### Asthma - information for patients [asthma-patient-information] About your asthma Asthma is a condition where the airways in your lungs become inflamed and narrow. When this happens you may wheeze, cough, feel short of breath, or feel tight in the chest. The inflammation is there even on the days you feel well, which is why treatment works best when it is taken regularly rather than only when you have symptoms. Your inhalers Your preventer inhaler contains a small dose of steroid. It treats the inflammation and reduces the chance of an asthma attack. It does not give instant relief, and it works only if it is taken as prescribed. Your reliever inhaler opens the airways within minutes. It does not treat the underlying inflammation. If you are using a reliever inhaler three or more times a week, your asthma is not as well controlled as it should be, and you should ask for a review rather than simply using more of it. Some people are now given a single inhaler that does both jobs. If that is what you have been prescribed, use it as we have written on your action plan and do not use a separate blue inhaler as well unless we have told you to. How you take the inhaler matters as much as which one you take. A large amount of the dose is wasted if the technique is not right. Please bring all of your inhalers to every appointment so we can watch you use them. Ask about a spacer if you have not been offered one. Things that can make asthma worse Colds and chest infections, cigarette smoke including other people's, vaping, pollen, house dust mite, animals, cold air, exercise, damp and mould, air pollution, and some medicines - particularly aspirin, ibuprofen and other anti-inflammatory painkillers, and beta blockers including eye drops. Hay fever, reflux and being overweight all make asthma harder to control, and all of them can be treated. If you smoke or vape, stopping is the single most useful thing you can do for your asthma. We can refer you for help with this, and the treatments available make a real difference. Vaccination Have the influenza vaccine every autumn, and the COVID-19 vaccine when you are offered it. Chest infections are the commonest trigger for an asthma attack. When your asthma is getting worse Warning signs are needing your reliever more often than usual, waking at night because of coughing or wheezing, being more breathless than usual on your normal activities, and peak flow readings falling below your usual best. If you notice these, follow your written action plan and contact your GP practice or asthma nurse the same week. Call 999 for an ambulance if you are too breathless to speak in full sentences, if your reliever inhaler is not helping or is not lasting, if your lips or fingers look blue, or if you are frightened by how breathless you are. Do not worry about wasting anyone's time. It is always better to be seen. Your written action plan We have given you a written asthma action plan. It sets out your usual treatment, what to do when your symptoms get worse, and when to get urgent help. Keep it where you can find it, and bring it to your appointments so we can keep it up to date. Further information: Asthma + Lung UK, www.asthmaandlung.org.uk, helpline 0300 222 5800. ### Asthma review [asthma-review] Asthma review. Control since last seen: Daytime symptoms: [days per week] Night waking due to asthma: [nights per month] Reliever use: [doses per week] Activity limited by asthma: [yes or no] Asthma control questionnaire score: [ACQ or ACT, and which] Attacks since last review: Oral steroid courses: [] Unscheduled care, A and E or admission: [] Time off work or school: [] Treatment: Current inhalers: [drug, device, dose, doses per day] Prescription collections in the last 12 months: [preventer and reliever] Inhaler technique observed today: [adequate, or the specific error seen] Spacer: [in use, replaced or not needed] Anything making it worse: Smoking or vaping: [] Nasal symptoms or polyps: [] Reflux symptoms: [] Weight and BMI: [] Occupational or home exposures: [] Beta blockers, aspirin or NSAIDs: [] Measurements: Peak flow [] L/min ([]% of best, best []) FEV1 [] L ([]%) FeNO [] ppb Blood eosinophils [] x10^9/L Impression: [controlled on current treatment, or uncontrolled with the reason] Plan: 1. Treatment: [unchanged, stepped up to, or stepped down to] 2. Inhaler technique rechecked: [] 3. Action plan reviewed and reissued: [yes] 4. Vaccination: [influenza, COVID-19, pneumococcal as indicated] 5. Review in [] months, sooner if [specific trigger to come back] ### Difficult asthma assessment [difficult-asthma-assessment] Assessment of difficult-to-treat asthma. Is it asthma? Objective evidence of variable airflow obstruction, and when: [] Alternative or additional diagnoses considered: [inducible laryngeal obstruction, dysfunctional breathing, bronchiectasis, COPD, heart failure, ABPA, eosinophilic granulomatosis with polyangiitis, tracheobronchomalacia] Investigations done to exclude them: [] Is the treatment being taken? Prescribed regimen: [] Prescription collections in the last 12 months: [preventer collections of 12] Inhaler technique observed today: [adequate, or the specific error seen] Adherence discussed without blame, and what the patient says: [] FeNO suppression test done: [yes with result, or no] What else is driving it? Nasal disease or polyps: [] Reflux: [] Obesity, BMI [] Obstructive sleep apnoea, Epworth [] Smoking or vaping, pack-years [] Occupational exposure, and whether symptoms improve away from work: [] Aspirin or NSAID sensitivity: [] Beta blockers: [] Anxiety, depression or panic: [] Ongoing allergen exposure at home, including pets and damp: [] Attack and steroid burden: Oral steroid courses in the last 12 months: [] Maintenance prednisolone, dose and duration: [] Cumulative steroid exposure and its consequences: [bone density, diabetes, cataract, weight, adrenal suppression] Admissions, HDU or ITU care: [] Phenotype: Highest blood eosinophil count, and when taken: [] x10^9/L FeNO off or on steroids: [] ppb Total IgE [] kU/L, aeroallergen specific IgE or skin prick: [] Aspergillus IgE and IgG: [] Age of onset: [] Sputum culture: [] CT chest: [] Impression: [difficult-to-treat asthma with modifiable factors, or severe asthma meeting criteria for specialist therapy] Plan: 1. [] 2. Referral to severe asthma multidisciplinary team: [yes or no, with reason] 3. Biologic considered: [drug and the eligibility criterion met, or not yet] ### New asthma patient [asthma-new-patient] Referred with: [] History: Symptoms: [wheeze, breathlessness, chest tightness, cough] Duration and pattern: [] Diurnal variation and night waking: [nights per week] Triggers: [exercise, cold air, pollen, animals, dust, aspirin or NSAIDs, work] Better away from work or on holiday: [yes, no or not applicable] Atopy: [eczema, hay fever, food allergy] Nasal symptoms and sense of smell: [] Attack history: Courses of oral steroids in the last 12 months: [] Attendances at A and E in the last 12 months: [] Hospital admissions, ever, and any HDU or ITU care: [] Best ever peak flow, and when: [] Current treatment and how it is actually taken: Preventer: [drug, device, dose, doses per day] Reliever: [drug, and doses used per week] Inhaler technique observed today: [adequate or the specific error seen] Adherence, by prescription collection where available: [collections in last 12 months] Spacer in use: [yes or no] Other: Smoking and vaping: [] Occupation and exposures: [] Reflux, nasal polyps, obesity, anxiety or depression: [] Beta blockers, aspirin or NSAIDs: [] Height [] cm Weight [] kg BMI [] Objective tests: Blood eosinophils [] x10^9/L FeNO [] ppb Spirometry FEV1 [] L ([]%), FVC [] L ([]%), ratio []% Bronchodilator reversibility: [change in FEV1 in ml and %] Peak flow diary: [amplitude per cent mean over two weeks] Total IgE and specific IgE or skin prick: [] Chest x-ray: [] Impression: [asthma confirmed on which test, or diagnosis not yet established] Plan: 1. [] 2. Inhaler technique checked and spacer issued: [] 3. Written personalised asthma action plan given: [yes] 4. Trigger and adherence discussion: [] 5. Review in [] weeks with [test or diary] ### Bronchiectasis - information for patients [bronchiectasis-patient-information] About your bronchiectasis Bronchiectasis means some of the airways in your lungs have become widened and scarred. Widened airways do not clear mucus properly, mucus that sits still becomes infected, and infection causes more damage. Treatment is aimed at breaking that cycle, and it works. Most of the treatment is something you do rather than something you take. 1. Clearing your chest, every day This is the most important part of your treatment. A respiratory physiotherapist will teach you a technique that suits you, usually a cycle of relaxed breathing, deeper breaths and huffing, sometimes with a small handheld device, and sometimes with positions that let gravity help. Do it every day, usually twice, and for longer when you have an infection. Ten to twenty minutes twice a day is typical. It is not glamorous and it is easy to let slip when you feel well, but it is the single thing that most reduces infections and keeps your lungs in better condition over years. If you were shown a technique once and are no longer sure you are doing it right, ask to be referred back. This is normal and worth doing. 2. Exercise Regular aerobic exercise - walking, cycling, swimming, anything that makes you breathe harder - helps clear the chest as well as improving your fitness. If breathlessness limits what you can do, ask about pulmonary rehabilitation. 