If you or someone you know suffers from asthma, you’re familiar with common symptoms like:

• Inability to draw a full breath
• Wheezing
• Chest tightness
• Coughing

But not everyone experiences asthma the same way, and sometimes an asthma attack can be severe, requiring first aid and treatment of the restricted airways blocking proper function of the respiratory system. Would you know the difference? Read on to explore this topic and make sure you know what to do if someone you love has a severe attack.

Who Is at Risk of a Severe Asthma Attack

First of all, doctors classify asthma as mild, moderate, or severe based on how bad its symptoms normally are and how frequently they occur. Some people have intermittent asthma, where they occasionally suffer an attack.
Others have persistent asthma. For these individuals, asthma is an ongoing challenge. They may have attacks several times a day and need full-time treatment and first aid.

Anyone Can Have a Severe Asthma Attack

Anyone with asthma, even the mild kind, can have a severe asthma attack, often caused by something in the environment that causes a sudden flare-up or exacerbation of the “normally-experienced” asthma symptoms.

By normal, we mean normal for that person.

This event is life-threatening, and the symptoms will continue to escalate unless action is taken on either the part of the patient or the loved one.
During a severe attack, the airways become inflamed and contract to the point that little to no air can get through. The body also begins to over-produce mucous, intended to clear the airways of he irritant, but it ends up further blocking them.

If this person is not removed from the stimuli contributing to severe asthma (perfume, pollen, campfire smoke, cat/dog dander, etc.) and/or has access to their rescue inhaler, asthma can exacerbate to the point of severe asthma.

According to CDC.gov, a virus, such as a coronavirus responsible for COVID-19, can also trigger severe asthma in someone with mild to moderate asthma.

And, of course, anyone who has asthma found out they had it after their first attack, so even someone who has never been diagnosed with asthma could potentially experience a severe attack the first time.

Factors That Increase Risk of a Severe Asthma Attack

You are at increased risk of having a severe event if you:

• Were first diagnosed after age 40
• Have gone to the ER during an attack within the last 10 days. Severe attacks often happen near each other.
• Take a steroid for your asthma. Note: the steroid itself doesn’t increase the risk. It’s the fact that you need one—correlation, not causation.
• Use your rescue inhaler more than twice a month.
• Have a co-existing condition, especially those of the heart or respiratory system

Signs of a Severe Asthma Attack

Doctors classify a severe attack as one that lands you in the emergency room or clinic. But before that happens, someone needs to recognize the person has a severe attack. Here’s what to look for:

Severe Wheezing

Severe wheezing is wheezing that a person can hear from across the room. It is the sound of air trying to force itself in and out of the airways. If this person has a rescue inhaler, they may be able to dilate their airways and stop the attack. But if they do not, this person may need first aid and treatment.

Uncontrollable Dry Coughing

The uncontrollable coughing is the result of a feeling of not being able to clear their throat. This cough usually sounds dry and tight, as opposed to wet coughs someone might have with a cold or flu that results in the person coughing something up.

Fast, Shallow Breathing

Because the person can’t get enough oxygen in one breath, they begin breathing rapidly, with each breath only pulling in a little air. Even with the rapid breathing, they’re unlikely to be getting enough oxygen to remain conscious, and that leads us to the next signs of severe asthma.

Chest Retraction

Normally, when you breathe, the chest retracts and releases with each breath. This requires muscle movement but also air pressure. The chest appears to cave in slightly during a severe asthma attack but doesn’t expand back out.

This is much easier to see in a baby or small child since their chests are smaller and still growing.

Panicked Feeling

This feeling of panic has two primary causes. First, if a person can’t breathe. That’s terrifying when the brain senses that it’s not getting enough oxygen, which provokes fear.

But the rapid breathing also activates the sympathetic nervous system that causes a fight or flight response. This causes the body to release adrenaline, which causes a panic feeling.

Anxiety and panic attacks can also trigger asthma in those who are susceptible to it, making this a vicious cycle in some.

Tight Chest

The person with asthma may cluck at their chest because it feels tight and painful.

Inability to Talk

A person having a severe asthma attack may try to speak, but sentences are cut short by quick breaths as they try to get out what they’re saying.

Blue Fingernails

The lips and fingernails turn blue first, so pay attention to those even if the face looks more or less normal.

Why does this happen? When the brain senses that the body isn’t getting enough oxygen, it will ration the little oxygen it gets to keep the brain, heart, and other vital organs working as long as possible.

That means non-essential extremities, fingers, toes, lips will go blue first.

Pale, Sweaty Face

The face may not turn blue immediately, but the person may start sweating, a natural fight or flight response from that earlier adrenaline release. You may also notice them getting paler.

These are signs of a severe asthma attack. Now, what should you do?

Creating a Severe Asthma Attack Action Plan

During an event, you certainly don’t have time to create an action plan. Instead, you’ll be thinking on your feet. But if you or a loved one even has mild asthma, creating an action plan for the two of you is a responsible step in the right direction.

• Talk about signs of a severe asthma attack and when it’s time to call 911.
• Talk to your loved one about known triggers. This is critical because if you need to move this person from the trigger, you need to know what you’re removing them from, if possible.
• Make sure you know how to use an inhaler and where your loved one keeps it.
• Learn the difference between respiratory distress and respiratory failure.
• Learn CPR and First Aid for respiratory distress.

