Evaluating patients for pulmonary issues, whether common or complex, demands significant time and expertise in primary care settings. Physicians must meticulously gather information about symptoms and medical history to determine the most appropriate diagnostic tests. Ideally, every primary care facility would have on-site lung function testing and advanced imaging capabilities, unhindered by cost or insurance limitations. Though, the reality frequently enough falls short of this ideal.

Initial Assessment: Key questions

The diagnostic process begins with targeted questioning to differentiate between various pulmonary and cardiac conditions. Key questions include:

• What are your symptoms?
• Is it just a cough, or is it accompanied by shortness of breath?
• Is the shortness of breath present at rest or only during exertion?
• Is there associated chest pain?

Neil Skolnik, MD, professor of family and community medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, emphasized the importance of these initial inquiries: Answers to all of those things will help define which directions and which tests you are going to get. Physical examination findings, such as wheezing or crackling sounds in the chest, can further guide the diagnostic process, suggesting respiratory or cardiac etiologies, respectively.

Essential on-Site Testing

While advanced imaging may not always be readily available, certain on-site tests can provide valuable initial insights. Wilson Pace, MD, professor emeritus of family medicine at the university of Colorado Denver, and at the University of Colorado Anschutz Medical Campus, Aurora, Colorado, who currently works as chief medical and technology officer at the DARTNet Institute, noted the utility of even basic tools: Even a simple chest x-ray can help you distinguish a heart failure picture from a more pulmonary picture. However, the availability of such resources varies across primary care settings.

Ruling Out Cardiac Issues

Given the overlap in symptoms between pulmonary and cardiac conditions, it is indeed crucial to promptly rule out urgent heart issues. Barbara Yawn, MD, researcher and adjunct professor of family and community health at the University of Minnesota, Minneapolis, highlighted the role of electrocardiograms (ECGs): Everybody is going to probably start with an ECG rhythm strip. You want to make sure that there isn’t something electrical with the heart going on. She added that an ECG is often the only direct cardiac test available in the primary care office, useful for detecting acute changes in cardiac function.

The Role of NT-ProBNP and echocardiography

When heart failure is suspected,an echocardiogram is the gold standard for assessing cardiac function. However, access to echocardiography may be limited by scheduling constraints and availability. As Dr. Pace explained, But that’s going to take scheduling and time to get. You’re not going to get that on the day you’re trying to make the differential diagnosis. In the interim,an N-terminal pro-B-type natriuretic peptide (NT-ProBNP) test can be a useful adjunct. Dr.skolnik advised,If the NT-ProBNP is elevated in the blood,the next logical step is an echocardiogram to look at heart function. If there is heart failure, you want to distinguish if it is heart failure with reduced or preserved ejection fraction.

Spirometry: An Underutilized Tool

Spirometry, a lung function test that differentiates between restrictive and obstructive lung diseases, remains underutilized in primary care. Alan kaplan, MD, chair of the Family Physician Airways Group of Canada, lamented that Spirometry, unfortunately, rarely gets done. Several factors contribute to this underutilization, including provider discomfort with interpreting results and limited availability of the test.

Dr. Yawn noted that We know that,unfortunately,a lot of primary care clinics had spirometry removed during COVID – and it never got put back in. The perceived risk of viral transmission during the test led to its discontinuation in many clinics, further limiting access for patients.

Contrasting views on Spirometry

While the value of spirometry is widely accepted, opinions differ on its utility in the acute setting. Dr. Pace argued that From my outlook, it’s a follow-up test like the echocardiogram, not an acute test like a chest x-ray or a blood test. he emphasized its importance in diagnosing and managing respiratory illnesses: Onc you get treatments initiated, if you think that there is a respiratory illness, then spirometry is the sine qua non. It is the diagnostic test for COPD. That is the test you need. Conversely, Dr. kaplan asserted that Spirometry absolutely has to be done. You want to get an idea if someone’s lung volumes are large or small. You also want to get an idea of diffusion capacity. Diffusion capacity measures how well the lungs transfer gases between the air and the blood.

Preserved Ratio Impaired Spirometry (PRISm)

A condition called preserved ratio impaired spirometry (PRISm) is gaining increased attention. Patients with PRISm exhibit symptoms similar to COPD but have normal obstructive pulmonary function test results.Dr.Yawn explained, So we aren’t sure what to do with these people, but we see a lot of them in primary care because they are symptomatic. These patients may benefit from respiratory therapy and management.

Additional Resources

For further guidance, the Family Practice Airways Group of Canada offers valuable resources, including:

• Proposed Primary Care Approach to Assessing Adults With Chronic Cough
• Proposed Primary Care Approach to Assessing Adults With Chronic Dyspnea