Acute bronchial asthma: signs of an attack, first aid and modern treatment

"Acute asthma" is not a specific form of the disease, but rather a common or clinical term for an acute exacerbation of asthma—an attack in which shortness of breath, wheezing, coughing, chest tightness, and limited breathing suddenly worsen. The World Health Organization describes asthma as a chronic lung disease in which inflammation and contraction of the muscles around the airways make breathing difficult; symptoms can be mild or severe and occur in attacks. [1]

During an attack, the bronchi constrict simultaneously due to muscle spasms, swelling of the mucous membrane, and mucus accumulation. This can cause a feeling of air "locked in," noisy breathing, prolonged exhalations, and anxiety. A familiar inhaler may provide less relief or last a shorter time. The Centers for Disease Control and Prevention (CDC) defines an asthma attack as a condition in which the airways swell, narrow, and mucus further impedes airflow. [2]

An acute exacerbation can range in severity from a mild deterioration that resolves quickly with a quick-relief medication to a life-threatening condition where a person has difficulty speaking, walking, or lying down, and blood oxygen saturation drops. The American College of Emergency Physicians emphasizes that severe attacks or attacks that do not respond to the patient's usual medication require immediate medical attention. [3]

The most severe form is status asthmaticus, or an acute, severe exacerbation that responds poorly to standard treatment with bronchodilators and systemic corticosteroids. Clinical literature describes status asthmaticus as an emergency with the risk of hypoxemia, carbon dioxide accumulation, respiratory failure, organ damage, and death if recognized late. [4]

The modern approach to acute asthma is based not only on relieving an attack but also on preventing the next one. The 2026 update of the Global Asthma Initiative states that treatment strategies are reviewed annually based on new scientific evidence; this is important because even rare but severe exacerbations can be dangerous, and appropriate anti-inflammatory therapy reduces the risk of recurrent attacks. [5]

Term	What does it mean?	Practical meaning
Acute bronchial asthma	A common name for an attack or exacerbation of asthma	Requires assessment of severity and prompt treatment.
Exacerbation of bronchial asthma	A sharp deterioration in symptoms and respiratory function	Can be treated at home only according to a pre-agreed plan
Severe asthma attack	Severe shortness of breath, poor response to inhaler, decreased oxygen	Urgent medical attention is needed
Status asthmaticus	Life-threatening exacerbation that is poorly responsive to standard therapy	Requires intensive monitoring and possible respiratory support
Uncontrolled asthma	Frequent symptoms, night awakenings, frequent quick-relief inhalers	Increases the risk of a future acute attack

Code according to ICD 10 and ICD 11

In the International Classification of Diseases, 10th revision, basic bronchial asthma is classified under J45, while the acute severe condition, known as status asthmaticus, is separately classified as J46. The World Health Organization classification explicitly specifies an exception for J45: the acute severe condition is classified under J46, which is important for medical documentation, statistics, and the correct coding of hospitalizations. [6]

In the International Classification of Diseases, 11th revision, asthma is classified under the category CA23, and CA23.31 is used for "unspecified asthma with status asthmaticus"; this condition is described as an acute exacerbation that does not respond to standard treatment with inhaled bronchodilators and steroids. National coding modifications may be used in different countries, so the final code in the medical record depends on the adopted version of the classifier and the diagnosis formulated by the physician. [7]

Classification system	Code	Formulation	When to use
International Classification of Diseases, 10th revision	J45	Bronchial asthma	For asthma as a disease
International Classification of Diseases, 10th revision	J46	Status asthmaticus	For acute severe attacks, especially with a risk of respiratory failure
International Classification of Diseases, 11th revision	CA23	Asthma	For asthma as a chronic inflammatory disease of the airways
International Classification of Diseases, 11th revision	CA23.31	Unspecified asthma with status asthmaticus	For severe acute exacerbation that is poorly responsive to standard treatment
National modifications of classifications	May differ	Specify severity, complication, exacerbation	Used according to the rules of a specific country

What happens in the bronchi during an acute attack?

