Asthma affects hundreds of millions of people worldwide, and WHO notes that most asthma deaths occur in low- and lower-middle-income countries, often because of under-diagnosis and limited access to inhaled medicines. Many deaths are preventable. Asthma attacks can kill young, otherwise healthy people, including health workers, as several cases in recent years have shown. Nurses need to recognise how severe an attack is, start treatment fast, and never be falsely reassured by a quiet chest.
Assessing severity in adults
| Severity | Features (any one) |
|---|---|
| Moderate | Increasing symptoms; peak flow (PEF) more than 50–75% of best or predicted; no features of acute severe asthma |
| Acute severe | PEF 33–50% of best or predicted; respiratory rate 25 or more; heart rate 110 or more; cannot complete sentences in one breath |
| Life-threatening | PEF below 33%; SpOâ‚‚ below 92%; silent chest; cyanosis; poor respiratory effort; exhaustion; altered conscious level; arrhythmia; hypotension |
| Near-fatal | Raised PaCOâ‚‚ and/or needing mechanical ventilation |
The silent chest is a red flag: so little air is moving that there is no wheeze. A patient who becomes quieter, drowsy or confused is tiring, not improving. In a patient with acute severe asthma, a normal or rising COâ‚‚ on a blood gas is a sign of exhaustion. See our ABG guide.
Immediate treatment
- Sit the patient upright and stay with them. Call for help if severe or life-threatening.
- Oxygen to maintain SpO₂ at 94–98%.
- Short-acting bronchodilator: salbutamol via spacer (multiple puffs, e.g. up to 10 puffs, one at a time) or nebulised (commonly 5 mg in adults), repeated or given back-to-back in severe attacks, as prescribed or per protocol. Use oxygen to drive nebulisers in severe asthma.
- Ipratropium bromide nebulised, added for acute severe or life-threatening asthma.
- Steroids early: for example oral prednisolone 40–50 mg in adults, or IV hydrocortisone if unable to swallow, as prescribed.
- IV magnesium sulfate (commonly 1.2–2 g over 20 minutes in adults) for acute severe or life-threatening asthma not responding, as prescribed by a senior clinician.
- Escalate early to critical care for life-threatening features or deterioration.
Monitoring
- Peak flow before and 15–30 minutes after bronchodilator, if the patient can do it.
- SpOâ‚‚, respiratory rate, heart rate, ability to speak, conscious level, and NEWS2.
- Potassium: high-dose salbutamol can lower it.
- Heart rate and tremor: expected effects of salbutamol, but report marked tachycardia or arrhythmia.
Children
- Signs of severe asthma include being too breathless to talk or feed, use of accessory muscles, recession, and SpOâ‚‚ below 92%.
- Salbutamol by spacer and mask in young children works as well as a nebuliser for many attacks.
- Oral prednisolone doses are weight-based, as prescribed.
- Children can deteriorate quickly. Watch for agitation, drowsiness and exhaustion.
Before discharge
Many people who die from asthma had a recent attack or hospital visit. Discharge is a crucial teaching opportunity:
- Check inhaler technique, every time. Poor technique is extremely common. Use a spacer with pressurised inhalers.
- Explain the difference between preventer (inhaled steroid) and reliever inhalers, and why the preventer must be used daily. Overuse of reliever alone is a warning sign of poor control.
- Give a written asthma action plan: what to do when symptoms worsen, and when to seek emergency help.
- Complete the course of oral steroids.
- Identify and avoid triggers: smoke (including cooking fires and tobacco), dust, cold air, infections, some medicines (e.g. NSAIDs in some people, beta-blockers).
- Arrange follow-up within a few days, with their regular clinic.
Nurses with asthma
Nurses with asthma should keep their reliever inhaler on them at work, tell a colleague or manager, and have an action plan. Workplaces should make sure emergency treatment is quickly available for staff as well as patients. See our report on the nurse who died after an asthma attack at work in Nigeria.
Based on BTS/SIGN/NICE asthma guidance, the Global Initiative for Asthma (GINA) and WHO asthma information. Doses must follow your prescription and local protocol.