Primary Care Capacity Gaps Threaten Respiratory Prevention

Respiratory disease prevention has to move upstream: into homes and workplaces where people are exposed to pollutants, into the immune system before allergic disease takes hold, and into primary care systems that are currently too under-resourced and fragmented to deliver on existing guidelines, let alone new prevention strategies, according to experts in 2 sessions on preventing and treating respiratory disease in primary and integrated care.

The sessions at the European Respiratory Society Congress 2026, which brought together a family physician, a primary care research leader, and a specialist in digital health data.

Exposures at Home, at Work, and in a Warming Climate

Alan Kaplan, MD, CCFP(EM), FCFP, CPC(HC), practicing family physician and the chair of the Family Physician Airways Group of Canada, opened by framing respiratory disease as the product of overlapping exposures: indoor air pollution from cleaning products, smoking, and biomass cooking fuels; outdoor pollution and traffic; occupational irritants; and a changing climate that is lengthening pollen seasons and intensifying extreme weather.

Indoor air quality, Kaplan said, is understudied relative to its impact. He pointed to Fresh Air Uganda, a project sponsored by the International Primary Care Respiratory Group (IPCRG), as an illustration of how exposure and disease can diverge from expectations: investigators looking for chronic obstructive pulmonary disease (COPD) in older male smokers in rural villages instead found substantial airway obstruction in younger women, tied to cooking over biomass fuel in poorly ventilated homes—exposure that also reaches the children growing up in those same households.¹

Kaplan also detailed emerging evidence linking early-life respiratory syncytial virus (RSV) infection to later asthma risk. RSV damages the airway epithelium, he explained, triggering release of alarmins and downstream type 2 cytokines (including IL-4, IL-5, and IL-13) that can set off the immune cascade underlying asthma. With RSV vaccination now available for pregnant women and monoclonal antibodies available for infants, Kaplan said the open question is whether preventing RSV infection will translate into fewer future asthma diagnoses.

“Not every case with RSV is going to develop asthma, but you see a lot of factors have to line up for that,” he said.

Looking at other ways to prevent asthma, he noted that allergen immunotherapy in children with allergic rhinitis has already been shown to reduce progression to asthma, with the benefit greatest when treatment starts younger.² He also flagged a growing body of observational data examining whether glucagon-like peptide-1–driven weight loss improves asthma control in patients with obesity.³

The Capacity Gap in Primary Care

Shifting the focus from biology to delivery, Siân Williams, CEO of IPCRG and honorary fellow at the University of Edinburgh, argued that primary care and community-based data are essential to answering the “how” and “why” questions that determine whether prevention strategies work in practice. However, primary care research remains chronically under-resourced.

She illustrated the strain guidelines place on frontline clinicians with a hypothetical-panel analysis by citing a 2022 study that modeled a 2500-patient primary care panel in the US.⁴ “If you count up all the guidelines that every specialty is giving primary care,” and tally the time needed to deliver them, Williams said, “it will take 26 hours a day for the physician. It's not going to work, and we all know that.”

She pointed to 2 research efforts that speak directly to overuse and quality of care. In a recent international survey of primary care prescribers and pharmacists, IPCRG found significant long-term use of systemic steroids for chronic management, not just acute flares, in asthma and COPD across low-, middle-, and high-income countries alike.⁵

“What that calls out for then is improved stewardship,” Williams said. “How do we find the data in pharmacy to know what's actually happening?”

Williams used North Macedonia's experience within the multicountry BreatheWell program as a case study in what implementation work looks like over time. A “teach the teacher” effort began around 2017 to build primary care capacity for smoking cessation in a country with roughly 40% smoking prevalence, including among clinicians.⁶ Initially, the program produced disappointing results because of limited access to pharmacotherapy and deeply normalized smoking. However, the team responded by pushing to make smoking-cessation training mandatory in undergraduate medical education, a policy Williams said is now being scaled with World Health Organization involvement nearly a decade after the pilot launched.