During an acute asthma attack, bronchial clearance narrows through three mechanisms: the muscles surrounding the bronchi contract, the mucous membrane swells, and secretions become thicker and more difficult to clear. This combination of processes explains why patients may simultaneously cough, wheeze, experience chest tightness, and not receive complete relief from a regular inhaler. [8]

The main physiological problem during an attack is difficulty exhaling. Air enters the lungs but exits slowly and incompletely, causing the chest to "overinflate," the respiratory muscles to tire, and the person to breathe more rapidly. If the obstruction worsens, the oxygen level in the blood may drop, and in an extremely severe attack, carbon dioxide levels begin to rise, a dangerous sign of respiratory exhaustion. [9]

Wheezing doesn't always reflect the severity of an attack. With moderate obstruction, whistling can be loud, but with critical bronchial constriction, air barely passes, and the chest may become "quiet." The Australian Asthma Guidelines specifically warn that a decrease in wheezing alone is unreliable as a sign of improvement, as it may reflect worsening airflow. [10]

An attack is often accompanied by anxiety, sweating, increased heart rate, and an inability to speak in long sentences. These symptoms arise not only from fear, but also from the actual strain on the respiratory system: the body must expend more energy on each inhalation and exhalation. Therefore, in emergency care, not only the patient's complaints are assessed, but also respiratory rate, pulse rate, blood oxygen saturation, ability to speak, and expiratory function parameters. [11]

After external improvement, bronchial inflammation may persist for several days. This explains why a person sometimes feels better after taking a bronchodilator, only to have symptoms return within 2-4 hours. Therefore, treatment of an acute attack should not be limited to short-term bronchodilation alone: most significant exacerbations require an anti-inflammatory component and a follow-up plan. [12]

Process in the bronchi	What's happening	How does it manifest itself?
Bronchospasm	The muscles around the bronchi contract	Wheezing, shortness of breath, feeling of lack of air
Edema of the mucous membrane	The bronchial wall thickens	Extended exhalation, tightness in the chest
Excess mucus	The lumen of the bronchus is partially blocked	Cough, phlegm, feeling of a "plug"
Air trap	The air comes out of the lungs worse	Bloated chest, fatigue
Exhaustion of the respiratory muscles	The person can no longer maintain ventilation.	Drowsiness, confusion, dangerous worsening

Causes and triggers of an acute attack

Acute asthma exacerbations are often triggered by a respiratory infection. The US Centers for Disease Control and Prevention notes that influenza, coronavirus infection, and respiratory syncytial virus can trigger asthma attacks and increase the risk of serious complications, including pneumonia, especially if asthma is poorly controlled. [13]

The second common trigger is allergens and airborne irritants: pollen, dust mites, mold, animal dander, cockroaches, tobacco smoke, aerosols, strong odors, chemical vapors, and air pollution. The World Health Organization lists cold symptoms, weather changes, dust, smoke, vapors, pollen, animal dander, strong soaps, and perfumes among the triggers. [14]

Physical activity, cold, dry air, and sudden temperature changes can also trigger attacks. This doesn't mean someone with asthma should avoid activity; on the contrary, with good control, most patients can lead an active life. However, if symptoms regularly occur while walking, climbing stairs, or engaging in moderate exercise, this is a sign of poor control and not a "normal feature" of asthma. [15]

Incorrect use of an inhaler, missing doses of disease-modifying anti-inflammatory therapy, and overreliance on quick-relief medications alone increase the risk of severe exacerbations. Current asthma guidelines emphasize reducing the risk of attacks, not just relieving current symptoms; therefore, a doctor reviews inhaler technique, treatment adherence, and the presence of a written action plan. [16]

Some attacks are associated with medications and underlying conditions. In some patients, bronchospasm may worsen after taking nonsteroidal anti-inflammatory drugs, with severe allergic rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obesity, occupational exposure to irritants, or continued smoking. Therefore, after an acute episode, it is important to consider not only "what to relieve now" but also why the attack occurred at this particular time. [17]

Trigger	Examples	What helps reduce the risk
Respiratory infections	Influenza, coronavirus infection, respiratory syncytial virus	Vaccination, early action plan for colds
Allergens	Pollen, dust mites, mold, animals	Allergy control, contact reduction
Irritants	Tobacco smoke, aerosols, chemical vapors	Elimination of smoke and strong odors
Weather and air	Cold, dry air, pollution	Respiratory protection, stress control
Treatment errors	Skipping basic therapy, incorrect inhalation technique	Training, inhaler testing, written plan
Associated diseases	Rhinitis, sinusitis, reflux, obesity	Comprehensive treatment of associated factors

