Respiratory Guidance & Information Page

Somerset LMC Respiratory Adviser - Information and Contact details

Somerset Respiratory Adviser (David Long) News

News Update 17 January 2022

Oxygen and Pulmonary Rehabilitation Referral Form.
Please see here updated referral form. It does differ from the EMIS form as its less to complete. However the EMIS form does complete teh majority of the basic fields so please use what evr form you feel is appropriate until the EMIS forms can be updated. One note is that on both forms they will ask for current spirometry and as we all know this is not available for the forseable future. BOC are happy to receive forms without these fields completed so it should not be a barrier to referring to the service.

Severe Asthma Service
Also see here revised and improved referral form. Its now in Xl format so easier to complete and has the e-mail of the co-ordinator for the form to be sent when completed. Any feedback would be welcome Ive sent 2 patients in so far and with each have sent a brief summary record in PDF format with the referral form to add extra context. When EMIS is working well it takes no more than 10 mins to fill the forms in, attach to the patients consultation and then use AccuRx to send email and add the form within the AccuRx e-mail. The only information that you would not normally collect and need to complete is the IgE, so if you anticipate referral in the near future bear this in mind and request when doing bloods.

SABA Overuse Document Finally  the “badged” SABA overuse document to replace the previous version which can now be sent to patents.


News Update 6 Dec 2021


Dear all,  Please see below documents on risk assessing your airways patients. EMIS searches can be downloaded from UCL partners website and it will risk stratify all your patients for you. More detailed information can be found here

The reasons this approach is helpful is that you can give a tailored approach to patient care. The 'one size fits all approach” is not applied to everyone, which uses valuable time and resources to do so. I would add that the way in which you adapt the framework can be adjusted for your needs. For instance I would perhaps argue using the letters which are also included in this news item the patients in Group 3 would not have to be seen by anyone. The QOF requirements would be met through the responses to the invite letters especially if you send out a self management plan with the letter as well. The letters themselves are an amalgamation of letters I've seen during my work with various practices. In practices where such a framework exists it ensures the patient who need to be seen are and those who are stable, are not unduly inconvenienced by their yearly review, helping reduce non attendance. I hope this helps.

Asthma Bad ScoreAsthma Good ScoreAsthma Invite Letter, Asthma Framework

COPD Concerns LetterCOPD CAT InviteCOPD Framework, COPD No change Request


News Update 29 Nov 2021

Dear all

Please see below updated table, Asthma and COPD 1st line choice inhaler. The only difference is the dosing of Kelhale.

2021 LMC Respiratory Nurse Advisor Inhaler Table


News Update 8 Nov 2021

Dear all,

A couple of items this week the first is an update on the inhaler chart recently sent out the second is an exciting new development for severe asthmatic patients.

INHALER CHART for an updated inhaler chart, one inhaler has been replaced pMdi LABA/LAMA.

Please remember the table is in word document format so that you can change the first line drugs you or your practice would like to use if you wanted. It is intended to be a consistent and cost effective first line approach for those clinicians who may not be familiar with the 128+ inhalers available.


Dr Stone et al has put together a short form attached for referring severe asthmatics in Somerset. We are lucky in that we are the first to be considered and to be asked to use this form. The idea being that once they get a few referrals from yourselves through this trial period they would then adapt/change as needed. The idea being then to switch to an electronic referral form and role out throughout the South West.

The forms will be reviewed in a weekly MDT and sent to appropriate specialist centre and because of the pre-workup and triage, it would hopefully fore—shorten the whole process for patients to be seen. It should not be that onerous a task, I intend keeping this on my desktop and then ‘cut and paste’ info into the document as needed.

So it would be great if you can think of any existing patients who meet the criteria fill in the short form and send to who would then send to the appropriate clinician/hospital to present at the weekly MDT.

I have a patient in mind already, so I hope this helps you as well.


News Update 1 Nov 2021

SABA Overuse Patient Leaflet.

Dear all, Please use the SABA overuse document to help patients understand the harm that this practice can cause. It can be downloaded HERE. As we know sometimes explaining more fully why we are asking patients to change behaviour, may have more of an impact.

Please use as you see fit. I personally keep the document on my desktop and send as an attachment in a text via AccuRx or it can be distributed via the pharmacists...

In time I am hoping it will be sanctioned with a logo from the CCG. As we wait for the document to go through this process, I thought it best to circulate now and in due course send an updated version which I would hope be embedded in EMIS.

We hope you find it useful.


News Update 25 Oct 2021

Updated inhaler choice chart, changes in licence ie Trimbow Nexthaler can now be used in COPD and addition of a cheaper LABA/ICS’s, Luforbec.

Dear All,

Please see the this document, which is an updated inhaler choice chart. Ive updated it, as there has been changes in licence ie Trimbow Nexthaler can now be used in COPD and addition of a cheaper LABA/ICS’s, Luforbec.

