Recommendations
Urgent
Perform a primary survey, assessing the patient’s airway, breathing, and circulation.[1]
Admit to an intensive care or high-dependency unit those patients requiring ventilatory support and those with acute severe or life-threatening asthma who fail to respond to standard therapy. To assess this, look for:[1][13]
Deteriorating peak expiratory flow (PEF)
Persistent or worsening hypoxia
Hypercapnia
Arterial blood gas analysis showing a fall in pH or rising hydrogen concentration
Exhaustion
Feeble respiration
Drowsiness, confusion, or altered consciousness
Respiratory arrest.
Obtain help from a senior/intensive care colleague immediately if critical care is required.[13]
Acute severe asthma in pregnancy is an emergency. Call for senior obstetric support.
In the community:
Key Recommendations
Treat with bronchodilators, oxygen, and corticosteroids. Necessary treatments are usually given concurrently for rapid improvement.[1]
Do not routinely prescribe antibiotics.[1][13]
Closely monitor the patient when giving treatment in any setting and titrate treatment according to response.[1]
People with asthma who have respiratory symptoms are at risk of becoming seriously unwell very quickly.[13] The patient may progress to a life-threatening exacerbation.
In people who present with an exacerbation of undiagnosed asthma, it is recommended to start MART (Maintenance And Reliever Therapy) alongside any treatment for the acute symptoms. This is a combination of Inhaled Corticosteroid with Formoterol).[34]
This topic covers the management of adults. See Acute asthma exacerbation in children. Children aged 12 years and older are generally treated the same as adults. However, consult your local paediatric guidance as there may be some differences in the treatment approach and weight-based dosing may be recommended in some adolescents.
The aim of treatment is to:[1]
Rapidly relieve airflow obstruction and hypoxaemia
Address the underlying inflammatory pathophysiology
Prevent relapse.
Perform a primary survey, assessing the patient’s airway, breathing, and circulation.[1]
For a patient in cardiorespiratory arrest, start CPR according to your regional adult advanced life support guidelines and call for help. In the UK, consult the Resuscitation Council guidelines.[59]
Obtain help from a senior/intensive care colleague immediately if critical care is required.[13]
Decide the management plan based on the patient’s clinical status. For details of how to classify the patient, see Diagnosis recommendations. See the Pregnancy (in hospital) section below for management of a pregnant patient.
Closely monitor all patients (assessing both symptoms and objective measures, including oxygen saturation where available, and where practicable, lung function testing) when giving treatment in any setting and titrate treatment according to response.[1] People with asthma who have respiratory symptoms are at risk of becoming seriously unwell very quickly.[13]
For details of how to classify the patient, see Diagnosis recommendations.
Admit to an intensive care or high-dependency unit those patients requiring ventilatory support and those with acute severe or life-threatening asthma who fail to respond to standard therapy. To assess this, look for:[1][13]
Deteriorating PEF
Persistent or worsening hypoxia
Hypercapnia
Arterial blood gas analysis showing a fall in pH or rising hydrogen concentration
Exhaustion
Feeble respiration
Drowsiness, confusion, or altered consciousness
Respiratory arrest.
Admit the patient and obtain help from a senior/intensive care colleague immediately.[13]
The patient should be accompanied by a nurse or doctor at all times.[13]
Oxygen
Urgently give supplementary oxygen to a hypoxaemic patient, using a face mask, Venturi mask, or nasal cannula with flow rates adjusted as necessary to maintain an oxygen saturation (SpO2) of 93% to 95%.[1]
Controlled, low-flow oxygen is associated with better outcomes than high concentration of oxygen.[1][51]
Monitor SpO2. Record oxygen saturation by pulse oximetry. Maintain arterial SpO2 at 93% to 95%.[1]
Do not delay oxygen administration in the absence of pulse oximetry.[13]
Repeat arterial blood gas within one hour of starting treatment if:[13]
initial PaO2 is <8 kPa (<60 mmHg) unless SpO2 is >92%, or
initial PaCO2 is 'normal' or raised, or
the patient’s condition deteriorates.
