Pulmonary Complaints#

Approach to common respiratory complaints in primary care. Most pulmonary presentations can be triaged effectively in the office—the key is identifying who needs urgent evaluation (respiratory distress, hypoxia, hemoptysis) versus outpatient management.

Key Principles#

• Acute vs chronic: Cough <3 weeks is acute; >8 weeks is chronic. Dyspnea timeline changes the differential dramatically
• Vital signs matter: SpO₂ <92%, RR >24, accessory muscle use → consider ED referral
• Smoking history: Pack-years drive lung cancer risk and COPD severity; always quantify
• Medication review: ACE inhibitors (cough), beta-blockers (bronchospasm), aspirin (aspirin-exacerbated respiratory disease)
• Chest X-ray threshold: Low threshold for CXR in smokers, hemoptysis, persistent symptoms, or abnormal exam

Topics#

Cough#

• Cough (Acute) — <3 weeks; viral URI vs bacterial vs post-infectious
• Cough (Chronic) — >8 weeks; upper airway cough syndrome, asthma, GERD triad

Dyspnea#

• Dyspnea (Acute) — hours to days; PE, pneumonia, HF exacerbation, asthma
• Dyspnea (Chronic) — weeks to months; COPD, HF, ILD, deconditioning

Other Respiratory Symptoms#

• Wheeze — asthma vs COPD vs cardiac wheeze vs focal obstruction
• Hemoptysis — bronchitis vs malignancy vs PE; always warrants workup

When to Refer to Pulmonology#

• Unexplained chronic cough after empiric treatment of common causes
• COPD requiring escalation beyond dual bronchodilators or frequent exacerbations
• Suspected interstitial lung disease (ILD) on imaging
• Hemoptysis with abnormal CXR or CT
• Uncontrolled asthma despite step 4+ therapy
• Abnormal PFTs requiring interpretation or bronchoscopy
• Lung nodule requiring surveillance or biopsy decision

When to Send to ED#

• SpO₂ <92% on room air (or significant drop from baseline)
• Respiratory rate >24 with distress
• Accessory muscle use, tripod positioning, inability to speak in full sentences
• Massive hemoptysis (>100 mL or ongoing bright red blood)
• Suspected PE with hemodynamic instability
• Acute asthma/COPD exacerbation not responding to initial nebulizer treatment