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Sleep disordered breathing (suspected or confirmed)

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)
  • Referring doctor must assess immediate risk of driving and provide appropriate counselling based on Assessing Fitness to Drive Guidelines (including avoiding driving altogether if necessary).
  •  Refer to Healthpathways or local guidelines.

Clinician resources

Patient resources

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Suspected or confirmed sleep apnoea with any of the following:
      • Epworth Sleepiness Scale score ≥ 16
      • dozing while driving at least 1-2/month
      • MVA or work-related accident related to sleepiness/inattention in last 12 months
      • unstable cardiovascular disease eg overt heart failure
    • Suspected or confirmed sleep hypoventilation with any of the following:
      • progressive neuromuscular disorder
      • established daytime hypercapnia (as demonstrated on ABG (if performed))
      • diagnostic sleep investigation demonstrating mean sleep saturation 85-90% (Mean sleep saturation <85% should ideally be seen within 2 weeks)
  • Category 2
    (appointment within 90 calendar days)
    • Suspected or confirmed sleep apnoea with any of the following:
      • Epworth Sleepiness Scale score 12-15
      • dozing while driving in last 12 months
      • MVA or work-related accident related to sleepiness/inattention in last 5 years
      • occupation involving driving / heavy machinery operation
      • significant comorbidities for example pulmonary hypertension, previous stroke, heart failure,
      • significant cardiac arrhythmias, neurological disease, acromegaly or hypothyroidism
      • Respiratory Disturbance Index of ≥ 30 respiratory events per hour on a diagnostic sleep investigation
  • Category 3
    (appointment within 365 calendar days)
    • Suspected or confirmed sleep disorders, including chronic insomnia, circadian rhythm disorders, parasomnias or sleep related movement disorders that do not meet criteria for Category 1 or 2 but still require specialist review

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

  • History of sleep disorder including duration and severity of symptoms, snoring, witnessed apnoeas, restless sleep, unrefreshing sleep, tiredness, inappropriate falling asleep
  • Management to date including any previously tried appliances (mandibular advancement splint, CPAP) and response
  • Current medications
  • Epworth Sleepiness Scale score
  • Full report from all previous sleep investigations (if already performed)
  • Occupation
  • Driving licence type
  • History of motor vehicle accidents or sleepiness/inattention when driving

3. Additional referral information Useful for processing the referral

No additional referral information required

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.