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- Asthma attack (moderate)
Asthma attack (moderate)
Assess severity by peak flow, treat, and only discharge the safe ones.
| If you find… | …then |
|---|---|
| PEF < 50%, RR ≥ 25, HR ≥ 110, can’t complete sentences | Acute severe asthma — ED |
| PEF < 33%, SpO₂ < 92%, silent chest, cyanosis, exhaustion, confusion | Life-threatening — 999 / resus |
| Previous ICU admission, near-fatal asthma, or recent admission | High risk — lower threshold to admit |
| Not responding to initial bronchodilator | ED |
- Onset, trigger (viral, allergen, smoke)
- Reliever use, preventer adherence, inhaler technique
- Previous admissions/ICU, oral steroid courses
- Night symptoms; who is at home
- RR, HR, SpO₂
- Peak flow vs best or predicted
- Ability to speak in sentences
- Chest: wheeze, air entry (silent chest is ominous)
Measure peak flow properly
Standing, deep breath, seal lips, blow as hard and fast as possible. Best of 3. Compare with their personal best (or predicted from age/height chart).
Spacer technique
Shake, attach the spacer, one puff in, then 5 tidal breaths. Repeat per puff. Many patients have never been shown.
Safe for home?
- PEF < 50% best/predicted
- RR ≥ 25 or HR ≥ 110
- Unable to complete sentences
- SpO₂ < 92%, silent chest, cyanosis, exhaustion or confusion
- PEF still < 75% after treatment
Any present: Severe / not safe for home → ED. None present: Moderate attack responding → treat and discharge with follow-up.
Asthma severity (BTS/SIGN/NICE)
- Moderate: PEF > 50–75% best/predicted, no severe features
- Acute severe: PEF 33–50%, RR ≥ 25, HR ≥ 110, unable to complete sentences
- Life-threatening: PEF < 33%, SpO₂ < 92%, silent chest, cyanosis, exhaustion, arrhythmia, hypotension, confusion
Moderate attacks may be treated in clinic. Consider discharge if PEF > 75% one hour after treatment and no other concerns.
| Investigation | Only if… |
|---|---|
| Peak flow | Before and 15–30 min after bronchodilator |
| SpO₂ | Every patient |
| No routine bloods / CXR | Unless pneumothorax/pneumonia suspected |
Management & advice
- Salbutamol via spacer: 4 puffs, then 2 puffs every 2 minutes up to 10 puffs (or nebuliser if more severe)
- Oral prednisolone
- Check inhaler technique; give a written asthma action plan
- GP/asthma nurse review within 48 h (2 working days)
Refer / follow-up
- Any severe or life-threatening feature → ED
- PEF < 75% after treatment → ED / medical assessment
| Drug | Dose | Duration / notes |
|---|---|---|
| Salbutamol 100 micrograms MDI via spacer BNF ↗ | Up to 10 puffs as needed; then 2–4 puffs every 4 h as needed | Until review |
| Prednisolone BNF ↗ | 40–50 mg once a day | 5 days (at least) |
| Preventer | Continue/step up per action plan — check adherence | Ongoing |
You’ve had a moderate asthma attack, and you’ve responded well to treatment. Take the steroid tablets every morning for 5 days and use your blue inhaler with the spacer when needed. Book to see your GP or asthma nurse within 2 days. If you need the blue inhaler more than every 4 hours, it isn’t helping, or you’re too breathless to talk, call 999.
Come back / call 111 — or 999 if severe — if:
- Reliever needed more than every 4 hours, or not helping
- Too breathless to talk, eat or sleep
- Lips turning blue, drowsy — call 999
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
- Discharging without a repeat peak flow
- No oral steroids
- No follow-up within 48 h
- Missing a silent chest
Revision practice. Work through a real or imagined case to rehearse the reasoning. It builds a model note to learn from. It doesn’t replace your judgement, your seniors or local guidance.
✎Blank clinic note template
Asthma attack (moderate) — clinic note
Doses are typical doses drawn from the guidance above. Always confirm in the current BNF/BNFc and your local antimicrobial policy.