Primary Care Respiratory UPDATE - Primary Care Respiratory Society [PDF]

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Volume 2 Issue 4 December 2015

Primary Care Respiratory UPDATE

www.pcrs-uk.org/pcru

HIGHLIGHTS ... PCRS-UK Direction 2016 Managing respiratory tract infections – practical guidance Top tips on breathlessness management Home oxygen prescribing – pull out chart PCRS-UK Respiratory leaders programme 2016

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Around-the-clock COPD symptom control1,2 with morning and evening administration.3

GL/ACL/1114/0056 Date of preparation: April 2015. Date of expiration: January 2016.

Significant and sustained bronchodilation from the first dose vs placebo.1,2

Prescribing information (Please consult the Summary of Product Characteristics (SmPC) before prescribing.)

Eklira® Genuair®

322 micrograms inhalation powder aclidinium Presentation: Each delivered dose (the dose leaving the mouthpiece) contains 375 μg aclidinium bromide (equivalent to 322 μg of aclidinium). Each metered dose contains 12.6 mg lactose monohydrate. Indication: Eklira Genuair is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and Administration: The recommended dose is one inhalation of 322 μg aclidinium twice daily. Consult SmPC and package leaflet for method of administration. Contraindications, Warnings, Precautions: Contraindications: Hypersensitivity to aclidinium bromide, atropine or its derivatives, including ipratropium, oxitropium or tiotropium, or to the excipient lactose monohydrate. Precautions: Should not be used to treat asthma or for relief of acute episodes of bronchospasm, i.e. rescue therapy. Paradoxical bronchospasm has been observed with other inhalation therapies. If this occurs, stop medicine and consider other treatment. Reevaluation of the treatment regimen should be conducted if there is a change in COPD intensity. Use with caution in patients with a myocardial infarction during the previous 6 months, unstable angina, newly diagnosed arrhythmia within the previous 3 months, or hospitalisation within the previous 12 months for heart failure functional classes III and IV as per the “New York Heart Association”. Consistent with its anticholinergic activity, dry mouth has

been observed and may in the long term be associated with dental caries. Also, use with caution in patients with symptomatic prostatic hyperplasia or bladder-neck obstruction or with narrow-angle glaucoma. Patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine. Interactions: Co-administration with other anticholinergic- containing medicinal products has not been studied and is not recommended. Although no formal in vivo drug interaction studies have been performed with Eklira Genuair, it has been used concomitantly with other COPD medicinal products including sympathomimetric bronchodilators, methylxanthines, and oral and inhaled steroids without clinical evidence of drug interactions. Fertility, Pregnancy and Lactation: It is considered unlikely that Eklira Genuair administered at the recommended dose will affect fertility in humans. Aclidinium bromide should only be used during pregnancy if the expected benefits outweigh the potential risks. It is unknown whether aclidinium bromide and/or its metabolites are excreted in human milk. The benefit for the breast-feeding child and long-term benefit of therapy for the mother should be considered when making a decision whether to discontinue therapy. Ability to drive and use machines: The effects on the ability to drive and use machines are negligible. The occurrence of headache or blurred vision may influence the ability to drive or use machinery. Adverse Reactions: Common: sinusitis, nasopharyngitis, headache, cough, diarrhoea. Uncommon: Blurred vision, tachycardia, dysphonia, dry mouth, rash, pruritus, urinary retention. Rare: Hypersensitivity. Not known: Angioedema. Legal Category: POM Marketing Authorisation Number(s): EU/1/12/778/002 - Carton containing 1 inhaler with 60 unit doses. NHS Cost: £28.60 (excluding VAT)

Marketing Authorisation Holder: AstraZeneca AB SE-151 85 Södertälje Sweden Further information is available from: AstraZeneca UK Ltd. 600 Capability Green Luton LU1 3LU, UK Tel: 0800 783 0033 / 01582 836836 Fax: +44 (0)1582 838 003 Email: [email protected] Date of Revision: 03/2015 RSP 15 0020 Eklira and Genuair are both registered trademarks. Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to AstraZeneca on 0800 783 0033. References: 1. Jones PW, Singh D, Bateman ED, et al. Efficacy and safety of twice-daily aclidinium bromide in COPD patients: the ATTAIN study. Eur Respir J. 2012; 40(4):830-6. 2. Kerwin EM, D’Urzo AD, Gelb AF, et al. Efficacy and safety of a 12-week treatment with twice-daily aclidinium bromide in COPD patients (ACCORD COPD I). COPD. 2012;9(2):90-101. 3. Eklira Genuair Summary of Product Characteristics. Barcelona, Spain: Almirall, S.A.