3. Vaccination Have the influenza vaccine every autumn, and the pneumococcal and COVID-19 vaccines when you are offered them. 4. Treating infections promptly You will get chest infections. What matters is recognising and treating them quickly. Signs of an infection are: more phlegm than usual, phlegm that changes colour, more breathlessness, more coughing, feeling generally unwell, or a fever, for more than about 24 to 48 hours. If this happens, start the plan we have agreed with you, or contact your GP practice. Courses of antibiotics for bronchiectasis are usually 14 days - longer than for an ordinary chest infection - because shorter courses tend to be followed by a rapid relapse. Before you start antibiotics, send a sputum sample if you possibly can. Knowing which bacteria are there is what allows us to choose an antibiotic that works, and the sample is much less useful once treatment has begun. 5. Keeping an eye on things We will usually check a sputum sample and your breathing tests at your routine reviews, and arrange a chest x-ray if your symptoms change. Tell us if you cough up blood, lose weight without meaning to, or notice that your usual infections are becoming more frequent. When to get help urgently Contact us or your GP the same day if you cough up more than streaks of blood, become much more breathless than usual, have chest pain, or are unwell with a high fever. Call 999 if you cough up a large amount of blood or are severely breathless. Further information: Asthma + Lung UK, www.asthmaandlung.org.uk, helpline 0300 222 5800. ### Bronchiectasis exacerbation plan [bronchiectasis-exacerbation-plan] Your plan for chest infections What counts as an infection needing treatment A change from your usual state, lasting more than 48 hours, with any of: - more phlegm than usual, or thicker phlegm - phlegm that has changed colour - more coughing - more breathlessness - feeling unwell, feverish or unusually tired - coughing up blood. What to do 1. Send a sputum sample before you start antibiotics. You have been given pots for this. Even if you have already started, still send one. 2. Increase your airway clearance. Do it more often than usual - three or four times a day if you can manage it - and for longer. This is as important as the antibiotic. 3. Start your antibiotic: First choice: [] [] mg [] times a day for 14 days. If you are allergic to it, or it has not worked before: [] [] mg [] times a day for 14 days. Take the full 14 days. Courses of 5 or 7 days often leave the infection smouldering, and it comes back within a few weeks. 4. Drink plenty of fluid, and rest. 5. Tell your GP practice or the respiratory team that you have started the plan. If you are not improving Contact us if you are no better after 5 to 7 days of antibiotics, or if you get worse at any point. You may need a different antibiotic based on your sputum result, or treatment through a drip. Get help urgently, or call 999, if you are severely breathless, have chest pain, are coughing up a large amount of blood, are confused or drowsy, or cannot keep fluids down. How often is too often If you are needing this plan three or more times a year, please ask for a review rather than simply repeating it. Frequent infections mean there is more we should be doing - which may be a change in your clearance regime, a long-term antibiotic, or treatment aimed at a specific organism in your sputum. ### Bronchiectasis tests - what we are looking for [bronchiectasis-test-bundle] Baseline investigation of newly diagnosed bronchiectasis. Everyone: Full blood count with differential white cell count Serum immunoglobulins G, A and M Serum electrophoresis Total IgE, and specific IgE or skin prick testing to Aspergillus fumigatus Aspergillus IgG (precipitins) Sputum culture for bacteria, including specific request for Pseudomonas Sputum culture for mycobacteria, including non-tuberculous mycobacteria Sputum for fungal culture CRP Spirometry with reversibility Guided by the history and the pattern on CT: Specific antibody responses to pneumococcal capsular polysaccharide, with post-immunisation levels if baseline is low Rheumatoid factor, anti-CCP antibodies, ANA and ANCA Alpha-1 antitrypsin level Cystic fibrosis testing: sweat test and CFTR genetics Testing for primary ciliary dyskinesia: nasal nitric oxide, then referral to a diagnostic centre HIV testing Assessment of aspiration and reflux Bronchoscopy if the disease is focal, to exclude an obstructing lesion Findings so far: [] Cause identified: [], or no cause identified after full assessment. ### New bronchiectasis patient [bronchiectasis-new-patient] Referred with: [] History: Duration of cough: [] Daily sputum: [volume, colour when well, colour when unwell] Blood in the sputum: [never, streaking, or frank, and how often] Breathlessness, MRC [1 to 5] Chest pain, fatigue, fevers, weight loss: [] Exacerbations in the last 12 months: [number, and how many needed intravenous antibiotics or admission] Antibiotics in the last 12 months: [] Points to a cause: Childhood pneumonia, whooping cough, measles or tuberculosis: [] Recurrent sinus or ear infection since childhood: [] Infertility or situs inversus: [] Neonatal respiratory distress: [] Rheumatoid arthritis or other connective tissue disease: [] Inflammatory bowel disease: [] Reflux, swallowing difficulty or recurrent aspiration: [] Previous or current asthma, and any history of allergic bronchopulmonary aspergillosis: [] Smoking and occupational exposure: [] Immunosuppressive treatment, past or present: [] Family history of bronchiectasis, cystic fibrosis or immunodeficiency: [] Current treatment: Airway clearance: [technique, taught by whom, how often actually done] Nebulised or inhaled treatment: [] Inhaled corticosteroid, and the indication for it: [] Long-term antibiotic: [] Vaccination: [influenza, pneumococcal, COVID-19] Examination: SpO2 []% on air Height [] cm Weight [] kg BMI [] [crackles, wheeze, clubbing, nasal disease] Investigations: CT chest: [lobes involved, traction bronchiectasis or cystic change, mucus plugging, tree-in-bud] Sputum culture including mycobacteria: [] Spirometry: FEV1 [] L ([]%), FVC [] L, ratio []% Aetiology screen: [see the bronchiectasis test bundle] Severity: Bronchiectasis Severity Index [] or FACED [] Chronic Pseudomonas aeruginosa infection: [yes or no] Impression: Bronchiectasis affecting [], with [] exacerbations per year, [chronic infection with organism or no chronic infection], cause [established or under investigation]. Plan: 1. Referral to respiratory physiotherapy for airway clearance: [] 2. Aetiology screen: [sent, awaited] 3. Sputum for culture and mycobacteria: [] 4. Vaccination brought up to date: [] 5. Pulmonary rehabilitation if exercise-limited: [] 6. Self-management plan and exacerbation antibiotic plan: [] 7. Review in [] months with [sputum, spirometry] ### Did not attend - letter before discharge [did-not-attend] Dear [], I see that you did not attend your appointments in my clinic on [] and []. I hope that this is not because you have been unwell. If you would still like to be seen, please contact us on the number below within the next three months and we will arrange another appointment. You are also welcome to telephone to discuss things instead of coming in, if that is easier. If we do not hear from you within three months, you do not need to do anything further and you will be discharged from the clinic. Your GP will be informed. If you need to be seen again after that, your GP can refer you back. If any of the following happen, please see your GP without waiting: a cough that will not go away or is getting worse, coughing up blood, worsening breathlessness, chest pain, or losing weight without trying to. If there is something that makes it difficult for you to attend - the time of day, getting here, needing an interpreter, or anything else - please tell us. We can usually work around it. With all best wishes, Yours sincerely, ### Discharge after no response [discharge-after-no-response] Dear [], Further to my letter of [], I have not heard from you. I very much hope that this means your symptoms have improved. I am now discharging you from the chest clinic, and I have written to your GP to let them know. If you develop any of the following, please contact your GP, who can refer you back to the chest clinic: a cough that persists or is getting worse, coughing up blood, worsening breathlessness, chest pain that is not explained, or losing weight without meaning to. If you would still like to be seen and simply have not managed to get in touch, please telephone the number below and we will help. With all best wishes, Yours sincerely, ### Invitation for a repeat chest x-ray [chest-x-ray-invitation] Dear [], When I saw you on [], we agreed that you should have a repeat chest x-ray to check that [the changes on the previous x-ray have cleared, or the specific reason]. Please come for this on [] , or at any time within three weeks after that date if that is more convenient, Monday to Friday between [] and [] . You do not need an appointment. Please go to [department and location]. It may make things easier if you bring this letter with you. You do not need to do anything to prepare, and you can eat and drink normally. Please tell the radiographer if you are, or might be, pregnant. We will write to you with the result, and to your GP. If you have not heard from us within [] weeks of having the x-ray, please telephone the number below rather than assuming that no news is good news. With all best wishes, Yours sincerely, ### Letter footer - dictation note and signature [letter-footer] Yours sincerely, [] [post-nominal