In this post I will outline the principles for treating an asthma attack. Please also check with your doctor/nurse to make sure that you have a plan in place for what do to. This article will likely not cover all the scenarios and details you need to know. Each person has a different situation so please use your common sense and seek clarification from your healthcare team.
What is an asthma attack?
Asthma is an inflammatory condition affecting the inner lining of the small airways in the lungs. These airways are surrounded by smooth muscle which normally controls how open or closed they are, in relation to the body’s requirements for air (exchange of oxygen and carbon dioxide). Excessive inflammation in the airways causes the airways to be “twitchy” and irritated, making them more sensitive to external triggers. When a person with asthma encounters a specific trigger, the smooth muscle spasms and constricts the airway in an abnormal way, and less air passes through. The inflammation itself also plays a role in narrowing the airspace, as the inner lining of the airway is thicker and there is more mucus production taking away some of the space.
When the smooth muscle suddenly constricts around the airway (bronchoconstriction), symptoms of asthma worsen quickly. Most patients describe a sudden onset of breathlessness, inability to exhale the air out of the lungs quickly enough, a sensation of chest tightness or constriction which is often associated with an audible wheeze or coughing.
Asthma attacks may occur without much warning and can be very scary. In many cases however there is usually a slow worsening in the symptoms of asthma over days-weeks preceding a major asthma attack, as the inflammation worsens in the airway.
Finally, it is important to note that asthma symptoms tend to wax and wane (are variable) on a daily basis. If this variability in symptoms increases, it can also be an indicator that asthma control is worsening and that a bigger asthma attack may be coming.
What triggers the asthma attack?
The triggers for asthma attacks can be different depending on the person. Many patients with asthma can sometimes identify a very specific trigger for an asthma attack (e.g. exposure to house dust, other organic dusts, a known allergen, strong emotion, intense physical exercise etc.).
However, in many cases, there is a progressive worsening of respiratory symptoms over days-weeks culminating in asthma attacks of increasing severity. Sometimes a viral infection (seasonal cold or flu) may trigger an overall worsening of asthma, other times it may be a change in environment or work practices, or a lack of controller treatment. It is not always easy to prevent worsening of asthma control as it is known to be a variable condition, and there will be good times and bad times. Taking controller treatment correctly and regularly while also maintaining an overall healthy lifestyle can help with asthma control. Seeing your doctor/nurse regularly also helps to identify the need to step up treatment as required.
Treatment of an asthma attack should be given quickly, as there is always a risk that the attack may worsen rapidly.
Generally, quick acting inhalers are used in the first instance to obtain a rapid relief.
Sometimes the attack may prevent you from inhaling the medication correctly, so a spacer may help to get the inhaler medication in.
In some situations a nebulizer may be used to provide bronchodilator medication (that opens up the airways). This medication is typically the same as the one contained in short acting inhalers.
Normally, most patients with asthma will have a “reliever” inhaler prescribed by their physician, and they should have this inhaler available at all times. The reliever inhaler can differ from patient to patient, but most will be familiar with inhalers such as Ventolin (salbutamol) – also known sometimes as the blue inhaler. Other similar inhalers are available as well. Inhalers containing salbutamol generally have a very rapid onset of their action to open up the constricted airways (minutes), but the effect does not last very long (a few hours). Some alternatives to salbutamol exist, but they may not be as effective as they have a different mechanism of action (e.g. Atrovent, or ipratopium). You can read more about the different types of inhaled medication here.
Some patients may only be given a single inhaler that is used on a regular basis, but can also be used in an asthma attack (single maintenance and reliever therapy – SMART treatment strategy). Normally this inhaler will either be called Symbicort or Foster and it contains two medications in the same inhaler. One medication is an inhaled corticosteroid which controls the airway inflammation when taken on a regular basis. The other medication is called formoterol, and is a bronchodilator that has a long duration of action (~ 12h) but also has a rapid onset of action (almost as quick as salbutamol), allowing it to be used as a reliever as well. By taking extra doses from such a combination inhaler, the asthma attack can sometimes be managed very effectively, by dilating the airways but also providing a boost of controller medication which may help prevent further worsening of the airway inflammation. Not all combination inhalers are however suitable to be used in this way, so please check with your doctor.
If breathlessness has come on too suddenly, it may be difficult to actually use the inhaler correctly, as you may be panting and breathing very rapidly. In these situations, it may be wise to take more inhaler doses than usual. If the asthma attack is not improving, repeating the reliever inhaler administration approximately every 15 minutes should be considered, while also keeping in mind that emergency treatment may be required. Have a low threshold to seek help from emergency services if the asthma attack is not going away or you don’t know what to do, as you may be dealing with a severe asthma attack which can be dangerous.
It is also generally helpful to have a spacer available at home, which is a larger chamber in which you spray the inhaler medication while breathing in from the other end.
A spacer allows you to better time the administration of the inhaler dose, especially when struggling to breathe during an asthma attack. It may allow for a higher and more effective dose of inhaled medication to reach the deeper parts of the lungs, where it is required. The videos below demonstrate how to use a spacer and which inhalers are compatible:
Some patients who really struggle with inhaler technique or who have a really severe asthma attack may sometimes be able to stop it by using a nebulizer device. However, nebulizers are not generally prescribed for all patients. It is important to note that inhaler treatment forms the basis of good asthma treatment, as there are very few options for medications available in a nebulized format.