Repeat blood gas measurements and pulse oximetry again at 4 to 6 hours if the patient’s condition has not improved.[13]
Monitor the patient for hypercapnia. Hypercapnia indicates the development of near-fatal asthma.[13] Call for emergency specialist/anaesthetic intervention if hypercapnia is present. Take care to avoid hypoxia as well as over-oxygenation.[13]
Short-acting bronchodilators
Beta-2 agonists
Give a high-dose inhaled short-acting beta-2 agonist (e.g., salbutamol) as a first-line agent as early as possible.[13]
Inhaled beta-2 agonists act quickly and have few side-effects.[13]
Inhaled beta-2 agonists are as efficacious and are preferable to intravenous beta-2 agonists.[13]
Administer by wet nebulisation driven by oxygen.[13]
Use a flow rate of at least 6 L/minute.[13]
Fit a high-flow regulator where oxygen cylinders are used.[13]
Avoid using an air-driven compressor owing to the risk of oxygen desaturation.[13]
Still administer nebulised therapy, even in the absence of supplemental oxygen.[13]
Measure and record PEF before and after the beta-2 agonist is given, and at least 4 times daily throughout the patient’s hospital stay.[13]
Use a metered-dose inhaler with a spacer for the beta-2 agonist if a nebuliser is not available. This recommendation is based on clinical experience because there is insufficient evidence for guidelines to recommend the use of a metered-dose inhaler with a spacer for life-threatening or acute severe asthma.[1][13]
Give intravenous beta-2 agonists for a patient in whom inhaled therapy cannot be used reliably.[13]
Consider monitoring serum lactate when using intravenous beta-2 agonists.[13]
In ventilated patients, consider parenteral beta-2 agonists in addition to inhaled beta-2 agonists. There is limited evidence to support this.[13]
Antimuscarinics
Add a nebulised antimuscarinic (e.g., ipratropium) to short-acting beta-2 agonist treatment, via an oxygen-driven nebuliser.[13]
Combined therapy can result in greater bronchodilation than a beta-2 agonist alone, leading to a faster recovery and shorter duration of admission.[13]
Corticosteroids
Give a corticosteroid immediately (as the earlier they are given the better the outcome).[13] The European Respiratory Society/European Academy of Allergy and Clinical Immunology (ERS/EAACI) and the Global Initiative for Asthma (GINA) recommend doing this within 1 hour (and GINA notes it can take 4 hours for clinical improvements to be observed).[1][51]
Give oral prednisolone, provided it can be swallowed and retained by the patient.[13] Oral corticosteroids are as effective as those given parenterally, and oral administration is faster and less invasive.[1][13]
Consider parenteral hydrocortisone or methylprednisolone as an alternative to oral treatment, where oral treatment is not possible (e.g., the patient is too dyspneic to swallow, is vomiting, or requires non-invasive ventilation or intubation).[1][13]
Continue prednisolone (or the alternative parenteral corticosteroid) until recovery (for a minimum of 5 days).[13] Switch the parenteral corticosteroid to an oral corticosteroid when an oral treatment can be tolerated by the patient.
Do not stop inhaled corticosteroids during prescription of oral or parenteral corticosteroids.[13]
Other supportive care
Give intravenous fluids if needed, and correct electrolyte imbalances.[13]
See Ongoing care (in hospital) section below.
If the patient is not improving after 15 to 30 minutes of treatment:[13]
Continue to give oxygen
Use continuous (i.e., ‘back to back’) nebulisation of salbutamol if there is an inadequate response to initial treatment. Alternatively, give repeat doses at 15 to 30 minute intervals.[13]
Continue ipratropium every 4 to 6 hours until the patient improves.[13]
If the patient still does not improve
Discuss the patient who has still not improved, despite initial management, with a senior clinician and the intensive care team. A senior clinician may consider the use of intravenous bronchodilators or intravenous aminophylline or mechanical ventilation.[13]
Consider monitoring serum lactate when using intravenous beta-2 agonists.[13]
Consider a single dose of intravenous magnesium sulfate for the patient with asthma with PEF <50% of best or predicted who has not responded well to initial inhaled bronchodilator therapy.[1][13]
[ 
]
[Evidence A]
Intravenous magnesium sulfate has been shown to reduce hospital admissions in severe exacerbations and in those who fail to respond to initial treatment.[51]
Consult senior colleagues before use.