I would like you to consider before switching patients on Fostair to Lurforbec ‘wholesale or blanket switching’ that there is only approx £3 difference in price on the low dose 100/6mcg 1p bd compared to Fostair. We all know that switching can be problematic in other areas, which are sometimes not factored into the price of an inhaler (ask any nurse). That said, certainly the Luforbec at moderate dose 100/6mcg 2p bd has a significant saving approx £8. As you will see from the chart I've included Luforbec at low and moderate dose and I think this is fine when considering stepping up/new treatments. The table is in word format so it can be modified to your own practice preferences.

The main aim of such a table is to clarify and make inhaler choice simpler for the clinicians not familiar with the 120 inhaler out there and make choices not just on cost but value which takes into account device type, ease of use, minimal critical errors...

I hope this helps. Remember I am always available to discuss any difficult airways disease cases my contact details are below.

Kind Regards

News Update 4 May 2021


Two documents, one from the Association for Respiratory Technology and Physiology (ARTP) and one from the Primary Care Respiratory Society (PCRS) have been produced to aid restoration of spirometry services by mitigating risk to both staff and patients. These were developed from a Task and Finish group established by the NHS England and NHS Improvement Clinical Policy Unit.

I attach them here for your information and implementation in your practice. If you feel you can meet the criteria to conduct safe spirometry testing . There are certain criteria to be met before considering restarting testing and it also discusses how best to tackle the backlog of patients.

This is very much “hot off the press” so we have no answers to some of the questions posed within the documents. We will of course be discussing this document at a CCG level and will inform you of the outcomes in due course. Regards David


News Update 8 February 2021


I've been quiet for some time, this is because you've been so busy and I don't like to bother you unless I think the news is important.   There are new inhalers available to help us improve outcomes for our patients. These are my personal views on how I would use them in practice.

Firstly though, I would like to try and clear up what a “specialist respiratory opinion' or ‘respiratory specialist initiated treatment’, means to me in primary care. This is a GPN or GP who has a specialist interest and through either formal or experiential learning feels they have the up-to date knowledge to provide good care provision and management of patients in a given specialty. Specialist titles is a widely debated topic which has been taking place over decades. I believe its up to you and your organisation to consider your individual role and take on this responsibility if you so wish. I work with many talented and experienced nurses within primary care who in my opinion meet the above ‘specialist’ criteria. So having a drug which is for "specialist consideration only “ does not mean referral to secondary care. This would cause the patients to be unnecessarily disadvantaged and burden our secondary care colleagues. Discuss treatment options with your specialist primary care colleague within your practice or even contact me if you need help.


Chiesi Product:  Trimbow pMDI is a triple therapy, LABA/LAMA/ICS for use in COPD patients and now Asthma. We should all be familiar on its use with COPD. With asthma it should be considered after discussion with a specialist (as above). A patient on medium dose ICS/LABA with one or more exacerbations in the last year. It improves lung function and reduces exacerbations. The addition of another bronchodilator has a bronchoprotection effect helping stabilise the airway further as when LABA were added to ICS in combination with Asthma.

AstraZeneca products:  Bevespi® pMDI is a dual bronchodilator, LABA/LAMA for COPD, so use it as you would the other LABA/LAMAs. Its useful as it's the the only dual bronchodilator pMDI
Trixeo® is a triple pMDI for COPD LABA/LAMA/ICS, for COPD (medium dose). Its useful as it does reduce exacerbations. Only add ICS after consideration by specialist as ICS are not good for all COPD patients.

Please also remember when looking at research studies about these drugs that the primary outcomes such as percentage of reduction or improvement are not markers to use in isolation. Especially if they are moving in the right direction significantly for patients. You also need to think about more practical applications such as reduction in items on a patients prescription, familiarity of current inhalers and compliance with treatments, they cannot be dismissed.

If you would like an educational session at anytime please e-mail me I have accumulated interesting case studies in asthma and COPD for instance.

Regards David




Please see attached document V1 for guidance about spirometry in Somerset. Please bear in mind the decision to undertake this should be a considered one and a few additional guidance points considered:

a. Nurse and two docs decide whether all agree spirometry needed (not wanted) and this will virtually only to be to confirm a clinical suspicion of COPD (otherwise it is a want)

b. The patient should be carefully assessed for likelihood of COVID19 - degree of isolation, workplace, protection etc and also symptoms.

c. If need and low risk I would suggest that it is performed at end of day in a room that won't be used overnight and can be cleaned next morning to be safe, it is done using bacterial.viral filters and with PPE / visor and if possible plastic screen too.

d. We should not be doing for the hospital at the current time as not funded to do in primary care - let alone for our specialist colleagues - though with resource that would be good.

