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Work up and diagnosis of patients presenting with respiratory symptoms, including those indicating COVID- 19 infection, during the COVID-19 pandemic requires a structured clinical assessment that minimises the risk for cross-infection.

Certain testing procedures – including spirometry – used as part of the diagnostic work up for patients presenting with respiratory symptoms have the potential to increase the risk of transmission of viral infections through droplet or aerosol formation. This presents a significant challenge for those administering such tests. There is, however, also an opportunity to restate best practice for making respiratory diagnosis.

For patients in whom a diagnosis of asthma is highly probable based on history, examination and presenting symptoms, a monitored trial of treatment with peak flow monitoring is already the PCRS recommended approach, with further investigations including spirometry reserved if the probability of asthma is intermediate or low.

Any undifferentiated respiratory symptom should always be evaluated from a comprehensive perspective with airflow tests being just one potential component of the clinical evaluation.

Some testing procedures can be done safely at home such as the peak expiratory flow rate (PEFR) diary, though it is important to ensure that the patient is well trained to undertake peak flow readings at home using maximal respiratory effort. This training can take place via video consultation.

For people with suspected COPD, PEFR <75% predicted suggests a degree of airflow obstruction and serial measurement over 2 weeks that does not vary but also remains low despite use of salbutamol for symptom relief would suggest fixed airflow obstruction and is suspicious for COPD in the context of supporting clinical history.

Confirmatory spirometry should be carried out at a later date when safe and readily available.

Prior to the COVID-19 pandemic PCRS was already recommending a network-based approach to respiratory diagnosis in people with chronic symptoms to improve patient experience, safety and effectiveness.

This approach is now more valid than ever because of the extra burden of risk to patient and professional and to ensure expertise supports the most rational approach to the diagnosis of respiratory conditions and non- respiratory causes of respiratory-related symptoms.