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PCRS-UK seeks new lay trustee Do you know anyone who works in the not for profit sector and has a personal interest in respiratory conditions?

The Primary Care Respiratory Society UK (PCRS-UK) is looking to recruit a lay trustee, with senior not for profit sector (ideally charity) experience. The ideal candidate will have experience (ideally direct involvement) with strategic collaboration/partnerships – with strong negotiating and entrepreneurial skills. S/he needs to be a strategic thinker with strong commercial and financial acumen – ideally with knowledge of statutory/grant funding sources (healthcare sector) The trustees meet 3 times per year in London with occasional teleconferences as required plus regular email correspondence. The board currently consists of two lay and three medical trustees. If you know someone who might be suitable please ask them to see the www.pcrs-uk.org for more information about the Society. More information about the role can be found at

https://www.pcrs-uk.org/news/lay-trustee-recruitment

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Executive, Anne Smith ([email protected]) or Patrick White, Chair of the Trustees, via [email protected] Those wishing to apply should submit a CV and supporting statement explaining why they are interested in the role and why they are suitable to [email protected] by 31 December 2015.

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NEW STRENGTH. SAME PRICE. Enabling appropriate prescribing at no extra cost. Fostair 100/6 and 200/6: 2 devices, 2 strengths, 1 price £29.32.

FOSTAIR NEXTHALER 100/6 dry powder inhaler FOSTAIR NEXTHALER 200/6 dry powder inhaler (Beclometasone dipropionate/formoterol fumarate dihydrate) Fostair NEXThaler prescribing information Please refer to Summary of Product Characteristics (SPC) before prescribing Presentation: Each Fostair NEXThaler 100/6 dry powder inhaler (DPI) metered dose contains 100 micrograms (mcg) of beclometasone dipropionate (BDP) anhydrous and 6mcg of formoterol fumarate dihydrate. Each Fostair NEXThaler 200/6 DPI metered dose contains 200 mcg of BDP and 6mcg of formoterol fumarate dihydrate. Indication: Regular treatment of asthma in patients who are not adequately controlled on inhaled corticosteroids (ICS) and ‘as needed’ short-acting beta2-agonist, or patients who are already adequately controlled on both ICS and long-acting beta2agonists (LABAs), where the use of an ICS/LABA combination is appropriate. Fostair NEXThaler is not indicated for the treatment of acute asthma attacks. Dosage and administration: For inhalation in adult patients (≥18 years). Fostair NEXThaler 100/6: 1 or 2 inhalations twice daily. Fostair NEXThaler 200/6: 2 inhalations twice daily. The maximum daily dose is 4 inhalations. Fostair NEXThaler has an extrafine particle size distribution; therefore, dose adjustment is required when patients are transferred from a formulation with a non-extrafine particle size distribution. When switching patients from previous treatments, it should be considered that the recommended total daily dose of BDP for Fostair NEXThaler is lower than that for nonextrafine BDP containing products and should be adjusted to the needs of the individual patient. However, patients who are transferred to Fostair NEXThaler from Fostair pressurised inhalation solution do not need dose adjustment. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate and magnesium stearate). Warnings and precautions: Use with caution in patients with cardiac arrhythmias, aortic stenosis, hypertrophic obstructive cardiomyopathy,

