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Swelling of legs, feet and ankles may indicate the development of pulmonary hypertension and requires GP assessment.

Consider hospital outpatient referral if:

• Frequent exacerbations to exclude bronchiectasis.

• If considering nebulised treatments or oxygen.

• Unintentional weight loss – for chest X-ray (lung cancer?). Consider investigation to exclude other causes.

• Severe symptoms or signs of cor pulmonale (e.g.: ankle swelling; MRC grade 4 / 5; FEV1 <30%; Sa0<92%).

• Diagnostic uncertainty e.g. symptoms disproportionate to lung function at initial assessment or follow up.

• Never smoked / occasional smoker.

• Age < 40 years.

and requires GP assessment