How to recognize the severity of an attack

A mild exacerbation typically manifests as increased coughing, wheezing, and shortness of breath, but the person is able to speak in sentences, walk, does not appear exhausted, and the quick-release medication provides noticeable relief. Even such an attack should not be completely ignored: if the need for a quick-release inhaler increases, symptoms return at night, or worsening symptoms recur for several days in a row, this indicates the need to reconsider the basic treatment. [18]

A moderate attack is characterized by more pronounced shortness of breath, difficulty speaking in long sentences, increased muscle tension in the neck and chest, increased heart rate, and a feeling that the usual inhaler dose is not providing complete relief. In this situation, it is important to follow the pre-determined plan prepared by your doctor, measure your peak expiratory flow rate (PEF) if available, and not delay seeking medical attention if symptoms worsen. [19]

A severe attack is defined as a condition in which a person has difficulty speaking, breathes rapidly and laboredly, is unable to lie down, feels severely weak, and the effect of a quick-relief inhaler is short-lived or absent. The Mayo Clinic classifies signs of an emergency as rapidly worsening shortness of breath or wheezing, lack of improvement with a quick-relief inhaler, and shortness of breath with minimal physical activity. [20]

Life-threatening signs include confusion, drowsiness, exhaustion, bluish lips or nails, a drop in blood oxygen saturation, a "quiet chest," a sudden decrease in breath sounds, a drop in blood pressure, or worsening after a brief improvement. In such cases, it is not advisable to wait for it to "go away on its own," as status asthmaticus can quickly progress to respiratory failure. [21]

The particular danger of acute asthma is that a severe attack can develop even in a person who typically experiences infrequent symptoms. Therefore, preventing exacerbations, having a written action plan, using the right inhaler, and understanding red flags are important not only for patients with severe asthma but also for people who consider their asthma "mild." [22]

Heaviness	Possible signs	What to do
Mild deterioration	Cough, wheezing, slight shortness of breath, good response to the drug	Follow an individual plan to manage symptoms
Moderate attack	Difficulty speaking in long sentences, rapid breathing	Contact your doctor or seek urgent evaluation.
Severe attack	It's hard to talk, hard to walk, the inhaler doesn't help much.	Urgent medical care
Life-threatening attack	Drowsiness, confusion, cyanosis, "quiet chest"	Calling emergency help
Suspicion of status asthmaticus	No response to standard therapy	Treatment in an emergency or hospital setting

Diagnosis and assessment in emergency situations

In an acute situation, diagnosis is most often made clinically: the doctor evaluates the patient's complaints, the rate of attack progression, a known asthma diagnosis, previous hospitalizations, the use of systemic corticosteroids, the frequency of use of a rapid-relief inhaler, and a possible trigger. At the same time, other dangerous conditions that can mimic an asthma attack are excluded: pneumonia, pneumothorax, anaphylaxis, pulmonary embolism, heart failure, and a foreign body in the airways. [23]

Key indicators during examination include respiratory rate, pulse rate, blood pressure, oxygen saturation, ability to speak, degree of respiratory muscle tension, and level of consciousness. These signs are often more important than subjective descriptions such as "I feel worse" or "I feel a little better," because the patient may underestimate the severity of the attack, especially if such episodes recur for many years. [24]

Peak expiratory flow rate (PEF) helps objectively assess the degree of bronchial constriction if the patient is able to perform the maneuver. Inpatient algorithms for adults recommend repeating peak expiratory flow measurements 15-30 minutes after the start of treatment and then regularly during hospitalization, as the dynamics of exhalation help determine whether the bronchi are truly opening. [25]

Arterial blood gas measurements are not necessary for everyone, but they become important in cases of severe or life-threatening stroke, low blood oxygen saturation, deteriorating condition, or suspected carbon dioxide accumulation. In adult algorithms, repeat blood gas measurements are considered if the initial oxygen level is low, carbon dioxide levels are normal or elevated, or the patient is deteriorating. [26]

A chest X-ray is not mandatory for every asthma attack. It is performed if there is a suspicion of pneumothorax, pneumonia, lung consolidation, a foreign body, cardiac pathology, or if the patient may require mechanical ventilation. This approach helps avoid overburdening the patient with unnecessary examinations while still detecting complications. [27]