Note: People with chronic lung disease should have a rescue inhaler containing albuterol or another rescue drug. They may also have an attack prevention inhaler (montelukast sodium) that works by blocking the immune system’s production of certain inflammatory substances (leukotrienes), but this is not a rescue inhaler. It’s a preventative. Know the difference.

First Aid for Asthma: How to Use a Rescue Inhaler

If possible, remove the person from the suspected irritant and find somewhere where they can get fresh air. Keep in mind, what you consider fresh air and what this person considers fresh air may be two different things. If this person is allergic to pollen, then taking them outside on a warm spring day may not be the best idea

• Shake the inhaler 10 to 15 times. Note: If you know the person regularly uses this inhaler, then you only need to shake it a couple of times to prime it, according to medlineplus.gov.
• Attach the spacer if available. Spacers deliver a slower, more continual dose which can be more effective than straight from the inhaler, especially if the person is struggling to take instructions.
• Place spacer or inhaler spout in the mouth. It’s not like the movies where people use inhalers by holding them up to their lips. The part that releases the medicine is in the mouth, and the mouth is closed.
• Press down on the inhaler while the person inhales deeply
• If possible, they should hold the medicine for 10 seconds. If they’re already very short of breath, this may not be possible.
• Repeat if symptoms continue
• Stay with the person until medical assistance arrives
• If this person becomes unresponsive, start CPR protocol.

CPR for a Victim of Asthma Attack

You only perform CPR on someone having an asthma attack which has stopped breathing and is non-responsive. You will follow standard CPR procedure as outlined in an ILCOR-aligned CPR training course. This should include rescue breaths.

Hands’ only CPR is normally acceptable if you prefer not to do mouth-to-mouth or don’t feel you can while doing compressions. Bystander hands-only CPR has been shown to be just as effective as CPR that includes rescue breathing, according to a review of three randomized trials published at nih.gov.

However, in the case of an asthma attack, the obstruction in the respiratory system has caused a lack of oxygen, so rescue breaths are essential if at all possible. One rescuer can give breaths and perform compressions with CPR training.

How Paramedics Handle a Severe Asthma Attack In the Field

According to JAMA, it takes seven to 14 minutes for an ambulance to arrive after you call 911. So, if your loved one is unresponsive, you should not wait to begin CPR. If they are still alert, you should begin first aid.

These could be the difference between life and death. Once emergency responders arrive, they will take the following actions.

Assessment

The EMT or paramedic will assess the situation.

This includes the ABC’s –airway, breathing, and circulation. Since they’ve been informed that this is an asthma attack, they will use an O2 Saturation monitor to get the victim’s oxygen levels. Carbon dioxide build-up is also a concern during an asthma attack, so they’ll attach another monitor to determine how much CO2 they’re breathing out (if they’re breathing).

If they’re still breathing, they’ll listen and watch for several of those signs of an asthma attack discussed in the above section. Is the person turning blue? Are they wheezing loudly? Have they tried their rescue inhaler?

If the person needs CPR when they arrive, they’ll stabilize the patient before proceeding.

This may seem like a lot of assessment steps, but emergency personnel can do all of this within seconds of arriving.

Provide Oxygen

Next, they’ll provide oxygen through a simple nasal cannula or facemask, which may work better if the victim is still struggling significantly.

Start the Nebulizer Treatment

A nebulizer is like a more powerful (and much larger) rescue inhaler. It may contain the same medicine but at a much higher dose and over a longer period of time. It delivers a steady flow of bronchodilation medication to stop the constricting in the respiratory system.

Albuterol is the main nebulizer medicine, but EMT may also add ipratropium to the machine. These two together are more effective than albuterol alone.

The victim stays on the nebulizer until they are no longer wheezing. A nebulizer can increase the person’s heart rate, which may already be fast because of the ordeal, so this is something they’ll monitor, although a racing heart will not be their primary concern.

Injections and IVs

In most cases, a little time on the nebulizer treatment resolves the issues. But emergency personnel must be ready for the possibility that the patient will destabilize. If they assess that there is a high risk of this, they may start a hydration IV and administer a steroid, such as methylprednisolone, which has been shown to reduce the need for admission due to severe asthma attacks.

They can also give steroids and other medications IM (muscle injection), if needed.

Airway Management

If the patient doesn’t respond to the above first aid and treatment, the next step is ventilation by way of a CPAP or BIPAP in the field. They will intubate (insert a tube) only if CPAP isn’t able to deliver air into the respiratory system.

Seeing the Doctor

The ambulance will typically take this person to the emergency room, where they will see a doctor. The doctor will examine the patient, make sure they understand how to manage their disease, and discuss prevention and treatment options. These may include being under observation or admission for a day or two.

First Aid for a Severe Asthma Attack

An attack is stressful for both the person having it and their loved one who helps them through it. If you have a friend or loved one at risk of a severe attack, then it’s critical that you learn CPR and first aid for asthma. Your actions could be the difference between life and death during these events. Share your experience of learning CPR and first aid with us.