When should I consider referring a patient with emphysema for specialist assessment or pulmonary rehabilitation?

Consider referring a patient with emphysema for specialist assessment when:

• There is diagnostic uncertainty or suspected severe COPD to confirm diagnosis and optimise therapy.
• The patient requests a second opinion.
• There is onset of cor pulmonale or symptoms disproportionate to lung function deficit.
• Assessment is needed for oxygen therapy, long-term nebuliser therapy, oral corticosteroid therapy, pulmonary rehabilitation, lung volume reduction procedures, or lung transplantation.
• There is bullous lung disease, a rapid decline in FEV1, frequent infections, haemoptysis, or dysfunctional breathing.
• Symptoms begin under 40 years or there is a family history of alpha-1 antitrypsin deficiency.

Refer for pulmonary rehabilitation specifically if the patient views themselves as functionally disabled by COPD, usually at Medical Research Council (MRC) dyspnoea grade 3 or above. Pulmonary rehabilitation is not suitable for patients unable to walk, with unstable angina, or recent myocardial infarction.

Ensure pulmonary rehabilitation programmes are accessible, timely, and multidisciplinary, including physical training, education, and psychological support.

Referral may be appropriate at all stages of the disease and not solely in the most severely disabled people.

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