CXR is recommended only in the following settings: –

• Suspected pneumothorax, pneumomediastinum, pneumonia
• Life threatening features
• Failure to respond to standard treatment
• Patients requiring ventilation

Transfer to ICU accompanied by a doctor prepared to intubate if:

1. Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
2. Exhaustion, altered consciousness
3. Poor respiratory effort or respiratory arrest

NIV should only be considered as a treatment for life threatening asthma when a senior intensivist/ anaesthetist that can proceed directly to intubation is present with the patient in the ED.

In management of pregnant patients — obstetrician input is recommended in cases of severe asthma and continuous foetal monitoring commenced.

Regardless of the PEFR, when any of the following features are present, admission may be appropriate:

• Life-threatening features at any time
• Pregnancy
• Lives alone
• Still have significant symptoms
• Concern over compliance
• Psychosocial problems
• Physical disability or learning difficulties
• History of severe asthma
• Presentation at night
• Exacerbation despite adequate dose steroids pre-presentation

Patients considered for discharge should meet all of the following criteria:

• No life-threatening features at any point (including pre-hospital)
• No features of severe asthma after initial treatment
• PEFR >75% best or predicted and stable one hour after initial treatment

OR

• PEFR > 50% best or predicted and stable two hours after initial treatment