Patient guide

First of all

A lung appointment starts with hearing your story. The more detailed the history you bring, the sooner the doctor can find the cause and avoid repeating tests. This list is a general guide, and you may not need all of it. If you do not have something, book the appointment anyway.

What should you bring?

1. CT films and reports, and chest X-rays. Bring both the film or disc and the radiologist’s written report. ATS says to tell your doctor if you have an earlier X-ray or CT, because a nodule that has stayed the same size over the years is reassuring. If you had a CT recently, bring older CTs too so the doctor can compare.

2. Spirometry results and earlier lung tests. Bring your spirometry sheet, breathing tests, sleep test and bronchoscopy report, if you have had them. NHS says that to diagnose asthma, a peak flow meter is sometimes used at home for a few weeks; if you have notes, bring them.

3. Your actual inhalers and spacer. ATS writes that you should take your inhaler and spacer with you every time you see your doctor, show how you use them, and get feedback. A photo of the box or the name of the medicine is not enough; bring the device itself, even if it is empty. The correct technique is in the “Inhalers and spacers” guide.

4. A list of all your medicines. Write down every oral, inhaled and injected medicine, over-the-counter painkillers and supplements by name, or bring the boxes. The reason is that some medicines affect the lungs. ATS says some blood pressure and heart failure medicines (ACE inhibitors) can cause a cough, and if you started coughing after a new medicine, be sure to say so. NHS also writes that aspirin, ibuprofen and beta blockers can trigger asthma symptoms in some patients. If you take a blood thinner, mention it specifically; ATS says you should ask your doctor about it before a bronchoscopy.

5. Your asthma or COPD action plan. If a doctor has already written a plan for you, bring it. NHS says you should take your asthma action plan to all asthma appointments.

6. Notes on your symptoms. Simply note down the following:

• When the cough started, whether it is dry or produces phlegm, and whether it disturbs your sleep at night. ATS says the doctor asks exactly these things.
• The usual color and amount of your phlegm when you are well, and any change in it. ATS considers this useful for spotting a COPD flare-up early.
• What makes you short of breath: stairs, brisk walking, cold air, dust, cats, perfume, exercise.
• How many times a week you need your reliever inhaler.

7. Smoking, hookah and work history. NHS writes that in a COPD assessment the doctor asks about smoking (current or past) and a family history of lung disease. For diagnosing pulmonary fibrosis, ATS gives weight to your job and to exposure to dust at home or at work. The doctor’s question is not a judgment; it is to find the cause.

8. One companion, if your problem is during sleep. NHS says that for snoring and breathing pauses at night, it helps to bring someone who has watched you sleep. If they cannot come with you, ask them to write down what they hear for a few nights or, if possible, record it.

What happens at the visit?

NHS writes that the doctor usually asks about your symptoms and history, listens to your chest, and may work out your height and weight. If the doctor thinks it necessary, they will request tests such as spirometry, CT, blood tests or a sleep test. These are explained in the “Lung tests” guide. This guide itself does not say which test is done at the same visit; ask the appointment center or the doctor.

Before you go

• If you have a spirometry appointment, ask in advance whether you should take your inhaled medicines that day. ALA says to take daily medicines as usual unless your doctor says otherwise, and if you use only a reliever inhaler, to avoid it for six to eight hours before the test if possible. ATS says not to smoke for at least one hour before the test. Your doctor will make these exact for you.
• If you have a bronchoscopy, read the “Bronchoscopy” guide.
• Write down your questions. For example: What is my diagnosis? What test is needed? When and how should I use the medicine? When should I come back? Which symptom means I should call immediately?
• If you have severe symptoms (gasping for breath, blue lips, confusion, chest pain), do not wait for the appointment. See the “When should I call urgently?” guide and call 115 (Iran’s emergency number).

After the visit

Before leaving, ask your doctor three things and write them down: what has been diagnosed or is still being investigated, what the medicine and daily routine are, and when and with which symptom you should come back sooner. Do not stop any medicine your doctor has given you without advice, even if you feel better.