Nebulised magnesium sulfate is not recommended for treatment in adults with acute asthma.[13]
Consult senior colleagues before using intravenous aminophylline.[13]
It is not likely to offer additional benefit, has known side effects, and a narrow therapeutic index.[13]
Consider in a patient with life-threatening asthma who has had a poor response to initial therapy.
Check blood theophylline levels on admission in any patient already taking oral aminophylline or theophylline.[13]
Check blood levels daily for a patient on aminophylline infusions until intravenous aminophylline is discontinued.[13]
Measure the serum theophylline concentration if aminophylline is continued for more than 24 hours (aim for a concentration of 10 to 20 mg/L [55–110 micromol/L], although lower concentrations may be effective).[13] Adverse effects can occur at this range; however, the frequency and severity increase at concentrations >20 mg/L (>110 micromol/L). Adjust the infusion rate as necessary.
Antibiotics
For details of how to classify the patient, see Diagnosis recommendations.
Oxygen
Urgently give supplementary oxygen to a hypoxaemic patient, using a face mask, Venturi mask or nasal cannula with flow rates adjusted as necessary to maintain an oxygen saturation (SpO2) of 93% to 95%. Avoid over-oxygenation.[1][13]
Controlled, low-flow oxygen is associated with better outcomes than high concentration of oxygen.[1][51]
Monitor SpO2. Record oxygen saturation by pulse oximetry. Maintain arterial SpO2 at 93% to 95%.[1]
Repeat arterial blood gas within one hour of starting treatment if:[13]
initial PaO2 is <8 kPa (<60 mmHg) unless SpO2 is >92%, or
initial PaCO2 is 'normal' or raised, or
the patient’s condition deteriorates.
Repeat blood gas measurements and pulse oximetry again at 4 to 6 hours if the patient’s condition has not improved.[13]
Do not delay oxygen administration in the absence of pulse oximetry.[13]
Monitor the patient for hypercapnia. Hypercapnia indicates the development of near-fatal asthma.[13] Call for emergency specialist/anaesthetic intervention if hypercapnia is present. Avoid hypoxia as well as over-oxygenation.[13]
Short-acting bronchodilators
Beta-2 agonists
Give a high-dose inhaled short-acting beta-2 agonist (e.g., salbutamol) as a first-line agent as early as possible.[13]
Inhaled beta-2 agonists act quickly and have few side-effects.[13]
Inhaled beta-2 agonists are as efficacious and are preferable to intravenous beta-2 agonists.[13]
Administer by wet nebulisation driven by oxygen.[13]
Use a flow rate of at least 6 L/minute[13]
Fit a high-flow regulator where oxygen cylinders are used.[13]
There is a risk of oxygen desaturation if using an air-driven compressor.[13]
Still administer nebulised therapy, even in the absence of supplemental oxygen.[13]
Measure and record PEF before and after the beta-2 agonist is given, and at least 4 times daily throughout the patient’s hospital stay.[13]
Use a metered-dose inhaler with a spacer for the beta-2 agonist if a nebuliser is not available. This recommendation is based on clinical experience because there is insufficient evidence for guidelines to recommend the use of a metered-dose inhaler with a spacer for life-threatening or acute severe asthma.[1][13]
Give intravenous beta-2 agonists to the patient in whom inhaled therapy cannot be used reliably.[13]
Consider monitoring serum lactate when using intravenous beta-2 agonists.[13]
Antimuscarinics
Add nebulised ipratropium to short-acting beta-2 agonist treatment, via an oxygen-driven nebuliser.[13]
Combined therapy produces significantly greater bronchodilation than a beta-2 agonist alone, leading to a faster recovery and shorter duration of admission.[13]
Corticosteroids
Give a corticosteroid as early as possible (as the earlier they are given the better the outcome).[13] The European Respiratory Society/European Academy of Allergy and Clinical Immunology (ERS/EAACI) and GINA recommend doing this within 1 hour (and GINA notes it can take 4 hours for clinical improvements to be observed).[1][51]
Give oral prednisolone, provided it can be swallowed and retained by the patient.[13] Oral corticosteroids are as effective as those given parenterally, and oral administration is faster and less invasive.[1][13]
Consider parenteral hydrocortisone or methylprednisolone as an alternative to oral treatment, where oral treatment is not possible (e.g., the patient is too dyspneic to swallow, is vomiting, or requires non-invasive ventilation or intubation).[1][13]
Continue prednisolone (or the alternative parenteral corticosteroid) until recovery (for a minimum of 5 days).[13] Switch the parenteral corticosteroid to an oral corticosteroid when an oral treatment can be tolerated by the patient.
