Emergency: Acute Asthma

An acute exacerbation of asthma is frightening for both the patient and the health care worker involved. This is one of the 'acute scenarios' that you should have a good grasp of before starting work. The BTS/SIGN guidelines (UK) are linked on the right and should be followed during clinical practice. We have digested these into exam-friendly steps below. Use these tips in conjunction with our general ABCDE proforma.

**These tools are for revision purposes only and should be supported by use of National and Local Guidelines**

Wash hands / wear gloves

Assess for danger

Check patient response

Call for senior help if the patient is acutely unwell

Assess airway

Patent? Able to talk in full sentences?
Look, listen and feel for breath sounds

If there is no patent airway, if there are no signs of life or breath, then ensure that an 'arrest call' is put out. Call 2222 and state your name, your ward location and the event.

Assess breathing

Colour - is the patient cyanosed?
Respiratory rate - is the patient tachypnoeac or cyanosed?
Are they gasping for air, pursed lips, nasal flaring?
Are they using accessory muscles?
Listen to breath sounds with stethoscope on front and back: wheeze? "Silent Chest"?
Measure: pulse oximetry
Measure: conduct an ABG
Measure: peak flow
Order: CXR, sputum sample
Assess severity of attack (see below)

Treat - prescribe medication:

Give OXYGEN, 85%, 10-15 L/minute to aim saturations of 94-98%
Salbutamol 5mg nebulised WITH OXYGEN, repeat every 15 minutes if no improvement
Ipratropium Bromide 0.5mg nebulised WITH OXYGEN
Prednisolone 30mg-50mg PO (if cannot swallow use 100mg-200mg IV Hydrocortisone)

If patient does not respond or if "Life Threatening" features consider

- Magnesium Sulphate 1.2-2mg IV over 20 minutes
- Urgent ITU outreach referral for consideration of intubation
- Salbutamol or Aminophylline infusion could be considered in ITU

Assess Circulation

Ankle oedema
Heart sounds
Measure: capillary refill time
Measure: blood pressure
Measure: heart rate
Measure: temperature (are they septic?)
Measure: urine output
Insert 2 wide bore cannulae
Take bloods: FBC, CRP, U&Es, Blood Cultures if septic
Consider giving IV fluids
Consider antibiotics if any indicators of sepsis

Assess disability

AVPU score
Blood sugar


Examine your patient - what precipitated this exacerbation?
Do they have a respiratory tract infection?
Have they been in trauma?

Assessing Severity of Asthma


Classify according to most severe feature

Near Fatal

Raised PaCO2, and/or requiring intubation and mechanical ventilation with raised inflation pressures

Life Threatening

PEFR <33% of best/predicted
Oxygen saturations <92%
PaO2 <8kPa
Normal PaCO2 (4.6-6kPa)
Silent chest
Poor respiratory effort (tiring)
Exhaustion/decreased GCS
pH <7.35

Acute Severe

Unable to complete sentences
Respiratory rate >25/min
Heart rate >110/min
PEFR <50% of best or predicted


Symptoms worse than baseline
PEFR >50-75% of best or predicted
No features of Acute Severe/Life Threatening/Near Fatal

written by: saaid_sufi; celine_lakra; joel_cunningham, first posted on: 25/01/2014, 23:51

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Moheb Robeel says...
Great algorthim, Thanks.
POSTED ON: 28/02/16, 16:11

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