Referral Guidelines for Respiratory Medicine at Hawkes Bay DHB
The outpatient Respiratory Medicine Department at Hawkes Bay Hospital is
comprised of specialist physicians, clinical nurse specialists, clinical physiologists,
physiotherapists, outpatient nurses, and clerical staff. As a multi-professional team
we assess over 3000 patients a year and offer a wide array of services including
specialist assessment and management, patient education, pulmonary
rehabilitation, and lung function assessment. As the primary and secondary care
management of chronic disease integrates further we hope to offer leadership,
guidance, and education for all aspects of respiratory disease, whether the service is
being delivered in the hospital or the community.
This document is set out to offer guidance on referrals to the respiratory
department, suggested management prior to referral, and an overview of referral
prioritisation criteria. It is based on national referral guidelines, and international
respiratory society guidelines. It is not exclusive and should not be seen as an
alternative to good clinical judgment.
Patients with acute respiratory symptoms, or decompensation of chronic symptoms
should be considered for either admission to hospital or liaison with the Respiratory
Department for urgent assessment.
It is helpful if referrals to the Respiratory department include adequate information
for appropriate prioritisation. The minimum information we normally require is:
 Symptoms
 Co-morbidities
 Medication – including relevant previous medication
 Smoking status
 Occupational/environmental exposure
 Physical examination findings
 Previous lung function results
 Results of relevant investigations
 Details of previous consultations if relevant
Patients being referred for specific conditions such as sleep disordered breathing or
tuberculosis may require more specific information such as Epworth Sleepiness
Score or TB contact details.
James Curtis
Respiratory Physician
Hawkes Bay DHB
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Index
1. Prioritising Respiratory Referrals to Hawkes Bay DHB
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2. Diagnosis based referral guidelines
 Asthma
 COPD
 Bronchiectasis
 Lung cancer
 Interstitial lung disease
 Tuberculosis
 Sleep disordered breathing
 Pleural effusions
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3. Symptom based referral guidelines
 Chronic cough
 Breathlessness
 Thoracic pain
 Haemoptysis
 Sleepiness
 Abnormal chest x-ray
 Recurrent/persistent chest infections
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Prioritising Respiratory Referrals to Hawkes Bay DHB
All referrals to the Respiratory Department are prioritised by either a specialist
physician or clinical nurse specialist.
Urgent
“when major clinical risk is present if treatment delayed”
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Suspected lung cancer
Possible infectious tuberculosis
Severe unstable asthma
Significant haemoptysis
Semi-urgent
“major functional impairment”
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Severe COPD +/- complications
Severe/High risk sleep disordered breathing
Symptomatic interstitial lung disease
Pleural effusions
Asthma requiring long term steroids
Suspected occupational lung disease
Poorly controlled COPD/Asthma/Bronchiectasis on optimal therapy
Cystic fibrosis
Opportunistic infections
Pulmonary vascular disease
Latent TB
Routine
“where clinical assessment and review may be beneficial”
Although we endeavour to see all routine referrals some patients may not be seen
due to pressure on the service. In this event we would hope to provide at least
formal lung function if appropriate and a letter of advice.
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Moderate sleep disordered breathing
Stable asthma/COPD
Pleural plaque or other stable radiological abnormality
Chronic cough with normal chest x-ray
Asymptomatic parenchymal lung disease
Asthma/COPD diagnostic uncertainty
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Diagnosis based referral guidelines
Asthma
Asthma Hawkes Bay can be an invaluable service to asthmatics and international
asthma guidelines (GINA) are a useful resource on guiding therapy. Individualized
treatment regimes with asthma action plans, patient education emphasizing selfmanagement, and regular support are essential.
Suboptimal control despite adequate therapy may reflect coexisting disease (i.e.
chronic rhinosinusitis, gastroesophogeal reflux disease, vocal cord dysfunction, and
cardiac disease), smoking, occupational exposure to sensitizing agents/dusts/fumes
(10% of adult asthma is work related), poor inhaler technique, and poor
concordance with treatment.
