REFERRAL GUIDELINES RESPIRATORY

Transcription

1 REFERRAL GUIDELINES RESPIRATORY Referral Form: The GP Referral Template is the preferred referral tool (previously known as the Victorian Statewide Referral Form) GP Referral Template This tool is housed in most major clinical software or can be downloaded from Click on category to advance to that page: Airways Bronchiectasis Asthma Chronic Obstructive Pulmonary Disease Infection Acute Trachea Bronchitis Pneumonia / Lower Respiratory Tract Infection Neoplasia Mesothelioma Lung Cancer Lung Nodules Parenchymal Pulmonary Fibrosis Sarcoidosis Other Intestinal Lung Disease Pleural Pleural Effusion Pneumothorax Pleural Plaques Services Not Provided Tuberculosis Refer to Infectious Diseases Sleep Issues Refer to Sleep Service T: Pulmonary Embolus Refer to Haematology IMPORTANT: The following information is mandatory: Demographic: Full name Date of birth Next of kin Postal address Landline & mobile number Medicare number Referring GP details Usual GP (if different) Interpreter requirements Clinical: Reason for referral Duration of symptoms Management to date and response to treatment Past medical history Current medications and medication history if relevant Functional status Psychosocial history Dietary status Family history Diagnostics as per referral guidelines HEAD OF UNIT Prof. Philip Bardin PROGRAM DIRECTOR A/Prof Andrew Block PLEASE NOTE: All referrals received by Monash Health are triaged by clinicians to determine urgency of referral. Patients assessed as having an urgent need are offered an appointment within thirty days as assessed by the clinician. Patients assessed as having a non-urgent need for appointments in clinics where there is no waiting list, are offered an appointments within four months on a treat in turn basis. Patients assessed as having a non-urgent need for appointments in clinics that have a waiting list, referrers and patients will be notified of the expected wait times. Where the wait time does not meet patient needs, alternative service providers can be found by searching the Human Services Directory at ENQUIRIES P: F: (03) Review July 2016

2 Airways Bronchiectasis Patient history: Should be considered in anyone with chronic or recurrent purulent sputum. Quantitate phlegm production when well and when ill. Past history of severe respiratory infection usually in childhood e.g. Whooping Cough. History of Asthma Spirometry with reversibility HRCT Lungs, but not during an exacerbation FBC, ESR Immunoglobulins plus IgG subfractions Sputum culture when patient otherwise well and with exacerbations Assess for sinus disease Assess for cor pulmonale Specialist assessment and management required for patients suspected of having Bronchiectasis Refer for hospital admission: Patient with diagnosis of severe Bronchiectasis Maintenance treatment: postural drainage/sputum clearing techniques are the cornerstone of long term management (to be referred to physiotherapist for education but not before CT scan). Long term antibiotics in consultation with Respiratory Physician. Fluvax and Pneumovax. Treatment of non-infective airways disease i.e. co-existing COPD and asthma should be considered. See below. Management of acute infective exacerbations e.g. acute bronchitis, pneumonia. Management in the community: antibiotics preferably post sputum culture/sensitivity. See Australian Antibiotic Guidelines. Manage co-existent acute / chronic sinusitis Asthma Patient history: Breathlessness, tightness, wheezing and cough Recognition of severity Spirometry Peak Expiratory Flow recording Oxygen saturation Asthma not readily controlled in GP setting Any feature of severe asthma (e.g. requiring frequent courses of prednisone) Frequent after hours attendance (ED or GP after hours service). Asthma with recurrent lung disease (e.g. Bronchiectasis, COPD) Asthma (i.e. uncertainty about diagnosis e.g. LVF) Severe: High flow oxygen, IV/oral steroids, nebulised beta agonists. Transfer to ED by ambulance Consider Adrenaline 200 micrograms SC (=2ml 1:10,000 or 0.2ml 1:1,000). Mild to Moderate: Prednisone +/- inhaled steroids Beta agonists, short &/or long acting Education including smoking cessation, monitoring (PEF), action plan etc. Refer for hospital admission: Acute moderate asthma not responding to GP management Acute severe asthma (via ambulance) e.g. coexistent pneumothorax or pneumonia, silent chest, cardiovascular compromise, altered consciousness, relative bradycardia or decreasing rate and depth of breathing Asthma with intercurrent disease e.g. Pneumonia 2

