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Asthma - Management
When should I admit a person to hospital?
- Admit all people with a life-threatening asthma exacerbation (peak expiratory flow rate [PEFR] usually < 33% best or predicted and/or oxygen saturation < 92%).
- Admit people with a severe asthma exacerbation (PEFR usually 33–50% best or predicted) who do not rapidly respond to initial treatment or who have a factor that warrants a lower threshold for admission.
- Admit people with a moderate asthma exacerbation (PEFR usually > 50% best or predicted) who have a factor that warrants a lower threshold for admission.
- The following factors should lower the threshold for admission:
- People under 18 years.
- Poor concordance.
- Person lives alone.
- Psychological problems such as depression, and alcohol or drug misuse.
- Physical or learning disability.
- Previous near-fatal attack or brittle asthma.
- Persistent exacerbation despite an adequate dose of oral corticosteroids before presentation.
- Presentation at night or in the afternoon.
- Pregnancy.
Clarification / Additional information
- Some people with a moderate to severe exacerbation (and no risk factors for a lower threshold of admission) may be managed in primary care only if they show a good response to initial treatment. The primary healthcare professional needs to make that decision on an individual basis. Their decision should be based on the knowledge of the person and how quickly they respond to initial treatment. If the healthcare professional has any doubt, does not have the appropriate facilities to assess and monitor treatment response, or cannot safely follow up the individual, admission to hospital is needed for further assessment.
- Determine whether a person is at further risk of deterioration or death by assessing their medical, behavioural, and psychosocial history. See Table 1.
Table 1. Important factors in near-fatal or fatal asthma exacerbation.
Medical risk factors | Behavioural or psychosocial risk factors |
|---|
Previous near-fatal episode of asthma (i.e. previous ventilation or respiratory acidosis) | Non-compliance with treatment or monitoring |
Previous hospital admission for asthma, especially within the past year | Failure to attend appointments, or previous self-discharge from hospital |
Requires three or more classes of asthma medication | Psychiatric illness or learning difficulties, denial |
Heavy use of beta2-agonist | Misuse of alcohol or drugs |
Repeated attendance at accident and emergency unit for asthma, especially within the past year | Current or recent major tranquillizer use |
'Brittle' asthma | Income or employment problems, social isolation |
— | Severe domestic, marital, or legal stress, child abuse |
— | Obesity |
|
Basis for recommendation
- These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
- Case-controlled studies have shown that people who die of asthma attacks or have near-fatal attacks are more likely to have associated adverse behavioural or psychological features. Deaths were also related to inadequate use of oral corticosteroids and poor follow up.
- People who die of asthma are also likely to have had severe disease, poor compliance with medication, a hospital admission or visit to an accident and emergency department for asthma in the previous year, or a previous near-fatal attack.
- An oxygen saturation (SpO2) of less than 92% is associated with a risk of hypercapnoea, which is a feature of life-threatening asthma. Hypercapnoea can only be detected by arterial blood gas measurement, not by pulse oximetry.
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