration during epidemic seasons. Abrupt onset of fever, myalgias, headache, and cough during influenza season creates high clinical suspicion. Rapid antigen testing and PCR confirm the diagnosis, though empiric treatment may proceed if clinical suspicion is high. Antiviral therapy with oseltamivir ideally begins within 48 hours of symptom onset but should be offered to high-risk patients regardless of duration. High-risk groups including adults over 65, pregnant women, immunocompromised patients, and those with chronic cardiopulmonary disease benefit from treatment even if initiated later. Annual influenza vaccination remains the primary prevention strategy.

COVID-19 continues to cause respiratory illness requiring recognition and appropriate management. Symptoms overlap significantly with other respiratory infections but may include anosmia and ageusia more distinctively. Testing via antigen or PCR confirms diagnosis. Antiviral therapy with nirmatrelvir-ritonavir (Paxlovid) reduces hospitalization and death when initiated within five days of symptom onset in high-risk patients. High-risk features include age over 50, immunocompromise, and chronic medical conditions. Vaccination with updated boosters provides the foundation for prevention. Isolation recommendations evolve with public health guidance but generally involve avoiding contact with others while symptomatic and infectious.

<image>Panel A: Pneumonia diagnostic criteria combining clinical features, radiographic findings, and severity scoring. Panel B: Outpatient antibiotic selection pathway based on patient risk factors and recent antibiotic exposure. Panel C: Influenza high-risk groups with antiviral treatment indications and timing considerations. Panel D: COVID-19 management algorithm including testing, treatment eligibility, and antiviral options.</image>

IX. Other Respiratory Conditions

Allergic rhinitis commonly coexists with and exacerbates lower respiratory conditions including asthma. Symptoms encompass rhinorrhea, sneezing, nasal congestion, and itching affecting the nose, eyes, and palate. Classification distinguishes seasonal (triggered by outdoor allergens including tree, grass, and weed pollens) from perennial (year-round triggers including dust mites, pet dander, and molds), and intermittent from persistent based on symptom frequency and duration. Intranasal corticosteroids represent first-line treatment, providing superior efficacy for all symptom dimensions. Oral or intranasal antihistamines address itching and sneezing effectively. Allergen avoidance when feasible complements pharmacotherapy. Allergen immunotherapy offers disease modification for moderate-severe allergic rhinitis inadequately controlled with medications.

Chronic cough requires systematic evaluation when persisting beyond eight weeks, as this duration excludes most acute post-infectious coughs. The three most common causes in non-smokers with normal chest radiograph are upper airway cough syndrome (post-nasal drip), asthma, and gastroesophageal reflux disease, which may occur in combination. Upper airway cough syndrome presents with throat clearing, post-nasal drip sensation, and response to antihistamines and decongestants. Cough-variant asthma may lack typical wheeze but demonstrates bronchodilator response or bronchial hyperreactivity on testing. Reflux-related cough may occur without classic heartburn; empiric proton pump inhibitor trial for eight weeks helps establish the diagnosis. Chest radiography and spirometry constitute initial workup, with additional testing guided by findings and treatment response.

Obstructive sleep apnea frequently accompanies and complicates other respiratory conditions. Risk factors include obesity, large neck circumference, male sex, and older age. Symptoms include snoring, witnessed apneas, unrefreshing sleep, and excessive daytime sleepiness. The STOP-BANG questionnaire provides validated screening with questions about Snoring, Tiredness, Observed apneas, blood Pressure, BMI, Age, Neck circumference, and Gender; scores of three or higher indicate high risk. Diagnosis requires polysomnography or home sleep testing demonstrating apnea-hypopnea index of five or more events per hour. Continuous positive airway pressure therapy remains the primary treatment, with weight loss, positional therapy, and oral appliances as alternatives for selected patients. Untreated sleep apnea contributes to resistant hypertension, cardiovascular disease, and motor vehicle accidents.

Referral to pulmonology becomes appropriate when primary care evaluation and management reach their limits. Diagnostic uncertainty despite initial workup warrants specialist evaluation for advanced testing and expertise. Severe or uncontrolled respiratory disease despite appropriate treatment indicates need for specialist management. Specialized testing including bronchoscopy, cardiopulmonary exercise testing, or advanced imaging may require pulmonology involvement. Consideration of biologic therapy for severe asthma requires specialist prescription and monitoring. Complex patients with multiple overlapping respiratory diagnoses benefit from specialist coordination of care.