First of all

This guide explains the tests in general terms and does not say which test can be done where or when. Which test you need is decided by your doctor. Preparation may differ slightly from one center to another, so put the instructions on the center’s or the doctor’s sheet first. The sources also differ on details such as how long to avoid smoking before a test, and we have written both.

Spirometry

What is it? The most common breathing test. ALA writes that it measures how much air you can breathe in and out and how fast. A doctor requests it for wheezing, shortness of breath or cough, to diagnose asthma and COPD, before surgery, and to see the effect of treatment.

How is it done? You sit upright, put on a nose clip and hold the device’s mouthpiece in your mouth. You take a deep breath and then blow out with all your strength and speed. ALA stresses that “this maximal effort is very important”. The test is repeated at least three times. You may be given a bronchodilator medicine and the test repeated to see whether your breathing improves. ATS says it takes about thirty minutes. It is not painful, but blowing hard can be tiring and can cause dizziness or coughing. If you feel dizzy, stop blowing right away and tell the technician (ATS).

Preparation:

• Take your daily medicines as usual unless your doctor or the center has said otherwise (ALA). ATS says you may be asked not to use a breathing medicine; ask your doctor which one.
• ALA says that if you use a reliever inhaler only when needed, avoid it for six to eight hours before the test if possible.
• Smoking: ALA says do not smoke for at least six hours before the test, and ATS says at least one hour. Follow the longer of the two instructions unless the center says otherwise.
• Wear loose clothing and do not eat a heavy meal before the test. ATS says do not eat a large meal within two hours of the test, avoid alcohol for eight hours, and avoid heavy exercise for half an hour.
• If you have a cold or flu, tell the center; they may change the appointment.

Who should tell the doctor in advance? ALA writes that if you have had a heart attack in the last month, have recently had eye, chest or abdominal surgery, have had a collapsed lung, or have tuberculosis, the test may be postponed until you recover.

Peak flow meter

A small handheld device that shows how fast you can blow air out. NHS says that to diagnose asthma, the doctor sometimes gives you this device to use at home for a few weeks so they can see how your lungs are working. In a COPD assessment it may also be used to rule out asthma. The doctor or nurse will show you how to blow and record the numbers correctly; do not use it by guesswork, and write the numbers down without judging them so the doctor can see them.

Gas transfer test (DLCO)

ATS says this test measures how well air passes from the lungs into the blood. You put on a nose clip and breathe through a mouthpiece: first you breathe out completely, then quickly take a deep breath in, hold it for about ten seconds, and then breathe out. The air you breathe in contains a very small amount of carbon monoxide, which ATS says is harmless. It is repeated up to five times and takes about thirty minutes. Preparation: do not smoke and stay away from smokers. If you use oxygen, it is usually stopped for a few minutes.

Measuring lung volumes

ATS also names another method, done in a closed booth (body plethysmography). In it you take short breaths against a closed mouthpiece, which may be uncomfortable. If you are uncomfortable in enclosed spaces, tell the technician in advance.

Pulse oximetry and the walking test

A finger device uses light to measure the oxygen in your blood without a needle. ATS says the number may not be accurate if circulation is poor, skin is dark, you wear dark nail polish or you have anemia. Remove nail polish. In diseases such as pulmonary fibrosis, breathing tests and oxygen measurements (such as the walking test) assess severity and follow the course, but ATS says they do not by themselves make the diagnosis.

Chest CT

Cross-sectional imaging with X-rays. NHS counts it among the additional tests in COPD, and ATS says that in pulmonary fibrosis the assessment starts with a thin-slice CT, and in a lung nodule, repeat CTs follow its growth. ATS writes that the radiation risk of a few CTs is “extremely low”. Preparation depends on the type of CT, for example whether a contrast agent is injected, and the imaging center or your doctor will tell you. Keep the film and the report and bring them to the visit.

Sleep study

ATS and NHS write that a sleep study records breathing, heart rate and oxygen during a night’s sleep and shows whether you have sleep apnea and how severe it is. ATS says it can be done for one night at a sleep center or, for some patients, at home. NHS says it is usually done at home and sometimes at a center. NHLBI adds that the doctor may ask for a sleep diary (duration and quality of sleep, daytime sleepiness).

