Printed on: September 13th, 2025

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Asthma: acute attacks and exacerbations

Asthma: acute attacks and exacerbations

This article was updated in March 2025.

The following abbreviations are used throughout this article:

In 2014, the RCP and other bodies reviewed all asthma-related deaths in the UK. The review highlighted the overuse of short-acting beta-agonists, underuse of inhaled corticosteroids and a failure of healthcare professionals to take asthma seriously (BJGP 2024;74(739):86). More than ten years later, not much has changed. Asthma deaths continue to rise. There were 1400 deaths in the UK in 2018 (most recent dataset available ONS). This is higher than other European countries.

Key learning points from the National Review of Asthma Deaths:

• Most deaths occurred before admission to hospital.
• Most deaths occurred in those with chronically severe asthma, but a minority occurred suddenly in those with a background of mild or moderate disease.
• Most who died were not given adequate doses of inhaled or oral steroids.
• Some patients are still dying because they have an attack triggered by NSAIDs or beta-blockers.
• In those who died, there was severe underuse of written Personalised Asthma Action Plans (PAAPs).
• Heavy or increasing use of beta-agonists was associated with asthma deaths (patients and doctors missing a vital cue).
• Behavioural and adverse psychosocial factors were present in the majority of patients who died (e.g. frequent DNAs/self-discharge from hospital, social isolation, unemployment/low income, obesity, severe relationship or legal stress).
• Those who have had a near-fatal asthma attack should be under specialist monitoring indefinitely.
• Those who have had a severe asthma attack should be under specialist care for at least a year.

A BJGP article in 2019 highlighted concern that the lessons of the National Review of Asthma Deaths had not been learned, particularly in relation to children and young people (BJGP 2019;69:405). It looked at 3 coroners’ cases of children who had died from asthma since the report was published, highlighting issues with their care.

• One case was a child seen multiple times in primary care with minimal objective assessment of her asthma.
• Two were children who, despite severe disease, were not referred to hospital or were referred but discharged when they failed to attend (remember, from a safeguarding perspective we should be thinking of this as ‘child not brought to appointment’).

A follow-up article in 2024 noted the tragic death of 10-year-old William Gray, who died from asthma seven months after attending the emergency department with a near-fatal attack. In those seven months, he was given four courses of oral steroids, but received no maintenance inhaled corticosteroid. Despite multiple severe acute exacerbations of asthma, there was no escalation of his treatment nor any onward referral to a specialist service (BJGP 2024;74(743):244). It seems that the lessons of the National Review of Asthma deaths have still not been learned.

The authors also point out a failure to regard exacerbations of asthma as a flare-up of a chronic disease. Instead, clinicians tend to view them as discrete episodes of illness.  

We may assess for current symptoms, but how well do we assess future risk?

• Do you review asthma control at every consultation?
• Do you review long-term asthma management after every exacerbation?
• Do you know when to refer? What happens if the child isn’t brought to the hospital appointment? What if they are not brought to primary care appointments?

NICE (NG245, 2024) recommends self-management of asthma through use of a PAAP. PAAPs are usually traffic light-based and give patients instructions on what to do in the event of worsening symptoms. They can be downloaded from the Asthma and Lung UK website. There are PAAPs for MART (maintenance and reliever therapy), AIR (anti-inflammatory reliever) and conventional (separate preventer and reliever inhaler) asthma regimens. These PAAPs have space for an indicative peak flow reading, but NICE says that:

• In adults, PAAPs should be based on symptoms or, occasionally, peak flow.
• In children, symptom-based plans are preferred.

PAAPs should also include:

• Triggers and how to avoid them, including indoor and outdoor air pollution.
• Advice to contact a health professional for review if asthma control deteriorates.

For those ≥17y using ICS as a standalone inhaler (not ICS-formoterol as part of MART), the PAAP may include:

•  Advice to quadruple preventer ICS for 7 days if asthma deteriorates (but do not exceed maximum licensed dose).

For many of us (patients and clinicians!), peak flow has been central to our decision-making about how bad asthma is and when to step up treatment or start oral steroids. Many of us have given our patients PAAPs with bespoke peak flows for red, amber and green territory.  

NICE has recommended that peak flow is not ROUTINELY used in the PAAP; however, it has said that some may benefit from this, for example, those who are poor at perceiving changes in their airways based on symptoms alone.  

We think this is a big change in practice – so big that we thought we might have got it wrong! So, we contacted NICE, which confirmed that our interpretation was correct. No peak flow in the PAAP for most people. Yes, really! 

NOTE: clinicians should still use peak flow when assessing a patient with acute asthma to help determine severity. See GEMS below.

NICE says we should review the PAAP and check that our patients understand how to use it:

• After every hospital admission for asthma, including virtual wards.
• At every acute primary care consultation (NICE doesn’t specify whether this is for acute asthma consultations or any acute consultation!).
• At annual review.

The 2024 SIGN guidance (SIGN 158) is summarised here. Note that the 2024 NICE guideline on management of asthma does not cover management of acute exacerbations of asthma.

Note that in moderate asthma or worse, oral prednisolone should be used – increased ICS is not sufficient.

