An acute asthma exacerbation in adults presents as an acute or subacute episode of progressive worsening of asthma symptoms, such as shortness of breath, wheezing, cough, and chest tightness.
Pulse rate, respiratory rate, subjective assessment of respiratory distress, accessory muscle use, and auscultation of the lung fields are key factors to assess during physical exam.
An increase in airway obstruction that can be quantified objectively by peak flow measurement or forced expiratory volume in 1 second (FEV₁) is typical in an acute exacerbation.
Early administration of bronchodilators and corticosteroids relieves airflow obstruction and helps to prevent future relapses. Severe exacerbations often require additional therapy including oxygen, magnesium, and, in some circumstances, mechanical ventilation.
Pneumonia, pneumothorax, pneumomediastinum, and respiratory failure are complications.
An asthma exacerbation is characterized by a progressive worsening of symptoms of asthma, including shortness of breath, wheezing, cough, and chest tightness, and a progressive decrease in lung function as measured by peak expiratory flow rate and FEV₁ from baseline. An exacerbation of asthma represents a change from the patient's usual status that is sufficient to require a change in treatment. Exacerbations may occur in patients with a pre-existing diagnosis of asthma or, occasionally, as the first presentation of asthma.
This topic covers the management of adults. Children 12 years and older are generally treated the same as adults. However, consult your local pediatric guidance as there may be some differences in the treatment approach and weight-based dosing may be recommended in some adolescents.
History and exam
Key diagnostic factors
- shortness of breath
- chest tightness
- sleep disturbance
- accessory muscle use
- wheezing, poor air movement, or diminished breath sounds
- inability to speak
Other diagnostic factors
- exercise limitation
- viral infection
- uncontrolled asthma symptoms
- high use of short-acting beta-2 agonists
- inconsistent use of inhaled corticosteroids
- incorrect inhaler technique
- low forced expiratory volume in 1 second (FEV₁)
- high bronchodilator reversibility
- current smoker (including e-cigarettes) or exposure to secondhand cigarette smoke
- exposure to allergens (including history of seasonal allergic rhinitis)
- air pollution
- poor indoor air quality
- chronic rhinosinusitis
- gastroesophageal reflux disease
- confirmed food allergy
- history of asthma
- history of hospitalization for asthma exacerbations
- one or more severe exacerbations in the last 12 months
- use of oral corticosteroids
- poor adherence to asthma treatment
- psychological or socioeconomic problems
- elevated blood eosinophils
- elevated fractional exhaled nitric oxide (FeNO)
- respiratory bacterial infection
1st investigations to order
- peak expiratory flow rate
- oxygen saturation
Investigations to consider
- chest x-ray
life-threatening exacerbation or impending respiratory failure
mild to moderate exacerbation
- Acute bronchiolitis
- Foreign body/obstruction
- Global strategy for asthma management and prevention
- Focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group
Asthma in adultsMore Patient leaflets
Peak flow measurement: animated demonstration
Expiratory wheezeMore videos
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