General preparation: ATS says to avoid alcohol for at least four hours before sleep. For details such as medicines and caffeine on the night of the test, ask the center. If someone has watched you sleep, bring them along.

After the test

The result of any test must be interpreted by the doctor together with your symptoms and examination. ALA says even some people with healthy lungs get an abnormal result, and a normal spirometry result sometimes does not rule out asthma (ATS). Do not read the number alone and do not draw conclusions on your own.

First of all

Inhalers are medicines that reach the lungs directly. ATS writes that using an inhaler correctly is hard: even with the best technique, perhaps only about 25 percent of the medicine reaches the lungs, and most people who make mistakes in technique get less than 15 percent. The biggest mistake is that pressing the inhaler and breathing in do not happen at the same time. For this reason the doctor often suggests a spacer. This guide does not give doses or schedules; your doctor sets those for you.

What is the difference between a controller and a reliever?

• Reliever (rescue): Used when you have symptoms. ATS says it relaxes the muscle around the airways and usually makes breathing easier within about ten minutes. You should always have one with you.
• Controller: Usually used daily, and over the long term it keeps inflammation and narrowing of the airways under control. ATS and NHS say controller inhalers are usually inhaled steroids and may be combined with a long-acting bronchodilator.
• NHS writes that some plans include a combination inhaler used both daily and when symptoms occur. Which plan you have is up to your doctor.

The names and shapes of inhalers vary. If you do not know which is the controller and which is the reliever, take the inhalers to your doctor or pharmacist and label each one.

Some important rules

• Do not stop a controller inhaler when you feel better. GINA writes that stopping an inhaled steroid often leads to dangerous worsening of asthma, and that you should talk to your doctor or nurse before stopping any asthma medicine. Feeling well usually means the medicine is working. Reduce or stop a medicine only on your doctor’s advice.
• Do not stop an oral steroid on your own either. GINA says that not taking it during a severe attack can have serious consequences.
• Inhalers are not addictive. In the sources we read for this guide, this sentence does not appear in so many words and a doctor must confirm it; if you are worried, ask your doctor.
• Heavy use of a reliever inhaler is a warning sign. NHS and NHLBI say that if you need it more than before, your symptoms wake you at night, or activity has become harder, see your doctor. This means the plan needs to be reviewed, not that you should use more.
• Rinse your mouth after a steroid inhaler: swish water in your mouth, gargle and spit it out (ATS). In its discussion of spacers, ATS names hoarseness and thrush as side effects of inhaled steroids.

How do we use an inhaler with a spacer?

ATS describes a spacer (holding chamber) as a tube that holds the puff for a few seconds so you do not have to breathe in and press at the same moment. This delivers more medicine to the lungs and lowers the risk of side effects such as hoarseness and thrush. A spacer does not work with powder inhalers, and some inhalers do not need a spacer (ATS). The steps, as written by ATS:

1. Make sure the canister is seated in its place in the plastic holder.
2. Remove the caps from the inhaler mouthpiece and the spacer.
3. Put the inhaler mouthpiece into the soft opening of the spacer. Keep the canister upright.
4. Shake the inhaler together with the spacer several times.
5. Breathe out to the end of a normal breath, away from the spacer.
6. Put the spacer mouthpiece behind your teeth and over your tongue and close your lips. If the spacer has a mask, place the mask over your nose and mouth so that no gap is left against the skin.
7. Press the canister once so the medicine goes into the spacer.
8. Breathe in slowly and deeply through your mouth. If the spacer whistles, you are breathing in too fast; no whistle should be heard.
9. Hold your breath for five to ten seconds.
10. Breathe out slowly.
11. If your doctor has told you to take more than one puff, wait about fifteen to thirty seconds (or as the leaflet inside the box says) and repeat steps 4 to 10.
12. Close the mouthpiece cap.
13. If it was a steroid inhaler, rinse your mouth.