Evaluation method	What does it show?	When especially needed
Examination and anamnesis	Attack severity and probable trigger	Always
Blood oxygen saturation	Risk of hypoxemia	Always during moderate to severe attacks
Peak expiratory flow rate	Degree of expiratory impairment	If the patient can perform the test
Blood gas composition	Oxygen, carbon dioxide, risk of respiratory failure	In case of a severe or worsening attack
Chest X-ray	Pneumonia, pneumothorax, other complications	In case of an atypical picture or severe course
Electrocardiography	Heart rhythm, strain, and other causes of shortness of breath	For chest pain, tachycardia, age and risk factors

Modern treatment of acute attack

The first line of treatment is to rapidly dilate the bronchi. In emergency care, this is achieved with an inhaled short-acting beta-2 agonist, such as salbutamol, administered via a metered-dose inhaler with a spacer or a nebulizer; the choice of method depends on the severity of the attack, the patient's age, cooperation, and available equipment. The British National Formulary recommends that the first line of treatment for acute asthma is a high dose of an inhaled short-acting beta-2 agonist, administered as early as possible. [28]

Oxygen is prescribed when blood oxygen saturation decreases. In hospital algorithms for adults, the goal is often formulated as maintaining blood oxygen saturation in the range of 94-98%, and oxygen is used in conjunction with bronchodilators and systemic corticosteroids during a severe attack. [29]

Systemic corticosteroids are used for all but the mildest exacerbations because they reduce inflammation, decrease the risk of relapse, and help stabilize the condition after the initial bronchodilator effect. The MSD Manual states that prednisone, prednisolone, or methylprednisolone are prescribed for all but the mildest exacerbations, and that oral and intravenous routes of administration are generally comparable in efficacy unless there is a compelling reason to choose the intravenous route. [30]

Ipratropium bromide is added for severe or poorly responding exacerbations, usually in combination with a short-acting beta-2 agonist. Australian guidelines recommend ipratropium as a first-line treatment for severe or life-threatening acute asthma and as a second-line treatment for those with inadequate response to salbutamol; the combination reduces hospitalizations and improves lung function in adults and older adolescents with severe exacerbations.[31]

Intravenous magnesium sulfate is considered as an adjunctive treatment for severe or life-threatening exacerbations when the response to repeated maximum doses of bronchodilators and systemic corticosteroids is inadequate. The MSD Manual notes that intravenous magnesium sulfate may modestly reduce the risk of hospitalization and improve lung function, especially in more severe exacerbations, but it is not a substitute for inhaled bronchodilators. [32]

Treatment	Why is it used?	Important clarification
Short-acting beta-2 agonist	Quickly expands the bronchi	First line in acute attack
Oxygen	Corrects hypoxemia	Needed when blood oxygen saturation decreases
Systemic corticosteroid	Suppresses inflammation and reduces the risk of relapse	The effect does not develop instantly.
Ipratropium bromide	Enhances the bronchodilatory effect during a severe attack	Particularly useful in severe exacerbations
Intravenous magnesium sulfate	Additional remedy for severe attacks	Used in cases of poor response to initial therapy
Respiratory support	Supports ventilation when breathing is exhausted	Requires an experienced team and monitoring

What not to do with acute asthma

Don't wait hours if an attack is getting worse and a regular inhaler isn't helping. The Mayo Clinic lists failure to improve with a quick-relief inhaler and shortness of breath with minimal activity as signs that require urgent evaluation, as a severe asthma attack can be life-threatening. [33]

Do not increase medication doses on your own beyond the plan previously agreed upon with your doctor. Excessive use of fast-acting medications can cause palpitations, tremors, anxiety, and create a dangerous illusion of control, while inflammation and bronchial swelling continue to worsen. [34]

Sedatives, alcohol, sleeping pills, or "calming" agents should not be used as a substitute for asthma attack treatment. Hospital treatment algorithms for acute asthma explicitly state: do not use sedatives of any kind, as they can depress breathing and mask a worsening condition. [35]

It's not safe to automatically take an antibiotic for every asthma attack. The MSD Manual states that antibiotics are only indicated when history, physical examination, or chest X-ray suggest a bacterial infection; most infections that cause asthma exacerbations are likely viral. [36]