qualifications] Consultant in Respiratory Medicine [department and organisation] Tel: [] Email: [] Copy to: [patient, GP, others] This letter was created using voice recognition software. This occasionally produces errors in spelling or wording. I apologise if any have occurred, and I would be grateful if you would let me know so that they can be corrected. ### New respiratory outpatient [new-respiratory-outpatient] History of presenting complaint: [] Previous medical history: [] Current medication and allergies: [] Family history: [] Personal and social history: Smoking status: [current, ex or never] (pack-years []) E-cigarettes or vaping: [device and duration, or no] Recreational drug use: [drug, route, duration, or no] Very brief advice given: [yes, no or not applicable] Referred to stop smoking service: [yes, no or not applicable] Nicotine replacement or pharmacotherapy offered: [type, or no] Alcohol: [] Occupation, current and previous: [] Home circumstances and who else is at home: [] Pets and birds: [] Recent travel: [] On examination: Height [] cm Weight [] kg BMI [] SpO2 []% on air BP [] mmHg Pulse [] bpm Respiratory rate [] ECOG performance status [] There was no pallor, cyanosis, jaundice, oedema, clubbing or cervical lymphadenopathy. Heart sounds: [] Breath sounds: [] Abdomen: [] Radiology: [] Hand-held spirometry: FEV1 [] L ([]% predicted) FVC [] L ([]% predicted) FEV1/FVC ratio []% Peak flow [] L/min ([]% predicted) Blood tests: [] Impression: [] Management plan: [] ### Respiratory follow-up review [respiratory-follow-up] Reviewed in the chest clinic. Diagnosis: [] Last seen: [] Since last seen: Symptoms: [better, unchanged, worse, and in what way] Exercise tolerance now: [] Exacerbations, courses of antibiotics or steroids: [] Unscheduled care or admissions: [] New symptoms: [] Weight: [] kg, change of [] Treatment: Current respiratory treatment: [] Taken as prescribed: [yes, or the specific problem] Inhaler technique checked today: [] Side effects: [] Changes made since last review: [] Results since last seen: Imaging: [] Lung function: [] Bloods: [] Microbiology: [] Examination: SpO2 []% on air, observations [] [] Impression: [] Plan: 1. [] 2. Investigations requested: [] 3. Discussed with the patient: [] 4. Follow-up: [in [] months, patient-initiated, or discharge] 5. If discharged: safety-netting given, and the specific symptoms that should prompt re-referral: [] Actions for the GP: [] ### COPD - information for patients [copd-patient-information] About your chronic obstructive pulmonary disease COPD is a long-term condition in which the airways are narrowed and the lung tissue is damaged, so air moves in and out less easily. It causes breathlessness, cough and phlegm, and periods where symptoms get worse, which we call flare-ups or exacerbations. COPD does not usually go away, but a great deal can be done to help you feel better, do more, and stay out of hospital. The four things that help most 1. Stopping smoking. If you smoke, stopping is the only thing shown to slow down further damage to the lungs, at any age and at any stage. It is difficult, and most people need several attempts. Medication and support together give the best chance, and we can arrange both. If you have already stopped, staying stopped is just as valuable. 2. Pulmonary rehabilitation. This is a supervised programme of exercise and education, usually twice a week for six to eight weeks. It improves breathlessness, fitness and quality of life more than any inhaler does, and it reduces the chance of being admitted to hospital. Many people are wary of exercising when they are breathless. Being breathless during exercise is not harmful, and the programme is designed around people who are. 3. Keeping active every day. Whatever you can manage, done regularly, is better than resting. Breathlessness on exertion is expected, and avoiding activity because of it leads to becoming less fit, which makes the breathlessness worse. 4. Vaccination. Have the influenza vaccine every autumn, and the pneumococcal, COVID-19 and RSV vaccines when you are offered them. Chest infections are the commonest cause of a flare-up. Your inhalers Inhalers help symptoms and reduce flare-ups. They work only if the technique is right, and a large proportion of the dose is wasted if it is not. Please bring all of your inhalers to every appointment so we can watch you use them. If a device is awkward for you, tell us, because there is almost always an alternative. Flare-ups A flare-up means your usual symptoms get clearly worse for more than a day or two: more breathless than normal, more phlegm, or phlegm that changes colour. If you have been given a rescue pack of antibiotics and steroid tablets, follow the written instructions we have given you, and tell your GP practice within a day or two of starting them so your treatment can be reviewed and the pack replaced. Get urgent medical help, or call 999, if you are much more breathless than usual and it is not improving, if you cannot manage to speak in full sentences, if you have chest pain, if you are coughing up blood, if you become drowsy or confused, or if your lips or fingers look blue. Living with COPD Feeling low or anxious is very common with COPD and is treatable. Please tell us if this is affecting you. Eating well matters in both directions: losing weight without meaning to is worth telling us about, and carrying extra weight makes breathlessness worse. If you are worried about money, heating or getting out of the house, say so. Cold, damp housing makes COPD worse, and there is practical help available. Further information: Asthma + Lung UK, www.asthmaandlung.org.uk, helpline 0300 222 5800. ### COPD rescue pack instructions [copd-rescue-pack] Your rescue pack You have been given a supply of antibiotics and steroid tablets to keep at home, so that you can start treatment quickly if you have a flare-up. This only works safely if it is used for the right thing at the right time, so please read this carefully and keep it with the tablets. How to tell you are having a flare-up For at least two days, and clearly worse than your usual day-to-day symptoms: - you are more short of breath than normal, or - you are coughing up more phlegm than normal, or - your phlegm has changed colour, usually to yellow, green or brown. Feeling a little more breathless on one bad day is not a flare-up. Neither is a runny nose or a sore throat on its own. What to take If you are more breathless than usual, start the steroid tablets: prednisolone [] mg once a day in the morning, for [] days. If your phlegm has increased or changed colour, start the antibiotic: [] [] mg [] times a day, for [] days. If both are true, start both. Finish the full course of each. Do not stop early because you feel better. What to do next Tell your GP practice within one or two days of starting the pack, even if you are improving. This is so your treatment can be reviewed, so the flare-up is recorded, and so your pack can be replaced. A rescue pack is meant to be used once and replaced, not kept and reused. Get urgent help, or call 999, if: - you are severely breathless, or it is getting worse rather than better - you cannot speak in full sentences - you have chest pain - you are coughing up blood - you become drowsy, confused or unusually sleepy - your lips or fingers look blue - you have started the pack and are no better after 48 hours. Important safety points Steroid tablets can raise your blood sugar. If you have diabetes, test more often while you are taking them and follow the advice you have been given about what to do if the readings are high. Steroid tablets can cause indigestion, disturbed sleep and mood changes. Taking them in the morning helps with sleep. Repeated courses of steroids carry risks to bones, eyes and blood sugar, which is another reason to tell us every time you use the pack. If you use the pack more than twice in a year, please ask for a review. Frequent flare-ups usually mean your treatment needs changing, not that you need more rescue packs. ### COPD review [copd-annual-review] COPD review. Since last seen: MRC dyspnoea scale [1 to 5], previously [] CAT score [], previously [] Exacerbations treated at home: [] Exacerbations needing admission: [] Any ventilatory support: [] Exercise tolerance: [metres on the flat] Treatment: Current inhalers: [drug, device, dose, doses per day] Inhaler technique observed today: [adequate, or the specific error seen] Prescription collections in the last 12 months: [] Rescue pack: [held, used how many times, and appropriately or not] Nebuliser or home oxygen: [] Mucolytic: [] Fundamentals: Smoking status: [current with pack-years, or ex with quit date] Very brief advice and treatment offered: [] Pulmonary rehabilitation: [completed and when, on the waiting list, declined, or due a repeat] Vaccination: [influenza, pneumococcal, COVID-19, RSV] Physical activity: [] Weight [] kg, BMI [], any unintentional weight loss [] Anxiety or depression screened: [] Measurements: SpO2 []% on air, at rest Post-bronchodilator FEV1 [] L ([]% predicted) Blood eosinophils [] x10^9/L [walk test result if done] Assessments due: Long-term oxygen assessment indicated: [yes if resting SpO2 92% or less on air when stable, or no] Referral for lung volume reduction or valve assessment considered: [yes or no] Alpha-1 antitrypsin checked at least once: [yes or no] Anticipatory care and treatment escalation discussed: [yes or not yet] Impression: [stable, deteriorating, or frequent exacerbator], MRC [], FEV1 []% predicted, [] exacerbations in the last 12 months. Plan: 1. [] 2. Self-management plan reviewed and reissued: [] 