, 2025-05-02 11:01:00
Examining a patient for common or complex pulmonary issues in a primary care setting takes time and expertise — physicians need to ask about symptoms and medical history and determine which tests to perform to narrow down the differential diagnosis. In an ideal world, every primary care setting features lung function tests and multiple imaging capabilities on site, and cost and insurance reimbursement are not limitations.
But it’s not an ideal world. With that in mind, Medscape Medical News asked leading primary care physicians for their advice and insight on navigating the realities of assessing patients for multiple pulmonary issues.
When it comes to testing on site, it depends on what is available, said Wilson Pace, MD, professor emeritus of family medicine at the University of Colorado Denver Anschutz Medical Campus, who currently works as chief medical and technology officer at the DARTNet Institute. “Even a simple chest x-ray can help you distinguish a heart failure picture from a more pulmonary picture.”
However, not every primary care service has x-ray capability, said Alan Kaplan, MD, chair of the Family Physician Airways Group of Canada. Kaplan was lead author of a case study that describes a 52-year-old woman with chronic obstructive pulmonary disorder (COPD) who complained to her family doctor of breathlessness. The case outlines practical aspects of diagnosis and management in this setting, including what to consider when someone with COPD starts to develop heart failure.
Initial questions to ask patients include: What are your symptoms? Is it just a cough? Is it cough and shortness of breath? A shortness of breath at rest or just with exertion? Is there associated chest pain?
“Answers to all of those things will help define which directions and which tests you are going to get,” said Neil Skolnik, MD, professor of family and community medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, in Philadelphia. On physical exam, if there is a lot of wheezing, think more along the lines of a respiratory condition. If there is a crackling sound in the chest, think more about heart failure, Skolnik said.
Ruling out urgent heart issues remains important.
“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,” said Barbara Yawn, MD, a researcher and adjunct professor of family and community health at the University of Minnesota at Minneapolis. An ECG is the only direct cardiac test that you can probably do in your office, Yawn added, and if a patient presents during an acute episode, you might do an ECG to see if there are changes in the T-wave and other patterns.
In contrast, if heart failure is suspected, the classic test to order is an ECG. “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,” Pace said.
Demographics like age, comorbidities, specific symptoms, and a physical exam can also guide testing.
Skolnik said, “For example, pulmonary function tests like spirometry are very helpful in gaining insight as to whether someone has active respiratory disease.”
Go With the Pro
Diagnosing pulmonary disorders includes ruling heart failure in or out. A useful assay is an N-terminal pro–B-type natriuretic peptide (NT-ProBNP) test. If the BNP is elevated in the blood, a next logical step is an ECG 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,” Skolnik said.
Pace cautioned that NT-ProBNP can also be elevated in COPD, but it typically goes much higher in heart failure. “There is a whole bunch of ancillary tests, but probably the critical ones are the NT-ProBNP level, a chest x-ray and an echocardiogram, which are probably the most helpful for differentiating things,” he added.
What Is the Situation on Spirometry?
Spirometry, unfortunately, rarely gets done, Kaplan said. Spirometry is a lung function test that can distinguish restrictive conditions — like fibrosis, sarcoidosis, or obesity-related lung restriction — from obstructive lung diseases — such as COPD, asthma, or emphysema. The test remains underutilized around the world, including in the United States, in part because some providers are uncomfortable interpreting the results or because it is just not available.
“We know that, unfortunately, a lot of primary care clinics had spirometry removed during COVID — and it never got put back in,” Yawn said. Patients are asked to breathe heavily in and out during the test, and uncertainty arose about the filters blocking transmission of the COVID virus. As a result, many primary care physicians have to refer patients to a pulmonary lab or to a pulmonologist or allergist to access spirometry.
Despite the widely accepted value of spirometry, testing a patient before and after they use a bronchodilator can take 30 minutes. “And that is 30 minutes of a technician’s time at a primary care office, probably my nurse or my medical assistant. That can really throw my whole schedule off, and so it is not easy to incorporate.”
Pace disagreed with Yawn about the value of performing spirometry in a primary care setting. “Somebody can prove me wrong, but when a patient is having an acute problem, you will see slightly different changes, but lungs full of water from heart failure are not going to have normal spirometry either. When you have people that have all kinds of mucus, water, or anything else going on, then their usual respiratory pattern becomes hard to interpret.
“From my perspective, it’s a follow-up test like the echocardiogram, not an acute test like a chest x-ray or a blood test,” Pace added. But it does play a valuable role. “Once 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.”
“Spirometry absolutely has to be done,” Kaplan said. “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 is a measure of how well the lungs can transfer gases between the air and the blood.
A condition to watch for is not new but is being newly discussed, Yawn said. It’s called preserved ratio impaired spirometry (PRISm). Patients with PRISm have the same symptoms as COPD, but they do not have obstructive pulmonary function test results.
“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,” Yawn said.
These patients may benefit from respiratory therapy and management, according to a study published in November 2024 in the Pragmatic and Observational Research journal.
Additional Resources
Kaplan recommended the following graphics/treatment algorithms provided by the Family Physician Airways Group of Canada: Proposed Primary Care Approach to Assessing Adults with Chronic Cough and the Proposed Primary Care Approach to Assessing Adults with Chronic Dyspnea