Please follow the link for a PDF version of the GEMS for download/printing: Acute severe asthma: GEMS

The SIGN guidance asks us to nebulise via oxygen if possible for those with severe or life-threatening asthma. This is to prevent oxygen desaturation if using an air-driven nebuliser. A flow rate of 6L/min is usually required to drive the nebuliser, and we are aiming to maintain oxygen saturation between 94–98%. If an oxygen cylinder is being used, it must have a high-flow regulator. If oxygen is not available, salbutamol should be nebulised via air. Where a nebuliser is not available, salbutamol should be given via a spacer.

The 2024 SIGN guidance does not recommend routine antibiotics for exacerbations in adults or children. It notes that most infections triggering acute asthma are viral, and the role of bacterial infection in asthma exacerbation has been overestimated.  

How often do you give antibiotics for exacerbations of asthma?

Twenty school-age children die of asthma each year in England and Wales, usually before reaching hospital. From October 2014, schools have been allowed to purchase a stock of salbutamol inhalers and spacers from pharmacies for emergency use. This follows a survey by Asthma UK that showed that 64% of children with asthma did not have access to salbutamol because they had left it at home/it was broken/run out, etc. (DTB 2014;52(10):110). Whether this will have any impact on asthma deaths in children is not yet known.

In 2002, a Cochrane review concluded that, in patients with mild–moderate asthma, cardioselective beta-blockers should not be withheld from those with heart disease (Cochrane 2002;CD002992). The Cochrane study was a meta-analysis of only 548 adults in 32 studies (so small numbers/study, and small numbers overall). Treatment with beta-blockers was for 1–7d only, so very short term.

An updated meta-analysis was published in 2014 and gave a more cautious interpretation of the data (Chest 2014;145(4):779):

• In asthmatics, cardioselective beta-blockers had the following effects:
  • Reduced FEV₁ (mean drop 7%, although 1 in 8 had a drop of 20% or more).
  • Reduced response to beta-agonists by an average of 10% (suggesting it would be harder to treat an asthma attack).
  • 1 in 33 had worsening of their asthma.
  • The responses were all dose related, with higher doses more likely to cause more problems.
• With non-selective beta-blockers:
  • The mean drop in FEV₁ was 10% (1 in 9 had a drop of 20% or more).
  • Response to beta-agonists reduced by 20%.
  • 1 in 13 had worsening of their asthma symptoms.

On this basis, some have concluded that cardioselective beta-blockers may be used cautiously in those with mild–moderate asthma. However, it is important to bear in mind:

• SIGN says that beta-blockers, including beta-blocker eye drops, are contraindicated in asthma.
• The BNF says that beta-blockers, including those considered to be cardioselective, should usually be avoided in patients with a history of asthma. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution and under specialist supervision, and the patient should be monitored for adverse effects. It reminds us that cardioselective beta-blockers (atenolol, metoprolol, bisoprolol and nebivolol) have less effect on bronchial beta receptors, but are not cardio-specific and some overlap exists.
• The National Review of Asthma Deaths (2014) reminds us that some patients in the UK are still dying because they have an attack triggered by beta-blockers.

Beta-blockers can be, and are, used in those with COPD.

Can the use of paracetamol increase the risk of asthma exacerbations? The ideal study would look at whether paracetamol vs. ibuprofen vs. placebo affected rates of asthma exacerbation. Unfortunately, no such study exists.

However, a USA-based double-blind RCT enrolled 300 children with mild asthma (on low-dose regular inhaled steroids) aged between 1 and 5y. It randomised them to receive either ibuprofen or paracetamol for pain or fever on an ‘as needed’ basis, and followed them up for 48w. The number of asthma exacerbations requiring steroids was the primary outcome. There was no placebo arm because it would be unethical to deny children analgesia for pain or antipyretics for fever (NEJM 2016;375:619).

• There was no significant difference in the number of asthma exacerbations between the two groups (0.81 (paracetamol) vs. 0.87 (ibuprofen).
• There was no difference in SABA use or unplanned healthcare use.

So, paracetamol does not increase the risk of asthma exacerbations.

Remember that 5% of children and 20% of adults with asthma have a direct reaction to NSAIDs/aspirin, and use of these drugs triggers a worsening of their asthma.

	Asthma: acute attacks and exacerbations Objectively assess severity of an acute exacerbation (including PEFR, pulse, respiratory rate, oxygen levels). Offer the appropriate treatment. Remember that if PEFR <75% best or predicted, oral prednisolone is usually indicated (for adults 40–50mg for at least 5d or until recovery). Do they need admission? Everyone who is admitted needs a primary care review within 2 working days (we know, you are thinking you might not have got the discharge summary by then!). Take this as an opportunity to review what they understand about asthma and their drugs. Could they have done anything differently to prevent the exacerbation, and do they know what to do next time? Have they got a PAAP? Do they understand it? Did they use it? Don’t forget to review their long-term disease control and set this exacerbation in the context of that long-term disease control. Antibiotics are not recommended routinely. Most infections are viral in origin.
	Audit the last 5 acute exacerbations of asthma in your practice: How well did you document objective values to help assess their asthma? If they were admitted, did you review them 2 days after discharge?Do they have a PAAP? Did they use it? Did it work? What was their long-term control before this exacerbation? If you arranged follow-up, did they come?
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Asthma and Lung UK - resources for healthcare professionals (includes great PAAPs for adults and children for MART, AIR and conventional asthma regimens; they can be downloaded for free or you can order free print versions)