Diagnosis

PCP Evaluation/Management Option

PCP Guidelines for Referral to Specialist

Asthma

Follow NHLBI guidelines (see attachment).

Obtain PFT’s with and without bronchodilators.

Monitor home peak flow measurements

Teat to reverse acute episodes and achieve effective control of chronic asthma.

Education should emphasize environmental controls and triggers including avoidance of smoking and secondhand smoke.

Proper inhalant technique and home peak flow measurements should be taught.

Consult for poor control as manifested by:

Chronic cough,

Continued or progressive symptoms,

Nocturnal awakening due to asthma

Repeated absence from school or work,

Limited activity,

Repeated emergency room or office visits for acute episodes,

Repeated or persistent use of oral corticosteriods, or for more severe complications such as need for hospitalization and/or intubation’s for respiratory failure.

Basic Pulmonary Exam

Evaluate symptoms and findings including chest pain, cough, dyspnea, hypersomnolence, increased or decreased breath sounds rales, wheezes, cyanosis, or clubbing.

Obtain office spirometry if equipped.

Consult for consideration of bronchoscopy, percutaneous lung biopsy, pleural biopsy or supraclavicular node biopsy.

Consult for unexplained pleural effusion, unexplained hemoptysis, lung masses, sarcoidosis, unusual infections, interstitial lung disease, or acute lung injury.

COPD/Chronic Bronchitis/Emphysema

Obtain PFT’s peak flow rates, arterial blood gasses, and drug levels as appropriate.

Manage home aerosol medications, oxygen use and respiratory therapy as needed.

Inquire about smoking and offer cessation resources.

Refer for respiratory failure or poor response to treatment (frequent emergency room visits, frequent or sustained use of oral corticosteroids, progressive dyspnea, hypoxemia, or hyprcapnia, or unexplained functional impairment).

Occupational Lung Disease

Refer for diagnosis and treatment.

Opportunistic Infections

Consider as possible manifestation of immunodeficiency.

Pneumonia/Acute Bronchitis

Consult for:

Poor response to treatment including pneumonia

unresolved within eight weeks,

x-ray abnormalities or

recurrent pneumonia.

Sleep Apnea

Evaluate sleep disorders with history, exam, polysomnography.

Treat conservatively for snoring, mild apnea.

Manage with weight control, thyroid management, control of HTN, CPAP and treatment of cardiac disturbances.

Refer for :

Evaluation of upper airway,

Sleep studies, or

Management of significant symptoms for apnea

refractory to initial therapy.

Smoking Cessation

Evaluate tobacco use.

Promote cessation by repeated advice, controlled nicotine administration and pulmonary.

Refer to programs for behavior modification or

education.

Tuberculosis or Fungal Infections

Diagnose with skin tests, sputum tests, and serological tests.

Provide appropriate anti-tuberculosis prophylaxis

Report active TB to health department

Refer for treatment of these conditions.