Do not stop inhaled corticosteroids during prescription of oral or parenteral corticosteroids.[13]
Other supportive care
Give intravenous fluids if needed, and correct electrolyte imbalances.[13]
See Ongoing care (in hospital) section below.
If the patient is not improving after 15 to 30 minutes of treatment:[13]
Continue to give oxygen
Use continuous (i.e., ‘back to back’) nebulisation of salbutamol if there is an inadequate response to initial treatment. Alternatively, give repeat doses at 15 to 30 minute intervals.[13]
Continue ipratropium every 4 to 6 hours until the patient improves.[13]
If the patient still does not improve
Discuss the patient who has still not improved, despite initial management, with a senior clinician and the intensive care team.
Closely monitor the patient (assessing both symptoms and objective measures, including oxygen saturation where available, and where practicable, lung function testing) when giving treatment in any setting and titrate treatment according to response.[1] People with asthma who have respiratory symptoms are at risk of becoming seriously unwell very quickly.[13] The patient may progress to a life-threatening exacerbation. See Life-threatening asthma (in hospital) sections above for management of these patients.
Consider a single dose of intravenous magnesium sulfate for the patient with acute severe asthma (PEF <50% of best or predicted) who has not responded well to initial inhaled bronchodilator therapy.[1][13]
Intravenous magnesium sulfate has been shown to reduce hospital admissions in severe exacerbations and in those who fail to respond to initial treatment.[51]
Consult senior colleagues before use.
Nebulised magnesium sulfate is not recommended for treatment in adults with acute asthma.[13]
Antibiotics
For details of how to classify the patient, see Diagnosis recommendations.
Short-acting bronchodilators
Immediately administer a short-acting beta-2 agonist (e.g., salbutamol) by repeated activations of a pressurised metered-dose inhaler via an appropriate large volume spacer.
Repeat the salbutamol dose using a nebuliser if there is no improvement.[13]
An antimuscarinic is not necessary and may not be beneficial in milder attacks.[13]
Evidence: Delivery of beta-2 agonists
In adults with mild to moderate acute asthma exacerbations, a spacer device with a pressurised metered-dose inhaler is as effective as a nebuliser for the delivery of beta-2 agonists. However, there is insufficient evidence for adults with severe and life-threatening asthma, therefore nebulisers are recommended for these patients.
The 2019 joint Scottish Intercollegiate Guidelines Network and British Thoracic Society (SIGN/BTS) guideline on the management of asthma recommends that for adults with mild to moderate asthma attacks, a beta-2 agonist can be given via repeated activations of a pressurised metered-dose inhaler plus spacer.[13] However, due to insufficient data on the use of metered-dose inhalers with spacers in acute severe or life-threatening asthma they recommend, where available, administering beta-2 agonists by wet nebulisation driven by oxygen for these patients.
The underpinning evidence is from a Cochrane systematic review (search date February 2013) in adults (n=729) and children (n=1897) with acute asthma requiring medical assistance.[60]
The Cochrane review included 39 randomised controlled trials (RCTs) comparing delivery of beta-2 agonists via metered‐dose inhaler plus spacer versus nebuliser.
Settings included the emergency department (31 RCTs), an equivalent community setting (2 RCTs), and inpatients (6 RCTs).
Treatment with beta-2 agonists was repeated and titrated as required.
All studies excluded people with life-threatening asthma.
Results were reported separately for adults and children.
For adults, there was no difference in hospital admission rates (subgroup analysis for adults: RR 0.94, 95% CI 0.61 to 1.43).
There was also no difference in length of stay in the emergency department (mean difference 1.75 minutes, 95% CI -23.45 to +26.95 minutes).
Peak flow and forced expiratory volume (FEV1) at 30 minutes or at the end of the study were also similar, including in adults with severe asthma (4 RCTs, n=99, final rise in FEV1 as a percentage of predicted: mean difference -1.60% predicted, 95% CI ‐4.49% to +7.69%).
