Lung Nodules
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Emergency Referrals

Important

If you believe your patient requires immediate attention, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice.

Acute exacerbation of asthma not responding to therapy
Asthma with any of the following features:
- coexistent pneumothorax
- pneumonia
- silent chest
- cardiovascular compromise
- SpO2 <<92%
- Failure to respond to acute management
- Respiratory distress
Bronchiectasis / CSLD with any of the following concerning features:
- altered consciousness
- hypoxia (<90% oxygen saturation) when this is not normal for the patient
- evidence of significant infective exacerbation (fever and/or high-volume purulent sputum
- new hemoptysis (clots or more than streaks
- new CXR changes indicative of cavitation, consolidation or pneumonia
Chronic obstructive pulmonary disease (COPD)
- Acute exacerbation not responding to outpatient therapy
- Acute respiratory failure
Cystic fibrosis with any of the following concerning features:
- respiratory distress
- new hemoptysis (clots or more than streaks)
- pleural effusion
- consolidation/pneumonia/fever
- non- response to antibiotics for chest infection
Significant haemoptysis defined as repeated expectoration of 5mL (1tsp) of blood or single episode of >20mL (1tbsp)
Any haemoptysis associated with pulmonary infiltrates on CXR/CT chest or acute derangement in renal function
Acute exacerbations of known ILD with any of the following concerning features:
- severely breathless/Class 4 dyspnoea  (ADL’s affected by dyspnoea)
- demonstrated worsening hypoxemia
- new arrhythmia/chest pain
Newly diagnosed or suspected ILD with radiographic evidence with Class 4 dyspnoea  (ADLs affected by dyspnoea
Suspected or known lung cancer with any of the following concerning features:
- massive haemoptysis (coughing up teaspoons or more of fresh blood)
- suspected large airway obstruction
- severe dyspnoea
- SVC obstruction
- significant hypercalcemia/hyponatremia with confusion
- symptomatic pleural effusion
Large symptomatic pleural effusion(s)
Features of infection/sepsis
Acute pneumothorax
Pulmonary hypertentsion with acute decompensation (hypoxia or right heart failure)
Pulmonary embolism
Severe infection with breathlessness at rest, new hypoxaemia (SpO2 <92-96%)
Dyspnoea of uncertain origin with any of the following concerning features:
- acute dyspnoea at rest
- new hypoxia (SpO2 < 90%)
- accompanied by confusion
Significant hypercalcaemia with acute kidney injury
Acute, severe symptoms – Lofgrens syndrome (fever, erythema nodosum and bilateral hilar lymphadenopathy)
Features of neuro-sarcoidosis such as headache, visual disturbance, ataxia or cranial nerve palsy
Suspected tuberculosis with significant haemoptysis (defined as repeated expectoration of 5mL (1tsp) of blood or single episode of >20mL (1tbsp)
Evidence of SVC obstruction
Significant hypercalcaemia
Radiological evidence of airway obstruction

Useful Management Information

Request for advice

Available to GPs who use GPSR and available at your local Health Service

Lung nodule(s) identified where:
- The GP requires further management advice
- Guidance is not available on HealthPathways
- The case does not clearly fit into any other referral categories
- Guidance is required in specific patient groups, such as the follow up of small pulmonary nodules (<6mm) in patients with a personal history of cancer.

Other Useful Information

Refer to HealthPathways or local guidelines.
National Lung Cancer Screening Program
Fleischner Society Guidelines 2017 | Timing for Follow-Up CT scans for incidental Lung Nodules1

Type	Risk	<6mm	6 - 8mm (> for subsolid)
Solid - Single	Low	None	6 - 12 months for consider at 18 - 24 months
	High	12 months (optional)	6 - 12 Months then at 18 - 24 months
Solid - multiple	Low	None	3 - 6 months then consider at 18 - 24 months
	High	12 months (Optional)	3 - 6 months then at 18 - 24 months
Non-Solid		No routine follow-up	6 - 12 months then 2-yearly for 5 years
Part-solid		No routine follow-up	3 - 6 months then yearly for 5 years
Multiple		3 - 6 months then annual for 5 years	3 - 6 months then based on most suspicious

(1) Not intended for patients <35 years, lung cancer screening, history of cancer or immunocopromised

(2) High-risk factors include older age, heavy smoking, irregular or spiculated margins, and upper lobe location.

Nodules that do not require referral include:
- Nodules with diffuse, central, laminated or popcorn patterns of calcification or macroscopic fat
- Juxtapleural (perifissural) nodules with characteristic triangular morphology < 10 mm diameter
- Solid nodules stable for at least 2 years
- Non-solid, part solid and atypical pulmonary cysts stable for at least 5 years
Review of previous imaging is very important to determine if nodules are new, enlarging, stable or decreased.
Follow up imaging of nodules should be performed at the same radiology service and on the same equipment, if possible.