When to consider referral to secondary care:
 Difficult to control asthma
 Diagnosis uncertain
 Suspected significant co-morbidities
 Features of severe asthma
o Frequent courses of steroids
o Frequent hospital/ED attendances
o Life-threatening attacks
 Need for hospital based lung function or patient education/support
Chronic Obstructive Pulmonary Disease
Although COPD is a chronic disease it is both treatable and preventable. There are a
number of documents to guide best practice with the local COPD-X guidelines, the
British NICE guidelines and international GOLD guidelines being the most helpful.
All emphasize the need to confirm the diagnosis with spirometry (postbronchodilator FEV1/FVC ratio <70%) particularly in smokers aged >40 years with
breathlessness, frequent cough/sputum, or recurrent chest infections.
When to consider referral to secondary care:
 Diagnostic uncertainty
 Frequent exacerbations
 Difficult breathlessness
 Consideration for pulmonary rehabilitation
Motivated patients with stable COPD suffering from moderate/severe
breathlessness impacting on quality of life should be referred for pulmonary
rehabilitation unless there is significant co-morbidity (unstable cardiac
disease, mobility issues etc)
 Need for hospital based lung function or patient education/support
 Significant bullous disease on chest x-ray
 Assessment for long-term oxygen therapy
 Diagnosis of COPD aged <40 yrs or severe COPD (FEV1 <50% predicted)
aged <50 yrs
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Bronchiectasis
Bronchiectasis is often mistaken for difficult asthma (which can co-exist) or COPD. It
is characterized by chronic productive cough. Although often a result of previous
infection it can reflect other underlying conditions. With adequate bronchial
hygiene, regular vaccinations, and a low threshold for treating associated
exacerbations with adequate antibiotics, the disease can be controlled.
When to consider referral to secondary care:
 All patients with suspected bronchiectasis should be referred to
secondary care for assessment.
Lung cancer
Any patient with suspected lung cancer (haemoptysis, chronic or changing cough,
breathlessness, unexplained chest/shoulder pain, hoarse voice >3 weeks, weight
loss, finger clubbing, cervical/supraclavicular lymphadenopathy) should have an
urgent chest x-ray. Although a staging CT scan may be needed it is best arranged in
secondary care to prevent delay in referral and inappropriate/inadequate scanning.
When to consider referral to secondary care:
 All patients with suspected lung cancer should be referred for urgent
assessment. These include:
o Smokers/ex-smokers aged >35 years with persistent (>1 week)
haemoptysis
o Chest x-ray suggestive of lung cancer
o Persistent hoarse voice in a smoker (consider ENT referral if
chest x-ray normal)
o Signs of superior vena caval obstruction
o Stridor (consider ENT referral if chest x-ray normal)
o High clinical suspicion of lung cancer
Interstitial lung disease
Symptom onset can be indolent, but progression may be rapid and x-ray changes
subtle and diverse making assessment difficult. The most frequent causes are
idiopathic pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, drug
reactions (amiodarone, methotrexate, and nitrofurantoin), occupational dust
exposure, and lung disease associated with connective tissue disease.
When to consider referral to secondary care:
 All patients with interstitial lung disease should be referred for
assessment
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Tuberculosis
Although the incidence of tuberculosis disease in New Zealand remains low
(10/100,000) clinical suspicion and vigilance is vital to disease control. Risk factors
include high deprivation, Maori and Pacific Island ethnicity, and immune
suppression (steroids, diabetes, alcohol abuse, chronic kidney disease).
Latent tuberculosis infection is much commoner (10% of population). It is not
infectious and often doesn’t require treatment
When to consider referral to secondary care:
 Suspected active tuberculosis disease
 Possible latent tuberculosis/inactive tuberculosis disease in a patient
being considered for long-term immune suppressing treatments
Sleep disordered breathing
Sleep apnoea (characterized by loud snoring, overnight choking/gasping, and
witnessed apnoeas) is common, affecting up to 20% of adults and doesn’t
automatically require further investigation. However, when in combination with
intrusive daytime sleepiness, difficult hypertension, heart failure, or polycythaemia
significant sleep disordered breathing should be considered.
Referrals for sleep disordered breathing should include information on level of
daytime symptoms, work/driving related issues, co-morbidities, and BMI. Prior to
referral the GP should try to identify and address sleep restriction/deprivation,
weight issues, alcohol/sedative use, and treat any chronic nasal/sinus disease.
