What is the appropriate first‑aid management for an acute asthma attack?

First Aid for Acute Asthma Attack

Immediately administer high-dose inhaled beta-agonist (salbutamol 5 mg or terbutaline 10 mg) via nebulizer with oxygen, or 10-20 puffs via metered-dose inhaler with spacer, and give oral prednisolone 30-60 mg (or IV hydrocortisone 200 mg) at once—these are the two essential first-line treatments that must be started without delay. 1

Immediate Assessment of Severity

Rapidly determine if this is a severe or life-threatening attack by checking for:

Features of Severe Asthma (any one indicates severe):

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow (PEF) <50% of predicted or personal best 1

Life-Threatening Features (require immediate hospital transfer):

• PEF <33% of predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma 1

Immediate Treatment Protocol

For ALL Acute Attacks:

1. High-dose inhaled beta-agonist - Start immediately:

   • Salbutamol 5 mg OR terbutaline 10 mg via oxygen-driven nebulizer
   • Alternative: 2 puffs from metered-dose inhaler into large spacer, repeated 10-20 times (total 20-40 puffs) 1

2. Systemic corticosteroids - Give immediately:

   • Prednisolone 30-60 mg orally OR
   • Hydrocortisone 200 mg IV (or both) 1

3. Oxygen - If available, give 40-60% oxygen to maintain saturations 2

For Life-Threatening Features - Add:

• Ipratropium bromide 0.5 mg nebulized with the beta-agonist 1
• IV aminophylline 250 mg over 20 minutes OR salbutamol/terbutaline 250 µg IV over 10 minutes
  • Critical caveat: Do NOT give bolus aminophylline if patient already takes oral theophyllines 1

Monitoring and Reassessment

• Measure PEF 15-30 minutes after initial treatment 1
• Continue nebulized beta-agonist every 4 hours if improving
• If NOT improving after 15-30 minutes, give nebulized beta-agonists more frequently 1

Criteria for Immediate Hospital Referral

Transfer to hospital if ANY of the following:

• Any life-threatening features present
• Features of severe attack persist after initial treatment
• PEF remains <33% of predicted 15-30 minutes after nebulization 1

Lower threshold for admission if patient seen in afternoon/evening, has nocturnal symptoms, previous severe attacks, rapid onset, or concerning social circumstances 1

Special Considerations

For Catastrophic Sudden-Severe Asthma:

High-risk patients should have a pre-arranged plan:

1. Call for help immediately
2. Inhale beta-agonist (5-10 mg nebulized or 20-40 puffs via spacer)
3. Swallow prednisolone 30-60 mg
4. Go directly to nearest hospital 1

For Children:

• Salbutamol 2.5 mg (age <2 years) or 5 mg (age >2 years) via spacer with face mask
• Prednisolone 1-2 mg/kg orally (maximum 40 mg)
• Reassess 10 minutes later 1

Critical Pitfalls to Avoid

• Never rely on wheeze alone - silent chest indicates severe obstruction 1
• Never delay steroids - early systemic corticosteroids reduce ICU admissions and hospitalizations 3
• Never use aminophylline if patient takes oral theophyllines without checking levels 1
• Never discharge until PEF is stable and >50% predicted 4

The severity of asthma attacks is consistently underestimated by patients, relatives, and doctors due to failure to make objective measurements—this contributes to preventable asthma deaths 1.