And without a spacer?

1. Put the canister in the holder correctly.
2. Shake it several times.
3. Remove the cap.
4. Breathe out to the end of a normal breath.
5. Hold the inhaler upright, mouthpiece down.
6. Put the mouthpiece behind your teeth and over your tongue and close your lips.
7. Press down fully once while breathing in deeply and slowly through your mouth.
8. Hold your breath for five to ten seconds.
9. Breathe out slowly.
10. If more than one puff is needed, wait fifteen to thirty seconds and repeat.
11. Close the cap.
12. If it is a steroid inhaler, rinse your mouth.

ATS says that if you cannot use the inhaler correctly without a spacer, use a spacer and use it every time.

Caring for the inhaler and spacer

• Priming: A new inhaler, and one that has not been used for a while (usually a few weeks), must be sprayed into the air as the leaflet inside the box says, to fill the dose chamber. The number of sprays differs for each medicine (ATS).
• Counting doses: Many inhalers have a counter. If yours does not, count the number of times you use it and compare it with the number on the label. ATS says floating the canister in water, or shaking it and listening, is not a correct way to find out how much medicine is left, and seeing a spray does not prove that medicine remains.
• Cleaning: The cleaning instructions for the inhaler and spacer are in the leaflet inside the box. ATS says some spacers pick up a static electric charge if they are not washed and stored correctly, and the medicine sticks to the wall. Keep the spacer clean and dry, and replace it when the rubber valve becomes stiff or brittle.
• Check the expiry date on the canister or box.
• Take your inhaler and spacer to every appointment and show your technique (ATS).

Powder inhalers use a different technique and do not use a spacer. ATS says some inhalers are activated by your breathing in, and for them you must be able to breathe in strongly enough. Learn the correct technique for each device from the leaflet inside the box, your doctor or your pharmacist.

Signs that mean you should see a doctor

• You need your reliever inhaler more than before, or its effect has become shorter.
• You wake at night with cough or wheeze.
• Usual activities, even exercise, have become harder.
• You do not know whether your technique is correct.
• You have a side effect of the medicine: hoarseness, thrush in the mouth, or anything else that worries you.

If you do not get better with the reliever inhaler, you are gasping and cannot say a sentence, or your lips have turned blue, call 115 (Iran’s emergency number) right now. See the “When should I call urgently?” guide.

First of all

This guide explains bronchoscopy in general terms and does not say where or by whom it is done. If your doctor thinks you need a bronchoscopy, follow their instructions and those of the center doing it. If they differ from what is written here, those instructions take precedence.

What is bronchoscopy?

ATS describes it as a procedure in which a doctor looks inside the airways of the lungs or takes samples from the lining and tissue. The tool is a thin, flexible tube (a bronchoscope) that is passed in through the nose or mouth and, like a camera, sends the picture to a screen. ALA writes that it is usually an outpatient procedure and you go home the same day.

Why is it done?

ATS gives the most common reasons as follows:

• Infection: to get a better sample from one area and find the exact cause, or when infections keep coming back.
• A spot on the lung: when an X-ray or CT has shown a “spot” that could be infection, cancer or inflammation.
• Airway blockage or collapse of part of the lung: to see it and take a sample, or to remove whatever is blocking the way (such as thick secretions).
• Bleeding: when someone has coughed up blood and the cause needs to be found.
• Noisy or abnormal breathing: to look directly at the throat, vocal cords, windpipe and main airways.

ATS says that X-rays and CT give information, but bronchoscopy lets you see inside the airway and take a specific sample. For this reason the doctor may consider it necessary even when you have had a CT. In some diseases, such as pulmonary fibrosis, it is needed only when the cause is not made clear by other tests (ATS).