One small study included in the review was in adult inpatients (n=28). Multiple treatments were allowed including standard doses of intravenous aminophylline and methylprednisolone.
There was no difference in administering a beta-2 agonist via a metered-dose inhaler plus spacer compared with a nebuliser in mean duration of hospitalisation (n=18, mean difference -0.60 days, 95% CI -3.23 to +2.03 days).
There were also no significant differences in lung function between groups.
Corticosteroids
Give corticosteroids as early as possible (as the earlier they are given the better the outcome).[13] The European Respiratory Society/European Academy of Allergy and Clinical Immunology (ERS/EAACI) and GINA recommend doing this within 1 hour (and GINA notes it can take 4 hours for clinical improvements to be observed).[1][51]
Give oral prednisolone, provided it can be swallowed and retained by the patient.[13] Oral corticosteroids are as effective as those given parenterally, and oral administration is faster and less invasive.[1][13]
Consider parenteral hydrocortisone or methylprednisolone as an alternative to oral treatment, where oral treatment is not possible (e.g., the patient is too dyspneic to swallow, is vomiting, or requires non-invasive ventilation or intubation).[1][13]
Continue prednisolone (or the alternative parenteral corticosteroid) until recovery (for a minimum of 5 days).[13] Switch the parenteral corticosteroid to an oral corticosteroid when an oral treatment can be tolerated by the patient.
Do not stop inhaled corticosteroids during prescription of oral or parenteral corticosteroids.[13]
Oxygen
Consider oxygen therapy. Titrate against pulse oximetry, if available. Do not withhold oxygen if oximetry is not available, but monitor for signs of hypercapnia or respiratory failure, such as deterioration or fatigue.[1] Oxygen saturation should be maintained at no higher than 93% to 95%.[1]
Other supportive care
Give intravenous fluids if needed, and correct electrolyte imbalances.[13]
Continue the patient's usual treatment and consider reviewing if there is evidence of poor control long-term or frequent exacerbation events.[13]
Assess response to treatment at 1 hour or earlier.[1]
See Ongoing care (in hospital) section below.
If the patient does not improve
Discuss the patient with moderate asthma who has not improved, despite initial management, with a senior clinician.
Closely monitor the patient (assessing both symptoms and objective measures, including oxygen saturation where available, and where practicable, lung function testing) when giving treatment in any setting and titrate treatment according to response.[1] People with asthma who have respiratory symptoms are at risk of becoming seriously unwell very quickly.[13] The patient may progress to a life-threatening exacerbation. See Life-threatening asthma (in hospital) sections above for management of these patients.
Admit the patient to hospital if:[13]
They have any feature of a life-threatening or near-fatal asthma attack (see Diagnosis recommendations)
They have a severe asthma attack that does not resolve after initial treatment
You have concerns about symptoms, previous history, or psychosocial issues, even if peak flow has improved to greater than 75% of best or predicted 1 hour after initial treatment.
Have a lower threshold for admission for:[13]
An afternoon or evening attack
Recent nocturnal symptoms or hospital admission
Previous severe attacks
A patient unable to assess their own condition
Concern over social circumstances.
From the emergency department, admit any patients whose peak flow is less than 75% of best or predicted 1 hour after initial treatment, or who meet any of the following criteria:[13]
Patient still has significant symptoms
You have concerns about adherence
Patient lives alone or is socially isolated
Patient has psychological problems
Patient has physical disability or learning difficulties
Previous near-fatal asthma attack
Asthma attack despite adequate dose of oral corticosteroid prior to presentation
Presentation at night
Pregnancy.
Consider admission to intensive care or high-dependency units for patients requiring ventilatory support and those with acute severe or life-threatening asthma who fail to respond to therapy.[13] Look for:
Hypercapnia[13]
Arterial blood gas analysis showing a fall in pH or rising hydrogen concentration[13]
Exhaustion or feeble respiration[13]
Respiratory arrest[13]
Poor respiratory effort[13]
Silent chest[1]
Pregnancy (see Pregnancy (in hospital) section below).