NOTE - With the swab accuracy being at best 70% and likely to be 50% - if they sound like COVID they probably are COVID and shouldn't be done no matter what a swab result says.



NON-ACUTE BREATHLESSNESS - I came across this algorithm and it’s an updated interactive version of the non-acute breathlessness pdf produced by the East and North Hertfordshire CCG guidance. I find it very helpful.


There have been enquiries regarding QOF points and the fact you are unable to conduct spirometry as yet. A regional document and advice will be circulated soon giving advice on spirometry in primary care and how best this can be re introduced.

QOF, As you know LTC have been suspended for now. These are income protected indicators. The recent QOF guidance states: "We recognise that there may have been changes in access to some diagnostic and specialist services as a result of COVID-19 activities which may mean that this care is not delivered within the usual timescales. Practices should continue to apply their clinical judgement to the appropriate management of affected patients” (BMA). The LMC and CCG are in dialogue currently to discuss these issue further. We will let you know when there are any other changes.

Kind Regards

David Long


NEWS 13 JULY 2020

Respimat inhaler device change

I hope you are keeping well. As you may or may not know The Respimat inhaler device changed recently so that the device can be kept by the patient and the canister replaced six times before then getting a new device.

The idea being it reduces waste and helps reduce the carbon footprint. This is a good thing but unfortunately the numbers in Somerset don't show this change is happening. Only 20% are using refills this should be ideally in the 80% plus range. If used as per the Somerset formulary it should equate to 4,000 inhalers and 16,000 refills so there is currently a lot of unnecessary waste as you can see from the diagram below.(diag. and data. from Boehringer Ingelheim Ltd).

Somerset formulary information is below, please think about this when issuing or re-authorising these inhalers, ‘be kind to the environment'.




We had a meeting yesterday at the CCG (Respiratory Clinical Programme Group) and we thought it a good idea to keep you informed about the National Spirometry Register and the ‘Somerset Solution’.

In short, we are meeting with all stakeholders/interested parties on May 5th (Times/venue to be announced). We want to deliver the educational component with the expertise we have in Somerset. However we need to discuss the governance issues and how best to approach this using national eg where they have introduced such programmes.

If you are interested in being part of this project please let Rachael know .

Kind Regards



Dear all,

It's that time of year!…no not Christmas, the GOLD 2020 report has been released. As we know the NICE and GOLD, COPD messages are becoming similar. However I feel the GOLD are more user friendly and something many of us are familiar with. It is also so important to keep up-to-date.

In this updated report the guidelines are focused on the non-pharmacological treatment for COPD putting them at the forefront of COPD patient care. There are quite a few changes and I would recommend a read to digest the main changes such as:

The pocket guide can be found here (for personal use);

It does simplify many things in tables, charts and figures. So even if you just browse through those and perhaps the key point boxes, maybe read further into a topic if its new to you, it will help you better care for your COPD patient group.

As always I am happy to attend you practice for ‘lunch and learn’, support of new clinicians to the respiratory specialty and support the more experienced clinicians with virtual clinics.


Dear all, SAVE THE DATE: Nurse Respiratory Day date is, the 28 April 2020, booked at Taunton Racecourse.

Please see the latest update of the inhaler first choice for practices to help standardise value prescribing. You will see I've used AirSalb (salbutamol) for both asthma and COPD. The rationale is that this is one of two pMDI licensed for both diseases and it is the cheapest pMDI.

As you know I am not an advocate for switching unnecessarily, so its for use when the clinician feels a change of treatment is needed or initiation of new treatments. This is only guidance and the reason I've shared the document in word format is so that you can alter it to your own preferences as a practice. I do hope it is helpful, I do not want to undermine or upset the CCG pharmacists good work. However I am very often asked what Inhalers I would use first line. Attached is my personal opinion, to try and standardise first line treatments a clinician could consider at a practice level in a cost effective and standardised way.


Dear all, I thought I might add a little context to the drive to reduce the amount of SABA use in asthmatics. We are doing well in Somerset reducing the amount of SABA, in fact we are in the top 10% in the country (Open prescribing).

However as you are aware, there are a core of individuals who despite our best efforts don’t seem to grasp the risks they are taking by overusing beta agonists. So here are a few facts that might help you understand the rationale behind the need to continue to pursue reduction and perhaps provide a way of explaining to the patient the risks.

First make sure you have no patients (>12yrs) on LABA alone or frequently using SABA (>3\week) alone with a diagnosis of asthma. If so they need to be on ICS (if LABA in a combination inhaler). I am sure you have already highlighted the high users of SABA. SABA use when the airways are not contracted and do not need relaxing is HARMFUL and can result in death.