3. Review in [] months, and sooner if [specific trigger to come back] ### New COPD patient [copd-new-patient] Referred with: [] History: Breathlessness, MRC dyspnoea scale [1 to 5] Cough and sputum: [daily, colour, volume] Blood in the sputum: [yes or no] Wheeze and chest tightness: [] Exercise tolerance: [metres on the flat, and stairs] What they can no longer do that they used to: [] Weight change: [] Exacerbation history in the last 12 months: Courses of antibiotics or steroids: [] Hospital admissions: [] Any ventilatory support: [] Risk factors: Smoking: [current or ex, pack-years, quit date] Vaping: [] Occupational dust, fume and vapour exposure: [] Biomass or indoor cooking fuel exposure: [] Childhood chest illness, prematurity, asthma: [] Family history of emphysema or liver disease, and age of onset: [] Comorbidity: Cardiovascular disease: [] Osteoporosis and fracture history: [] Anxiety and depression: [] Nutrition, weight [] kg, BMI [] Bronchiectasis symptoms: [] Current treatment and how it is taken: Inhalers: [drug, device, dose, doses per day] Inhaler technique observed today: [adequate, or the specific error seen] Adherence by prescription collection: [] Home oxygen or nebuliser already in place: [] Examination: SpO2 []% on air BP [] mmHg Pulse [] bpm Height [] cm Weight [] kg BMI [] [barrel chest, accessory muscle use, pursed lip breathing, chest signs, ankle oedema] Investigations: Post-bronchodilator spirometry: FEV1 [] L ([]% predicted), FVC [] L, ratio []% Full lung function including gas transfer: [] Blood eosinophils [] x10^9/L Alpha-1 antitrypsin level: [] Chest x-ray: [] CT chest: [] ECG and echocardiogram if indicated: [] Full blood count for anaemia or polycythaemia: [] Impression: COPD confirmed on post-bronchodilator ratio below 0.7, FEV1 []% predicted, MRC [], [] exacerbations in the last year, [with or without] a history of hospitalisation. Plan: 1. Smoking: [very brief advice given, referred to stop smoking service, pharmacotherapy offered] 2. Pulmonary rehabilitation: [referred, or reason not] 3. Vaccination: [influenza, pneumococcal, COVID-19, RSV as eligible] 4. Inhaled treatment: [drug and device, chosen with the patient] 5. Inhaler technique taught and checked: [] 6. Self-management plan and rescue pack: [issued or not, with reason] 7. Assessment for long-term oxygen: [not indicated, or arranged] 8. Treat comorbidity: [] 9. Review in [] months ### New interstitial lung disease patient [ild-new-patient] Referred with interstitial lung disease. History: Breathlessness: [onset, rate of change, MRC 1 to 5] Cough: [dry or productive, duration] Best exercise tolerance in the last year, and now: [] Weight loss, fever, fatigue: [] Chest pain: [] Occupational history, every job in order: [] Asbestos: [trade, years, and the nature of the exposure] Silica, coal, metal dust, welding fume: [] Wood dust, textile dust, grain: [] Personal protective equipment used: [] Environmental and antigen exposure: Birds kept, now or in the past, including a partner's: [species, years] Feather bedding, duvets and pillows: [] Damp, mould or water damage at home or work: [] Hot tub, humidifier or air conditioning: [] Farming, hay, compost, mushrooms: [] Any relationship between symptoms and being at home, at work, or away: [] Drugs, now and previously: [amiodarone, methotrexate, nitrofurantoin, bleomycin, immune checkpoint inhibitors, and any drug started within a year of symptoms] Radiotherapy to the chest: [] Recreational drug use, including inhaled: [] Connective tissue disease review: Joint pain, swelling or morning stiffness: [] Raynaud phenomenon: [] Dry eyes or dry mouth: [] Rash, photosensitivity, Gottron papules, mechanic's hands: [] Muscle weakness, difficulty rising from a chair or lifting arms: [] Reflux and dysphagia: [] Mouth ulcers, hair loss: [] Other: Smoking: [pack-years, quit date] Family history of pulmonary fibrosis or early grey hair or bone marrow failure: [] Reflux: [] Cardiac history: [] Examination: SpO2 []% at rest on air, [] after exertion Height [] cm, weight [] kg Crackles: [fine, velcro, distribution] Clubbing: [] Joints, skin, nails and nailfold capillaries: [] Signs of pulmonary hypertension or right heart failure: [] Investigations: High resolution CT: [pattern, distribution, honeycombing, traction bronchiectasis, ground glass, mosaicism, air trapping on expiration] Full lung function: FVC [] L ([]%), TLCO []%, and any previous values for comparison Walk test with oximetry: [distance, nadir SpO2] Autoimmune screen: [ANA, ENA, rheumatoid factor, anti-CCP, myositis panel, ANCA, CK] Serum precipitins or specific IgG to relevant antigens: [] Echocardiogram: [] Bronchoscopy with lavage or biopsy, if indicated: [] Impression: [radiological pattern] on CT, with [] % predicted FVC and [] % predicted TLCO, most consistent with [], to be discussed at the ILD MDT. Plan: 1. Discussed at ILD multidisciplinary meeting on [] 2. Antifibrotic or immunosuppressive treatment: [considered, started, or not indicated] 3. Antigen avoidance: [specific advice given] 4. Oxygen assessment: [] 5. Pulmonary rehabilitation: [] 6. Vaccination: [] 7. Smoking cessation: [] 8. Lung transplant discussion, or referral: [yes, no, with reason] 9. Clinical trial eligibility considered: [] 10. Review in [] months with repeat lung function ### Pulmonary fibrosis - information for patients [pulmonary-fibrosis-information] About pulmonary fibrosis Fibrosis means scarring. In pulmonary fibrosis, the tissue between the tiny air sacs of the lung becomes thickened and scarred. That makes the lungs stiffer and makes it harder for oxygen to pass into the blood, which is why the main symptoms are breathlessness on exertion and a dry cough. There are many different causes. Some are related to an exposure - dusts at work, birds, mould, or a medicine. Some occur alongside conditions such as rheumatoid arthritis. In some, no cause is found, and the commonest of these is called idiopathic pulmonary fibrosis. Which one you have matters, because the treatments are different, which is why the tests have been thorough. Your diagnosis, as it stands: [] What can be done Scarring that has already formed does not reverse. But that is not the same as nothing being possible, and several things genuinely help. Treatments to slow it down. For some types of fibrosis there are medicines called antifibrotics, which slow the rate at which lung function declines. For fibrosis driven by inflammation or by an autoimmune condition, treatments that damp down the immune system may be used instead. We will discuss which applies to you. Removing the cause, where there is one. If an exposure is contributing - birds, mould, a medicine - stopping it is one of the most effective things available, and the advice is worth following strictly. Pulmonary rehabilitation. A supervised exercise and education programme. It improves breathlessness and what you are able to do, and it is one of the strongest recommendations in fibrosis care. Oxygen. If your oxygen level falls when you exert yourself, oxygen can improve what you can manage. We test for this rather than guess. Treating other things that make breathlessness worse - reflux, heart disease, anaemia, weight, and anxiety. Vaccination, to reduce chest infections. Stopping smoking, if you smoke. Lung transplant is an option for a small number of people, and the assessment needs to happen early rather than late. We will tell you if this is something to consider for you. Research. Fibrosis is an active area of research and there may be a trial you are eligible for. Ask us - we will not always think to raise it. What to expect Pulmonary fibrosis behaves differently in different people. Some remain stable for years; in others it progresses more quickly. We monitor with breathing tests, usually every three to six months, and it is the change over time rather than any single result that tells us what is happening. It is reasonable to ask us about the future, and we will be honest with you, including about what we do not know. You do not have to have that conversation before you are ready, and you can come back to it. Living with it Breathlessness is frightening, and there are practical techniques that help - breathing control, pacing, using a handheld fan. Ask, because these are taught rather than obvious. Cough can be the most wearing symptom, and there are treatments worth trying. Tell us about low mood and anxiety. Both are common with this diagnosis and both are treatable. Ask about benefits, blue badge and support at home earlier than you think you need to. Contact us if You become more breathless than usual over days or a few weeks, rather than months. A sudden worsening needs to be assessed promptly and not waited out. Further information: Asthma + Lung UK, www.asthmaandlung.org.uk, helpline 0300 222 5800. Action for Pulmonary Fibrosis, www.actionpf.org. ### After a lung cancer diagnosis - information for patients [lung-cancer-diagnosis-information] What we discussed today We have told you that the tests show lung cancer. I am sorry to be giving you this news. Most people remember very little of a conversation like this one, which is why it is written down here. Please read it again when you are ready, and share it with whoever you want to. What we know so far The type of cancer: [] Where it is: [] What the tests have shown about whether it has spread: [] What we still need to find out: [] What happens next [] Your lung cancer nurse specialist is []. Their number is []. They are your main point of contact and you can ring them with any question, however small it seems. Most people find they have questions a