GP Management of Acute Asthma Attack: Simple Guide
A GP can and should manage most acute asthma attacks at home with immediate bronchodilators and steroids, but must refer to hospital immediately if life-threatening features are present or if the patient doesn't respond adequately to initial treatment within 15-30 minutes. 1
What GPs CAN and SHOULD Do:
Immediate Assessment (Takes 2 minutes)
Measure these objective parameters - don't rely on wheeze alone:
- Peak Expiratory Flow (PEF) - most critical measurement
- Respiratory rate
- Pulse rate
- Ability to speak in complete sentences 1
Immediate Treatment for Moderate-Severe Attacks
If PEF <50% predicted/best OR can't complete sentences OR pulse >110 OR respiratory rate >25:
Nebulised bronchodilator immediately:
- Salbutamol 5 mg OR terbutaline 10 mg
- Use oxygen to drive nebuliser if available (40-60%)
- If no nebuliser: give 2 puffs β-agonist via spacer, repeat 10-20 times 1
Systemic steroids immediately:
- Prednisolone 30-60 mg orally 1
Reassess at 15-30 minutes - this is mandatory before leaving 1
Home Management Criteria (PEF >50%)
You can treat at home if:
- PEF improves to >50-75% after treatment
- Patient can speak normally
- Pulse <110, respiratory rate <25 1
Follow-up required:
- Review within 24-48 hours
- Provide written asthma action plan
- Step up maintenance therapy 1
What GPs MUST NOT Do:
Absolute Contraindications
Never give sedation - this is explicitly contraindicated in acute asthma 1
Do not give bolus aminophylline if patient already takes oral theophyllines 1
Do not give antibiotics unless bacterial infection is confirmed - they are unhelpful in acute asthma 1
Do not perform chest physiotherapy - it's unnecessary 1
When GPs MUST Refer to Hospital Immediately
Life-threatening features (send immediately):
- PEF <33% predicted/best
- Silent chest, cyanosis, or feeble respiratory effort
- Bradycardia or hypotension
- Exhaustion, confusion, or coma 1
Severe features persisting after initial treatment:
- PEF remains <33% at 15-30 minutes post-nebuliser
- Any severe features persist (can't complete sentences, pulse >110, respiratory rate >25, PEF <50%) 1
Lower threshold for admission if:
- Attack occurs in afternoon/evening
- Recent nocturnal symptoms or previous severe attacks
- Concern about patient's ability to assess severity
- Poor social circumstances 1
Common Pitfalls to Avoid
Underestimating severity is the leading cause of preventable asthma deaths. The guidelines emphasize that doctors and patients commonly fail to appreciate severity by not making objective measurements 1. Always measure PEF - clinical assessment alone is unreliable.
Underusing corticosteroids remains a major problem. Between 1991-1993, only 71% of acute attacks received systemic steroids despite clear guidelines 2. Give prednisolone 30-60 mg immediately in all moderate-severe attacks 1.
Relying on wheeze is dangerous - wheeze may be absent in severe asthma due to poor air movement (silent chest) 3. This is actually a life-threatening sign requiring immediate hospital transfer.
Not reassessing after treatment - you must check PEF 15-30 minutes after nebuliser before deciding on home management 1. Failure to do this can miss deteriorating patients.