Ensure any patient being transferred is accompanied by a doctor prepared to intubate.[13]
Treat all pregnant women with acute severe asthma in hospital.[13]
Call for senior obstetric support. Quickly refer to critical care pregnant women with acute, severe asthma.[13]
Acute severe asthma in pregnancy is an emergency and should be treated vigorously.[13]
Treat with drug therapy as for non-pregnant patients including systemic corticosteroids and magnesium sulfate (see above for details of treatment for life-threatening, acute severe, and moderate asthma exacerbations).[34]
Immediately deliver high-flow oxygen to maintain a saturation of 93% to 95%.[1]
Progesterone-driven increase in minute ventilation may lead to relative hypocapnia and respiratory alkalosis and higher PaO2, but oxygen saturations are unaltered.[13]
Acidosis is poorly tolerated by the fetus.[13]
Use continuous fetal monitoring.[13]
Continue to monitor signs and symptoms
Continue to monitor symptoms.[13] Continue to record the heart and respiratory rate.[13]
Measure and record peak expiratory flow (PEF) 15 to 30 minutes after starting treatment, and thereafter according to the response.[13] Measure PEF at least 4 times daily during the patient’s hospital stay.[13]
Measure serum potassium and blood glucose concentrations.[13] If the patient is on aminophylline/theophylline, continue monitoring blood theophylline levels.
Continuing pharmacotherapy
Continue prednisolone (or the alternative parenteral corticosteroid) until recovery (for a minimum of 5 days).[13]
Following recovery, corticosteroids can generally be stopped abruptly.[13] In practice, this tends to apply if given for no more than 14 days.
Doses do not need tapering provided the patient receives inhaled corticosteroids.
Taper doses for the patient on maintenance corticosteroid treatment or where corticosteroids are required for 3 weeks or more.[13]
Discharge
Consider discharge for the patient who:[13]
Has clinical signs compatible with home management
Is on reducing amounts of a short-acting beta-2 agonist (preferably no more than every 4 hours)
Is on medical therapy that they can continue safely at home.
Discharge the patient from the emergency department if their peak flow is greater than 75% of best or predicted 1 hour after initial treatment, unless they meet any of the following criteria:[13]
Patient still has significant symptoms
You have concerns about adherence
Patient lives alone or is socially isolated
Patient has psychological problems
Patient has physical disability or learning difficulties
Previous near-fatal asthma attack
Asthma attack despite adequate dose of oral corticosteroid prior to presentation
Presentation at night
Pregnancy.
Do not base the timing of discharge on a single physiological parameter.[13]
Check and record inhaler technique prior to discharge.[1][13] The patient should have been on discharge medication for 12 to 24 hours prior to discharge.[13]
In a recovered patient, aim for a PEF >75% of best or predicted before considering discharge. Agree the patient’s discharge with a respiratory physician if the PEF diurnal variability is >25%.[13]
Consider an extended observation period prior to discharge in all patients who received a nebulised short-acting beta-2 agonist prior to presentation.[13]
Generally treatment should be stepped up for a period after an exacerbation (especially if the exacerbation occurred on a background of long term poor asthma control).[1] Arrange the necessary ongoing treatment before the patient goes home.[1] This should include the assessment of preventer (controller) medication with the aim of reducing reliever usage. GINA recommends that patients should resume their normal reliever inhaler before discharge (if a different one was used for acute management) and be transitioned back to as-needed rather than regular use of this, based on symptomatic and objective improvement.[1] Regular use of a short-acting beta-2 agonist inhaler may mask worsening asthma and can increase risk of further exacerbations.[1] In people who present with an exacerbation of undiagnosed asthma, it is recommended to start MART (Maintenance And Reliever Therapy) alongside any treatment for the acute symptoms. This is a combination of Inhaled Corticosteroid with Formoterol). This may be stepped down to ‘as needed’ post discharge.[34]
Ensure the patient has a supply of inhaled corticosteroid and bronchodilator(s), and check and record their inhaler technique.[13]
Arrange a structured review by a member of the specialist respiratory team prior to discharge.[61]
Ensure the patient has a written asthma action plan, has had their inhaler technique assessed, and arrange follow-up with a general practitioner (GP) within 2 working days post-discharge (to further assess and optimise their asthma management).[13][34] Asthma and Lung UK: adult asthma action plan Opens in new window Send a discharge letter to the GP and refer the patient to an asthma liaison nurse or chest clinic.[13] Hospitalised patients should have follow-up with a hospital specialist asthma nurse or respiratory physician approximately 1 month after admission.[13] Work together with the patient to support them and aim to improve their long-term asthma care if needed. See Patient discussions.