ischemic heart disease, severe heart failure, severe arterial hypertension, aneurysm, thyrotoxicosis, diabetes mellitus, phaeochromocytoma and untreated hypokalaemia. Caution should also be used when treating patients with known or suspected prolongation of the QTc interval (QTc > 0.44 seconds). Formoterol itself may induce QTc prolongation. Potentially serious hypokalaemia may result from beta2-agonist therapy and may also be potentiated by concomitant treatments (e.g. xanthine derivatives, steroids and diuretics) and increase the risk of arrhythmias. Formoterol may cause a rise in blood glucose levels. Fostair NEXThaler should not be administered for at least 12 hours before the start of anaesthesia, if halogenated anaesthetics are planned. When treatment with Fostair NEXThaler is discontinued the dose should be tapered, treatment should not be stopped abruptly. Treatment should not be initiated during exacerbations or acutely deteriorating asthma. Treatment should be discontinued immediately if the patient experiences a paradoxical bronchospasm. Use with caution in patients with pulmonary tuberculosis or fungal/viral airway infections. Systemic effects: Systemic effects of ICS may occur, particularly at high doses for long periods, but are less likely than with oral steroids. These include Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, cataract and glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression and aggression. Prolonged treatment with high doses of inhaled corticosteroids may result in adrenal suppression and acute adrenal crisis. Lactose contains small amounts of milk proteins, which may cause allergic reactions. Interactions: Beta-blockers should be avoided in asthmatic patients. Concomitant administration of other betaadrenergic drugs may have potentially additive effects. Concomitant treatment with quinidine, disopyramide, procainamide, phenothiazines, certain antihistamines (e.g. terfenadine), monoamine oxidase inhibitors and tricyclic antidepressants can prolong the QTc interval and increase the risk of ventricular arrhythmias. L-dopa, L-thyroxine, oxytocin and alcohol can impair

cardiac tolerance towards beta2-sympathomimetics. Hypertensive reactions may occur following co-administration with monoamine oxidase inhibitors including agents with similar properties (e.g. furazolidone, procarbazine). Concomitant treatment with xanthine derivatives, steroids or diuretics may potentiate a possible hypokalaemic effect of beta2-agonists. Hypokalaemia may increase the likelihood of arrhythmias in patients receiving digitalis glycosides. Fertility, pregnancy and lactation: Fostair NEXThaler should only be used during pregnancy or lactation if the expected benefits outweigh the potential risks. Effects on driving and operating machinery: Fostair NEXThaler has no or negligible influence on the ability to drive and use machines. Side effects: Common: tremor. Uncommon: nasopharyngitis, oral candidiasis, hypertriglyceridaemia, headache, tachycardia, sinus bradycardia, angina pectoris, myocardial ischaemia, throat irritation, exacerbation of asthma, dyspnoea, oropharyngeal pain, dysphonia, cough, nausea, fatigue, irritability, prolongation of QTc interval, cortisol free urine decreased, blood cortisol decreased, blood potassium increased, blood glucose increased, electrocardiogram poor r-wave progression. Unknown frequency: psychomotor hyperactivity, sleep disorders, anxiety, depression, aggression, behavioural changes (Refer to SPC for full list of side effects). Legal category: POM Pack and price: £29.32 1x120 actuations Marketing authorisation number: PL 08829/0173, PL 08829/0174. Marketing authorisation holder: Chiesi Limited, 333 Styal Road, Manchester, M22 5LG Date of preparation: Oct 2015

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Chiesi Limited on 0161 488 5555.

CHFTB20150915. Oct 15.

BC_3337_Chiesi_Fostair High Dose DPS - Primary Care Respiratory Update (re-size of BC_3339)_V1F.indd 1