day or two later. That is expected, and it is what the number is for. Your case is discussed at a meeting of chest doctors, surgeons, cancer specialists, radiologists, pathologists and specialist nurses. We will contact you after that meeting with the recommendation and arrange to see you. Questions people usually want to ask You do not have to ask everything at once, and you can ask the same question more than once. Common ones are: what type is it, has it spread, what treatment is possible, what will the treatment involve, what will it do to how I feel, and what does this mean for how long I have. Some of these we can answer now and some we cannot answer until the remaining tests are back. If we do not know, we will say so rather than guess. It helps to write your questions down as you think of them, and to bring someone with you to appointments. Things that help now If you smoke, stopping now still helps. It improves how well treatment is tolerated and reduces complications from surgery. We can arrange support and medication immediately, and this is not a criticism of you. Keep as active as you comfortably can. Fitness affects which treatments are possible. Eat what you can manage. Tell us if you are losing weight. Tell us about pain, breathlessness, cough or low mood. All of these can be treated, and treating them is part of cancer care from the beginning, not something that only happens later. Practical and financial help A cancer diagnosis often has immediate practical consequences - work, driving, travel insurance, benefits, caring responsibilities. Your nurse specialist can put you in touch with people who deal with this every day. Ask early rather than when things are difficult. Macmillan Cancer Support: 0808 808 00 00, www.macmillan.org.uk Roy Castle Lung Cancer Foundation: 0333 323 7200, www.roycastle.org If you are struggling Feeling frightened, angry, numb or unable to sleep is a normal response, not a weakness. Tell us if it is not easing, because there is help. ### Lung cancer tests - what each one is for [lung-cancer-staging-tests] About the tests we have arranged We need to answer two questions before we can recommend treatment: what exactly the abnormality is, and whether it has spread. Different tests answer different parts of that, which is why there is usually more than one. It can feel slow. Each test has to be done, reported, and then discussed by the team, and the order matters because each one tells us where to look next. CT scan A detailed x-ray picture of the chest and upper abdomen, usually with an injection of dye into a vein. It shows the size and position of the abnormality and whether the lymph nodes are enlarged. It takes a few minutes. PET-CT scan A scan that shows how active tissue is, not just what it looks like. You are given an injection of a small amount of radioactive sugar and rested quietly for about an hour, then scanned. Cancer cells usually take up more of the sugar and appear bright. PET-CT is very good at finding areas we would otherwise miss, but inflammation and infection also light up, so a bright area is not proof of cancer. That is why we often still need a sample. If you have diabetes, tell us, because the preparation needs adjusting. Getting a sample Looking at cells under a microscope is the only way to be certain what something is, and modern lung cancer treatment depends on tests done on the tissue itself. We choose the method that gives the most information with the least risk, which depends on where the abnormality is. Bronchoscopy: a thin camera passed into the airways, with samples taken from inside them. EBUS, or endobronchial ultrasound: a bronchoscopy with an ultrasound probe at the tip, which lets us see the lymph nodes in the centre of the chest through the airway wall and pass a fine needle into them. This is the standard way of checking whether lymph nodes are involved, which matters a great deal for treatment. CT-guided biopsy: a needle passed through the skin into the abnormality, using the CT scanner to guide it. Used when the abnormality is near the outside of the lung. There is a risk of causing a leak of air from the lung, which sometimes needs a drain and an overnight stay. Draining fluid: if there is fluid around the lung, a sample is taken with a needle and examined for cancer cells. Other tests you may be offered MRI of the head, to check whether the brain is involved. Breathing tests and sometimes an exercise test, to see how well you would cope with surgery or radiotherapy. Blood tests, including kidney and liver function. What happens to the results Everything is brought together at a meeting called the lung cancer multidisciplinary team, or MDT. Chest doctors, surgeons, cancer specialists, radiologists, pathologists and specialist nurses meet weekly to agree a recommendation, which we then discuss with you. Your lung cancer nurse specialist is your point of contact throughout, and is the person to ring with questions between appointments. If you smoke Stopping smoking now still helps, even at this stage. It reduces complications from surgery, improves how well radiotherapy and chemotherapy are tolerated, and improves outcomes. We can arrange support and medication straight away. ### Suspected lung cancer [suspected-lung-cancer] Seen in the suspected lung cancer clinic. Referred with: [imaging finding, symptom, or screening result] Date of first suspicion of cancer or referral: [] History: Cough, and any change in a long-standing cough: [] Haemoptysis: [amount, frequency, duration] Breathlessness, MRC [1 to 5] Chest, shoulder or back pain: [] Hoarseness: [] Weight loss: [] kg over [] months Appetite and swallowing: [] Bone pain: [] Headache, seizures, focal neurology or personality change: [] Fatigue: [] Risk and background: Smoking: [current or ex, pack-years, quit date] Occupational exposure, particularly asbestos: [job, years, and what was done] Previous cancer, and treatment received: [] Family history: [] Previous imaging available for comparison, and dates: [] Comorbidity relevant to treatment: Cardiac disease: [] COPD or ILD, and lung function: [] Renal and liver function: [] Autoimmune disease, or immunosuppressive treatment: [] Anticoagulation: [] Cognition, and any concerns about capacity: [] Who is at home, and what support there is: [] ECOG performance status [] Weight [] kg Height [] cm BMI [] SpO2 []% on air Examination: Cervical and supraclavicular lymph nodes: [] Chest: [] Clubbing: [] Liver edge, skin nodules, bone tenderness: [] Neurological examination: [] Investigations to date: Chest x-ray [date and finding] CT chest and upper abdomen with contrast [date and finding] Bloods including full blood count, renal, liver, bone profile and LDH: [] Impression: [radiological stage and the differential], with an ECOG performance status of [], suitable for [radical intent, systemic anticancer therapy, or best supportive care] pending staging and tissue. Plan: 1. [PET-CT, EBUS, CT-guided biopsy, bronchoscopy, pleural sampling, MRI head] 2. Lung cancer nurse specialist informed: [] 3. Discussed at lung cancer MDT on [] 4. Patient told: [what has been said today about the likely diagnosis] 5. Next contact: [who, when, and how] 6. Lung function and fitness assessment if radical treatment is possible: [] ### Asking the GP to arrange nodule follow-up [nodule-follow-up-by-gp] Dear Dr [], Re: [patient name, date of birth, NHS number] This patient was referred to the [] team. The CT scan performed on [] showed an incidental [sub-solid or solid] nodule of [] mm in the [] lobe. The appearances are of a low-risk nodule. The calculated risk of malignancy was []%. Nodules of this kind are usually harmless, and an operation is not recommended at this size: in the great majority of cases the nodule turns out to be benign, and the treatment would be worse than the disease. If it grows on follow-up imaging, we would then recommend further investigation and possible removal. Under an arrangement agreed with [commissioner or ICB], follow-up CT for nodules of this type may be requested in primary care, to avoid unnecessary secondary care appointments. I would be grateful if you would arrange a non-contrast CT thorax [annually, or at the intervals below] for a total of [] years: Scan due [] Scan due [] Scan due [] Scan due [] Surveillance can stop after [] provided the nodule remains unchanged. If any report shows growth or a change in character, the radiologist will recommend re-referral, and the chest clinic will also be notified. Please refer the patient back to us at that point, or sooner if they develop new or worsening cough, haemoptysis, breathlessness or unexplained weight loss. The patient has been given written information explaining the nodule, the plan, and when the surveillance ends. If you would prefer that we retain follow-up in secondary care, please let me know and we will arrange it. Please do not hesitate to contact me on the number below with any queries. Yours sincerely, ### Lung nodules - information for patients [nodule-patient-information] About the small spot found on your scan Your scan has shown a small spot in the lung, which doctors call a nodule. Lung nodules are common. They are found in a large proportion of people who have a CT scan of the chest for any reason, and the great majority are not cancer. Most are the scar of an old infection - something that happened years ago and healed - or a small collection of harmless tissue. Because a small number do turn out to be important, we do not simply ignore them. The safest and least invasive way to tell the difference is to look again after an interval and see