How to recognise an asthma exacerbation (attack)

Asthma attacks can be dangerous

Early warning signs or symptoms of an asthma exacerbation (asthma attack) include cough, extra use of reliever inhaler, difficulty breathing, wheezing, or difficulty sleeping because of these symptoms. Asthma Control test (ACT)score below 20 also indicates a possible exacerbation or attack. Asthma attacks can be very severe and dangerous. They can flare up without warning. Early warning signs of an asthma attack must be recognised both by patients and doctors to prevent deterioration This applies to patients and health care professionals.

Asthma is a chronic ongoing disease

Asthma is an ongoing chronic disease and what happens is that there are times when people with this disease are very well, and others when it flares up. These flare-ups can be very sudden or they can develop slowly over weeks.

Acute sudden asthma attacks are easy to diagnose

When someone with asthma suddenly becomes short of breath, which may include wheezing (that is a whistling nose coming from the chest) most people with asthma and most doctors will recognise this and make the diagnosis. In these circumstances treatment will usually be started quickly.

Asthma awareness is needed to recognise gradual onset attacks

Clinical awareness of asthma by doctors and attention to detail is necessary to diagnose an asthma attack that is developing slowly. It can take a few weeks sometimes for an attack to develop.

Asthma expertise essential in primary care and ED/A&E

Asthma is a very common disease. Therefore anyone working in Early warning signs of an asthma flare up include new difficulty breathing, wheezing and coughing. Doctors often get caught out because asthma attacks can develop slowly. So its essential that any doctor (or nurse) who sees patients in primary care or in emergency departments should know how to diagnose an asthma attack that is developing. See information on asthma here.

Diagnose asthma flare-up until proved otherwise

Any patient presenting with increased use of their reliever inhaler, cough, wheeze, or shortness of breath is developing an asthma attack until proved otherwise. Detailed history and lung function measurement is essential – take asthma seriously. Waking at night and failure to respond to bronchodilator reliever and fluctuating peak flow help facilitate early diagnosis.

By the time wheezing is heard FEV1 has dropped up to 30%

A common mistake made by health care professionals is that they rely on their stethoscope to assess severity of asthma. The problem is that by the time wheezing is heard with a stethoscope there may be up to 30% obstruction of airflow. 1, 2,3,4,5,6 So the terms ‘mild wheeze’ or ‘slight wheeze’ are misleading and provide a false sense of reassurance for clinicians. Much more important to measure lung function (spirometry or Peak Expiratory Flow (PEF) and respiratory rate. Most importantly, during a severe attack there may be no abnormal findings – so the medical history and lack of response to reliever medication are essential to take note of.

  1. Spence DP, Graham DR, Jamieson G, Cheetham BM, Calverley PM, Earis JE. The relationship between wheezing and lung mechanics during methacholine-induced bronchoconstriction in asthmatic subjects. American Journal of Respiratory and Critical Care Medicine. 1996;154(2):290-4. Link
  2. Springer C, Godfrey S, Picard E, Uwyyed K, Rotschild M, Hananya S, et al. Efficacy and safety of methacholine bronchial challenge performed by auscultation in young asthmatic children. Am J Respir Crit Care Med. 2000;162(3 Pt 1):857-60.
  3. Sanchez I, Avital A, Wong I, Tal A, Pasterkamp H. Acoustic vs. spirometric assessment of bronchial responsiveness to methacholine in children. Pediatr Pulmonol. 1993;15(1):28-35.
  4. KOH YY, CHAE SA, MIN KU. Cough variant asthma is associated with a higher wheezing threshold than classic asthma. Clinical & Experimental Allergy. 1993;23(8):696-701. Link
  5. Noviski N, Cohen L, Springer C, Bar-Yishay E, Avital A, Godfrey S. Bronchial provocation determined by breath sounds compared with lung function. Arch Dis Child. 1991;66(8):952-5.
  6. McFadden ER, Jr., Kiser R, DeGroot WJ. Acute bronchial asthma. Relations between clinical and physiologic manifestations. N Engl J Med. 1973;288(5):221-5.

Evolving asthma attacks need aggressive treatment

Increase corticosteroid treatment – inhaled or orally – should be initiated soon as possible to avoid an attack developing.

Self-Management plans should include how to recognise attacks

People with asthma must be taught that onset of cough, wheeze, shortness of breath or difficulty breathing are early warning signs of a developing exacerbation or attack. This would help patients prepare for consultations for uncontrolled asthma. It is extremely helpful for a clinician if a patient brings recordings of lung function (Peak Flow, spirometry) and also details of symptoms in the last few weeks (Ideally the results of an ACT (Asthma Control Test) and a record of the number of times the reliever has been used and how effective it has been. This information will help both patient and doctor (or asthma trained nurse) in deciding on treatment for the attack.

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