When to consider referral to secondary care:
 Suspected sleep apnoea with associated intrusive daytime sleepiness,
heart failure, difficult hypertension, or polycythaemia
 Suspected obesity related hypoventilation
 Suspected narcolepsy, periodic limb movement disorder, or other
parasomnias
Pleural effusions
Pleural effusions can reflect a broad range of problems. All patients with a suspected
pleural effusion should have a chest x-ray, and if the cause is likely to be pulmonary
(i.e. not heart failure) referral to secondary care for further assessment. Referral
should include information on symptoms, smoking status, occupational history, comorbidities and medication.
When to consider referral to secondary care:
 Pleural effusions felt unlikely to be heart failure
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Symptom based referral guidelines
Chronic respiratory symptoms are common, and the cause is not always
immediately clear. If referral to secondary care is felt to be appropriate the referral
should include information on symptoms, co-morbidities, medication, smoking
status, occupational/environmental exposure, physical examination findings, and
results of relevant investigations.
Chronic cough
Chronic cough can be a distressing symptom and affects a large number of people.
Cough lasting for >6 weeks should be investigated further with a chest x-ray. In the
setting of a normal chest x-ray the causes for chronic cough are:
 Cough variant asthma
 Rhinosinusitis
 Gastroesophageal reflux
 ACE inhibitors
Sequential treatment trials with a minimum of six weeks of inhaled corticosteroid;
intranasal steroids +/- antihistamines; proton-pump inhibitors + lifestyle advice re:
reflux; and ACEI withdrawal is advised.
When to consider referral to secondary care:
 No response to treatment trials
 Chronic productive cough ?bronchiectasis
 Associated dyspnoea
 Abnormal chest x-ray
Breathlessness
Patient complaining of chronic breathlessness should be considered for a chest xray, spirometry, ECG, blood count, renal function and oximetry if available.
When to consider referral to secondary care:
 Unexplained breathlessness where significant cardiac disease is felt
unlikely
 Disproportionate/difficult breathlessness in a patient with known lung
disease
 Need for detailed lung function (i.e. lung volumes, gas transfer)
Thoracic pain
Patients with persisting pleuritic/thoracic wall pain should have a chest x-ray.
When to consider referral to secondary care:
 Pleuritic/thoracic wall pain with abnormal chest x-ray
 Pleuritic/thoracic wall pain with significant concern of underlying
sinister disease (i.e. smoker, asbestos exposure, previous malignancy)
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Haemoptysis
Exclude epistaxis and haematemesis. All patients with haemoptysis should have a
chest x-ray.
When to consider referral to secondary care:
 Persistent (>7 days), recurrent, or significant (>25mls per cough)
haemoptysis
Sleepiness
Excessive daytime sleepiness is common (~ 30% of the population) as is fatigue.
Common causes include sleep restriction/deprivation, shift-work, ageing,
depression, and chronic medical conditions including sleep disordered breathing.
Patients being referred for suspected sleep disordered breathing should have
attention paid to sleep hygiene, weight, alcohol/sedative use, and co-morbidities.
When to consider referral to secondary care:
 Suspected sleep apnoea with associated intrusive daytime sleepiness,
heart failure, difficult hypertension, or polycythaemia
 Suspected obesity related hypoventilation
 Suspected narcolepsy, periodic limb movement disorder, or other
parasomnias
Abnormal chest x-ray
Chest x-ray abnormalities can reflect many underlying conditions. Comparison to
previous x-rays/reports is helpful. Although further investigation with a CT may be
needed this may be best arranged in secondary care to prioritise appropriately,
avoid delay, and ensure the correct scan is carried out.
When to consider referral to secondary care:
 All patients with persistent or suspicious x-ray or CT changes should be
considered for referral to secondary care for further evaluation
Recurrent/persistent chest infections
Patients with slow to resolve symptoms of respiratory tract infection, or recurrent
infections require further investigation. A chest x-ray, spirometry, sputum cultures
(MC&S and AAFB) and blood count are essential. Consider treating any associated
sinus disease, and identifying and treating any gastroesophogeal reflux disease.
When to consider referral to secondary care:
 Recurrent/persistent chest infections with concern of underlying
sinister pathology
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