When should I consider referring a patient with chronic bronchitis to a specialist?

Consider referring a patient with chronic bronchitis to a respiratory specialist if any of the following apply:

• There is diagnostic uncertainty, such as difficulty distinguishing chronic bronchitis or COPD from asthma, bronchiectasis, or other lung conditions.
• The patient has severe or rapidly worsening disease, for example, a forced expiratory volume in 1 second (FEV1) less than 30% predicted or rapidly declining lung function.
• There are symptoms or signs suggestive of lung cancer, such as haemoptysis or suspicious chest X-ray findings, warranting urgent referral.
• The patient is under 40 years old or has a family history of alpha-1-antitrypsin deficiency, which requires specialist assessment and possible family screening.
• There are frequent respiratory infections to assess preventable factors and exclude bronchiectasis.
• Cor pulmonale (right heart failure secondary to lung disease) is suspected.
• Assessment is needed for advanced therapies such as oxygen therapy, long-term non-invasive ventilation, nebuliser therapy, long-term oral corticosteroids, or lung surgery.
• The patient has chronic refractory cough that does not respond to empirical treatment or when the diagnosis is uncertain.

Referral urgency depends on the clinical situation, with urgent referral indicated if lung cancer is suspected.

Additionally, consider referral for pulmonary rehabilitation if the patient is functionally disabled (Medical Research Council dyspnoea scale grade 3 or above) or has had a recent hospitalisation for an acute exacerbation.

These recommendations align with NICE guidelines and other UK clinical guidance on COPD and chronic bronchitis management ¹,³,⁴,².