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Asthma

Red flags

Consider immediate referral for patients with the following

  • Acute exacerbations of asthma showing the following features
    • Hypoxia (Pulse oximetry less than 92 mmHg)
    • Central cyanosis
    • Poor respiratory effort or exhaustion
    • PEF less than 33% of predicted
    • Hypotension (less than 90mmHg systolic associated with signs of respiratory distress)
    • Distress not settling with initial treatment

Other important information for referring practitioners

The aim of asthma management is to control the disease. Complete control is defined as:

  • No day or night symptoms
  • Minimal or no need for beta agonist treatment (less than 2-3 times/week)
  • No exacerbations
  • No limitation to physical activity
  • Minimal side effects

If control is poor consider:

  • Occupational asthma
    • Check eosinophils count and IgE level
  • Poor compliance and technique
  • Triggers
  • Smoking
  • Medications causing asthma
    • Aspirin
    • NSAIDs
    • Beta blockers
    • Eye drops (timolol)
  • GORD
  • Allergic rhinitis/sinusitis
  • Asthma education
  • Immunisations
    • Influenza vaccine
    • Pneumococcal vaccine
  • Differential diagnoses
    • COPD
    • Heart failure
    • Hyperventilation
    • Inhaled foreign body
    • Infection
    • Tumours
    • Bronchiectasis
    • Interstitial lung disease
    • Allergic bronchopulmonary aspergillosis
    • Aspiration
    • Vocal cord dysfunction

Lifestyle factors

  • Cease smoking
  • Exercise
    • 30 mins moderate exercise 5 times weekly
    • Advise precautions against exercise induced asthma
  • Healthy weight
  • Breathing retraining programs
    • Yoga
    • Physiotherapy led breathing training

General management principles

  • Optimise regular use of appropriate dose of preventer
    • Usually a combination long acting beta agonist and inhaled steroid
    • Choose inhaler device that the patient uses best, including spacer use
  • Give patient an asthma action plan
    • Ensure patient has a peak flow device for self-monitoring
  • Rational treatment plan
    • Mild infrequent intermittent asthma
      • Use beta agonist prn
    • Chronic mild asthma
      • Use inhaled corticosteroid
      • Short acting beta agonist prn
    • Exercise induced asthma
      • Use beta agonist 30 mins before exercise
      • Intal forte
    • Poorly controlled chronic asthma
      • Combination long acting beta agonist/low dose corticosteroid inhaler
      • Short acting beta agonist prn
      • Short term oral steroids for exacerbations
    • Poorly controlled moderate asthma
      • As above but consider add on:
        • High dose inhaled corticosteroid
        • Leukotriene antagonist
        • Long acting beta agonist
        • Short acting beta agonist prn
    • Poorly controlled severe asthma (should be referred to specialist)

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • Reason for referral
  • History of asthma
    • Duration
    • Severity
    • Triggers
    • Frequency of exacerbations
  • Management to date
    • Include last two specialist letters if seen previously at another centre
  • Medications
    • Include previously tried medications if associated with treatment failure or problems
    • Include full medication list and allergies
  • Investigations
    • FBC (eosinophil count, anaemia, high WCC)
    • Spirometry
    • CXR

Additional referral information (useful for processing the referral)

  • Allergy testing

Consider referral if:

  • Asthma is poorly controlled despite optimal therapy.
  • Considering long term oral steroids
  • Doubt about diagnosis unable to be resolved despite investigation in primary care

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

  • 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

  • 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
  • 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
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • 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.)
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