BETA AGONIST overuse causes:


  1. Beta 2 downregulation
  2. decreased brochoprotection
  3. decreased bronchodilation
  4. increseed allergic response
  5. increase eosinophilic airway inflammation

(Drazen JM, NEJM 2009; Hancox, Respir Med 2000 ; Aldridge, AJRCCM 2000; Johnston S,Thorax 2009 Vol64, no9)

You can now appreciate why some patients use more and more beta agonist, as the airways destabilise the more they feel they need to use their inhaler, ‘a vicious circle’.



The latest regarding spirometry training and registration is still to “carry on as you are”. It is high on the agenda at the respiratory CCG meetings and we are formulating a solution for Somerset. As soon as anything is finalised we will let you know.

Regarding spirometry currently, a few practices are successfully training HCA’s to perform spirometry testing. I have no issues with this but I am sure there are a few differing opinions regarding this practice. However, in the current environment, I think it is a good way forward for some practices and individuals to undertake. It releases experience clinicians to do clinical work, rather than undertake time consuming tasks. With the right education (I can help with this) and support it should work well. This process is key to implementation. With this in mind I have been given permission by the author (Lucie Gillard) to share the good work she is undertaking in her practice (see attached docs). It may be helpful if you are thinking of going in this direction.

The national register is not due to be in operation until April 2021, hopefully by then Somerset will have a working solution that will meet everyone’s needs.

GPN Respiratory Update Day 28th April 2020 @ Taunton Racecourse

Hold the date...

Agenda TBC, however the last 2 years have had tremendous feedback and have been oversubscribed so we hope to build on this success. Book a place in the usually way through SGPET.


Dear all,  Please click on this link

It a humorous but accurate view on the spirometry register. It will hopefully put into context and answer some fundamental questions about this initiative.

I’ve only just been made aware of this and thought it an exceptional representation of most people discuss this issue with.

Kind Regards  David Long 


I hope you have had a wonderful summer. I thought it might be useful to share concerns that have been flagged up via my work with the GPN’s. One is that of pulmonary rehabilitation and QOF recording confusion. QOF states ‘offered or referred” the operative word being “offered”, so don’t forget to tick the box if you’ve done this.

In Somerset anyone with dysfunctional breathlessness, symptomatic and disabled with an MRC dyspnoea score of 2 or more (ie not all with MRC 2) as opposed to national guidance of 3 or more can be referred, which is great for our COPD population. Whilst we are on the subject of pulmonary rehab. the new contract will have the ability to run ‘pop up' clinics in 4 areas:

Pop-up venues (fixed programmes):

As a reminder rolling programme venues:

Referral process is as before. A formal launch will be forthcoming along with more information I thought it would be good to think about referral of patients depending on when the fixed programmes start in your area, as there needs to be a certain number of patient for a programme to run.


I would also like to draw your attention to an article about a pragmatic approach to caring for patients with difficult asthma, produced the PCRS As you know when difficult asthma is concerned, I am always here for advice and guidance via e-mail ( or by calling Somerset LMC (01823 331428), I can also undertake patient reviews if necessary. The idea being to reduce the number of difficult or poorly controled asthma referrals to specialist service and educate the GPN in the process. The article highlights the difference between difficult and severe asthma and its the severe patients who are not being referred when appropriated much to their detriment.
When you think a patient is at the severe stages you can refer to the ‘severe asthma service’ based at Musgrove Park Hospital. They will review the referral in the MDT setting which is county wide.


One interesting fact I found out this week and was not aware of, is that the ‘respimat inhaler’ has significantly less environmental impact than an MDI as it does not rely on propellent but a spring mechanism to activate. Also you may not aware the respimat inhaler device will be changing slightly soon (old stock will be used up first). The rationale is to allow six months use of the device itself but the canister can be replaced separately, making it a much ‘greener’ device. More information about this and information to give patients can be found here .
Last but not least I have produced case studies for asthma and COPD and would be happy undertake a free ‘lunch and learn’ opportunity to discuss the cases (need 8 week notice). I also have the respiratory, asthma and COPD updates to present if you have not taken part in this learning opportunity already. Contact me if you wish to take part in this free opportunity to improve respiratory knowledge as a practice or group.
One question which was asked at the lead nurse meeting last night was around reviewing patients with asthma and not having capacity. I will think on this and discuss with others. To perhaps provide a structured way of approaching this issue ie by telephone consult and risk stratification you can conduct via EMIS… so we can at least concentrate on the patients at risk of exacerbation or hospitalisation.
Well “thats all folks’, any new information I think may help I will share, until then take care.


Not much has been happening in a news worthy sense for a few weeks now. However NICE have updated the COPD treatment algorithm (see attached). The main points are getting the non-inhaler treatments implemented if appropriate FIRST, which is sound advice no matter what guidance you follow.

