• Ask about possible trigger factors, such as a recent upper respiratory tract infection.
• Ask about the type and duration of symptoms, what treatment has been started (if any), and whether treatment has improved symptoms.
• Assess the severity of the exacerbation:
• Look for signs of exhaustion (inability to complete sentences) and cyanosis (bluish lips or extremities).
• Examine the person's chest and record the respiratory rate, pulse, and blood pressure.
• Record the peak expiratory flow rate (if the person is old enough to comply) and use the best of three recordings to grade the severity of the attack on the basis of the person's best or predicted value:
• Moderate: more than 50–75%.
• Acute severe: 33–50%.
• Life-threatening: < 33%.
• Measure a person's oxygen saturation in room air using pulse oximetry (if available).
• Ask about depression, alcohol misuse, poor compliance with medication, social isolation and previous exacerbations as these factors will reduce the threshold for hospital admission.

In depth

• Admit all people with a life-threatening asthma exacerbation (peak expiratory flow rate [PEFR] usually < 33% best or predicted and/or oxygen saturation < 92%).
• Admit people with a severe asthma exacerbation (PEFR usually 33–50% best or predicted) who do not rapidly respond to initial treatment or who have a factor that warrants a lower threshold for admission.
• Admit people with a moderate asthma exacerbation (PEFR usually > 50% best or predicted) who have a factor that warrants a lower threshold for admission.
• The following factors should lower the threshold for admission:
• People under 18 years.
• Poor concordance.
• Person lives alone.
• Psychological problems such as depression, and alcohol or drug misuse.
• Physical or learning disability.
• Previous near-fatal attack or brittle asthma.
• Persistent exacerbation despite an adequate dose of oral corticosteroids before presentation.
• Presentation at night or in the afternoon.
• Pregnancy.

In depth

• Prescribe a short course of oral prednisolone. The usual dose for someone not taking a regular corticosteroid is:
• Child < 2 years: 10 mg once a day for 3 days
• Child 2–5 years: 20 mg once a day for 3 days
• Child 6–12 years: 30–40 mg once a day for 3 days
• Adult or child > 12 years: 40–50 mg once a day for 5 days
• Do not prescribe antibiotics routinely, unless symptoms and signs suggest a bacterial infection.
• Advise the person (or parent of a child) to use their short-acting beta₂-agonist via a large-volume spacer.
• For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
• For a child, give 2 puffs every 2 minutes according to response, up to 10 puffs.
• Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response.
• After the short-acting beta₂-agonist has been given (up to 10 puffs), advise the person (or parent of a child):
• To return to using their short-acting beta₂-agonist as-required, up to four times a day (not exceeding 4-hourly use).
• To monitor their peak expiratory flow rate (PEFR) and symptoms. If symptoms worsen, or PEFR decreases after starting treatment, they should seek further medical advice.
• Follow up a person (ideally) within 24 hours, or sooner if they deteriorate, and within 1 week after an exacerbation.

In depth

• One week after an asthma exacerbation in all people:
• Assess the exacerbation:
• Ask about the duration and severity of the exacerbation compared with any previous episodes. Record the number of exacerbations and hospital admissions.
• Identify possible trigger factors, such as exercise, work, or allergens.
• Optimize treatment:
• Ask about compliance with treatment before the exacerbation and review the person's inhaler technique (correcting problems).
• Provide advice on lifestyle, vaccinations, diet, exercise, and smoking. If the individual or parent of the child smokes, advise them to stop.
• Consider stepping-up treatment by increasing inhaled corticosteroids or adding in new preventive therapy.
• Review self-management education and written action plan:
• Review the person's understanding of how to recognize an exacerbation and what to do at the early signs of an exacerbation (increase beta₂-agonist and start oral corticosteroids).
• Reinforce understanding by updating the written action plan.

In depth

• Organize urgent hospital admission.
• Give high-flow oxygen (40–60%) with a tight-fitting mask. If pulse oximetry is available, adjust the flow rate to maintain an oxygen saturation of 94–98%.
• Give a short-acting inhaled beta₂-agonist:
• For life-threatening asthma, give via a nebulizer, if available. Repeat every 20–30 minutes according to clinical response.
• Ideally, nebulizers should be oxygen driven (flow rate of 6 L/min usually needed) to avoid worsening hypoxia.
• For severe attacks, give via a nebulizer (preferred for children if available) or use a pressurized metered-dose inhaler with a large-volume spacer.
• For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs.
• For a child, give 2 puffs every 2 minutes according to response, up to 10 puffs.
• Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response.
• For moderate attacks, use a pressurized metered-dose inhaler with a large-volume spacer.
• Give the first dose of a course of prednisolone.
• Monitor peak expiratory flow rate (if the person can comply) and oxygen saturation (if available) to assess response to treatment.
• If the person does not respond to a beta₂-agonist, consider continuous nebulized beta₂-agonists or addition of ipratropium bromide (via a nebulizer). However, aim to get the person to hospital urgently.

In depth

• One week after an asthma exacerbation in all people:
• Assess the exacerbation:
• Ask about the duration and severity of the exacerbation compared with any previous episodes. Record the number of exacerbations and hospital admissions.
• Identify possible trigger factors, such as exercise, work, or allergens.
• Optimize treatment:
• Ask about compliance with treatment before the exacerbation and review the person's inhaler technique (correcting problems).
• Provide advice on lifestyle, vaccinations, diet, exercise, and smoking. If the individual or parent of the child smokes, advise them to stop.
• Consider stepping-up treatment by increasing inhaled corticosteroids or adding in new preventive therapy.
• Review self-management education and written action plan:
• Review the person's understanding of how to recognize an exacerbation and what to do at the early signs of an exacerbation (increase beta₂-agonist and start oral corticosteroids).
• Reinforce understanding by updating the written action plan.

In depth

• Advise overweight people that a healthy diet and regular exercise will help with weight reduction and improve asthma control:
• Advise people (if possible) to take 30 minutes of exercise to increase their heart rate at least five times weekly. For more information on weight loss, see the CKS topic on Obesity.

In depth

• Advise smokers with asthma to stop smoking and provide them with the appropriate help. For more information, see the CKS topic on Smoking cessation.
• Advise people with asthma to, as far as possible, avoid exposure to tobacco smoke. For parents who smoke and have a child with asthma, this means either stopping smoking (the best option), or not smoking in the same room as the child (or, preferably, not smoking in the house).

In depth

• Advise an influenza and a pneumococcal vaccination if asthma is severe and requires hospital admission or frequent use of corticosteroids.
• For more information, see the CKS topics on:
• Immunizations - seasonal influenza.
• Immunizations - pneumococcal.

In depth

• Advise to report symptoms of conditions that could worsen asthma, such as rhinitis, sinusitis, gastro-oesophageal reflux disease, and sleep apnoea.

In depth

• Advise to avoid (if possible) known trigger factors, especially at times when asthma is poorly controlled.
• Advise all adults to report promptly any worsening asthma control during work.

In depth