Basic anti-inflammatory therapy should not be discontinued once symptoms have subsided. The World Health Organization emphasizes that inhaled medications help control symptoms and allow people with asthma to lead active lives; however, preventing future attacks requires regular monitoring of the disease, not just relieving an acute episode. [37]

Error	Why is it dangerous?	The right tactics
Wait until shortness of breath increases	Respiratory failure may be missed	Seek help urgently
Exceeding doses without a plan	Risk of side effects and treatment delays	Follow the written plan
Take sedatives	Possible respiratory depression	Do not use during an attack.
Take an antibiotic "just in case"	Does not help with viruses and asthma inflammation	The decision is made by the doctor
Cancel basic therapy	The risk of a recurrence increases	Discuss changes with your doctor
Assess severity only by whistles	A "quiet chest" may be more dangerous than loud whistles	Look at the general condition and oxygen

Hospitalization, discharge and prevention of relapse

Hospitalization is necessary if the attack is severe, blood oxygen saturation is low, peak expiratory flow remains low after treatment, symptoms rapidly recur, there is respiratory failure, concomitant severe illnesses, or insufficient conditions for safe monitoring at home. Hospital algorithms recommend discussing patients with life-threatening symptoms with a senior physician and the intensive care team, and if symptoms worsen, consider more frequent inhalations, intravenous magnesium sulfate, and respiratory support. [38]

Before discharge, it's important to ensure the patient is stable: breathing has improved, the need for rapid-relief medication is reduced, blood oxygen saturation is safe, peak expiratory flow has improved, the patient understands the treatment plan and knows how to use the inhaler. Discharging a patient simply because "felt better in 30 minutes" without an anti-inflammatory plan and training remains high. [39]

After an acute attack, a review of long-term therapy is necessary. This includes reviewing the diagnosis, assessing symptom control, inhalation technique, treatment adherence, allergic and infectious triggers, smoking, occupational irritants, and comorbidities. Updated guidelines from the British Thoracic Society, the National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network are aimed specifically at improving diagnosis, management, and reducing the risk of attacks. [40]

A written asthma action plan should explain which symptoms are considered worsening, how to change treatment in the "yellow zone," when to start additional prescribed medications, and when to seek emergency care. Such a plan is especially important for people with a history of severe attacks, hospitalizations, nighttime symptoms, frequent use of a quick-relief inhaler, and low self-perception of breathlessness. [41]

Infection prevention is a separate part of acute asthma management. The US Centers for Disease Control and Prevention recommends that people with asthma be vaccinated against common respiratory infections when approved by their healthcare provider; influenza, coronavirus infection, respiratory syncytial virus, and pneumococcal infection can worsen asthma and trigger an attack. [42]

Stage	What needs to be done	For what
In emergency care	Severity assessment, oxygen, bronchodilators, corticosteroids	Quickly relieve the threat to breathing
In hospital	Re-evaluation of expiration, oxygen, and response to treatment	Don't miss the deterioration
Before discharge	Checking stability and inhalation technique	Reduce the risk of recurrence
After discharge	Revision of basic therapy	Reduce inflammation and future flare-ups
Long term	Action plan, trigger control, vaccination	Prevent further severe attacks

FAQ

Is acute asthma the same as an asthma attack? In most cases, yes: this term refers to an acute exacerbation or attack of bronchial asthma. If the attack is severe and does not respond well to standard medications, the doctor may use the term "status asthmaticus," which refers to an emergency with a risk of respiratory failure. [43]

How do you know if an attack has become dangerous? Signs of danger include rapidly worsening shortness of breath, inability to speak in sentences, lack of improvement after using a rapid-relief inhaler, shortness of breath with minimal activity, drowsiness, confusion, bluish lips, severe weakness, or a "quiet" chest. If these signs occur, seek emergency care rather than wait for a scheduled appointment. [44]

Why does an inhaler sometimes stop working? During a severe attack, the bronchi are constricted not only by spasms but also by mucosal swelling and inflammation, so bronchodilator action alone may not be enough. In such situations, oxygen is needed as indicated, along with repeated bronchodilators, systemic corticosteroids, and medical supervision. [45]