<image>Panel A: Allergic rhinitis classification and treatment stepwise approach from antihistamines through immunotherapy. Panel B: Chronic cough evaluation algorithm showing common causes and empiric treatment trials. Panel C: STOP-BANG questionnaire with scoring and interpretation for sleep apnea risk. Panel D: Pulmonology referral indications organized by diagnostic, severity, and treatment complexity categories.</image>

X. Special Populations

Pediatric asthma presents unique diagnostic and management considerations. Diagnosis in children under five years proves challenging because spirometry is unreliable and multiple conditions cause recurrent wheezing in this age group. Recurrent episodes of cough, wheeze, and difficulty breathing triggered by viral infections, allergens, or exercise suggest asthma even without confirmatory spirometry. Treatment parallels adult stepwise approaches with age-appropriate medication doses and delivery devices. Spacers with face masks enable MDI use in infants and young children who cannot coordinate inhaler technique. School management requires written asthma action plans provided to school nurses and appropriate rescue medication availability. Growth monitoring is prudent for children on inhaled corticosteroids, though effects on adult height are minimal with appropriate doses.

Respiratory conditions during pregnancy require careful attention to both maternal and fetal welfare. Uncontrolled asthma poses greater risk to the fetus than does asthma medication, making continued treatment essential. Inhaled corticosteroids and SABAs are safe throughout pregnancy; budesonide has the most safety data among ICS options. LABAs combined with ICS may continue when needed for control. COPD is uncommon in women of reproductive age given typical onset after forty. Pneumonia during pregnancy carries increased severity and complications, lowering the threshold for hospitalization and intensive monitoring. Influenza vaccination is specifically recommended during pregnancy regardless of trimester.

Elderly patients with respiratory disease require attention to multiple age-related factors. Device selection should account for decreased inspiratory flow and coordination challenges; some patients cannot generate adequate flow for dry powder inhalers. Cognitive impairment may limit ability to follow complex regimens or recognize deterioration. Comorbidities including heart failure, which produces overlapping symptoms, require careful diagnostic distinction. Side effect sensitivity increases, particularly to anticholinergic effects including confusion and urinary retention, and to systemic corticosteroid effects including bone loss, glucose elevation, and delirium. Polypharmacy raises interaction concerns requiring medication review.

Tobacco cessation represents the most impactful intervention for respiratory health across all conditions and populations. Every clinical encounter should include asking about tobacco use status and documenting findings. Advising all users to quit with clear, strong, personalized messages reinforces the importance of cessation. Assessing readiness to quit identifies patients prepared for active cessation support versus those requiring motivational intervention. Assisting with quit attempts involves setting quit dates, providing pharmacotherapy, and offering behavioral support. Arranging follow-up maintains accountability and enables support during the challenging post-quit period. Combination therapy with varenicline or bupropion plus nicotine replacement optimizes quit rates.

<image>Panel A: Pediatric asthma diagnosis challenges and age-appropriate treatment approaches including device selection. Panel B: Pregnancy respiratory management emphasizing medication safety and treatment continuation. Panel C: Elderly respiratory patient considerations including device selection, cognition, and side effect sensitivity. Panel D: Five As tobacco cessation framework with specific actions at each step.</image>

Summary

• Asthma diagnosis requires demonstrating variable airflow obstruction through symptoms, spirometry with reversibility, or bronchoprovocation testing
• Asthma treatment follows a stepwise approach with inhaled corticosteroids as the foundation; SMART therapy using ICS-formoterol for both maintenance and relief is emerging as standard
• Asthma control assessment guides treatment adjustment; well-controlled patients may step down while those not well-controlled need adherence assessment then step-up
• COPD diagnosis requires post-bronchodilator FEV1/FVC below 0.70; staging uses FEV1 percent predicted with GOLD categories from 1 (mild) to 4 (very severe)
• COPD treatment prioritizes smoking cessation; LABA-LAMA combination is preferred for most patients; add ICS if eosinophils at or above 300 or frequent exacerbations
• COPD exacerbation treatment includes increased bronchodilators, oral corticosteroids for five days, and antibiotics if increased dyspnea with purulent sputum
• Inhaler technique requires assessment and retraining at every visit; spacers improve MDI delivery and reduce local corticosteroid side effects
• Outpatient CAP treatment: amoxicillin, doxycycline, or azithromycin for healthy patients; respiratory fluoroquinolone or beta-lactam plus macrolide if comorbidities
• Chronic cough lasting over eight weeks most commonly results from upper airway cough syndrome, asthma, or GERD
• Smoking cessation is the most important intervention for COPD and should be addressed using the Five As at every encounter

Key Terms

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