Preparation

• Fasting: ATS says you usually should not eat or drink from the midnight before, or for about eight hours before the procedure. ALA also says midnight. The center will tell you the exact time.
• Medicines: Ask your doctor about your daily medicines. In particular, if you take a blood thinner or an anti-clotting medicine, ask whether it must be stopped (ATS). Do not decide this yourself.
• Smoking: If you smoke, tell your doctor and do not smoke before the procedure (ATS).
• Dentures: Remove them before the procedure (ATS).
• A companion: The sedative stays in the body for several hours. ATS and ALA say someone must be with you and take you home, and you must not drive yourself.
• Consent form: The doctor explains the procedure and its risks and takes written consent. Ask any questions you have right then (ALA).

What happens during the procedure?

Based on ATS and ALA, it is usually like this:

• A nurse asks about your history and medicines, and an IV line is placed.
• Blood pressure, heart rate and blood oxygen are monitored continuously, and you receive extra oxygen through a mask or nasal tube.
• A numbing gel or spray may be applied to the nose and throat to reduce coughing and gagging, and then an intravenous sedative is given that makes you calm and drowsy. ALA says the sedation is light and you do not find the tube uncomfortable.
• The tube passes through the nose or mouth, behind the throat, and between the vocal cords into the airways.
• ATS says you may feel that you cannot get enough air, but there is usually enough room beside the tube for breathing, and the doctor can pause to let you rest.
• The duration depends on the purpose. ATS writes fifteen minutes to an hour, and ALA about thirty to forty-five minutes.

Risks

ATS writes that bronchoscopy is a safe procedure and serious complications such as an air leak or heavy bleeding are rare (less than five percent). Possible ones are:

• Discomfort and coughing as the tube passes.
• A drop in blood oxygen, which is usually mild and returns by itself. If it stays low, the doctor gives oxygen or stops the procedure.
• An air leak from the lung (pneumothorax), rarely and mostly during a biopsy. If it is large, a chest tube may be needed.
• Bleeding after a biopsy, which is usually small, mixes with phlegm and stops by itself.
• Infection, with a low probability.

After the procedure

• You stay in the recovery area until the sedative wears off. Do not eat or drink anything until the numbness has completely gone (ATS).
• Do not drive for the rest of the day, and go home with your companion.
• Normal: a mild sore throat, hoarseness, cough, muscle ache, and a mild fever for up to a day that is not a new infection (ATS). ALA says throat lozenges may ease the sore throat.
• You may see slightly bloody phlegm. ATS says bleeding after a biopsy is usually small and stops by itself.
• The sedative impairs memory. ALA recommends that the doctor also share the result with a family member. Ask them to write down the explanations.
• Results: ATS says the doctor can tell you right away what the airways looked like, but laboratory results usually take one to four days or more. ALA writes that some results take two to four days and some a week or more.

When should you call?

Call 115 (Iran’s emergency number) right now or go to the emergency department if:

• You are more short of breath, you are gasping, you cannot say a sentence, or your lips have turned blue.
• You have new chest pain.
• You cough up blood and the amount is more than a few spots or streaks. ATS says that if you cough up more than “a few teaspoons” of blood after discharge, call your doctor immediately; NHS also says that coughing up more than a few spots of blood is an emergency.

Call your doctor the same day if: a fever lasts longer than one day (ATS), your symptoms get worse, or you do not know whether what you see is normal. If you cannot reach a doctor, go to the nearest emergency department. The full list is in the “When should I call urgently?” guide.

First of all

Oxygen and CPAP are both used as prescribed and set by a doctor. This guide explains what these devices are and how to use them safely; it does not say that any doctor or practice provides these services. If your doctor thinks it necessary, you get the device from a supplier, who will teach you how to use it.

Home oxygen

Who needs it?

ATS writes that the most common reason for supplemental oxygen is lung disease, but heart and sleep conditions can also make it necessary. When the lungs cannot deliver enough oxygen to the blood, the doctor prescribes oxygen. Blood oxygen is measured with an arterial blood sample (the most accurate) or a finger pulse oximeter. Some patients need it only during activity or sleep. ATS says most people do not know when they need oxygen, so shortness of breath alone is not the test. NHS writes that in COPD home oxygen stops blood oxygen from falling dangerously low, but it is not a treatment for the main symptoms such as breathlessness. The decision is based on your doctor’s measurements.

