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Home | Articles | Respiratory | Acute Asthma

Acute Asthma

Last updated 14th September 2022

Risk of Dying From Asthma

  1. Most asthma deaths are preventable. Disease factors, poor medical management and patient’s behaviour/psychosocial status all predict a poor outcome
  2. Disease factors – most deaths occur in chronic severe asthma
  3. Poor medical management – inadequate assessment, treatment, follow up and referral. Beware inappropriate prescription of Beta blockers and NSAIDs
  4. Behavioural/psychosocial factors -see section below

SIGN/BTS Recognise 5 Categories of Acute Asthma As Follows

1 Near Fatal Asthma

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

2 Life Threatening Asthma

Any one of the following in a patient with severe asthma

  • Altered conscious level
  • Exhaustion
  • Hypotension
  • Cyanosis
  • Silent chest
  • Poor respiratory effort
  • PEF <33% of best or predicted
  • SpO2 <92%
  • PaO2 <8kPa
  • “normal” PaCO2 4.6-6.0kPa

3 Acute Severe Asthma

Any one of:

  • inability to complete sentences in one breath
  • PEF 33-50% best or predicted
  • RR >25/min
  • HR > 110/min

4 Moderate Asthma

Increasing symptoms but…

  • No features of acute severe asthma and…
  • PEF 50-75% best or predicted

5 Brittle Asthma

  • Type 1 – wide PEF variabilty >40% diurnal variation for >50% of the time over a period of >150 days despite intensive therapy
  • Type 2 – sudden severe attacks on a background of apparently well controlled asthma


  1. PEFR or FEV1 – PEFR easier during acute attack
  2. SpO2 – noting whether on or off oxygen
  3. Gases if SpO2 <92% on or off oxygen
  4. CXR – to exclude pneumothorax and consolidation
  5. Routine bloods including WCC and CRP

Interpretation of Arterial Blood Gases

  1. Hydrogen ions >45 indicates acidosis
  2. Normal PaO2 >10.6 kPa – significantly hypoxic if < 8 kPa
  3. Normal PaCO2 4.7-6.0 kPa isn’t normal in the context of acute asthma – indicates potentially life threatening asthma
  4. CO2 retention if >6.0 kPa – indicates near fatal asthma

Immediate Management Acute Severe Asthma

  1. Oxygen – for all hypoxaemic patients with acute severe asthma using face mask, venturi mask or nasal cannulae to maintain SpO2 94-98%
  2. Salbutamol – 5mg 4-6 hourly by oxygen driven nebuliser.
  3. Ipratropium – 0.5mg 4-6 hourly by oxygen driven nebuliser
  4. Prednisolone – 40-50mg od unless tabs cannot be swallowed and retained in which case Hydrocortisone 100 mg qds IV. Continue Prednisolone at 40-50mg daily for at least 5 days or until recovery. Doses do not need tapering unless on maintenance steroid or steroid required for three or more weeks
  5. Do not give antibiotics routinely and avoid sedatives

If Life Threatening Features Present

  1. Discuss further options with senior clinician ± intensivists
  2. Consider single dose Magnesium 1.2-2.0g IV (which is 2.4 – 4.0ml of 50% magnesium sulfate injection) in 50ml or 100ml of 0.9% sodium chloride over 20 minutes.
  3. Consider nebulised Salbutamol more frequently eg 5mg up to every 15-30 minutes or continuously at 5-10mg/hr using an appropriate nebuliser.

Additional Measures if Not Settling

  1. Discuss with senior clinician, consider magnesium if not already given, more frequent nebulised salbutamol as above
  2. Senior clinician may recommend IV salbutamol, IV aminophylline or progression to NIV/full ventilation. If NIV should be on ICU because of risk of cardiovascular collapse.
  3. IV salbutamol – use infusion formulation 5mg/ml. Add 5ml solution to 500ml Dextrose 5% or Saline 0.9% to give concentration 10 micrograms/ml and infuse at 5 micrograms/min (30ml/hr) adjusting according to response and heart rate , in range 3-20 micrograms/min (18-120ml/hr)
  4. IV Aminophylline – 5mg/kg (usually 250mg) in 5% dextrose over 20 min unless already taking oral theophylline. Can be continued as infusion of 500 micrograms/kg/hr, adjusted to maintain plasma concentration 10-20mg/L, if necessary

When to Call The Anaesthetist

  1. If any features if life threatening asthma present.
  2. Or if PaO2 < 6kPa despite high flow O2, or if PaCO2 > 6 kPa or rising.

Referral to Respiratory Nurse Specialist

  1. All patients with asthma should be referred to a respiratory nurse specialist within 48 hours of admission.
  2. Those based at DGRI are Phyllis Murphie (33860) and Yvonne Scott (32007)

Asthma Discharge Bundle

  1. The Respiratory Team have prepared an asthma discharge bundle which can be accessed by clicking on the link below.  If printing this for a patient, please ensure you send to the COLOUR print queue – “followyou_colour” as there is coloured text on the reverse.
  2. It has a tear-off slip at the bottom which is double sided.  This provides the patient with a temporary asthma action plan, worsening advice, advice on when to see their GP and links to asthma education.

Behavioural/Psychosocial Factors Predicting Poor Outcome

These are one or more of:

  • Poor compliance
  • Failure to attend appoinments
  • Fewer GP contacts
  • Frequent home visits
  • Self discharge from hospital
  • Psychosis, depression, self harm
  • Major tranquilliser use
  • Denial
  • Alcohol or drug abuse
  • Learning difficulties
  • Employment/income problems
  • Social isolation

Aspirin, NSAIDs and Asthma

  1. A significant number of asthmatics are allergic to aspirin/NSAIDs
  2. Avoid in patients with previous asthmatic reaction to aspirin/NSAIDs and in those at high risk ie asthma with nasal polyps or chronic rhinitis.
  3. For all other asthmatics in whom aspirin or NSAID indicated, inform patient of risk and observe for 3 hours after first dose


Content updated by Yvonne Scott & Alison Moore