Uncontrolled asthma in adults
The information on this page will help you understand how to assess, treat and follow up asthma flare ups and asthma attacks in adults. Click here to see our guidance on uncontrolled asthma in children.
Although some asthma attacks come on without warning, many build up slowly, over hours to days. This means that there is often a window of opportunity to treat them in primary care before symptoms escalate into an emergency.
Making sure that your patient knows the signs of worsening asthma is therefore essential so they can get early help.
Signs of worsening asthma
- Feeling breathless, coughing, tight chest, wheezing
- Symptoms waking you up at night
- Finding it harder to do everyday things like housework, playing with children, or going to work
- Using your reliever inhaler more than usual
- Peak flow dropping below 80% of your usual score
You must make it clear in the amber section of your patient’s personalised asthma action plan what actions they should take when they notice they are getting worse.
This can include increasing both bronchodilators and inhaled corticosteroids (ICS).
Patients on low dose ICS maintenance treatment (≤400μg budesonide equivalent) might benefit from quadrupling their inhaled steroid dose as soon as they notice they are getting worse. Patients on a Maintenance and Reliever Therapy regime automatically increase their ICS when they use their inhaler as a reliever.
Reliever inhalers will need to be used more frequently when asthma is flaring up.
If your patient is not improved or getting worse, they may need a short course of oral steroid tablets (Prednisolone) to stamp out the inflammation that is causing their symptoms.
The usual dose is 40–50mg for 5 days or until they are recovered. If your patient gets worse at any point, make sure they know to seek help.
Click here for a patient advice leaflet about Prednisolone
You should review your patient after 48 hours to check that they are improving. If they are not getting better
- Do not stop the prednisolone
- Ensure that they are reviewed immediately by an experienced clinician or their usual GP to see why they are not improving.
They may have an alternative diagnosis or need hospital admission.
Assessing an asthma attack
All asthma attacks should be considered as severe until the actual severity level is confirmed.
Don’t rely on how your patient looks or acts, as even patients with life-threatening asthma can appear calm. They may look and sound less severe after taking a dose of their reliever inhaler, so bear in mind when they last used it when you are assessing them.
The level of severity determines what management your patient needs.
To work out what level your patient is at, you first need to measure and record the following objective measurements:
Think SHARP
S = SATs
H = heart rate
A = ability to talk in sentences
R = respiratory rate
P = peak flow
There are 3 levels of severity: moderate severe asthma; acute severe asthma; acute life-threatening asthma.
Life threatening asthma attacks
Signs of a life-threatening asthma attack
- Peak flow of less than 33% of their best or predicted PEFR
- Oxygen saturation of less than 92%
- Confusion (not knowing where they are or appearing drowsy and disorientated)
- Exhaustion
- Irregular heart rate
- Low blood pressure
- Cyanosis (bluish lips, fingertips or toes)
- Poor respiratory effort
- Silent chest (where the airways have closed to the extent that breath sounds cannot be heard)
If your patient has ANY life threatening signs, you will need to call 999 for an ambulance, and say that they are having an asthma attack with life threatening features.
Whilst you are waiting for the ambulance, give oxygen to maintain their saturations between 94–98% and nebulised salbutamol 5mg and ipratropium (Atrovent) 0.5mg if available, ideally via oxygen.
If nebulised salbutamol is not available, give 10 puffs of salbutamol inhaler via a spacer, leaving 30 seconds between each puff.
Give your patient Prednisolone 40–50 mg if available.
Continue giving nebulised salbutamol, or 10 puffs of salbutamol inhaler via a spacer, until the ambulance arrives.
Acute severe asthma attacks
Signs of an acute severe asthma attack
- Peak flow of 33%-50% of their best or predicted PEFR
- Oxygen saturations of less than 92%
- Unable to complete sentences in one breath
- Respiration rate over 25 breaths per minute
- Heart rate more than 110 beats per minute.
Give your patient oxygen to maintain their saturations between 94–98% and nebulised salbutamol 5mg if available, ideally via oxygen.
If nebulised salbutamol is not available, give 10 puffs of salbutamol inhaler via a spacer, leaving 30 seconds between each puff.
Give your patient prednisolone 40–50 mg if available
If there is no response to treatment, with PEFR remaining under 50% of their best or expected and heart and respiration rates not improving, you will need to call 999 for an ambulance, and say that they are having an asthma attack which is not responding to treatment.
Check your patient’s notes for any factors that should lower the threshold for admitting them to hospital.
Moderate asthma attacks
Signs of a moderate asthma attack
- Peak flow of less than 50%-75% of their best or predicted PEFR
- Oxygen saturations of more than 92%
- Speaking in full sentences
- Respiration rate below 25 breaths per minute
- Heart rate below 110 beats per minute.
Give your patient 4 puffs of salbutamol inhaler via a large volume spacer, followed by 2 puffs every 2 minutes if they don’t respond, up to 10 puffs.
If there is with PEFR remaining under 75% of their best or expected and heart and respiration rates not improving, give nebulised salbutamol 5mg if available, ideally via oxygen.
Give your patient Prednisolone 40–50 mg if available.
Recovery at home
If your patient responds well, with heart and respiration rate settling and PEFR increasing to more than 50% of their best or predicted, then they can continue their recovery at home, staying on 40-50mg of prednisolone for 5 days (or until they have recovered) in addition to their inhaled corticosteroids.
Adjust their treatment regime if needed, especially if you have identified any factors which affect asthma control.
Safety netting
You must give your patient an Asthma Action Plan which explains clearly what they should do if there any further deterioration. They must seek medical help if they have:
- night-time symptoms or if
- their reliever inhaler isn’t lasting 4 hours at a time
- They are worried or concerned, or someone who lives with them is worried.
Arrange a follow-up appointment within 2 working days to check they're recovering. You can give them the Asthma + Lung UK asthma attack recovery plan.
Check their
- inhaler technique and
- make sure they have a reliever inhaler and spacer if required.
You can also show them the Asthma + Lung UK asthma attack video so they know what to do in an emergency.
Post-attack reviews
Every asthma attack represents a failure in long-term management which should be explored in a post-attack review with an asthma-trained healthcare professional.
The purpose of a post attack review is to work out what caused the attack and what needs to be done to prevent another one. This review should follow the format of an annual review with adherence, inhaler technique, triggers, lifestyle and any other factors which affect asthma control discussed.
Amend your patient’s asthma plan if you have made any medication changes and make an appointment for 4-8 week’s time to review them.
Patients who have had a near-fatal asthma attack should be kept under specialist supervision indefinitely.
A respiratory specialist should follow up all patients admitted with a severe asthma attack for at least one year after the admission.
Asthma attacks are frightening, and your patient may feel worried or stressed afterwards. The Asthma +Lung UK Helpline is here to reassure, support and advise your patient - and you, too - if there’s anything either of you want to talk through in confidence with one of our specialist nurses.