Asthma and chronic obstructive pulmonary disease (COPD) are overwhelmingly the most common respiratory problems in primary care. They pose significant diagnostic and management problems for GPs.

Asthma

Asthma is common at all ages, is increasing in incidence and occurring in younger age groups.

Diagnosis

Diagnosis may be challenging, particularly in children (see Chapter 14). Diagnosis of moderate or severe asthma is generally straightforward, especially as many patients will have a long past history of asthma or other atopic symptoms. Explore the past history for ‘weak chests’ and ‘wheezy bronchitis’ as children and ‘bronchitis’ and ‘everything goes onto my chest’ as an adult – there are many undiagnosed asthmatics in the community. Asthma can arise de novo in adults, most commonly in their twenties. It is often wrongly diagnosed as COPD in older age groups. In some patients airflow obstruction appears irreversible on spirometry but a course of corticosteroids may unveil reversibility. Mild asthma may present with nocturnal cough only, a patient who describes always taking a long time to recover from everyday colds and URTIs, or someone in whom physical exertion (e.g. running, swimming) is limited by breathlessness or cough often has undiagnosed asthma. A history of cough in the small hours, of coughing on exercise and when allergens are around (hay fever season, changing the beds, brushing the cat) should all alert you to the possibility of asthma. By the time a patient reaches the surgery there are frequently no expiratory wheezes or anything else abnormal to hear in the chest. Diagnosis relies on a careful history, peak flow diaries and spirometry with bronchodilator challenge (which many surgeries now undertake).

Management

While effective treatment for asthma exists for all but the most severe, compliance is often poor and so symptoms are often poorly controlled. Helping patients to:

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