Are antibiotics needed during an acute asthma attack? Not always and not automatically. Antibiotics are used only if there is evidence of a bacterial infection, such as a corresponding clinical picture, examination, or radiographic findings; most infectious triggers of asthma exacerbations are viral, and antibiotics are ineffective against them. [46]

Can an attack be treated at home? Mild deterioration can be managed at home only according to a written plan prepared in advance by a doctor, if symptoms quickly subside and do not recur. If the effect is incomplete, short-lived, or the condition worsens, urgent medical evaluation is necessary. [47]

How does status asthmaticus differ from a normal attack? Status asthmaticus is a severe exacerbation that responds poorly to standard treatment and can lead to hypoxemia, carbon dioxide accumulation, respiratory failure, and death. It is not a situation for home monitoring. [48]

Does every person with asthma need a nebulizer? No, not everyone. For many exacerbations, a metered-dose inhaler with a spacer can be effective, but in severe attacks, with poor cooperation or significant respiratory failure, the medical team may use a nebulizer and oxygen. The choice of device depends on the severity of the attack and the care setting. [49]

How can you prevent a recurrence of an acute attack? It's important to review your baseline therapy, check your inhalation technique, identify triggers, treat rhinitis and other comorbidities, have a written action plan, and discuss vaccinations against respiratory infections. This approach is more important than simply keeping a quick-relief medication at home. [50]

Key points from experts

Professor Ian D. Pavord, Professor of Respiratory Medicine at the University of Oxford, Honorary Consultant Physician at Oxford University Hospitals, and Fellow of the Academy of Medical Sciences, UK, is a leading researcher in this area. His work is important for understanding why an asthma attack cannot be viewed solely as a "bronchospasm": eosinophilic inflammation and type 2 inflammation are associated with an increased risk of exacerbations and sensitivity to corticosteroids, so after an acute episode, it is important to assess the inflammatory phenotype and tailor anti-inflammatory treatment, rather than simply increasing the frequency of inhaler use. [51]

Professor Kian Fan Chung, Professor of Respiratory Medicine, Specialist at Royal Brompton and Harefield Hospitals, is a co-leader of the European Respiratory Society and American Thoracic Society Severe Asthma Working Group. His key thesis is that severe and difficult-to-control asthma requires confirmation of the diagnosis, a search for comorbidities, and phenotyping, as recurrent acute attacks are often associated with under-recognized treatable features, and not just the severity of bronchospasm. [52] [53]

Dr. Helen K. Reddel, a respiratory physician and asthma researcher, is the scientific lead for the Global Asthma Initiative. A practical takeaway from the Global Asthma Initiative 2026 strategy: the goal of treatment is not only to relieve the current attack but also to reduce the risk of future severe exacerbations, because even patients with rare symptoms can have dangerous attacks if their anti-inflammatory defenses are inadequate. [54]

Experts from the British Thoracic Society, the National Institute for Health and Care Excellence, and the Scottish Intercollegiate Guidelines Network (SICHN) have released their 2024 joint guidelines, emphasizing accurate diagnosis, monitoring, and risk reduction for attacks. For patients, this means that after an acute episode of asthma, it's important not only to receive a discharge summary but also to review objective tests, inhaler technique, a self-management plan, and a long-term treatment plan. [55]

Experts from the American College of Emergency Physicians. Their practical message is especially important for the home: a severe attack that does not respond to the patient's usual medications requires immediate medical attention; sweating, weakness, rapid pulse, cold, clammy skin, fainting, and severe shortness of breath may indicate a potentially fatal condition. [56]

Result

Acute asthma is an attack or exacerbation of asthma in which inflamed and narrowed bronchi severely impair airflow. The main symptoms are shortness of breath, wheezing, cough, chest tightness, difficulty exhaling, and the need for a quick-relief medication; the main danger signs are lack of response to an inhaler, inability to speak, severe weakness, cyanosis, drowsiness, or a "quiet" chest. [57]

Current treatment for an acute attack includes rapid assessment of severity, an inhaled bronchodilator, oxygen for hypoxemia, systemic corticosteroids for most significant exacerbations, ipratropium for a severe attack, and intravenous magnesium sulfate for those with an inadequate response to initial therapy. After stabilization, a review of long-term asthma control is essential, because the best way to treat acute asthma is to prevent another severe attack. [58]