Exacerbations are very debilitating for a patient and attempts must be made to break the cycle in a patient with recurrent exacerbations.[51]
In the patient with severe asthma and adverse behavioural or psychosocial features, determine the reasons for their exacerbation and send details of their admission, discharge, and potential best PEF to their GP. These patients are at risk of further severe or fatal exacerbations.[13]
In the community, arrange immediate hospital admission via an ambulance for any patient with possible life-threatening asthma and for patients withacute severe asthma (including pregnant patients).[13] See Diagnosis recommendations.
Alert the receiving hospital unit.
Consider other factors, such as failure to respond to treatment, comorbidities, or social circumstances, when considering which patients to refer.[13]
Moderate exacerbations can often be treated in the community (if appropriate resources and expertise is available).[1][13]
Admit to hospital patients with features of acute severe asthma present after initial treatment or patients with previous episodes of near-fatal asthma.[13]
People with asthma who have respiratory symptoms are at risk of becoming seriously unwell very quickly.[13]
These patients should have immediate access to a health professional trained in the emergency treatment of asthma.[13]
Appropriate treatment should be started (where available) while transfer to hospital is arranged.[1] Stay with the patient until the ambulance arrives.[13]
The patient may receive a short-acting beta-2 agonist via oxygen-driven nebuliser in the ambulance.[13]
Most asthma deaths occur before admission to hospital.[13]
Life-threatening asthma
Arrange immediate hospital admission.[13] Give a short-acting beta-2 agonist, antimuscarinic (e.g., ipratropium), oxygen, and a systemic corticosteroid while awaiting transfer.[1]
Give oxygen, if available, to maintain an oxygen saturation (SpO2) of 93% to 95%.[1]
See Life-threatening asthma sections above for details of drug and oxygen treatments, and when to escalate.
Acute severe asthma
See Acute severe asthma (in hospital) section above for details of drug and oxygen treatments, and when to escalate.
Admit any patient with acute severe asthma to hospital via an ambulance.[13]
Appropriate treatment should be started (where available) while transfer to hospital is arranged.[1] Stay with the patient until the ambulance arrives.[13]
Send written assessment and referral details to the hospital.
The patient may receive a short-acting beta-2 agonist via oxygen-driven nebuliser in the ambulance.[13]
Moderate asthma
Treat in the community and assess response to treatment (assessing symptoms and, if available, oxygen saturation and lung function testing).[1][13]
See Moderate asthma (in hospital) section above for details of drug and oxygen treatments, and when to escalate.
Arrange immediate hospital admission via an ambulance if the patient has:[13]
Features of acute severe or life-threatening asthma present after initial treatment
Previous near-fatal asthma.
Have a lower threshold for admission for:[13]
An afternoon or evening attack
Recent nocturnal symptoms or hospital admission
Previous severe attacks
A patient unable to assess their own condition
Concern over social circumstances.
Always consider transfer to hospital in any patient where the symptoms continue or worsen despite treatment.[1]
Follow-up after treatment or discharge from hospital
Continue oral prednisolone until recovery (for a minimum of 5 days). Continue to monitor symptoms and PEF.[13]
Arrange early follow-up (within 2 working days) after an exacerbation, regardless of whether it was managed in hospital or in the community.[1][13][34] Work together with the patient to support them and aim to improve their long-term asthma care if needed.
Exacerbations are very debilitating for a patient and attempts must be made to break the cycle in a patient with recurrent exacerbations.[51]
Check inhaler technique
Ensure the patient has a written asthma action plan Asthma and Lung UK: adult asthma action plan Opens in new window
Make sure it is appropriate for their level of control and for their health literacy.[1] This should include details of how they should respond to worsening asthma. See Patient discussions.
Modify treatment according to guidelines for chronic persistent asthma
Address potentially preventable contributors to hospital admission.
Flag the patient identified as being at increased risk of asthma-related death for a more frequent review.[1]
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