Do all patients with asthma exacerbations require hospital admission?

Hospital Admission for Asthma Exacerbations: A Severity-Based Approach

Not all patients with asthma exacerbations require hospital admission—the decision depends on exacerbation severity, response to initial treatment, and specific risk factors. 1

Severity Classification Determines Disposition

The admission decision is fundamentally based on objective assessment of severity and response to treatment within 15-30 minutes to 1 hour of initial bronchodilator therapy. 1

Mild Exacerbations

• PEF >70% predicted after initial treatment: Can be managed at home 1
• These patients have only a 14% relapse rate after discharge without glucocorticoids 2
• Require oral corticosteroids and close outpatient follow-up within 1-4 days 1

Moderate Exacerbations

• PEF 40-69% predicted after initial treatment: May require admission 2
• If discharged with glucocorticoids, this group has a 6% relapse rate within 10 days 2
• Children meeting moderate criteria after 1 hour have an 84% chance of requiring hospitalization 1
• These patients need 5-12 hours of ED observation while awaiting steroid effect 2

Severe Exacerbations

• PEF <40% predicted after initial treatment: Require hospital admission 1, 2
• Patients with PEF <20% who remain <40% after inhalant therapy need 4+ days to resolve and should be admitted 2
• Children meeting severe criteria after 1 hour have >86% chance of requiring hospitalization 1

Mandatory Admission Criteria

Immediate hospital referral is required for any of the following: 1

Life-Threatening Features (Admit Immediately)

• PEF <33% predicted or best 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, drowsiness, or coma 1
• Normal or elevated PaCO₂ (5-6 kPa) in a breathless patient 1
• Severe hypoxia: PaO₂ <8 kPa despite oxygen 1
• Respiratory arrest 1

Severe Features Persisting After Initial Treatment

• PEF 15-30 minutes after nebulization <33% of predicted or best 1
• Inability to complete sentences in one breath 1
• Respiratory rate >25 breaths/min 1
• Heart rate >110 beats/min 1
• Use of accessory muscles 1

Risk Factors Lowering Admission Threshold

A lower threshold for admission is appropriate in patients with: 1

• Timing: Presentation in afternoon/evening rather than morning 1
• Recent deterioration: New onset nocturnal symptoms or worsening symptoms 1
• Previous severe attacks, especially with rapid onset 1
• History of near-fatal asthma or previous intubation 1
• Multiple recent healthcare utilization: ≥2 hospitalizations in past year, ≥3 ED visits in past year, or any ED visit/hospitalization in past month 1
• Poor symptom perception or inability to assess severity 1
• Concerning social circumstances or inadequate home support 1
• Current oral corticosteroid use or recent discontinuation 2

Special Populations

Infants and Young Children

• Higher risk of respiratory failure—lower threshold for admission 1
• Respiratory rate >60 breaths/min signals serious distress 1
• SaO₂ <90-92% indicates need for hospitalization 1
• Lack of response to short-acting β₂-agonists mandates admission 1

Patients on Chronic Steroids

• Increased risk of severe exacerbations—consider admission more readily 2
• Those recently stopping glucocorticoids are at higher relapse risk 2

Common Pitfalls to Avoid

Do not rely solely on subjective assessment—many patients and physicians underestimate severity, which contributes to preventable deaths. 1 Always obtain objective measurements (PEF or FEV₁) before and after initial treatment. 1

Do not discharge patients too quickly—glucocorticoids require 6-12 hours for clinical benefit. 3 Patients with moderate exacerbations may need prolonged ED observation. 2

Evening discharges carry higher relapse risk—this timing factor should lower your threshold for admission. 1, 2

Failure to implement self-management prior to ED visit predicts poor outcomes—only 27% of hospitalized patients had measured PEF, 19% had increased inhaled steroids, and 22% had started oral steroids before presentation. 4 This indicates need for admission and intensive education. 4

Discharge Criteria When Admission Not Required

Patients can be safely discharged when: 1

• PEF >75% predicted or personal best 1
• Diurnal variability <25% 1
• No nocturnal symptoms 1
• Sustained response to bronchodilators 1
• Adequate home circumstances and reliable follow-up 1

All discharged patients require oral corticosteroids (prednisolone 30-60 mg daily for 1-3 weeks), increased inhaled steroids, written action plan, PEF meter with education, and follow-up within 1 week. 1