It also recommends triple therapy inhalers. However in my opinion, the inhaler algorithm introduces ICS too early based on, 1 hospitalisation (severe exacerbation) or 2 moderate exacerbation (needing steroid or antibiotics) it does footnote the warnings regarding ICS. It also highlights the need to comprehensively assess patient post trial of treatment and STOP if no benefit. . It also recommends that prednisolone 30mg od for 5/7 is given to minimise the time patients are on this potent therapy. A news item has been produced by PCRS

Most of you will be adhering to the GOLD strategy and I see no reason to deviate from this currently. As all guidelines, it does give clear advise in some areas, which you can use. For me GOLD gives you clearer parameters to consider before using ICS and before stopping patients already on ICS ie eosinophils among other reasons.

The other new guidance comes from BTS/SIGN Asthma, a partial update. Among other recommendations it does not advocate regular FeNo testing in primary care. It has simplified the phased pharmacological treatment phases and recommends referral to secondary care instead of increasing treatment options as before.a briefing paper by PCRS can be found here

Ive attached both documents, as this is only a brief introduction so that you know they are out there. You can read them to your hearts content. If you would however want a free ‘lunch and learn’ in which we can explore the changes in more depth please let me know. Equally I am always on the end of an e-mail or I can undertake a virtual clinic should you wish to discuss respiratory patients.

COPD Visual summary treatment algorithm. 

BTS Asthma Guideline Quick Reference guide 2019.


NEWS 24 JUNE 2019

Somerset Respiratory Team Newsletter, usefiul documents

COPD Self Management Plan for Exacerbation

Somerset Respiratory Dashboard


NEWS 30 MAY 2019

Smokefree Health and Wealth Wheel
This rotating wheel is a useful resource, showing the benefits to health and pocket when someone quits smoking. On one side of the wheel it displays how quickly a smoker's health will improve when they quit after 20 minutes, 8 hours and 72 hours, right up to 10 years after quitting. The other side of the wheel shows how much money a smoker could save when they quit.

Order your smokefree Health and Wealth Wheel

“Quitting smoking is one of the best things you’ll ever do for your health” booklet
This booklet offers helpful tips for quitting smoking. It outlines the benefits of quitting for a smoker’s health, the impact that quitting can have on friends and family, as well the amount of money that could be saved. The booklet also offers advice on the different types of support available, and helps smokers to plan their quit attempt, to boost their chance of success.

Order your smokefree booklet

If you have any questions, please feel free to email



Antibiotic guidance

A brief but very informative podcast has been produced by the PCRS about the guidance around antibiotic prescribing. I would recommend taking 10 mins to have a listen...

NEWS 18 APRIL 2019

You may have seen the advice to change patients inhalers to the same device including BBC news coverage and 14 page inhaler choice document.

Device consistency has always been at the forefront of device choice and remains an important factor. However it has come to my attention that you may feel the need to switch to DPI’s. This is not how the recent advice should be interpreted.

Whatever device the patient wants to use and can use correctly be it DPI or MDI is paramount.

With this in mind I have attached a grid to help you consider what devices are available for airways disease and in my opinion cost effective. It can be adapted by the practice if you wish.

NEWS 26 MARCH 2019

  1. Fostair Nexthaler is now licensed for Maintenance and Reliever Therapy (MART)

Things to consider:

• The register is hinted at but not formalised by the CQC

• If you train and register now you will need to be reassessed soon after the scheme starts.

• There are substantial costs involved for the training and registration and no funding stream has been negotiated via NHS England. This        central funding should be provided, as it is a Quality Assurance Initiative.

• Spirometry training is always ongoing due to the turnover of the workforce. Whatever training is made available it needs to be readily accessible.

• There may be a local solution to the initiative; this will be discussed at the CCG Respiratory Clinical Program Group.

The advise for now, is that you need not worry for the next couple of years about registration - but you should be able to indicate why you believe that you are competent to perform / report on spirometry. We should have a better understanding of the educational and financial landscape by then. We will of course keep you all informed of any changes or local initiatives.

More information can be obtained :'

SWITCHING INHALERS - It is becoming apparent as I travel around GP practices that there is increasing frustration from GP,’s GPN ’s and moreover patients about switching inhalers on such regular basis. The concerns are that although there may be a central cost saving (sometimes due to rebates) the cost and impact to the patient and clinician is more. Although you may feel pressured to make changes it is you as a clinician who should make a judgment on what drugs should be used when as you have a much clearer understanding of the patients you care for. This personalised care has much less of an impact on the wider healthcare system as a consequence. A guide was produced in the past and I think still has value today, please see here. I hope this helps.



An alternative Mucolytic available for COPD or Bronchiectasis

NACSYS 600mg Effervescent Tablets. (EMC 2017)

Key points:

NACSYS 600mg od, Effervescent Tablets. EMC 2017       Holdiness M. Clin Pharmacokinet. 121-134. 1991


Stop Smoking Day 13/03/2019, please follow this link for support packs or campaign packs.