whether the nodule has changed. Why we are watching rather than removing it An operation to remove a nodule this small is a bigger undertaking than the problem usually warrants. Most nodules of this size are harmless, and surgery carries real risks. Watching is not us doing nothing; it is the test. Nodules that are not cancer stay the same size. Nodules that are growing show it on a repeat scan, and if that happens we act on it. What happens now Your next scan is due in [] . It will be arranged by [] . If the scans stay unchanged until [] , we will stop scanning and discharge you, because a nodule that has not changed over that period is very unlikely to be anything to worry about. If a scan shows a change, we will contact you and arrange to see you in clinic. What you should do Please do keep the appointments, even if you feel completely well. Feeling well is expected, and it does not tell us anything about the nodule. If you smoke, stopping is the most useful thing you can do. It reduces the chance that this nodule, or another one, turns out to matter. We can arrange support and medication. Contact your GP or us if you develop a new or changing cough, cough up blood, lose weight without meaning to, or become breathless. These are not expected from a nodule of this size, and they should be looked at rather than waited out. It is normal to find this unsettling Being told that something has been found, and then being asked to wait, is uncomfortable. Most people find the first few weeks the hardest, and it settles. If it is preying on your mind, tell us - it is a reasonable thing to ring about. ### Pulmonary nodule surveillance plan [nodule-surveillance-plan] Pulmonary nodule assessment. Nodule found on: [scan type and date, and why it was done] Comparison with previous imaging: [date of earliest available prior imaging, and whether the nodule was present] Nodule characteristics: Site: [lobe and segment] Size: [] mm maximum diameter, volume [] mm3 Character: [solid, part-solid with solid component of, or pure ground glass] Margins: [smooth, lobulated, spiculated] Number: [solitary, or number and distribution] Other findings: [emphysema, fibrosis, lymphadenopathy] Risk: Age [], smoking [current, ex with quit date, or never], pack-years [] Asbestos or other occupational exposure: [] Previous malignancy: [] Family history of lung cancer: [] Brock model risk of malignancy: []% Herder model risk after PET-CT: []% Assessment: [below the size threshold for follow-up, or under surveillance, or being worked up for possible malignancy] Plan: 1. [discharge with no further imaging, interval CT, PET-CT, biopsy, or referral for treatment] 2. Next scan due: [month and year], to be requested by [chest clinic, GP, or radiology recall] 3. Surveillance ends: [month and year] if stable 4. Patient informed of the plan and the reason for it: [yes] 5. Smoking cessation offered: [] If the nodule grows on any interval scan, the patient should be referred back to the chest clinic rather than continuing surveillance. ### Indwelling pleural catheter - information for patients [indwelling-pleural-catheter-information] About your indwelling pleural catheter Fluid has been collecting between your lung and your chest wall, and it is making you breathless. Draining it helps, but it tends to come back, and repeated visits for repeated drainage is a poor way to spend the time you have. An indwelling pleural catheter is a soft, thin tube placed through the skin into that space, and left in. It is tunnelled a short distance under the skin, which holds it in place and reduces the risk of infection. The end sits under a dressing on your chest. You, or a district nurse, or a family member we have trained, can then drain the fluid at home whenever it builds up, without coming into hospital. Having it put in It is done under local anaesthetic, usually as a day case, and takes about 30 minutes. You are awake. You may feel pushing and pressure but should not feel sharp pain - tell us if you do. Afterwards you will have a dressing over the site. It is common to feel achy for a few days. Draining at home We will drain it [] times a week to begin with, and adjust that according to how much fluid comes and how you feel. Drain to symptoms rather than to a target: the aim is that you are comfortable, not that a particular amount comes out. Stop draining if you develop chest tightness or a persistent cough during the drainage, even if fluid is still coming. That is the lung reaching the end of its stretch, and continuing is uncomfortable and not useful. Try again next time. Keep the dressing dry and intact. Do not swim or take baths. Showering is usually fine with the dressing covered - we will show you. Over weeks to months, the fluid often reduces and in some people stops altogether, because the two surfaces stick together. If that happens the tube can be removed. Contact us the same day if: - the skin around the tube becomes red, hot, swollen or painful - there is pus or an unpleasant smell at the site - you have a fever, or feel shivery and unwell - the fluid changes and becomes cloudy or smells - the tube comes out, splits, or leaks around the site - you become more breathless, or the fluid stops draining and you are breathless - you have new chest pain. Infection is the main risk with an indwelling catheter, and it is very treatable when it is caught early. It is always better to ring. Who to contact [team name and number], [hours]. Out of hours: [] . Practical points You can usually carry on with normal daily activities, work and travel with the tube in. Tell us before you fly or travel a long distance, so we can plan. Tell any other clinician looking after you that you have a pleural catheter, particularly if you are admitted to hospital or need a scan. ### Pneumothorax - information for patients [pneumothorax-patient-information] About your pneumothorax A pneumothorax is a collection of air between the lung and the chest wall. The air takes up space, so the lung cannot expand fully. People often call it a collapsed lung. It happens when a small air leak develops on the surface of the lung. In younger, taller people this often occurs without any injury or warning, from a small bleb on the lung surface. In people with existing lung disease, such as emphysema, it can happen because the lung tissue is already fragile. Air that leaks out is gradually reabsorbed by the body once the leak seals. What happens next Treatment depends on how big the pneumothorax is, how breathless you are, and whether you have other lung disease. Options are: Observation. If you are not very breathless and the pneumothorax is small, doing nothing except watching is often the best treatment. The air reabsorbs on its own over days to a few weeks. Aspiration. Air is drawn out through a needle under local anaesthetic. A chest drain. A tube is placed between the ribs under local anaesthetic to let the air out continuously, usually needing a stay in hospital. Some people are suitable for a small device that lets them go home with the drain in place. We will tell you if that applies to you. Surgery. If the leak does not seal, or if the pneumothorax comes back, an operation can seal the surface of the lung and stick it to the chest wall. Your plan: [] After you go home You may have some chest discomfort for a while. Simple painkillers usually help. Come back to hospital urgently, or call 999, if you become more breathless, develop worse chest pain, feel faint, or your heart is racing. A pneumothorax can enlarge again, and it can do so quickly. Smoking If you smoke, stopping matters more here than almost anywhere else. Smoking substantially increases the chance of a pneumothorax happening again. We can arrange support and medication, and this is the single most useful thing you can do to avoid going through this a second time. Flying Do not fly until the pneumothorax has fully resolved and this has been confirmed on a chest x-ray. Current guidance is that flying is reasonable once the x-ray confirms resolution and you have recovered, and your team will tell you the interval they advise. Check with your insurer as well. Diving Do not scuba dive again unless you have had surgery to prevent recurrence and have been assessed as fit to dive. This is a permanent restriction otherwise, and it is not a formality: a pneumothorax at depth can be fatal. Coming back A pneumothorax comes back in a substantial minority of people, most often in the first year. Knowing the symptoms means you will recognise it quickly. Sudden breathlessness or sudden one-sided chest pain should be assessed the same day. ### Undiagnosed unilateral pleural effusion [pleural-effusion-workup] Unilateral pleural effusion, cause not yet established. History: Breathlessness, and over what period: [] Chest pain, and whether pleuritic: [] Cough and sputum: [] Fever, night sweats, weight loss: [] Orthopnoea, ankle swelling, known heart failure: [] Known malignancy, and treatment: [] Asbestos exposure: [job, years, and what was done] Smoking: [pack-years] Recent surgery, immobility or thromboembolism: [] Drug history, including anticoagulants and drugs causing effusions: [] Rheumatological or liver disease: [] Recent travel and TB contact: [] Examination: SpO2 []% on air, observations [] Side and estimated size: [] Lymphadenopathy, clubbing, chest wall signs: [] Signs of heart failure, chronic liver disease or nephrotic syndrome: [] Imaging: Chest x-ray: [] Thoracic ultrasound: [size, septations, echogenicity, pleural thickening, diaphragmatic nodularity, safe site marked] CT chest with contrast in the pleural phase, performed before