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Chronic cough

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Asthma

  • Acute exacerbation of asthma not responding to therapy
  • Asthma with any of the following concerning features:
    • coexistent pneumothorax
    • pneumonia
    • silent chest
    • cardiovascular compromise
    • altered consciousness
    • relative bradycardia
    • decreasing rate and depth of breathing

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

Interstitial lung disease (ILD)

  • Acute exacerbations of known ILD with any of the following concerning features:
    • severely breathless/Class 4 dyspnoea (ADL’s affected by dyspnoea)
    • demonstrated worsening hypoxaemia
    • new arrhythmia/chest pain
  • Newly diagnosed or suspected ILD with radiographic evidence with Class 4 dyspnoea (ADLs affected by dyspnoea)

Lung cancer

  • Suspected or known lung cancer with any of the following concerning features:
    • massive haemoptysis
    • suspected large airway obstruction
    • severe dyspnoea
    • SVC obstruction
    • hypercalcaemia/hyponatremia with confusion
    • symptomatic pleural effusion

Pleural disorders

  • Large symptomatic pleural effusion
  • Acute pneumothorax

Pulmonary hypertension

  • Acute decompensation (hypoxia or right heart failure) with pulmonary hypertension

Sarcoidosis

  • Hypercalcaemia with acute kidney injury

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)
  • Refer to Healthpathways or local guidelines.
  • There are many causes of persistent cough. These can be categorised into:
    • respiratory
    • ENT (PN drip)
    • gastrointestinal
    • drug related (ACEI, aspirin, beta blockers)
    • cardiac (heart failure)

Treatment trial:
Ensure occult sino-nasal disease, unresolved infectious bronchitis and acid reflux have been considered and treated appropriately. ACE inhibitors should be ceased and an alternate medication substituted (e.g. angiotensin 2 receptor antagonists).

  1. Four-week trial of PPI
  2. If unsuccessful, or symptoms of PN drip, commence a six-week trial of intra nasal steroid
  3. If unsuccessful, or evidence of asthma, commence a four-week trial of inhaled steroids
  4. If unsuccessful, complete CT chest scan (including high resolution images) and refer to specialist.

 

Clinician resources

 

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • No Category 1 criteria
  • Category 2
    (appointment within 90 calendar days)
    • No Category 2 criteria
  • Category 3
    (appointment within 365 calendar days)
    • Cough present for > 8 weeks with normal CXR and normal spirometry and no improvement following treatment trial as specified in Other useful information

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention not otherwise accessible to the patient
  • For advice regarding management
  • To engage in an ongoing shared care approach between primary and secondary care
  • Reassurance for GP/second opinion
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)

2. Essential referral information Referral will be returned without this

  • Symptoms
    • Duration and severity
    • Associated syncope, incontinence, SOB
  • Relevant examination findings
    • History of ENT problems or GORD
    • Check uniform lung expansion and any percussive changes
  • Medications including results of treatment trial as per defined in Other useful information
  • FBC, ELFT and ESR results
  • CXR

3. Additional referral information Useful for processing the referral

  • Symptoms including:
    • any diurnal variation in severity (e.g. nocturnal or positional)
    • triggers e.g. air temp, food, talking, exercise
    • swallowing difficulties
    • voice change
  • High resolution chest CT (if already performed)
  • Spirometry pre and post bronchodilator
  • Smoking and occupational history if relevant
  • Previous gastroscopy findings

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.