NHS Lambeth Clinical Commissioning Group

NHS Southwark Clinical Commissioning Group

Lambeth and Southwark Adult Breathlessness Assessment Algorithm

STEP 1 The history and examination still constitutes 90% of most diagnoses

STEP 2 Identify Type of Breathlessness (Code breathlessness using READ code 173)

Provide patients with chronic persistent breathlessness leaflet ‘Taking Charge of your Breathlessness’

STEP 3 Tier 1 Investigations for presentation of chronic breathlessness

The minimum tests required for all patients presenting with chronic breathlessness:

Initial Consultation / Full Blood Count / Urea & Electrolytes / Liver Function Test
ECG (scan using "photo" setting) / Albumin/Creatinine Ratio / Microspirometry (FEV1)
Thyroid Function Test / NT-ProBNP / Chest X-ray (if not done within last 6 months)
Subsequent Consultation
Holistic Assessment / PHQ4 (screening for anxiety PHQ2 and depression GAD2) – Assess the extent to which anxiety and/or depression are contributing to the breathlessness, and/or associated distress, and/or ability to self-manage / Peak Flow Diary / Breathlessness Score – MRC Scale
  • From the tests results identify possible contributory factors to the breathlessness and confirm suspected diagnoses through step 4 investigations

STEP 4 Tier 2 Investigations for presentation of chronic breathlessness

Based on history, examination and tier 1 investigations should further tests be carried out to confirm diagnoses or to provide further information? Only order tests if you would act upon the results.

Common Causes of Breathlessness / Further Examinations/Tests / Possible Diagnoses/Reasons for Breathlessness
Cardiac /
  • If raised BNP refer via choose and book to one stop heart failure clinic to diagnose or exclude heart failure (echo and specialist opinion together)
  • Consider 24/7 day tape if patient has intermittent symptoms – palpitations/falls/dizziness
  • Consider Echocardiogram if murmur/abnormal BNP/abnormal chest x-ray/abnormal ECG
  • Consider stress/exercise echocardiography if exertional dyspnoea along with an assessment of cardiovascular risk
  • Consider using GSTFTCardiology Choose & Book advice and guidance option for opinion on further investigations
/
  • Heart failure
  • Angina-equivalent
  • Valve disease
  • Arrhythmia
  • Ischemic heart disease

Respiratory /
  • Referral to diagnostic spirometry if FEV1 < 80% predicted
  • Consider using the respiratory singlepoint of referral for advice and guidance on further investigations and onward management
/
  • Obstructive airways disease
  • ILD
  • Obesity
  • Scoliosis
  • Neuromuscular
  • pulmonary hypertension
  • hyperventilation
  • poor home air quality eg damp/no ventilation

Mental Illness and Addiction /
  • GAD 7 and PHQ9
  • Addiction assessment
/
  • Anxiety and/or depression
  • hyperventilation

Fitness and Lifestyle /
  • Audit score for alcohol
  • Eat Well Plate and Food Diary (template on Southwark Intranet)
  • If available use 7 day pedometer assessment for patients with MRC 1-3
  • UseShort Physical Performance Battery (SPPB), including the 4 Meter Gait Speed Test to assess frailty with patients with MRC 4-5
/
  • low levels of fitness
  • obesity
  • smoking/alcohol

Anaemia/Kidney Disease /
  • Use choose and book advice and guidance option to get further opinion from a nephrologist or haematologist before testing or referral
/
  • Malignancy
  • Deficiency anaemia
  • Renal Failure
  • Chronic disease anaemia

STEP 5 Consider Contributing Factors to Breathlessness

Guideline Adapted from IMPRESS Breathlessness Algorithm Agreed July 2014 (Review date: January 2015)