full drainage: [] Pleural fluid: Appearance: [] pH [] (measured on a blood gas analyser, not a dipstick) Protein [] g/L, serum protein [] g/L LDH [] U/L, serum LDH [] U/L Glucose [] Light's criteria: [transudate or exudate] Cytology sent, volume: [] mL Microscopy, culture and sensitivity, including into blood culture bottles: [] Mycobacterial culture: [] Other: [amylase, triglycerides, cholesterol, haematocrit] Blood tests: Full blood count, renal, liver, bone profile, LDH, CRP: [] NT-proBNP: [] Autoantibodies if indicated: [] Impression: [transudate with likely cause, or exudate with differential] Plan: 1. [therapeutic aspiration, chest drain, local anaesthetic thoracoscopy, image-guided pleural biopsy, or observation] 2. Volume drained and symptomatic response: [] 3. Discussed at [pleural or lung cancer MDT] on [] 4. Follow-up: [] with [repeat imaging or results] ### Sleep apnoea and CPAP - information for patients [osa-cpap-information] About obstructive sleep apnoea When you sleep, the muscles that hold your throat open relax. In obstructive sleep apnoea, the throat narrows or closes completely for a few seconds at a time, so breathing stops or becomes very shallow. Your brain briefly wakes you to reopen the airway - usually without you knowing - and this can happen dozens or hundreds of times a night. The result is broken sleep. That is why people with sleep apnoea feel unrefreshed and sleepy during the day despite spending long enough in bed, and why their partner may notice loud snoring and pauses in breathing. It is common, it is treatable, and treating it usually makes people feel substantially better. About CPAP CPAP stands for continuous positive airway pressure. A small machine by the bed blows air through a tube into a mask you wear at night. The gentle pressure holds your throat open, so the airway does not collapse. It is not oxygen, and it does not breathe for you. It is a splint made of air. Used regularly, CPAP reduces daytime sleepiness, improves concentration and mood, improves quality of life, and helps blood pressure control. Most people who stick with it say they had forgotten what proper sleep felt like. The first two weeks This is the part worth knowing about in advance, because it is where most people who give up do so. The mask feels strange at first. Almost everyone finds it odd, and most people get used to it within one to two weeks. Common early problems, all of which we can fix: - a leaking mask, or marks on the face: usually the wrong size or the wrong style, and there are many alternatives - a dry nose or mouth: a humidifier can be added - a blocked nose: treatable, and worth telling us about - feeling that the pressure is too much: the machine can be adjusted, and can be set to build up gradually while you fall asleep - taking the mask off in your sleep without remembering. Please do not decide it is not for you in the first fortnight. Contact the sleep service instead - almost every early problem has a straightforward solution, and it is much easier to fix at two weeks than at six months. Use it every night, for the whole night. Benefit depends on hours of use. Using it for a few hours at the start of the night gives you a fraction of the benefit. Driving This matters, so please read it carefully. Do not drive when you feel sleepy. That applies to everyone, always. If you have sleep apnoea and are excessively sleepy, you must tell the DVLA, and you must not drive until your symptoms are controlled. You can be prosecuted if you do not. Once you are established on treatment and no longer sleepy, most people return to driving normally. If you drive for a living, tell us, because the rules for bus, coach and lorry licences are stricter and we can prioritise your assessment. We will tell you what applies to you and will support your licence application. Insurers need to know as well. Other things that help Losing weight, if you are overweight, can substantially reduce sleep apnoea and in some people resolves it. It is the only treatment that alters the underlying problem rather than holding the airway open. Avoid alcohol in the evening; it relaxes the throat muscles. Avoid sleeping tablets and sedatives unless they have been prescribed for you knowing you have sleep apnoea. Sleeping on your side rather than your back helps some people, particularly those whose apnoea is mild or mainly happens on their back. Stop smoking, which contributes to airway irritation and swelling. Further information: Sleep Apnoea Trust, www.sleep-apnoea-trust.org. ### Snoring and sleep advice [sleep-and-snoring-advice] Advice on snoring and sleeping better Your sleep study did not show significant obstructive sleep apnoea. That is good news, and it means CPAP is not the right treatment for you. It does not mean the snoring or the poor sleep is imaginary, and there is a good deal that helps. Reducing snoring Losing weight, if you are overweight, is the most effective single measure. Even a modest loss can make a noticeable difference, because much of the narrowing is caused by tissue around the throat. Avoid sleeping on your back. Snoring is often much worse in that position. Some people manage this with a pillow arrangement or by sewing something uncomfortable into the back of a night shirt; there are also positional devices. Sleeping propped up slightly, rather than flat, helps some people. Reduce alcohol, particularly in the evening. Alcohol relaxes the throat muscles and reliably worsens snoring. Stop smoking. Smoking irritates and swells the lining of the airway. Avoid sleeping tablets and tranquillisers, which have the same effect on throat muscle tone as alcohol. Treat a blocked nose. Persistent nasal obstruction, hay fever or nasal polyps make mouth breathing and snoring worse, and are treatable. Tell your GP if your nose is constantly blocked. A mandibular advancement splint - a device worn in the mouth at night that holds the lower jaw slightly forward - helps many people who snore, and is also a treatment option for mild sleep apnoea. The best results come from ones fitted by a dentist with an interest in this; devices are also sold directly to the public. Do not use one if you have significant dental disease or jaw joint problems without getting advice first. Sleeping better generally Keep the same bedtime and rising time every day, including at weekends. Regular timing does more for sleep quality than anything else on this list. Get daylight early in the day, and be active during the day. Do not exercise vigorously in the two hours before bed, but a gentle walk after dinner is helpful. Avoid screens and bright light for an hour or two before bed. Keep the bedroom dark, quiet and cool. Too warm is a common and easily fixed cause of broken sleep. Avoid caffeine after the early afternoon, and avoid alcohol as a way of getting to sleep - it helps you fall asleep and then fragments the second half of the night. If you cannot sleep, get up and do something quiet in low light rather than lying there. Lying awake in bed trains the brain to associate bed with being awake. If poor sleep has become a long-term problem, ask about cognitive behavioural therapy for insomnia. It works better than sleeping tablets and the benefit lasts. It is available online as well as in person. Come back to us if - you or your partner notice pauses in your breathing at night - you become sleepy during the day, particularly while driving - you gain a significant amount of weight - the snoring is causing difficulty in your relationship, which is a good enough reason on its own. Further information: NHS advice on snoring, www.nhs.uk/live-well/sleep-and-tiredness ### Suspected obstructive sleep apnoea [suspected-osa] Referred with suspected obstructive sleep apnoea. Sleep history: Snoring: [nightly, and whether reported by a bed partner] Witnessed apnoeas or choking or gasping at night: [] Waking unrefreshed, morning headache, dry mouth: [] Nocturia: [times per night] Usual bedtime and rising time, and hours actually asleep: [] Shift work: [] Naps: [] Insomnia symptoms, and whether sleep onset or maintenance: [] Restless legs or limb movements: [] Alcohol in the evening: [units and timing] Sedatives or opioids: [] Sleepiness: Epworth Sleepiness Scale [] out of 24 Impact on work, home and mood: [] Driving: Holds a driving licence: [no, group 1, or group 2] Occupational driver: [yes or no] Has fallen asleep or come close to it while driving: [] Advice given about not driving while sleepy, and about the duty to notify the licensing authority if excessive sleepiness is present: [given] Risk factors and consequences: Weight [] kg, height [] cm, BMI [], collar size [] Weight change: [] Neck, jaw and airway: [Mallampati, retrognathia, tonsils, nasal patency] Hypertension, and how many agents: [] Atrial fibrillation, ischaemic heart disease, stroke: [] Type 2 diabetes: [] Hypothyroidism: [] Acromegaly: [] Resistant hypertension or unexplained polycythaemia: [] Screening score: STOP-BANG [] out of 8 Considered instead of, or as well as, obstructive sleep apnoea: Obesity hypoventilation: [daytime SpO2, bicarbonate] Neuromuscular or chest wall disease: [] COPD, and possible overlap: [] Narcolepsy or other central hypersomnia: [] Depression, anaemia, thyroid disease: [] Plan: 1. [home oximetry, home respiratory polygraphy, or inpatient polysomnography] 2. Priority: [urgent if occupational driver, or symptomatic with high Epworth, or significant comorbidity] 3. Weight, alcohol, sleep timing and positional advice given: [] 4. Follow-up with results: [] ### Smoking, vaping and what was offered [smoking-cessation-record] Tobacco and nicotine: