When should I consider referring a patient with chronic respiratory failure to secondary care for further management?

Consider referring a patient with chronic respiratory failure to secondary care for further management when:

• There is diagnostic uncertainty or need to confirm diagnosis and optimise therapy.
• Suspected severe COPD or respiratory failure (e.g., FEV1 below 50% predicted with respiratory failure).
• Onset of cor pulmonale or symptoms disproportionate to lung function deficit, suggesting other complications.
• Assessment for oxygen therapy or long-term nebuliser therapy is required.
• Assessment for non-invasive ventilation (NIV) or invasive ventilation is indicated, especially if the patient is slow to wean from ventilation or has hypercapnic or acidotic respiratory failure.
• Rapid decline in lung function (FEV1) or frequent exacerbations occur.
• Presence of symptoms or signs of respiratory impairment such as orthopnoea, particularly if PaCO2 is elevated or respiratory function tests show significant impairment (e.g., FVC or VC <50% predicted, SNIP or MIP below thresholds).
• Consider referral for multidisciplinary management including pulmonary rehabilitation, physiotherapy, and palliative care.

Referral may be appropriate at all stages of disease, not only in the most severely disabled patients, and can be to respiratory physicians or trained members of the COPD team depending on local services and patient needs ¹,².