06/11/2015 15:45

FOSTAIR 200/6 Beclometasone + formoterol FOR ADULT ASTHMA

NEW

FOSTAIR pMDI 100/6 (pressurised metered dose inhaler) FOSTAIR pMDI 200/6 (pressurised metered dose inhaler) (Beclometasone dipropionate/formoterol fumarate dihydrate) Fostair pMDI prescribing information Please refer to the full Summary of Product Characteristics (SPC) before prescribing Presentation: Each Fostair pressurised metered dose inhaler (pMDI) 100/6 dose contains 100 micrograms (mcg) of beclometasone dipropionate (BDP) anhydrous and 6mcg of formoterol fumarate dihydrate. Each Fostair pMDI 200/6 dose contains 200 mcg of BDP and 6mcg of formoterol fumarate dihydrate. Indications: Asthma: Regular treatment of asthma in patients who are not adequately controlled on inhaled corticosteroids (ICS) and ‘as needed’ short acting beta2-agonist, or patients who are adequately controlled on both ICS and long-acting beta2-agonists (LABA), where the use of an ICS/LABA combination is appropriate. COPD (Fostair 100/6 only): Symptomatic treatment of patients with severe COPD (FEV1 0.44 seconds). Formoterol itself may induce QTc prolongation. Potentially serious hypokalaemia may result from beta2-agonist therapy and may also be potentiated by concomitant treatments (e.g xanthine derivatives, steroids and diuretics) and increase the risk of arrhythmias. Formoterol may cause a rise in blood glucose levels. As Fostair contains a corticosteroid, it should be administered with caution in patients with pulmonary tuberculosis or fungal/viral airway infections. Fostair should not be administered for at least 12 hours before the start of anaesthesia, if halogenated anaesthetics are planned. Fostair treatment should not be stopped abruptly. Treatment should not be initiated during exacerbations or acutely deteriorating asthma. Fostair treatment should be discontinued immediately if the patient experiences a paradoxical bronchospasm. Systemic effects: Systemic effects of ICS may occur, particularly at high doses for long periods, but are less likely than with oral steroids. These include Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, cataract and glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression and aggression. Prolonged treatment with high doses of inhaled corticosteroids may result in adrenal suppression and acute adrenal crisis. Interactions: Beta-blockers should be avoided in asthmatic patients. Concomitant use of other beta-adrenergic drugs can have potentially additive effects, therefore caution is required when theophylline or other beta-adrenergic drugs are prescribed concomitantly with formoterol. Concomitant treatment with quinidine, disopyramide, procainamide, phenothiazines, antihistamines, monoamine oxidase inhibitors and tricyclic antidepressants can prolong the QTc interval and increase the risk of ventricular arrhythmias. L-dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance towards beta2-sympathomimetics. Hypertensive reactions may occur following co-administration with monoamine oxidase inhibitors. Concomitant treatment with xanthine derivatives, steroids

BC_3337_Chiesi_Fostair High Dose DPS - Primary Care Respiratory Update (re-size of BC_3339)_V1F.indd 2

or diuretics may potentiate a possible hypokalaemic effect of beta2-agonists. Hypokalaemia may increase the likelihood of arrhythmias in patients receiving digitalis glycosides. Fertility, pregnancy and lactation: Fostair should only be used during pregnancy or lactation if the expected benefits outweigh the potential risks. Effects on driving and operating machinery: Fostair is unlikely to have any effect on the ability to drive or operate machinery. Side effects: Common: pharyngitis, oral candidiasis, headache, dysphonia. Uncommon: influenza, oral fungal infection, oropharyngeal candidiasis, oesophageal candidiasis, vulvovaginal candidiasis, gastroenteritis, sinusitis, rhinitis, pneumonia, granulocytopenia, allergic dermatitis, hypokalaemia, hyperglycaemia, restlessness, tremor, dizziness, otosalpingitis, palpitations, blood pressure increased, prolongation of QTc interval, electrocardiogram change, tachycardia, tachyarrhythmia, atrial fibrillation, hyperaemia, flushing, cough, productive cough, throat irritation, asthmatic crisis, pharyngeal erythema, diarrhoea, dry mouth, dyspepsia, dysphagia, burning sensation of the lips, nausea, dysgeusia, pruritus, rash, hyperhidrosis, urticaria, muscle spasms, myalgia, C-reactive protein increased, platelet count increased, free fatty acids increased, blood insulin increased, blood ketone body increased, blood cortisol decrease. Rare: ventricular extrasystoles, angina pectoris, paradoxical bronchospasm, angioedema, nephritis, blood pressure decreased. Very rare: thrombocytopenia, hypersensitivity reactions, including erythema, lips, face, eyes and pharyngeal oedema, adrenal suppression, glaucoma, cataract, dyspnoea, exacerbation of asthma, peripheral oedema, bone density decreased. Unknown frequency: psychomotor hyperactivity, sleep disorders, anxiety, depression, aggression, behavioural changes (Refer to SPC for full list of side effects). Legal category: POM Packs and prices: £29.32 1x120 actuations. Marketing authorisation number: PL 08829/0156, PL 08829/0175. Marketing authorisation holder: Chiesi Limited, 333 Styal Road, Manchester, M22 5LG Date of preparation: Oct 2015 Aerochamber Plus® is a registered trademark of Trudell Medical International.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Chiesi Limited on 0161 488 5555.

