Respiratory history

The respiratory history should focus on key system-specific symptoms related to the respiratory system.

A respiratory history focuses the consultation on the respiratory system. This is usually because a patient presents with a respiratory problem such as shortness of breath or wheeze.

The idea of a system-specific history is to explore key factors that are relevant to the affected system during the consultation. In respiratory disease, this may include pertinent past medical history (e.g. asthma/COPD), inhaler use, smoking history, occupational exposures, and even childhood illnesses.

Breathlessness is a major symptom of respiratory disease.

Shortness of breath or breathlessness is a very common symptom related to many underlying pathologies including lung disease. It is important to determine the onset and chronicity of breathlessness. For example:

• Sudden onset: may be consistent with pneumothorax or pulmonary embolism
• Acute onset: may be due to an exacerbation of asthma or COPD
• Chronic onset: may be secondary to fibrosis or COPD

As well as onset, you need to determine the duration of breathlessness, whether it is getting better or worse, and whether it is associated with any other symptoms (e.g. chest pain with pulmonary embolism). It is useful to ask when the breathlessness is worse. For example, is it exacerbated at work that might suggest occupational asthma.

The key symptoms to determine in the respiratory history include:

• Breathlessness
• Chest pain (SOCRATES mnemonic): focus on location, whether the pain is unilateral or bilateral, and if there is a pleuritic component (i.e.worse on breathing in)
• Wheeze: anything precipitates it (e.g. cold, exercise, animals)?
• Cough: productive/non-productive
• Sputum: colour, quantity, consistency, smell
• Haemoptysis: how often and how much?
• Atopy history: itchy eyes, runny nose, eczema symptoms
• Weight loss: may suggest lung cancer

It is vital to determine whether there is any pre-existing lung disease.

Ask about any pre-existing lung diseases such as asthma, COPD, or bronchiectasis. With each condition, determine whether these are well controlled (i.e. minimal symptoms) or poorly controlled (i.e. recurrent symptoms despite treatment).

When discussing previous medical problems always establish:

• Age of diagnosis (i.e. asthma as a child)
• Treatment for condition (i.e. salbutamol PRN and Seretide 2 puffs BD)
• Any complications (i.e. ITU admissions, need for intubation and ventilation)
• Additional treatments (i.e. nebulisers, non-invasive ventilation, long-term oxygen therapy)
• Last follow-up & recommendations (e.g. last acute exacerbation)

With pulmonary disease, remember to ask about any previous TB!

Patients with pulmonary disease may have undergone previous thoracic surgery.

Establish whether the patient has undergone thoracic surgery including the type of operation, date, and any complications. If the patient had surgery for lung cancer, determine if they are still under follow-up or having adjuvant therapy (i.e. treatment after surgery).

It is essential to note the type of inhaler, device, concordance, and technique with every patient.

Remember to ask all patients about inhalers and other medications during the consultation. Don’t forget to ask about adaptors (e.g. spacer) and whether they are getting side-effects.

For example:

• Which inhalers are they currently taking?
• Do they use a spacer?
• Do they use their inhaler every day?
• When was their inhaler technique last checked?
• Do they have home oxygen therapy or home nebulisers?

Ensure you ask about any current or recent steroids courses. Consider asking about steroid side-effects if long-term use or recurrent courses.

Some pulmonary diseases are inherited like cystic fibrosis.

Ensure you enquire about any conditions that run through the family and consider drawing out a family tree. It is useful to know whether any family members have a history of atopy or have previously been diagnosed with TB.

It is vital to determine the functional impact of their symptoms, particularly breathlessness.

Relevant components on social history that are related to respiratory disease include:

• Smoking history: type, amount, pack-years (don’t forget E-cigarette use that can cause vaping-associated lung injury)
• Occupation (current & previous): exposure to organic (e.g. moulds) or non-organic (e.g. asbestos) material?
• Hobbies: close contact with any specific animals or birds?
• Pets
• Recent travel and long haul flights
• Asbestos exposure
• Vaccinations: COVID, pneumococcal, influenza

Functional impact

When determining the functional impact of their symptoms such as breathlessness, ensure you ask them questions relative to their daily life:

• Can you manage a flight of stairs?
• Are you able to walk to the shops from your house?
• Do you have to stop to catch your breath after 100 yards?

Answers to these questions can be used to determine the grade on the Medical Research Council (MRC) dyspnoea scale. This is a scale graded 1-5 based on the severity of breathlessness.

Always end by discussing the patient’s ideas, concerns & expectations.

1. Do you have an idea about what could be going on?
2. Is there anything that is worrying/concerning you at the moment?
3. Is there anything you were hoping for from this consultation?
4. Do you have any further questions today?