“Think about that North Macedonia 10-year story, and be prepared for the long term,” Williams warned.

The Equity Risk in Digital Health

Nicholas Hopkinson, MBBS, PhD, professor of respiratory medicine at the Imperial College London, framed digital health data of all kinds not as an end in itself but as a means to a fairly basic set of goals: helping people avoid suffering, diagnosing disease early enough to act on it, tracking whether a condition is progressing, and catching acute exacerbations before they become emergencies. At the population health level London's Ultra Low Emission Zone is an example of policy-evaluation data at work: the charging scheme has reduced traffic-related air pollution and was associated with a catch-up in lung growth among children who benefited from the cleaner air.

At the individual level, that same logic extends to digital health tools. Hopkinson pointed to PROactive, a multinational consortium that has turned activity-monitor data into standardized physical-activity measures for patients with COPD now accepted by regulators, including the European Medicines Agency and the FDA, for use in drug-labeling claims. A second, larger effort, Mobilise-D, has extended that work beyond COPD to conditions including Parkinson's disease and femoral fracture, with detailed monitoring now capturing gait metrics like cadence and stride length rather than just overall activity levels.

But Hopkinson was equally direct about the trade-offs. Digital tools carry real costs, he said. There is the financial burden, but also the burden of time and anxiety they place on patients to continuously monitor symptoms and upload data. He also raised an open question about clinical value. While detecting a COPD exacerbation 12 to 24 hours earlier than symptoms alone would reveal it sounds useful, whether that lead time actually improves outcomes still needs to be tested, he said.

The most pointed warning concerned equity.

“If you have a digital-by-default system, it will channel resources towards the digitally literate and away from populations that are likely to be the most in need of support, who are the least able to interact with digital technology,” he said.

The Throughline: Integration, Sooner

Across all 3 talks, the session's organizers returned to a common theme: current respiratory care is too siloed, with primary, secondary, and tertiary care acting in sequence rather than in parallel. Kaplan argued for pulling that integration earlier, so patients are not waiting through a lengthy referral chain before receiving coordinated care.

“Shouldn't the primary and secondary and tertiary care be working together, integrating the resources that are available sooner, so our patients can get care sooner?” he said.

References

1. van Gemert F, Kirenga B, Chavannes N, et al. Prevalence of chronic obstructive pulmonary disease and associated risk factors in Uganda (FRESH AIR Uganda): a prospective cross-sectional observational study. Lancet Glob Health. 2015;3(1):e44-51. doi:10.1016/S2214-109X(14)70337-7

2. Woelk C, Stranzl T, Contoli M, et al. Long-term, real-world effectiveness of allergen immunotherapy in children and adolescents with allergic rhinitis and asthma. Allergy. 2025;80(12):3331-3341. doi:10.1111/all.70085

3. Saadat S, Chow TG, Tang X, Almandoz JP, Messiah SE, Xie L. Glucagon-like peptide-1 receptor agonists in asthma and obesity-associated asthma: a systematic review of clinical outcomes and translational mechanisms. J Allergy Clin Immunol Pract. Published online May 20, 2026. doi:10.1016/j.jaip.2026.05.010

4. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the time needed to provide adult primary care. J Gen Intern Med. 2023;38(1):147-155. doi:10.1007/s11606-022-07707-x

5. Franceschini J, Williams S, Fitch N, et al. Global perceptions and practices on systemic corticosteroid use for asthma and COPD in primary care: results from a multinational survey on prescribers and community pharmacists. npj Prim Care Respir Med. Published online August 20, 2026. doi:10.1038/s41533-026-00549-8

6. New study points to solutions for quitting tobacco in North Macedonia. News release. World Health Organization. June 23, 2023. Accessed September 7, 2026. https://www.who.int/europe/news/item/23-06-2023-new-study-points-to-solutions-for-quitting-tobacco-in-north-macedonia