Refer a patient with an acute asthma exacerbation to secondary care if there are signs of a life-threatening exacerbation, such as cyanosis, drowsiness, exhaustion, poor respiratory effort, confusion, oxygen saturation less than 92%, hypotension, PEF less than 33% of best or predicted, or a silent chest NICE CKS.
Arrange hospital admission if there are signs of an acute severe exacerbation that do not respond to initial treatment, including inability to complete sentences, oxygen saturation below 92%, respiratory rate over 25 breaths per minute, pulse over 110 beats per minute, or PEF between 33-50% NICE CKS.
Consider urgent transfer to hospital if symptoms worsen despite initial treatment or if the patient exhibits signs of a moderate exacerbation with inadequate response, such as poor response to inhaled bronchodilators, or if the patient is unable to manage at home safely NICE CKS.