Re: vaping advice

Please read letter regarding vaping and new resources/information.


NEWS 3 January 2019

There is currently some confusion over asthma management plans. One would hope this brief item will help diffuse any concerns you may have. Please note this item relates to the Asthma UK Action plan but may be pertinent to other plans in circulation. The main questions are:

Q1 Do I have to fill in all the action plan ie percentage drop in peak flow?

A1 In short, No. There is no evidence to suggest a symptom driven plan is any better or worse than using peak flow measurements to gauge deteriorating asthma control. So you can cross out the peak flow boxes if you wish and any other part that is not pertinent to the patient for that matter. Using symptom recognition to initiate patient action if you and the patient agree.

Q2 The plan still includes spaces to allow patient to increase their ICS, this has normally meant doubling ICS dose (amber section) is this still used?

A2 In short No. Evidence suggest that doubling does not help patients and quadrupling may be helpful. However if you quadruple the dose you need to be aware of not giving very high doses of ICS and LABA. The advice is that if the patient is not taking their preventer it should be started at this point. If they deteriorate then seek help sooner as detailed in the plan.

At the Respiratory Clinical Programme Group in Somerset, self management plans (Asthma and COPD) are being reviewed and one would hope a Somerset wide plans will be forthcoming in the new year and embedded into EMIS thereafter. "

Not sure if we need to evidence this but my hunch is practices nurses just need to have the guidance.


NEWS 6 December 2018

Firstly I would like your help. At the recent Respiratory Clinical Programme Group it was agreed that a SOMERSET wide self management plan for both asthma and COPD would be a good idea. With this in mind could you send me your self management plans if they are different to the asthma UK plan or the Somerset COPD plan. We would like to update our current plans and would dearly like to see what is actually in use currently. If you could send them to me at I will forward them to the group. I will of course send you all the updated plans once the exercise has been completed.

The next item again is about sharing good practice and I would dearly love to understand what mechanism you use to inform you of a discharge of a respiratory patient from hospital to allow you to put in place the appropriate follow up. Not every practice has a mechanism in place and it would be good to hear what works elsewhere and share this. If you could email me as above I would be very grateful.

Most of you now know about “right Breathe” website and the app. However I was informed of an excellent way in which it can benefit patients.

Within the app you have the opportunity to set a profile. If you chose the patient profile it allows the patient to choose their own inhalers. this gives them information about the inhaler, inhaler technique video and a way of setting diary entries/alarms to remind them to take the drugs.

I am currently at the Winter BTS and the SIGN/BTS asthma guidance was presented and a consultation document produced for consultation and updating in 2019. Available is NICE COPD partial update

More information on this in later news but if you want to read them they are available online currently.

The last item concerns the launch of a five year plan to improve lung health which was launched on the 5th December. This is a welcome document and is good to see respiratory disease coming to to the fore at a national level. It covers many recommendations to improve outcome for patients with lung disease. I will not list here but you can read the report .

I started my new role in September of this year and the time has flown by. The nurses I have come into contact with during this time have been exceptional and I would like to thank you all for engaging with this new initiative and look forward to working with you in the coming year to improve outcomes for respiratory patients in Somerset.

As this will be the last communication of the year from me I would like to wish you all a very Merry Christmas and a Happy New Year. 


News 16 November 2018 - GOLD Strategy Update 2019 published

The strategy has updated two main areas:

  1. ABCD INITIAL assessment model has been simplified. This model was never intended for follow up therapy . It also includes using eosinophils (= 0.3 taken when patient is in a stable state) as a biomarker for patients who would likely respond to ICS.
  2. It has developed a follow-up treatment guide based on symptoms as a way to decide which treatment to consider for patients who present with either predominant breathlessness or exacerbations. It also includes consideration of deescalating treatments.

Another area that I feel needs highlighting and should form part of any clinical assessment is the management cycle (pp 28 of the pocket guide), a simple but effective aid memoir.

The consensus is that we continue using local and GOLD strategies until the NICE guidance is published (Dec 2018). We can then advise and inform once digested.


News 12 November 2018 - Good Practice Information

I thought it might be a good idea to share good practice when I come across it. This is a simple but effective way of ensuring that patients understand what medication they are taking and for what disease. It also improves correct inhaler technique, compliance and can reducing consultation time.

This ‘top tip’ came about from a symposium discussion at this years PCRS conference. A GP when prescribing an inhaler will put on the prescription and subsequently medication label, something along the lines of ‘ Take salbutamol for relief of your asthma”. If it is a new prescription for an inhaler and they have not had time to do the inhaler technique a request is also put on the script “please can the pharmacist show inhaler technique”. This will help you, the pharmacist and patient alike.

