Referrals to specialists are made for a number of reasons as outlined below.1,2
Asthma is a clinical diagnosis and it is often possible to make the diagnosis in primary care based on a good clinical assessment, corroborated with objective tests available in primary care (such as peak flow varying over time or spirometry with reversibility). If the diagnosis is not clear and/or other diagnoses need to be excluded, a referral may be needed to arrange investigations that require specialist facilities (such as challenge tests, full lung function assessment and tests of eosinophilic airway inflammation). However, sometimes just discussing a complex case with a specialist may be helpful for a primary care physician.
If an occupational cause is suspected, the patient should be referred promptly for tests to confirm the diagnosis, and manage the challenge of eliminating work-related exposure and the medicolegal aspects of compensation. The key feature is a history of occupational worsening of asthma, often after an asymptomatic period (latency). Bakers, laboratory animal handlers, spray painters, solderers and plastic workers are at particular risk of occupational asthma.
Despite following a structured approach (such as SIMPLES)2, it is sometimes not possible for a primary care physician to help patients bring their asthma under control, and referral may be considered. A pulmonologist is likely to go back to the beginning and reconsider the diagnosis, reassess practical issues such as adherence and inhaler technique, and address smoking cessation, trigger avoidance, and comorbidities before advising stepping up to more specialised treatment. They are also more likely to have access to more diagnostic tests and other specialist team members, such as a respiratory physiotherapist. Most guidelines recommend specialist advice before commencing a third controller medication, high-dose inhaled steroids, regular oral steroids, omalizumab or mepolizumab.
A few patients are at high risk of very severe or fatal asthma attacks and should be under specialist care. These at-risk asthma patients may be identified by their past history of life-threatening asthma, often require high doses of treatment to control troublesome symptoms, and many have psychosocial problems that make it difficult for them to look after their asthma.
- Concerned or anxious patient
It may be helpful to request a specialist consultation to reassure concerned or anxious patients. The specialist may not say anything different to the family doctor, but sometimes it helps patients to have the advice reinforced by a pulmonologist.3
Further information on referrals can be found in the feature article ‘Shared care in asthma: a role for primary and secondary healthcare professionals’.
1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed July 2016).
2. Ryan D, et al. Prim Care Respir J 2013;22:365–373.
3. Agusti A, et al. Eur Resp J 2016;47:410–419.