Smoking status: [current, ex or never] Type: [cigarettes, roll-ups, cigars, pipe, waterpipe, cannabis with tobacco] Amount and duration: [] per day for [] years Pack-years: [] Age started: [] Quit date if ex-smoker: [] Previous quit attempts, and what was used: [] Longest previous quit: [] Other smokers in the household: [] E-cigarettes or vaping: [never, current or ex] Device and nicotine strength: [] Used to quit smoking, alongside smoking, or independently: [] Motivation to stop today: [ready now, thinking about it, not now] Confidence in stopping, out of 10: [] Offered today: Very brief advice given: [yes] Referral to stop smoking service: [accepted, declined, or already under] Pharmacotherapy discussed: [nicotine replacement therapy - patch plus a short-acting form, varenicline, cytisinicline, bupropion, or a vaping product] Prescribed or supplied: [] Follow-up arranged: [] Carbon monoxide reading: [] ppm ### How to collect a sputum sample for TB testing [sputum-sample-for-mycobacteria] How to collect a sputum sample for a TB test What the test is for We are testing your phlegm for a group of bacteria that includes the one that causes tuberculosis, and for related bacteria called non-tuberculous mycobacteria. These related bacteria live in soil and water and are usually harmless, but they can settle in lungs that are already damaged. What we need Three separate samples, collected on three different days, at least 24 hours apart. First thing in the morning is best, because phlegm collects in the lungs overnight and the morning sample is the one most likely to give an answer. We have given you three pots with labels that have your details on them, and a bag for each. How to collect a good sample 1. Do not open the pot until you are ready to use it. It is sterile inside. 2. As soon as you wake up, before you eat or drink anything, brush your teeth and rinse your mouth with water. Do not use mouthwash - it can kill the bacteria we are trying to grow. 3. Take three deep breaths in through your nose, breathing out slowly through pursed lips each time. 4. After the third breath, cough deeply from your chest and spit what comes up into the pot. 5. What we need is phlegm from your lungs, not saliva from your mouth. Saliva cannot be tested. It usually takes a few good coughs, and it may take a couple of minutes. 6. Screw the lid on firmly so it cannot leak. Write the date on the pot and put it in its bag. Storing and returning the samples If you can bring each sample in on the day you produce it, that is best. Otherwise, keep the pot in the fridge, in its bag, away from food, and bring it in as soon as you can. Do not keep samples at home for more than three days. Bring them to [] . Practical points Try not to start on a Thursday or Friday, because the third day then falls at the weekend. If you cannot produce phlegm three days running, bring in two, or even one. One good sample is far better than none. If you cannot cough anything up at all, contact us. There are other ways of getting a sample, including a saline mist that helps bring phlegm up, and we can arrange this. Tell other people in your household not to open the pots, and keep them out of reach of children. Your results Some results are available within a few days. Growing these bacteria in the laboratory is slow, and a final result can take up to eight weeks. We will contact you with the results, and we will not wait for the final culture before starting treatment if you need it sooner. Thank you - this is a test where the care you take with the sample really does decide whether it gives us an answer. ### Blood gas result [blood-gas-result] [Capillary or arterial] blood gas, [date and time]: Sampled on [air, or oxygen at flow rate and device, FiO2] pH [] PaCO2 [] kPa PaO2 [] kPa Bicarbonate [] mmol/L Base excess [] Lactate [] mmol/L SpO2 by pulse oximeter at the time []% Interpretation: [] ### Bronchoscopy - information for patients [bronchoscopy-patient-information] About your bronchoscopy A bronchoscopy lets us look directly inside your airways and take samples. A thin flexible tube with a camera on the end is passed through your nose or mouth, down past the vocal cords and into the airways of the lungs. The tube is about the width of a pencil. The test usually takes 20 to 30 minutes, and you will be in the department for around half a day. Before you come Do not eat for [] hours before the test. You may drink clear fluids until [] hours before. Take your usual medicines with a small sip of water, unless we have told you otherwise. If you take a blood thinner - warfarin, apixaban, rivaroxaban, edoxaban, dabigatran, clopidogrel, ticagrelor or prasugrel - contact us before the test, because it may need to be stopped for a few days first. Do not stop it on your own. If you have diabetes, contact us for advice about your medication and the fasting. You must bring someone who can take you home, and you should not be alone for the first 12 hours afterwards. On the day We will check who you are and what we have planned, and answer your questions before you sign a consent form. Your throat and nose are numbed with a local anaesthetic spray, which tastes bitter and makes your throat feel strange. Most people are also offered sedation through a small needle in the back of the hand. It does not put you to sleep, but it makes you drowsy and relaxed, and most people remember little about the test. You will be given oxygen, and your heart rate and oxygen level are monitored throughout. You will be able to breathe normally the whole time. The tube does not block your airway. Coughing during the test is common and expected. Afterwards You will rest in the department until the sedation wears off, usually one to two hours. Do not eat or drink anything for [] hours after the test, until the throat anaesthetic has worn off, because you could choke. For 24 hours after sedation, do not drive, cycle, operate machinery, drink alcohol, sign legal documents or look after young children on your own. A sore throat, a hoarse voice, a mild cough and small streaks of blood in the phlegm for a day or two are all normal. Risks Bronchoscopy is a commonly performed and generally safe test, but no procedure is without risk. Common and usually minor: sore throat, hoarse voice, cough, small amounts of blood in the phlegm, a temporary fall in oxygen level, and a temperature on the evening of the test. Uncommon: bleeding needing treatment, chest infection. Rare: a collapsed lung, needing a drain, which is a particular risk when a sample is taken from the lung tissue itself; a reaction to the sedation; and very rarely a serious complication of the heart or lungs. We will explain which of these apply to the specific samples we plan to take, because the risk depends on what is done. When to get help afterwards Contact us or go to your nearest emergency department if you cough up more than streaks of blood, become breathless, develop chest pain, or become feverish and unwell in the days after the test. Your results Some results are available within a few days. Samples sent for growing bacteria take longer, and tests for tuberculosis and related organisms can take up to eight weeks. We will contact you with the results and arrange follow-up as we have discussed. ### Bronchoscopy booking checklist [bronchoscopy-booking] Bronchoscopy request. Patient name and NHS number: [] Date of birth: [] Contact telephone number: [] Referring consultant: [] Indication and clinical question: [] Relevant imaging, with date and where it can be viewed: [] Target [lobe and segment, or lesion location] Procedures requested: [inspection, washings, brushings, endobronchial biopsy, transbronchial biopsy, EBUS with stations, cryobiopsy] Samples required: [microbiology including mycobacteria, cytology, histology, molecular and PD-L1 testing, lymphocyte subsets] Safety: Anticoagulant or antiplatelet: [drug, indication, last dose, plan for stopping and restarting] Bleeding history or known coagulopathy: [] Platelets and INR if relevant: [] Renal function: [] Diabetes and treatment, including insulin and GLP-1 agonists: [] Ischaemic heart disease, recent acute coronary syndrome or stroke: [] Baseline SpO2 and oxygen requirement: [] Known difficult airway, or previous problem with sedation: [] High risk of tuberculosis or other transmissible respiratory infection: [] Pregnancy: [] Weight and BMI: [] Practical: Mobility and whether a hoist is needed: [] Interpreter required, and language: [] Advocacy or capacity considerations, and who holds a welfare power of attorney: [] Hospital transport needed: [] Escort home available, and where they will be discharged to: [] Inpatient or outpatient: [] For requests from another organisation: Referring hospital and department: [] Address and GP details: [] Who should receive the report: [] ### Full lung function results [full-lung-function] Full lung function ([date]): Height [] cm; weight [] kg; BMI [] FEV1 [] L ([]% predicted, z-score []) FVC [] L ([]% predicted, z-score []) FEV1/FVC ratio []% (LLN []) Peak flow [] L/min ([]% predicted) TLC [] L ([]% predicted) RV [] L ([]% predicted) RV/TLC []% TLCO [] ([]% predicted) KCO [] ([]% predicted) Reference equations: [GLI 2012 and GLI 2017 for transfer factor] Interpretation: [] ### Hand-held spirometry results [hand-held-spirometry] Hand-held spirometry in clinic ([date]): FEV1 [] L ([]% predicted) FVC [] L ([]% predicted) FEV1/FVC ratio []% Peak flow [] L/min ([]% predicted) Best of [] attempts; technique [acceptable and repeatable, or the limitation] [pre-bronchodilator, or post-bronchodilator with drug and dose] Interpretation: []