The doctor sets the amount

ATS calls oxygen a medicine. The prescription specifies the flow rate for rest, activity and sleep, and it may differ for each. ATS warns that too little oxygen puts a strain on the heart and brain, and too much oxygen can slow breathing to a dangerous degree. So do not raise or lower the amount yourself, and do not change it without your doctor’s instruction.

Types of devices

As written by ATS:

• Oxygen concentrators filter room air and run on electricity or a battery. The home model is heavy and on wheels, and the portable model is lighter. Some portable models deliver oxygen in pulses. Ask your doctor to measure your oxygen at rest and during activity with the portable device before you choose.
• Liquid oxygen is kept in an insulated tank and needs no electricity.
• Cylinders hold compressed oxygen. A large cylinder is not portable and needs frequent refilling. A small cylinder is suitable for going out.

Safety rules

ATS writes that oxygen itself does not explode or burn, but it makes a flame stronger, and clothing or hair can catch fire quickly. NHS and NHLBI also speak of the fire risk. The rules:

• Never smoke while using oxygen. ATS and NHS say this explicitly.
• Keep oxygen at least two meters (six feet) away from an open flame. Think of flame heaters, gas stoves, candles, matches and lighters.
• Stay away from people who smoke. If someone at home smokes, they should do it outside or in another room.
• Keep the cylinder in a safe place or secure it to the wall. ATS warns that if a cylinder falls and cracks, it can shoot off like a rocket.
• Do not keep flammable materials near oxygen (NHLBI).
• Get training on using the device from the supplier or your doctor (ATS).

NHLBI says oxygen is generally safe and has side effects such as dryness or bleeding of the nose, fatigue and morning headache, which should be reported to your doctor. ATS also says that a morning headache, confusion or difficulty waking in COPD patients can be a sign of raised carbon dioxide and needs urgent attention.

If the device breaks or the power goes out

ATS does not give much detail on device failure. Its explicit advice is that a small cylinder can serve as a backup during a power cut or device failure, and that you should stay in contact with the supplier. So:

• Ask your doctor and supplier in advance what your backup is, and write the supplier’s number next to the device.
• If the oxygen stops and you have a backup, switch to it and call the supplier.
• If the oxygen has stopped and you have severe shortness of breath, cannot say a sentence, your lips or skin have turned blue or gray, or you have suddenly become confused, call 115 (Iran’s emergency number) right now (NHS). Do not wait for a repair.
• If you have no backup and you have symptoms, go to the nearest emergency department.

Travel

NHS says that if you use oxygen, tell the travel company and the airline before booking, and a medical form may be needed. ATS writes to check each airline’s rules about portable concentrators and to have enough oxygen for every stage of the trip. NHS says airlines usually do not accept cylinders but may accept a portable concentrator.

CPAP for sleep apnea

What is it?

ATS writes that CPAP delivers a steady, gentle air pressure through a mask and keeps the airway open during sleep. The mask can cover the nose, the mouth or both. The doctor prescribes the device and its setting. Automatic devices (APAP) adjust the pressure to your breathing, and the two-level type (BPAP) is more comfortable for some patients.

Getting used to the device

ATS says that for the most benefit, use it every time you sleep, whether at night or during the day. The benefits: less snoring, better sleep and daytime alertness, better blood pressure control and possibly a lower risk of heart problems. The devices record hours of use, pressure and air leak, and the doctor uses these data to fix problems.

To make it more comfortable (ATS):

• Try a different mask; there are many types and sizes.
• Use a heated humidifier so the nose and mouth do not dry out.
• Use comfort features such as a slow pressure ramp and reduced pressure when breathing out.
• Ask whether another type of device is more comfortable.
• Get help from your doctor or therapist.

Common side effects, as written by NHLBI: a blocked or runny nose, dry eyes or mouth, and nosebleeds. If you develop stomach discomfort or bloating, stop the device and call your doctor.

Cleaning

ATS does not give a cleaning method and says to ask your doctor or the device supplier. Follow the instructions on the device’s leaflet.

