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Sample Topic: Asthma

Asthma : Last revised in December 2013


When is a referral recommended in people with asthma?

  • The decision to refer is influenced by local referral pathways, the individual, and the experience of the primary healthcare provider.
  • In addition to respiratory physicians and paediatricians with a specialist interest in respiratory medicine, such specialists as dietitians, physiotherapists, occupational therapists, and respiratory nurse specialists may be involved in the management of asthma at any stage.
  • Admit or refer adults for specialist assessment or further investigation in the following situations:
    • The diagnosis is unclear or in doubt:
      • Unexpected clinical findings (for example crackles, clubbing, cyanosis, cardiac disease).
      • Persistent non-variable breathlessness.
      • Monophonic, unilateral or fixed wheeze or stridor.
      • Persistent chest pain or atypical features.
      • Prominent systemic features (for example weight loss, myalgia, fever).
      • Persistent cough or sputum production.
      • Spirometric or peak expiratory flow measurements that do not fit the clinical picture (for example unexplained restrictive spirometry).
    • Suspected occupational asthma.
    • Non-resolving pneumonia.
    • Inadequate response to maximum guideline treatment.
  • Admit or refer children for specialist assessment or further investigation in the following situations:
    • The diagnosis is unclear or in doubt (the younger the child, the more difficult it is to be sure that wheezing is due to asthma):
      • Unexpected clinical findings (for example abnormal voice, focal chest signs, dysphagia, inspiratory wheeze, stridor).
      • Symptoms present from birth, or perinatal lung problem.
      • Excessive vomiting or posseting.
      • Severe upper respiratory tract infection.
      • Persistent productive cough.
    • Family history of unusual chest disease.
    • Failure to thrive.
    • Parental anxiety.
    • Inadequate response to maximum guideline treatment, particularly if oral corticosteroids are needed frequently, or use of the maximum dose of inhaled corticosteroids.
  • The urgency of a referral to secondary care or admission to hospital should be appropriate to the clinical situation.
  • For indications of when to admit someone with an acute exacerbation of asthma, see When to admit to hospital in Scenario: Acute asthma exacerbation.

Basis for recommendation
These recommendations are based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].