The patient knows why and how to take their medication. The pharmacist knows why they need the medication and can inform the practice of over or under use of medications. For the busy clinician they can be assured the medication is being used correctly and this will be subsequently reinforced on subsequent visits. Have a discussion with your team.

You may be doing something similar, if you are, I would love to know how its working, or any other initiative you feel has impacted positively on your respiratory patients ( ) I know it may not be acceptable for all, for numerous reasons but think this is an excellent small measure which has had a positive impact.


News 25 October - New Products of Note

Flutiform K-Haler

I can hear you say “not another inhaler to add to the 109 already out there!”. Its here, and why do I think its worth a mention? It adds another useful combination therapy to our ‘bag of tricks’ for asthma patients only.

It is a pMDI, ICS/LABA that is the only breath-activated device available in this combination. So this will allow you to consider this device and drug combination for patients who have ASTHMA and are already using breath-activated devices or those you feel would benefit due to poor technique. with their current device. Needless to say it has to be used in accordance with the SIGN/BTS asthma guidance for ICS/LABA.

Briefly it is for 12yrs and older on lower dose fluticasone propionate 50 mcg/ 5mcg formoterol the medium dose being fluticasone propionate 125 mcg/ 5mcg formoterol. If the research is to be believed it has a very good deposition on the lungs of a mean of 43%, compared to the usual 30%.

AeroChamber plus Flow-Vu

Nothing new here? We are all very familiar with the AeroChamber spacer device and why we use it. The company have produced a spacer device that although 15p-30p more depending on style type prescribed, has in my mind significant benefits over the older device we are familiar with. First and fore most its anti-static, so no need to waste drug priming the device and more drug is delivered to the patient. It has been demonstrated to reduce hospital admission (19%) and ED attendance (13%) compared to other conventional non-antistatic devices. How often do we forget to tell patients to wash the device regularly in soapy water and leave the soap on the device to air dry (helps reduce anti-static)? This device is dishwasher safe which is a big bonus for practicality. It is more cost effective as it needs to be replaced every year as opposed to the current version every 6 months. There are other improvements such as an outlet valve that blows away from the patients face. However for me the above is enough for me to consider prescribing this above the normal Aerochmaber. If you want more detailed current information about Spacer device why use them and how? Follow this link

You may have had all this information already, if you have I apologise but for those who haven’t I think these productsare worth keeping in mind when you review patients. You can look on the products website or ask for visit by the representative if you want further information.

News 5 October - Opinion News Slot

Cough in COPD

We all know of patients that despite the traditional methods to help their cough such as:

· Stopping smoking

· Optimal inhaler therapy

· Correct treatment for exacerbation i.e. extending antibiotic course length (see Somerset COPD guidance)

· Cold, pollution and other irritant avoidance

· Keeping hydrated

· Flu & pneumonia vaccinations

· Pulmonary rehabilitation

· Mucolytic therapy (remembering to reduce frequency from tds to bd after successful 3/12 trial)

COPD patients still have difficulty expectorating and clearing phlegm causing an increase in exacerbation frequency. One physiotherapy technique is the Active Cycle of Breathing this is one technique usually used in cystic fibrosis or Bronchiectatic patients. It is however very useful technique to help clear sputum in a less explosive and traumatic way for your COPD patients. This technique used effectively can help patients significantly, however when patients find this ineffective other methods can be used. Therapeutic devices, which help the removal of mucous from the airways such as, flutter devices. One new product that can be prescribed is the Aerobika it should only be considered after all the previous methods have failed. Why I think this helps more than others is due to the way it works at the earliest part of expiratory phase, no metal parts. On a more practical level it can be cleaned in a dishwasher and microwave bag as well as the usual methods and last a year (approx. £46).

Sputum clearance is an important and integral part of treatment for your COPD patients especially if they are productive and have frequent exacerbations. By employing the above methods you will reduce the impact on patients and the health service.

As always I would welcome and constructive feedback , I realise this is not a comprehensive review of interventions but want to highlight areas that in my experience make a big difference to patients.

News 25 September - Spirometry National Register a Local Perspective

It is hoped that by April 2021 anyone involved with undertaking or producing a report / interpretation for a clinician on spirometry will need to be assessed and deemed competent by a nationally approved assessment led by ARTP and be approved for entry onto a national register.

A key point is that you do not need to receive training via an ARTP accredited provider but assessed. So training needs can be met in other ways. Once registered you will need to be reassessed every 3yrs. At the current time this is not an expectation - but with boundaries of professional competence it is important the those undertaking, producing a report for a clinician should have the appropriate skills necessary. The clinician should be assured the spirometry is good quality - and interpret the spirometry report in a clinical context (much like xrays and other tests) to decide on diagnosis.

Things to consider:

• The register is hinted at but not formalised by the CQC

• If you train and register now you will need to be reassessed soon after the scheme starts.

• There are substantial costs involved for the training and registration and no funding stream has been negotiated via NHS England. This central funding should be provided, as it is a Quality Assurance Initiative.

• Spirometry training is always ongoing due to the turnover of the workforce. Whatever training is made available it needs to be readily accessible.

• There may be a local solution to the initiative; this will be discussed at the CCG Respiratory Clinical Program Group.

The advise for now, is that you need not worry for the next couple of years about registration - but you should be able to indicate why you believe that you are competent to perform / report on spirometry. We should have a better understanding of the educational and financial landscape by then. We will of course keep you all informed of any changes or local initiatives.

More information can be obtained :


News 20 September - New Respiratory Dashboard available

New Respiratory Dashboard is available!

The rationale being: "Given the complexity of prescribing in respiratory care and the plethora of medicines available, it was agreed by a national group of respiratory specialists that it would be useful to help see the variation in prescribing of respiratory medicines across England.

The aim of this dashboard is to highlight the variation in prescribing across the CCGs in England so that CCGs and local health economies can utilise this data at local level to decide if this variation is warranted or unwarranted and if and how they may wish to address this.”

Undoubtedly it will take time to review and formulate opinions we will of course keep you updated of any initiatives or thoughts. It might for the time being be of interest to you and your practice.


News 12 September- Cost Effective Prescribing of Inhaled treatments for Asthma

There is a need for a simple document that outlines first line choices of inhaled treatment to be used in respiratory care. The rationale is to simplify matters for those who are not that familiar with the newer options available from the 100 plus choices, reduce cost, improve ‘brand prescribing’ and patient safety.

To help in this matter, David Long has put together a matrix of choices which you can adapt to your own Medical Centres preferences. It is intended for the whole practice to agree and adopt. If another choice is required, the patient is sent to the respiratory specialist in the practice for instruction and inhaler choice dependent on the class or classes of drug required.


News 3 Sept 2018 - Primary Care Respiratory Society 'interesting bits’...

A study looking at the patients perception of asthma control, highlighted how and why patients do not use ICS. Also why there is a lack of patient engagement in asthma reviews. This article certainly provided an interesting insight. I think this is something that as a group we need to think about and work on, counteracting the patient perception. Read the summary by following this link

click on the July button at the bottom of the PCRS webpage to see other interesting respiratory articles.

I would be interested to hear your opinions on how we could improve this perception of not engaging the patient. I for one advocate using health status questionnaires such as the asthma control test. This helps not only engage the patient and improve consultation satisfaction but helps you as a clinician pinpoint problems the patient is experiencing and discuss solutions. It will also tell you if you repeat the scoring after an intervention if the patient has had any benefit. Hence having to see the responses to both the pre and post intervention questionnaires is important, as certain domains may well have changed from the previous questionnaire but have the same total score.

This is a brief update as I have only just commenced my new role. I do hope this is helpful and will of course keep you updated in due course as to the events and news happening within the respiratory specialty.

Warm regards

David Long

COVID 19 - Information and Guidance

26 May 2020

Digital Asthma

Through this difficult time we have endeavored to try and maintain safe and effective services for our patients. One way in which we have embraced this is through IT. A document came to my attention which builds on our current practices and details ways in which we can use digital technology to continue and enhance this way of working. It revolves around asthma but there are many recommendations which could be applied in other disease areas. The Report recommends:

We will be working on the recommendations at a strategic level and perhaps this will give you an idea of the future of respiratory care and what can be done right now.

Regards David Long

14 May 2020

Free Respiratory Training available.


11 May 2020

Details of the Clenil 100mcg batch variation.


7 May 2020 - Respiratory Physiotherapy Advice Service (3 month Pilot)

A new pilot service is starting for breathing pattern disorders such as Asthma or COPD patients who have anxiety related symptoms. Bronchiectasis patients may benefit from the service if sputum clearance is an issue or they exacerbate frequently. The attached document is self explanatory and provides more detail on who best to refer. Needless to say, if you don't use it ,you will loose it. It's seems a good service that would benefit a range of patients, best of all its county wide.


9 April 202 - Inhalers - Important Information

Repeatedly information is sent out regarding inhaler shortages in particular CHIESI products. We are a high user of Fostair in Somerset for a good reason, it works well as it’s a good combination of particular drugs. For some reason, as stock levels in the UK are NOT an issue these particular inhalers are being targeted (cost?). In accordance with the BTS document (Apr 2020), there should be no issue with Clenil from the 3rd April.

Why should I care about this and bother you with another e-mail? I have seen patients hospitalised with life-threatening asthma attacks due to inappropriate and rushed switching of inhalers in the past. This would be bad in this current situation. 

My advice is to continue prescribing the drugs the patients and you have confidence in