What not to do

• Do not quietly put CPAP aside. If you are uncomfortable or it seems not to help, tell your doctor. ATS says most sleep specialists will work with you to find the cause, and if CPAP does not work there are other options.
• Do not drive when drowsy. ATS says sleep loss caused by apnea can lead to falling asleep at the wheel.
• Avoid alcohol for at least four hours before sleep, and take sleeping pills only on your doctor’s advice (ATS, NHS).

When should you get urgent help?

Call 115 right now if your oxygen has stopped or is not enough and you are gasping, your lips have turned blue, you have sudden confusion, or someone is hard to wake. Also with CPAP, if you are gasping severely in sleep or awake and cannot say a sentence. Call your doctor the same day if you have developed a new or severe morning headache, or you cannot tolerate the device. The full list is in the “When should I call urgently?” guide.

First of all

Most lung diseases can be managed with a doctor at regular appointments. But there are a few situations in which you should not wait. This list does not cover everything. If you are worried or unsure, call. NHS says that even if you are not sure, checking does not waste anyone’s time. In Iran the emergency number is 115. Our sources are British and American, and we have replaced their contact routes (999, 111 and 911) everywhere with 115 or “the same day”; this division is ours and a doctor must review it.

In all 115 cases, do not drive yourself. NHS says to ask someone to take you or to call an ambulance, and to take your medicines and inhalers with you.

1. Call 115 right now or go to the emergency department

You cannot finish a sentence

NHS writes that if you are gasping, choking or cannot speak, get emergency help immediately. This is the same for asthma, COPD, fibrosis and any other lung disease.

Blue, gray or very pale lips, tongue or skin

NHS says the lips or skin become very pale, blue or gray. On dark skin the change is easier to see on the palms. NHS also treats pneumonia with blue or blotchy skin, lips or tongue as an emergency. Treat blue fingernails as a warning sign too (fingernails are not stated explicitly in our sources and a doctor must confirm).

The reliever inhaler does not work

NHS writes that during an asthma attack, if you are getting worse, do not get better after using the reliever inhaler as your doctor’s plan says, or do not have your inhaler with you, call the emergency services. If you have a written action plan, follow it, but do not delay.

A swollen throat or tongue and sudden trouble breathing after a trigger or an insect sting

The NHS calls this anaphylaxis, a severe allergic reaction that usually starts within minutes of contact. The signs are a swollen throat and tongue, difficulty breathing or very fast breathing, difficulty swallowing, a tight throat or hoarse voice, wheezing, feeling dizzy or fainting, and cold or blue skin. Call 115 and say you think it is anaphylaxis. If you have an adrenaline auto-injector, use it. Lie down and raise your legs, or sit up slowly if breathing is difficult. Do not stand or walk, even if you feel better.

Sudden breathlessness with chest pain, or a swollen, painful leg

NHS writes that sudden breathlessness, chest pain or upper back pain, a very fast heartbeat or fainting can be a blood clot in the lung (embolism) and is life-threatening. The signs of a clot in the leg: pain and swelling in one leg, often the calf, with skin that may be red, bluish or darker. If you have these two together, do not wait.

Chest pain or heaviness spreading to the arm, neck or jaw

NHS, on its breathlessness page, counts these as emergencies. Do not put chest pain down to lung disease; a doctor must find the cause.

Bloody phlegm, more than a few spots

NHS divides coughing up blood into two groups. If you cough up more than a few spots or streaks of blood, or the blood comes with breathlessness, a very fast heartbeat, or chest or upper back pain, call 115. NHS says these may be a blood clot in the lung. (The sources do not give an exact amount for “a lot”; the difference is “a few spots and streaks” versus more than that.) For small amounts, see the next section.

Confusion or extreme drowsiness, especially in a COPD patient

NHS says sudden confusion is an emergency. ATS writes that in a COPD patient, confusion, difficulty waking or a morning headache can be a sign of raised carbon dioxide and must be treated immediately. If someone at home is excessively sleepy and hard to wake, do not wait.

