C5. Specialist referral

Confirmation of the diagnosis of COPD and differentiation from chronic asthma, other airway diseases or occupational exposures that may cause airway narrowing or hyper- responsiveness, or both, often requires specialised knowl­edge and investigations. Indications for which consultation with a respiratory medicine specialist may be considered are shown in Box 6.

Box 6: Indication for referral to specialist respiratory outpatient services
Reason Purpose
Diagnostic uncertainty and exclusion of asthma Establish diagnosis and optimise treatment.

Check degree of reversibility of airflow Obstruction
Unusual symptoms such as haemoptysis Investigate cause including exclusion of Malignancy
Rapid decline in FEV1 Optimise management
Moderate or severe COPD Optimise management
Onset of cor pulmonale Confirm diagnosis and optimise treatment
Assessment of home oxygen therapy: ambulatory or long-term oxygen therapy Optimise management, measure blood gases and prescribe oxygen therapy
Assessing the need for pulmonary rehabilitation Optimise treatment and refer to specialist or community-based rehabilitation service
Bullous lung disease Confirm diagnosis and refer to medical or surgical units for bullectomy
COPD <40 years of age Establish diagnosis and exclude alpha1-antitrypsin deficiency
Assessment for lung transplantation or lung volume reduction surgery Identify criteria for referral to transplant Centres
Frequent chest infections Rule out co-existing bronchiectasis
Dysfunctional breathing Establish diagnosis and refer for pharmacological and non-pharmacological management

FEV1, forced expiratory volume in 1s; COPD, chronic obstructive pulmonary disease.
Box adapted from British Thoracic Society Statement (British Thoracic Society 2008b).