Respiratory and Sleep Medicine

Adult

Asthma

• Acute exacerbation of asthma not responding to therapy
• Asthma with any of the following features:
  • coexistent pneumothorax
  • pneumonia
  • silent chest
  • cardiovascular compromise
  • drowsiness
  • poor respiratory effort
  • SpO2 ≤92%
  • failure to respond to acute management
• Respiratory distress

Bronchiectasis / chronic suppurative lung disease (CSLD)

• Bronchiectasis / CSLD with any of the following concerning features:
• altered consciousness
• hypoxia (<90% oxygen saturation) when this is not normal for the patient
• evidence of significant infective exacerbation (fever and/or high-volume purulent sputum)
• new haemoptysis (clots or more than streaks
• new CXR changes indicative of cavitation, consolidation, or pneumonia

Chronic obstructive pulmonary disease (COPD)

• Acute exacerbation not responding to outpatient therapy
• Acute respiratory failure

Cystic fibrosis

• Cystic fibrosis with any of the following concerning features:
  • respiratory distress
  • new haemoptysis (clots or more than streaks)
  • pleural effusion
  • consolidation/pneumonia/fever
  • non- response to antibiotics for chest infection

Haemoptysis without known lung disease

• Significant haemoptysis defined as repeated expectoration of 5mL (1tsp) of blood or single episode of >20mL (1tbsp)
• Any haemoptysis with acute dyspnoea, measured hypoxia, altered consciousness, hypotension, tachycardia or chest pain
• Any haemoptysis associated with pulmonary infiltrates on CXR/CT chest or acute derangement in renal function

Interstitial lung disease (ILD)

• Acute exacerbations of known ILD with any of the following concerning features:
  • increasing breathlessness
  • worsening hypoxaemia
  • new arrhythmia/chest pain
• Newly diagnosed or suspected ILD with radiographic evidence with worsening dyspnoea (at rest or with dressing/undressing)

Lung cancer

• Suspected or known lung cancer with any of the following concerning features:
  • massive haemoptysis (coughing up teaspoons or more of fresh blood)
  • suspected large airway obstruction
  • severe dyspnoea
  • SVC obstruction
  • significant hypercalcaemia/hyponatremia
  • symptomatic pleural effusion

Mediastinal lymphadenopathy

• Evidence of SVC obstruction
• Significant hypercalcaemia
• Radiological evidence of airway obstruction

Pleural disorders

• Large symptomatic pleural effusion(s)
• Features of infection/sepsis
• Acute pneumothorax

Pulmonary hypertension

• Pulmonary hypertension with acute decompensation (hypoxia or right heart failure)

Recurrent respiratory infections without known lung disease

• Severe infection with breathlessness at rest, new hypoxaemia (SpO2 <92-96%)

Sarcoidosis

• Significant hypercalcaemia with acute kidney injury
• Acute, severe symptoms – Lofgrens syndrome (fever, erythema nodosum and bilateral hilar lymphadenopathy)
• Features of neuro-sarcoidosis such as headache, visual disturbance, ataxia or cranial nerve palsy

Shortness of breath / dyspnoea without a known cause

• Dyspnoea of uncertain origin with any of the following concerning features:
  • acute dyspnoea at rest
  • demonstrated hypoxia (SpO₂ ≤ 90%)
  • accompanied by confusion

Tuberculosis / non-tuberculosis mycobacterial infections

• Suspected tuberculosis with significant haemoptysis (defined as repeated expectoration of 5mL (1tsp) of blood or single episode of >20mL (1tbsp)

Non-tuberculosis mycobacterial infections

• Suspected tuberculosis with significant haemoptysis (defined as repeated expectoration of 5mL (1tsp) of blood or single episode of >20mL (1tbsp)

Paediatric

Other referrals to emergency not covered within these conditions

• Inhaled foreign body
• Severe acute exacerbation of asthma
• Pneumonia with or without parapneumonic effusion
• Unexplained hypoxia or hypercarbia
• Severe acute respiratory distress
• Acute respiratory illnesses

Chronic suppurative lung disease including (non-CF) bronchiectasis

• Hypoxia or hypercarbia
• Haemoptysis

Severe or complex asthma

• Significant respiratory distress not responding to appropriate dose of bronchodilator or worsening despite appropriate dose of bronchodilator
• Hypoxia

Suspected or confirmed airway lesions

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia
• Severe life-threatening events

Immunological disorder or oncological diagnosis with suspected or confirmed respiratory involvement

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia
• Suspected Sepsis and febrile neutropenia

Chronic neonatal lung disease/bronchopulmonary dysplasia

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia

Specific lung infections

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia

Congenital lung lesions

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia

Suspected or confirmed interstitial lung disease

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia

Chronic cough (stipulate >4 weeks duration)

• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia

Haemoptysis

• Large volume haemoptysis (>20ml)
• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia

Pleural diseases

• Acute pneumothorax management
• Acute pneumonia with pleural effusion
• Moderate to severe increased work of breathing
• Hypoxia or hypercarbia