Fever with severe breathlessness

For pneumonia, NHS says to go to the emergency department if you are gasping and cannot speak, your lips or skin are blue or blotchy, you are coughing up blood, or you have suddenly become confused. Fever with milder breathlessness is “the same day” (next section).

Home oxygen has stopped or is not working and you have symptoms

ATS has no specific advice for this situation and only says you should have a backup and contact with the supplier. If the oxygen stops, switch to the backup and call the supplier. If you are gasping severely when the oxygen stops, your lips have turned blue or you are confused, call 115. Beyond this, your doctor must specify for you.

Suspected carbon monoxide poisoning (heater gas)

Carbon monoxide is colorless and odorless and comes from appliances such as gas or kerosene heaters, gas water heaters, stoves, wood and charcoal fireplaces and generators, especially if they are badly installed, faulty or not serviced. The symptoms, as written by NHS: headache, dizziness, nausea or vomiting, weakness and tiredness, confusion, chest and muscle pain, shortness of breath and loss of vision. NHS says the symptoms may come and go, get worse in the suspect room and improve after you leave. If several people in one home have headache and nausea at the same time, think of poisoning (this point is not stated explicitly by NHS and is ours).

• Get out of the room or building immediately, switch off the suspect appliance if you can, and do not go back until it has been checked (NHS).
• If you have shortness of breath, sudden confusion, loss of consciousness, weakness, or chest and muscle pain, call 115. Do not drive yourself.
• If you have milder symptoms such as headache, dizziness or nausea, still get help from a doctor or emergency department as soon as possible (NHS). Do not let it go because you feel better in the fresh air.
• Once you are safe, have the appliance checked by an authorized technician. NHS says gas appliances should be installed and serviced by a qualified engineer or technician.

2. Call your doctor the same day or go to the emergency department

If you have any of these, do not wait for an appointment several days away:

• You need your reliever inhaler more than before, your symptoms wake you at night, or activity has become harder (NHS, NHLBI).
• You have seen a few spots or streaks of blood in phlegm or a tissue. NHS says that in this case you should see a doctor as soon as possible.
• COPD: more breathlessness than usual in daily tasks, more or new cough, a change in the color (yellow, green or brown) or amount of phlegm, fever and more tiredness. ATS says “getting help early” is very important and a change in phlegm is often the first sign.
• Fever with cough and breathlessness: For pneumonia, NHS says that for cough, fever, yellow or green phlegm, chest pain when breathing or coughing, and breathlessness, you should see a doctor the same day. The risk is higher in older people and in those with lung or heart disease.
• Pain or swelling in one leg without breathlessness: NHS, on its breathlessness page, counts this among the signs that need urgent assessment.
• Palpitations: a fast, slow or irregular heartbeat or a fluttering feeling in the chest (NHS).
• A cough that gets worse or suddenly becomes harsh, chest pain, or a painful swelling in the neck (NHS, cough page).
• After a bronchoscopy: a fever that lasts more than one day (ATS).
• Daytime sleepiness that is dangerous for driving, or a new, severe morning headache.
• Oxygen or CPAP: the device is not working properly or you cannot tolerate it.

A cough lasting more than three weeks is not an urgent sign but needs assessment. NHS says to see a doctor about a cough lasting more than three weeks, and if it comes with fever, night sweats or unexplained weight loss, tuberculosis should also be considered (NHS, tuberculosis). Follow this up within the same week.

If you cannot reach any doctor

• If the symptom is from group 1, do not wait for a call back; call 115 or go to the nearest emergency department.
• If it is from group 2 and the doctor does not answer, go the same day to a hospital emergency department or a 24-hour clinic.
• If you do not know which group it fits, choose the more worrying group.
• Take your inhalers, spacer, medicine list and CT documents with you. If you use oxygen, take a backup device or cylinder as well, and tell the person at reception.
• If you are alone, let someone know you are on your way.
• Tell the call handler that you have asthma, COPD or home oxygen.

A reminder

This page does not diagnose and does not replace a doctor. Signs that are not listed here may also be urgent. If in doubt, call 115.