Referral criteria from primary care - asthma

With respect to acute asthma (1):

Criteria for admission include:

• any features of a life-threatening or near-fatal asthma attack
• any features of a severe attack that persist after initial treatment
• patients whose peak flow is greater than 75% best or predicted one hour after initial treatment may be discharged from ED unless they meet any of the following criteria, when admission may be appropriate:
  • still have significant symptoms
  • concerns about adherence
  • living alone/socially isolated
  • psychological problems
  • physical disability or learning difficulties
  • previous near-fatal asthma attack
  • asthma attack despite adequate-dose steroid tablets prior to presentation
  • presentation at night
  • pregnancy

A lower threshold for admission is appropriate in patients:

• seen in the afternoon or evening rather than earlier in the day
• with recent onset of nocturnal symptoms or worsening of symptoms
• who have had previous severe attacks, especially if the onset was rapid
• in whom there is concern over their assessment of severity of symptoms
• in whom there is concern over the social circumstances or relatives' ability to respond appropriately (1)

With respect to referral suggested criteria in chronic asthma, NICE have stated (2):

• asthma in individuals aged 12 years and older
  • if asthma is not confirmed by eosinophil count, FeNO, BDR (bronchodilator reversibility) or PEF variability but still suspected on clinical grounds, refer for consideration of a bronchial challenge test
    • diagnose asthma if bronchial hyper-responsiveness is present
  • refer people with asthma that is not controlled on treatment containing a high dose of ICS (inhaled corticosteroids) to a specialist in asthma care
  • for people aged 12 and over with asthma that is not controlled on moderate-dose MART(Maintenance and Reliever Therapy) despite good adherence:
    • check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count
      • if either of these is raised, refer to a specialist in asthma care
  • refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA (Leukotriene Receptor Antagonist) and a LAMA (Long-Acting Muscarinic Antagonist)
  • refer people with suspected occupational asthma to an occupational asthma specialist
    
    
• asthma in children aged 5 years to 11 years old
  • with respect to diagnosis
    • if asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds, either perform skin prick testing to house dust mite or measure total IgE level and blood eosinophil count
      • if there is still doubt about the diagnosis, refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test
  • with respect to management
    • refer children to a specialist in asthma care if their asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA (long-acting beta-2 agonist) maintenance treatment (with or without an LTRA, depending on previous response)
      
      
• asthma in children under 5 years old
  • with respect to the suggested asthma algorithm:
    • if symptoms do not resolve during the trial period, take the following sequential steps:
      • check inhaler technique and adherence
      • check whether there is an environmental source of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution)
      • review whether an alternative diagnosis is like
    • if none of these explain the failure to respond to treatment, refer the child to a specialist in asthma care
      
      
    • if suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy and a trial of an LTRA has been unsuccessful or not tolerated, stop the LTRA and refer the child to a specialist in asthma care for further investigation and management
      
      
    • refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period

Reference:

1. British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) 2019. British Guideline on the Management of Asthma. A national clinical guideline
2. NICE (November 2024). Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN)