When to consider referral

  • Diagnostic uncertainty.
    • Referral may be needed for this reason for some ethnic minorities, for whom normal ranges for forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) are not known.
  • COPD that is very severe (for example FEV1 less than 30% predicted) or worsening (rapid decline in FEV1).
  • Continued smoking, if the primary healthcare professional considers that referral would increase the likelihood of smoking cessation.
  • The person with COPD requests a second opinion.
  • Cor pulmonale.
  • Dysfunctional breathing (abnormal breathing patterns associated with anxiety).
  • Onset of symptoms at an age younger than 40 years, or a family history of alpha1-antitrypsin deficiency.
  • Frequency of exacerbations or infections
    • is disproportionate to severity of COPD raising possibility of an alternative diagnosis
    • leads to excessive steroid/antibiotic use
    • self reported by the patient are not clearly true exacerbations and a second opinion re not treating them all with steroids/antibiotics is sought. (any of the above)
  • Symptoms disproportionate to lung function.
  • For assessment of the need for Lung Surgery  (for example, for a person with bullous lung disease who is still symptomatic on maximal therapy)
  • For pulmonary rehab (Specialist Nurses). - see below
  • For assessment by Specialist Nurses of the need for:
    • Long-term oxygen therapy. - see below
    • Ambulatory oxygen therapy- see below
    • Short-burst oxygen therapy (no assessment needed if palliative care management) - see below
    • Nebulizer therapy or long-term oral corticosteroids - see below

Primary care investigations/management prior to referral

  • Investigations required before referral:
    • CXR
    • Spirometry
    • FBC
  • Management prior to referral:
    • Simple COPD should be managed in primary care via the treatment ladder linked below. Referrals for uncomplicated COPD where the patient has not exhausted the options on the ladder will be cancelled, unless reasoning for the referral is explicit.
    • Please include a history of therapy tried before with referral .

Management options for stable COPD



Clinic options available

·         Routine respiratory clinics – available at RCH, CRCH, Penrice, Bodmin and WCH

·         Specialist Respiratory Nurse led clinics (Generic email cpn-tr.MidRespiratoryTeam@nhs.net) when diagnosis is established, and the following is being considered:


1) Pulmonary rehab (8 week course with exercises & education aimed at reducing burden of disease):


Inclusion Criteria:

Exclusion criteria:

Confirmed diagnosis of COPD

Unstable angina

FEV1 < 60%

MI within 6 weeks

Able to take part in group activities

Uncontrolled cardiac arrhythmias

Understanding of commitment required

Unstable hypertension


Severe cognitive impairment


Locomotor or other severe exercise limiting condition


2) Long term oxygen therapy (do not start without specialist assessment!)

All respiratory patients already on LTOT should be referred to the respiratory nurses. The service is guided by BTS guidelines to review these patients on oxygen therapy every 6 months with an annual ABG to assess their prescription. 

Inclusion Criteria (any of the following)

Exclusion criteria:

Sats ≤92% on room air

Continued smoking (risk of fire/explosion)

FEV1 <30% predicted (consider in 30-49%)

Medical management not optimised



2ndry polycythaemia


Peripheral oedema/raised JVP



3) Ambulatory Oxygen therapy


Inclusion Criteria (any of the following)

Exclusion criteria:

LTOT users who wish to use O2 outside house

Continued smoking (risk of fire/explosion)

COPD sufferers who desaturate on movement or are severely limited by exertional breathlessness who would leave the house more if relieved

Unable to carry equipment


4) Home nebulisers: Avoid referrals for this. There is poor evidence for this, so specialist nurse referral is a means of gatekeeping to avoid inappropriate use


Red Flags

·         CXR suggestive of malignancy

·         Normal CXR where there is a high suspicion of lung cancer

·         If the person with chronic obstructive pulmonary disease (COPD) reports haemoptysis, then perform a CXR. If Haemoptysis is persistent, then refer as per 2WW.



Date reviewed                     28/02/2019

Next review due                  28/02/2020

Sifter name                          Dr Alex Burns


Version No. 5.1