Shortness of breath in adults

Red flags

Consider immediate referral for patients with the following in conjunction with breathlessness

  • Worsening dyspnoea with O2 sats <90%
  • Moderate haemoptysis
  • Cyanosis
  • Pleural effusion
  • Consolidation
  • CXR findings suggesting malignancy
  • Evidence of RLD

The following features may lead to more urgent categorisation

  • Weight loss
  • Possible need for domicillary oxygen
  • Progressive SOB with no cause after investigation
  • Clubbing

There are many causes of shortness of breath. These can be categorised into:

  • Respiratory (Infective, related to chronic lung disease (COPD, bronchiectasis, restrictive LD, occupational LD, asthma,TB), cancer, foreign body, allergic, sarcoid)
  • Cardiac (heart failure, ischaemic heart disease, valvular heart disease, arrhythmias, pulmonary HT)
  • Vascular (pulmonary emboli, infarction)
  • ENT/endocrine related (laryngeal obstruction, thyroid enlargement causing tracheal compression, thyrotoxicosis)
  • Gastrointestinal (GORD, tracheo-oesophageal fistula, aspiration)
  • Haematological (anaemia, leukaemias)
  • Neurological/neuromuscular (degenerative (MS, MND, myasthenia gravis, Guillian-Barre syndrome)
  • Psychogenic (anxiety)
  • Chronic debility or obesity related
  • Drug related

It is important to at least arrive at a probable diagnosis as this will determine which specialty to refer. It should be possible to arrive at a diagnosis in most cases by careful history and examination with directed investigations. If unable to arrive at even a probable diagnosis consider referral to General Medicine.

Other important information for referring practitioners

It is important to arrive at a probable diagnosis as this will determine specialty of referral. A comprehensive history is very important. Look for:

  • Evidence of progression,
  • Cough (productive or not)
  • Diurnal variation
  • Exercise tolerance
  • Orthopnoea
  • Drug factors
  • Smoking history
  • Allergies
  • Pets (esp birds)
  • Infective contacts
  • Occupational factors.

Basic investigations include

  • Sputum microscopy and culture (if present)
  • Spirometry (pre and post bronchodilator)
  • CXR
  • ECG

If these do not suggest a diagnosis consider the following as directed by clinical suspicion.

  • Echocardiogram/BNP testing (NB BNP ordered in general practice is not covered by Medicare and will incur a cost to the patient)
  • CT chest
  • Full lung function testing (will require specialist referral for this to be performed)
  • D-dimer proceeding to VQ scan if positive (however these patients should be referred urgently if D-dimer positive)
  • Gastroscopy.

Referral requirements

A referral may be rejected without the following information.

  • Reason for referral
  • Symptoms
    • Duration and severity
      • Progression of symptoms and timeline
      • Severity (assessed by walking distance exercise tolerance or SOB at rest
        • cyanosis
      • Any diurnal variation in severity (e.g nocturnal or positional)
      • Associated symptoms e.g. cough, chest pains etc
      • Any recent infectious contacts
  • Other relevant medical conditions (respiratory, diabetes, HT or otherwise)
  • Medications
    • Include full medication list and allergies
    • List any therapeutic trials and results
  • Smoking and occupational history if relevant
  • FH e.g. history of thromboembolism
  • Relevant examination findings
    • Respiratory rate at rest
    • Tracheal deviation, check thyroid
    • Any local LN enlargement
    • Check for central cyanosis and clubbing
    • Examine ENT
    • Check uniform lung expansion and any percussive changes
    • Auscultatory abnormalities (BS, wheezes, creps, rales etc and position if localised)
  • Investigations where indicated
    • FBC, E/LFT, ESR
    • CXR
    • Spirometry pre and post bronchodilator
    • ECG
    • Sputum microscopy C&S if productive cough associated
    • Sputum cytology if cancer suspected

Additional referral information (useful for processing the referral)

  • CT chest or CTPA if done
  • Pulse oximetry
  • Echocardiogram if done
  • V/Q scan if thromboembolic disease suspected
  • Gastroscopy findings if previously performed
  • Specialist letters if seen for this condition previously
  • Serum ACE level
  • TFTs
  • Allergy testing results

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

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