3 Airways cont. Chronic Obstructive Pulmonary Disease (COPD) Patient history: Recognition of severity Breathlessness, exercise tolerance Cough and sputum R) heat failure Intercurrent disease (e.g. lung cancer) Spirometry, reversibility Nutritional state Assess for osteoporosis, obstructive sleep apnoea, polycythaemia, reflux Specialist assessment and management required for: Optimal management including other diagnostic considerations i.e. intercurrent disease Pulmonary function testing Nutritional advice Physiotherapy assessment (exercise, rehabilitation, sputum clearing) Home oxygen assessment Refer for hospital admission: Acute exacerbations Respiratory failure Smoking cessation Fluvax and Pneumovax Formal steroid trial (must be with formal PFTs before and after) Inhaled steroids, anticholinergics, long acting beta agonists, antibiotics and mucolytics may all be useful Optimise techniques of various drug delivery devices Ongoing monitoring Nutritional advice Pulmonary Rehabilitation - Physiotherapy 3

4 Infection Acute Tracheo Bronchitis Patient history: Smoking Inhalation of irritants Relevant past respiratory history e.g. asthma Cessation of smoking Symptomatic treatment Broad spectrum antibiotics Consider flu vaccination for recurrent attacks Chest X-Ray Sputum M & C Specialist assessment and management not usually required Refer for hospital admission for significant co-morbidities: Consider admission for significant co-morbidities Pneumonia/Lower Respiratory Tract Infection Patient history: Standard history and examination with particular emphasis on the following: Respiratory rate, pulse, blood pressure and confusion Significant co-morbidities (diabetes, cardio respiratory) Social circumstances Manage at home/community Appropriate broad spectrum antibiotics may be considered at presentation and 6-8 weeks post treatment Consider bronchial carcinoma where history of smoking Sputum M & C If Chest X-ray change unresolved Severe pneumonia, significant co-morbidity and/or adverse social circumstances Severe pneumonia defined by tachypnoea, tachycardia, hypotension, confusion, high or low temperature, high urea, high or low WCC, multilobar disease Failure to resolve satisfactorily in the community 4

5 Neoplasia Mesothelioma Lung Cancer Lung Nodules Patient history: Generally present with lateral chest pain, weight loss, shortness of breath and systemic symptoms. At risk group includes, among others: Plumbers, builders, mechanics, ship engineers, railway engineers, wharfies, and truckies with asbestos exposure CT Chest Chest X-Ray Specialist assessment and management required URGENTLY 5

6 Parenchymal Pulmonary Fibrosis History: Breathlessness, dry cough, exercise intolerance. Clubbing may be present. Crackles (lower zone Velcro sign) May need bronchoscopic evaluation prior to treatment. Specialist assessment and management required Restrictive spirometry. HRCT (non-contrast). Sarcoidosis History: Patient may present acutely with Erythema Nodosum (EN) and other extra pulmonary symptoms of signs. Often asymptomatic Specialist assessment and management required Chest x-ray (changes compatible with diagnosis). ESR, Calcium, LFT, FBC. Ophthalmology review. Other Interstitial Lung Disease History: Increasing dyspnoea/dry cough Specialist assessment and management required Chest x-ray report. HRCT, non-contrast 6

7 Pleural Pleural Effusion History: Breathlessness and symptoms and signs of underlying condition e.g. heart failure, neoplasia and infection. Outpatient Specialist assessment and management required Pneumothorax History: Sudden onset of chest pain and/or breathlessness Refer for hospital admission Consider development of tension pneumothorax requiring immediate drainage. This is associated with haemodynamic compromise. Note: Traumatic pneumothorax or haemopneumothorax should always be drained. Pleural Plaques History: History of asbestos exposure. See at risk occupational groups above. Outpatient Specialist assessment and management required 7