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)

Lung nodules are traditionally defined as ≤30 mm in diameter. This section is relevant to both screening detected and incidental (scan performed for a different reason) lung nodules.

Any one of the following:

National Lung Cancer Screening Program with:

High RIsk (Cat 5) or Very High Risk (Cat 6) nodules
Calculated risk of malignancy >30%

	Solid	Part Solid	Non-solid (Ground glass)
Nodule Size (1)	>8mm	Solid component >8mm	-
Nodule Volume (2)	≥268 mm3	Solid component ≥268 mm3	-
Change from precious scans (within 24 months)	- Progressive growth over 3 or more scans - Increase in size of >1.5 mm or volume of >25%	- Progressive growth over 3 or more scans - Solid component >4mm or >34mm3 which is new or growing	- Doubling in size within 12 months

Other features:

Growing nodule within a larger airway (segmental or more proximal)
Progressive atypical cyst compared to previous scan(s)
Regional lymphadenopathy
Frank metastatic disease with no other obvious source

(1) Dimensions are average of long and short axes, rounded to the nearest millimetre. Where only the largest diameter is provided in the imaging Report, this measurement can be considered

(2) Volume calculated from radiology volumetric software.

Category 2 (appointment within 90 calendar days)

Any once of the following:


National Lung Cancer Screening Program	- Moderate Risk (Cat 4) nodules where community follow up is not possible or where additional clinical risk factors are present.

	Solid	Part Solid	Non-Solid (Ground glass)
Nodule Size (1)	6 - 8 mm	Solid component 6 - 8 mm	>30mm
Nodule Volume (2)	>113 to <268mm3	Solid component 113 to <268mm3	-
Change from previous scans (within 24 months)	Nodule 4 to <8 mm (113 to <268mm3) which is new or growing	Solid component of nodule <4mm (<34mm3) which is new or growing	Doubling in size within 12 months

Other Features:

Nodule within a larger airway (segmental or more proximal)
Atypical pulmonary cyst (multilocular or thick walled)
Personal history of cancer - Request for Advice is available, if required, for small nodules that do not meet standard criteria.

(1) Dimensions are average of long and short axes, rounded to the nearest millimeter. Where only the largest diameter is provided in the imaging Report, this measurement can be considered as a surrogate for the average.
(2) Volume calculated from radiology volumetric software.

Category 3 (appointment within 365 calendar days)

There are no Category 3 criteria. Support for managing nodules <6 mm (that do not meet criteria for change from previous scans above) can be obtained by Request for Advice, if required.

If your patient does not meet the minimum referral criteria

Assessment and management information may be found on a range of conditions at HealthPathways
If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested:
- Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
Please note that your referral may not be accepted or may be redirected to another service

Standard Referral Information

Reason for request

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

Relevant clinical information about the condition

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
All conservative options that have been pursued unsuccessfully prior to referral
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
Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Patient's Demographic Details

Full name (including aliases)
Date and country of birth
Residential and postal address including whether patient resides at an aged care facility
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Name of delegate and contact details (Department of Corrective Services)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander
Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

Full name
Full address
Contact details – telephone, fax, email
Provider number
Date of referral
Signature
Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

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.)

Essential Referral Information

Chest imaging and details of radiology provider
Details and pathology results (if available) of previous malignancies
NLCSP screening report, if applicable
Patient characteristics which influence risk of malignancy:
- Personal history of cancers
- Patient history, symptoms, and indication for CT (if CT performed for respiratory (infective) symptoms, consider short interval repeat CT depending on radiological likelihood of malignancy (e.g., 8–12 weeks)
- Detailed smoking history including tobacco, marijuana, electronic cigarettes, and illicit drugs
- Family history of lung cancer
- Ethnicity
- Occupational exposures
- Known underlying lung disease, for example, COPD, Interstitial lung disease
- Medications, for example, anticoagulation, immunosuppressive drugs

Additional Referral Information

Historical imaging (if available)
FBC, ELFT and any other relevant pathology results

Send Referrals To

Smart Referrals

Preferred Method
About Smart Referrals

Secure Web Transfer

Send to: Gold Coast Health Service District

Internal Referrals

Respiratory (E-Blueslips)
Sleep Clinic Adult (E-Blueslips)

Fax

(07) 5687 4497

Post

Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

1300 559 083

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

Dr Maninder Singh

Medical Director Respiratory and Sleep Medicine

Facilities

Gold Coast University Hospital

Robina Hospital

If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.

Lung NodulesAdult