Acute asthma (asthma attack)

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    Last updated: June 2023

     

    Asthma attack is a substantial worsening of asthma symptoms. The severity and duration of attacks are variable and unpredictable.

    Assessment of the severity of asthma attack

    The severity of the asthma attack must be rapidly evaluated by the following clinical criteria. Not all signs are necessarily present.

     

    Assessment of severity in children over 2 years and adults [1] Citation 1. British guideline on the management of asthma. A national clinical guideline First published 2003. Revised edition published July 2019.
    https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma/ [Accessed 12 January 2023]         [2] Citation 2. Global INitiative for Asthma. Global Strategy for Asthma Management and Prevention. 2022 update.
    https://ginasthma.org/gina-reports/ [Accessed 12 January 2023]         [3] Citation 3. WHO Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. WHO Regional Office for Europe; 2022.
    https://www.who.int/europe/publications/i/item/9789289057622 [Accessed 12 January 2023]

     

    Mild or moderate attack Severe or life-threatening attack
    Able to talk in sentences Cannot complete sentences in one breath
    or
    Too breathless to talk or feed

    Mild or moderate increase of

    respiratory rate (RR)

    		 Very high RR
    Children 2-5 years: > 40/minute
    Children > 5 years and adults: > 30/minute

    Normal or mild increase of heart rate (HR)
    Children 2-3 years: ≤ 180/minute
    Children 4-5 years: ≤ 150/minute

    Children > 5 years and adults: ≤ 120/minute 

    		 Very high HR
    Children 2-3 years: > 180/minute
    Children 4-5 years: > 150/minute
    Children > 5 years and adults: > 120/minute

    SpO2 ≥ 90% (≥ 92% for children 2-5 years)

    SpO2 < 90% (< 92% for children 2-5 years)

    and

    No criteria of severe or life-threatening attack

     

    Signs of life-threatening attack:

    Altered level of consciousness (drowsiness, confusion, coma)
    Exhaustion

    Silent chest
    Cyanosis
    Arrhythmia or hypotension in adults

     

    Treatment

    Reassure the patient. Treatment and follow-up depend on the severity of the attack and the patient’s response:

    Mild to moderate attack

    • Place the patient in a 1/2 sitting position.
    • Administer:
      • salbutamol metered-dose inhaler (MDI) 100 micrograms/puff: 2 to 10 puffs every 20 minutes during the first hour. In children, use a spacer a Citation a. If a conventional spacer is not available, use a 500 ml plastic bottle: insert the mouthpiece of the inhaler into a hole made in the bottom of the bottle (the seal should be as tight as possible). The patient breathes from the mouth of the bottle in the same way as they would with a spacer. The use of a plastic cup instead of a spacer is not recommended (ineffective).  (use face mask in children under 3 years). Single puffs should be given one at a time, let the child breathe 4 to 5 times from the spacer before repeating the procedure. A spacer can also be used in adults to increase effectiveness.
      • prednisolone PO: one dose of 1 to 2 mg/kg (max. 50 mg) for children over 5 years and adults
      • oxygen if SpO2 < 94% b Citation b. If pulse oxymetry is not available, administer oxygen continuously in case of moderate, severe or life-threatening attack. .
    • If the attack is completely resolved:
      • Observe the patient for 1 hour (4 hours if they live far from the health centre) then give outpatient treatment: salbutamol MDI for 24 to 48 hours (2 to 4 puffs every 4 to 6 hours depending on clinical evolution) and prednisolone PO (same dose as above once daily) to complete 5 days of treatment. 
      • Reassess after 1 to 2 days: address any identified risk factor, reassess need for salbutamol and long-term treatment. If the patient is already receiving long-term treatment, reevaluate the severity of the asthma (see Chronic asthma), review compliance and correct use of medications and adjust treatment if necessary.
    • If the attack is only partially resolved, continue with salbutamol MDI (2 to 10 puffs every 1 to 4 hours) until symptoms subside. For children up to 5 years, administer one dose of prednisolone PO as above if symptoms recur within 3 to 4 hours. When the attack is completely resolved, proceed as above.
    • If symptoms worsen or do not improve, treat as severe attack.

    Severe attack

    • Hospitalise c Citation c. If signs of life-threatening attack, transfer to intensive care unit as soon as possible. ; place the patient in a 1/2 sitting position.
    • Administer:
      • oxygen to maintain SpO2 between 94 and 98% b Citation b. If pulse oxymetry is not available, administer oxygen continuously in case of moderate, severe or life-threatening attack. .

      • salbutamol + ipratropium nebuliser solutions using a nebuliser (continue oxygen via nasal cannula during nebulisation):

    Children < 5 years

    salbutamol 2.5 mg (1.25 ml) + ipratropium 0.25 mg (1 ml) every 20 minutes for the first hour

    Children 5 to 11 years

    salbutamol 2.5 to 5 mg (1.25 to 2.5 ml) + ipratropium 0.5 mg (2 ml) every 20 minutes for the first hour

    Children 12 years and over
    and adults

    salbutamol 5 mg (2.5 ml) + ipratropium 0.5 mg (2 ml) every 20 minutes for the first hour

    The two solutions should be mixed in the drug reservoir of the nebuliser. Assess symptoms at the end of each nebulisation.

    If there is no nebuliser, use salbutamol MDI (same dose as for mild to moderate attack) and ipratropium MDI 20 micrograms/puff, 4 to 8 puffs every 20 minutes for the first hour.

    • prednisolone PO: one dose of 1 to 2 mg/kg (max. 50 mg)
      If prednisolone is not available, or if the patient cannot take oral treatment, administer:
      • Children: dexamethasone PO/IV/IM, one dose of 0.15 to 0.6 mg/kg (max. 16 mg)
      • Adults: hydrocortisone IV, 4 mg/kg (max. 100 mg) every 6 hours for 24 hours
    • If symptoms do not improve after one hour:
      • transfer to intensive care unit
      • insert an IV line
      • oxygen to maintain SpO2 between 94 and 98% b Citation b. If pulse oxymetry is not available, administer oxygen continuously in case of moderate, severe or life-threatening attack.
      • continue salbutamol (solution for nebuliser) without ipratropium, and corticosteroids as above.
      • administer one dose of magnesium sulfate by IV infusion in 0.9% sodium chloride over 20 minutes, monitoring blood pressure:
        • Children: 40 mg/kg (max. 2 g)
        • Adults: 2 g
    • If symptoms improve: continue salbutamol (solution for nebuliser) every 1 to 4 hours (depending on symptoms) and oxygen as above. Assess symptoms at the end of each nebulisation. When possible, switch to salbutamol MDI and continue as for mild to moderate attack.
    • If the attack is completely resolved, observe the patient for at least 4 hours. Continue the treatment with salbutamol (MDI) and prednisolone PO and reassess as for a mild to moderate attack.

     

    Notes:

    • In pregnant women, treatment is the same as for adults. In mild or moderate asthma attacks, administering oxygen reduces the risk of foetal hypoxia.
    • For all patients, irrespective of the severity of the asthma attack, look for underlying lung infection and treat accordingly.

     

    Footnotes
    • (a)If a conventional spacer is not available, use a 500 ml plastic bottle: insert the mouthpiece of the inhaler into a hole made in the bottom of the bottle (the seal should be as tight as possible). The patient breathes from the mouth of the bottle in the same way as they would with a spacer. The use of a plastic cup instead of a spacer is not recommended (ineffective).
    • (b) If pulse oxymetry is not available, administer oxygen continuously in case of moderate, severe or life-threatening attack.
    • (c)If signs of life-threatening attack, transfer to intensive care unit as soon as possible.
    References
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