06/11/2015 15:45

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Primary Care Respiratory UPDATE The Primary Care Respiratory Update is published quarterly and distributed to members of the Primary Care Respiratory Society UK.

www.pcrs-uk.org/pcru

Editor Dr Hilary Pinnock, Reader, Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh General Practitioner, Whitstable Medical Practice, Whitstable, Kent

Editorial board Ian Culligan, Specialist Respiratory Physiotherapist, Wirral Dr Stephen Gaduzo, Chair PCRS-UK Executive, Stockport Dr Laura Ingle, PCRS-UK Education Committee, and GP, Oxford Dr Basil Penney, GPwSI in Respiratory Medicine, Darlington Anne Rodman, Independent Respiratory Advanced Nurse Practitioner and Education for Health Regional Trainer, Lichfield

Dr Iain R Small, General Practitioner, Peterhead, Co-chair

Editorial Office and Publishers Primary Care Respiratory Society UK Unit 2, Warwick House Kingsbury Road Curdworth, Warwicks B76 9EE Tel: +44 (0)1675 477600 Fax: +44 (0)1361 331811 Email: [email protected]

PCRS-UK Quality Award Development Group

Ruth Thomas, Senior Community Respiratory Nurse, Milton Keynes Steph Wolfe, Independent Respiratory Nurse Specialist (Primary Care)

PCRS-UK Chief Executive Anne Smith

Communications Consultant and Freelance Journalist Francesca Robinson

Advertising and sales

Policy Advisor

Contact Gail Ryan Primary Care Respiratory Society UK Unit 2, Warwick House Kingsbury Road Curdworth, Warwicks B76 9EE Tel: +44 (0)1675 477600 Fax: +44 (0)1361 331811 Email: [email protected]

Bronwen Thompson

Supplements and reprints From time to time PCRS-UK publishes supplements to the regular journal, which are subject to review by the editorial board. PCRS-UK also offers licencing opportunities for bulk reproduction of this journal. For further information, contact Gail Ryan Primary Care Respiratory Society UK Unit 2, Warwick House Kingsbury Road Curdworth, Warwicks B76 9EE Tel: +44 (0)1675 477600 Fax: +44 (0)1361 331811 Email: [email protected]

Printed in the UK by Caric Print Ltd, Bournemouth, Dorset in association with Stephens & George Magazines Ltd. Printed on acid-free paper

PCRS-UK Operations Director Tricia Bryant Competing interests are declared to PCRS-UK and this information is kept on file. The opinions, data and statements that appear in this journal are those of the contributors. The publisher, editor and members of the editorial board do not necessarily share the views expressed herein. Although every effort is made to ensure accuracy and avoid mistakes, no liability on the part of PCRS-UK, the editor or their agents or employees is accepted for the consequences of any inaccurate or misleading information. © 2015 Primary Care Respiratory Society UK. All rights reserved. Apart from fair dealing for the purposes of research or private study, criticism or review, and only as permitted under the Copyright, Designs and Patent Act 1988, this publication may only be produced, stored or transmitted, in any form or by any means, with the prior permission in writing of Primary Care Respiratory Society UK. Enquiries concerning reproduction outside those terms should be submitted to Primary Care Respiratory Society UK via [email protected] The Primary Care Respiratory Society UK is a registered charity (Charity No: 1098117) and a company limited by guarantee registered in England (Company No: 4298947). VAT Registration Number: 866 1543 09. Registered offices: PCRS-UK, Unit 2 Warwick House, Kingsbury Road, Sutton Coldfield B76 9EE. Telephone: +44 (0)1675 477600 Facsimile: +44 (0)121 336 1914 Email: [email protected] Website: http://www.pcrs-uk.org The Primary Care Respiratory Society UK is grateful to its corporate supporters including AstraZeneca UK Ltd, Boehringer Ingelheim Ltd, Chiesi Ltd, GlaxoSmithKline, Napp Pharmaceuticals, Novartis UK, Pfizer Ltd and TEVA UK Ltd for their financial support which supports the core activities of the Charity and allows PCRS-UK to make its services either freely available or at greatly reduced rates to its members. See http://www.pcrs-uk.org/sites/pcrs-uk.org/files/files/ PI_funding.pdf for PCRS-UK statement on pharmaceutical funding.