Normally, if you have been recommended a nebulizer by your doctor, you would also use salbutamol (+/- ipratopium) during an asthma attack, but the dose is usually much higher than in an inhaler. Therefore, nebulizers are generally for severe attacks when you are really unable to use your inhaler at all because of your symptoms or when there is a need to treat the attack aggressively (because of its severity). The inhaler medication comes in a solution which is usually mixed in with normal saline and aerosolized by the machine over a few minutes. Again, if you need to use a nebulizer to treat an asthma attack, have a very low threshold for calling the emergency services in case you are not improving quickly.
What to do if immediate measures do not work?
As stated above, the order of interventions in an asthma attack are generally as follows: use of the reliever inhaler with or without a spacer, consider repeating the administration a few times every ~ 15 minutes, consider using a nebulizer if you know how to use it and have the right medication for it available. Follow-up treatment may then be needed as your symptoms improve as the effects may wear off and you would also need to prevent new attacks (see below).
If you are having a really bad asthma attack and may struggle to cope, it is very important to let someone know – it could be a family member or a friend who may help you with administering your reliever treatments and with calling for professional help as required. If after the initial treatments you are not seeing an improvement, consider calling emergency services as some asthma attacks can be dangerous. There is no shame in asking for help if you really need it and sometimes it may be better to actually see someone qualified in the emergency room, receive the appropriate treatment and return home in a safe manner. Circumstances for this of course may vary around the world so it is important to have a plan in place on how to deal with an asthma attack. A written asthma action plan that you devise with your doctor can actually be very helpful in an emergency, when you may not be able to think clearly about the next steps (because you can become extremely breathless). This plan can include appropriate treatment steps, any additional tablets or medication to take to prevent recurring attacks, useful telephone numbers to call in an emergency.
Indicators of a severe asthma attack / when to consider seeking help
Just to clarify the section above, if any of these things are happening while you are having an asthma attack, you should consider call for help as soon as possible:
- you do not have access to reliever medication at all (no rapidly acting inhaler or no doses left)
- you are unable to use the reliever inhaler because you are too breathless (most of the medication ends up in your mouth or you cannot hold your breath at all after inhaling)
- after repeatedly using the reliever inhaler, you notice no improvement or worsening
- you are becoming drowsy or sleepy
- your breathing is completely stuck, you are only able to take very shallow breaths despite using reliever medication
- your wheezing becomes quieter or completely silent, but you are continuing to feel just as breathless
- if using a pulse oximeter at home, the SpO2 value (oxygen saturation) drops below normal levels (usually below 94%). Very important however to get a correct reading on the pulse oximeter (you should be able to get a good pulse signal and leave the oximeter on for at least a few seconds until the values stabilize). Having a pulse oximeter at home is actually not necessary for most patients, as it can actually distract you from doing other, more important things (such as focusing on your breathing and taking inhalers correctly). You should only use a pulse oximeter if you have discussed this beforehand with your doctor, so that you know how to interpret the values in your case (and not to panic unnecessarily).
- you are really worried about the asthma attack for any other reason. For example this is the worst asthma attack in a string of recent attacks, or it came on during a chest infection or other acute illness, or you have a history of really severe asthma attacks which previously required hospitalization or intensive care admission.
Even if you are having a very severe asthma attack it is really important to try not to panic and to follow logical steps: try to control your breathing, take reliever inhalers as well as you can with correct inhaler technique, use a spacer if required, get in touch with a friend or family member to let them now that you are having issues, call for qualified help early if required. Panicking really does make the situation worse, as you would likely start to hyperventilate, worsening your symptoms.
Preventing future attacks
One of the goals of treating the asthma attack should also be to try to prevent such episodes in the future. Severe asthma attacks sometimes occur after a period of worsening asthma control. It is important to not only think about treating the acute situation (the symptoms of the asthma attack), but to consider how to return to having well controlled asthma. Several bad asthma attacks can happen in a sequence when control is lost, and this can be a dangerous situation. Be mindful that short acting inhalers only have an effect for a few hours and that they do not control the airway inflammation.
Controller treatment is normally stepped up in the aftermath of a bad asthma attack to try to regain control. You should make a plan on how to do that with your doctor before the attack happens, to be prepared. Typically this may involve doubling the doses of inhaled corticosteroids (which are either given on their own in a separate inhaler, or as part of a combination inhaler).
Remember that well controlled asthma means that you very rarely need to use reliever inhalers (perhaps up to twice per week, only during the day) and you are able to engage in most of your daily activities without any trouble. If that is not your situation, an asthma check with your doctor should be considered.
Asthma attacks may worsen during episodes of chest infections, so it is important to be prepared for this scenario – i.e. making sure you have a reliever inhaler ready and that you are not running low on doses of your controller medication. It may be that you have to temporarily increase your controller treatment doses until the infection passes. If you are struggling with an infection, do try to discuss with your doctor about ways to recognize the signs and to treat it (for example if you are having a bacterial infection you may be prescribed antibiotics). Sometimes a “rescue pack” of antibiotics and oral corticosteroids may be prescribed to you to have available in your house.
If there is an indication that asthma is not well controlled, with many asthma attacks in a short period of time for any reason, a brief course of oral corticosteroids (tablets) may sometimes be prescribed by your doctor (usually 5-7 days) to help reduce the inflammation in the airways which is leading to the attacks.
After a bad asthma attack, it is important to go for an asthma check with your doctor to see what happened and if you may be able to better prepare for the next one and try to prevent it by having good controller treatment.