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CONTENTS

Primary Care Respiratory UPDATE

SPECIAL FEATURES

Journal Round-Up ....................................... 24

Editor’s Round-Up Hilary Pinnock ..................................................... 7

PCRS-UK News Round-Up .......................... 35 Delivering Excellence Locally

Chair's perspective: A new direction for PCRS-UK Stephen Gaduzo .................................................. 8

Scanning the horizon: How to get ahead of the game Fran Robinson ................................................... 38

Inspiring, thought provoking and challenging: the PCRS-UK 2015 national conference Francesca Robinson ..............................................11

Enthusiastic new PCRS-UK affiliated group launches in North Shields Fran Robinson, Judith Lawrence ............................... 39

REGULAR FEATURES Policy Round-Up Bronwen Thompson .............................................15 Getting the Basics Right Managing dilemmas in respiratory tract infections and antibiotics prescribing Fran Robinson, Kevin Gruffydd-Jones ......................... 18 Top Tips: Breathlessness Noel Baxter, Debbie Roots ...................................... 22

PCRS-UK leadership programme inspires two practice nurse entrepreneurs to aim high Fran Robinson ................................................... 40 PCRS-UK Respiratory Leadership Programme 2016 Noel Baxter ...................................................... 41 Update your clinical practice: excerpt of educational item from npj Primary Care Respiratory Medicine ............44

SPECIAL PULL-OUT FEATURE Home oxygen prescribing: An update

Pulse oximeters to self-monitor oxygen saturation levels as part of a personalised asthma action plan for people with asthma Robin Carr ........................................................ 23 Volume 2 Issue 4 December 2015

5

A NEW VIEW... ...OF AN ESTABLISHED COMBINATION*

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An intuitive, award-winning inhaler with clear feedback for patients3-5 20% savings vs Seretide® Accuhaler®6

*Licensed for use in adults aged 18 years and older only.

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Volume 2 Issue 4 December 2015 21

Dec layout2_Layout 1 08/12/2015 16:41 Page 24

Primary Care Respiratory UPDATE

Top Tips: Breathlessness Noel Baxter and Debbie Roots

Persistent and disabling breathlessness is a common condition that is a strong prognostic indicator for hospitalisation and premature death. It is easily missed. People describe feeling embarrassed about it and they gradually withdraw from activities where attention may be drawn to it and become increasingly deconditioned. Many consider it a sign of aging rather than something that can be treated. These episodes can be punctuated by acute worsening of a chronic problem or can represent a new problem. 1. 10% of the adult population have chronic breathlessness but less than half have this problem recorded – Make the MRC breathlessness score part of your annual health check so that it is detected earlier. It is sensitive for non COPD causes too1 2. 80-90% of people with COPD have another long term condition that could also be making them breathless – Do an annual breathlessness review at the same time as the annual COPD or Heart Failure review so that you are regularly ruling out other causes2 3. Use a breathlessness assessment algorithm (e.g. http://www.impressresp.com/index.php?option=com_docman&task=doc_download&gid=101&Itemid=82) designed by peers and experts. It will help you reach a more complete and accurate diagnosis and allow you to feel more confident in dealing with the problems identified. Two-thirds of causes will be cardio-respiratory1 4. Assume that people who are breathless experience anxiety and fear regardless of cause. The question is how much and how to intervene. Measure using an anxiety and depression score and refer or treat accordingly 5. Have and use a pulse oximeter to aid assessment of acute breathlessness. It is cheap and easy to use. A new finding of oxygen saturation of