Asthma | Acute Management | ABCDE

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This guide provides an overview of the recognition and immediate management of asthma using an ABCDE approach.

The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.

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Clinical features of asthma

Asthma is characterised by paroxysmal and reversible airway obstruction. The disease involves both bronchospasm and excessive production of secretions.

Acute asthma can be life-threatening and therefore early recognition and appropriate management are of paramount importance.

Typical clinical features of acute asthma include:

• Shortness of breath
• Wheeze
• Tachypnoea
• Hypoxia

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Tips before you begin

General tips for applying an ABCDE approach in an emergency setting include:

• Treat all problems as you discover them.
• Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
• Make use of the team around you by delegating tasks where appropriate.
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
• Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
• If you require senior input, call for help early using an appropriate SBARR handover structure.
• Review results as they become available (e.g. laboratory investigations).
• Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
• Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
• Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.

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Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.

You may be asked to review a patient with asthma due to shortness of breath and/or wheeze.

Introduction

Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.

Interaction

Introduce yourself to the patient including your name and role.

Ask how the patient is feeling as this may provide some useful information about their current symptoms.

An inability to speak in full sentences indicates significant shortness of breath.

Preparation

Make sure the patient’s notes, observation chart and prescription chart are easily accessible.

Ask for another clinical member of staff to assist you if possible.

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.

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Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

• Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
• Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.

Interventions

Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airway using a head-tilt chin-lift manoeuvre:

1. Place one hand on the patient’s forehead and the other under the chin.

2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.

Jaw thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

Other interventions

If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Breathing

Clinical assessment

Observations

Review the patient’s respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Tachypnoea is a common feature of asthma exacerbations and indicates significant respiratory compromise.
• Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.

Review the patient’s oxygen saturation (SpO₂):

• A normal SpO₂ range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO₂ retention.
• Hypoxaemia is a typical clinical feature of asthma.

See our guide to performing observations/vital signs for more details.

Auscultation

Auscultate both lungs:

• Wheeze is a common finding in asthma exacerbations (it can become less apparent with increasing airway obstruction).
• Reduced air entry is a concerning finding indicating significant airway compromise and a need for senior clinical input.
• Absent air entry is a specific area of the chest may suggest underlying pneumothorax.

Percussion

Percuss the patient’s chest to identify:

• Areas of dullness which may be associated with pleural effusion or lobar collapse.
• Areas of hyper-resonance associated with pneumothorax.

Investigations and procedures

Arterial blood gas

Take an ABG if indicated (e.g. low SpO₂) to quantify the degree of hypoxia.

Typical ABG findings in asthma include low PaO₂ and low PaCO₂. A normal or raised PaCO₂ is concerning as it indicates that the patient is tiring and failing to ventilate effectively.

Peak expiratory flow rate (PEFR)

PEFR can be used to assess the severity of the patient’s asthma exacerbation and their subsequent response to treatment. However, PEFR recording shouldn’t delay the administration of oxygen and nebulised medications.

Chest X-ray

A chest X-ray may be useful in ruling out other respiratory diagnoses if shortness of breath is the primary issue (e.g. pneumothorax, pneumonia, pulmonary oedema). Chest X-ray should not delay the emergency management of acute asthma.

Interventions

Oxygen

Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. You can then trial titrating oxygen levels downwards after your initial assessment.

If the patient is conscious, sit them upright as this can also help with oxygenation.

Beta-2 agonist (salbutamol)

A high-dose inhaled beta-2 agonist (i.e. salbutamol) should be administered as a first-line treatment in the management of acute asthma:²

• Mild to moderate asthma: use either pressurised multiple-dose inhaler (pMDI) plus spacer or oxygen-driven nebulisation to administer salbutamol.
• Severe asthma: use oxygen-driven nebulisation to administer salbutamol.
• Life-threatening asthma: use continuous oxygen-driven nebulisation to administer salbutamol.

Repeat doses of salbutamol at 15-30 minute intervals or give continuous nebulised salbutamol at 5-10 mg/hour if there is an inadequate response to initial treatment.

Steroid therapy

Steroids reduce mortality, relapses, subsequent hospital admission and requirement for beta-2 agonist therapy. The earlier steroids are administered, the better the outcome:²

• Administer steroids to all patients presenting with acute asthma (typically 40-50mg of oral prednisolone).
• If the oral route is unavailable, hydrocortisone can be administered intravenously as an alternative.
• Continue prednisolone 40-50mg daily for at least five days after the exacerbation or until recovery.

Ipratropium bromide

Combining nebulised ipratropium bromide with a nebulised beta-2 agonist produces significantly greater bronchodilation than a beta-2 agonist alone:²

• Add nebulised ipratropium bromide (0.5 mg 4-6 hourly) to beta-2 agonist treatment for patients with acute severe or life-threatening asthma or those with a poor initial response to beta-2 agonist therapy.

Magnesium sulphate

There is evidence that magnesium sulphate has a bronchodilatory effect in adults.²

Consider giving a single dose of IV magnesium sulphate for patients with:

• Acute severe asthma who have not had a good initial response to inhaled bronchodilator therapy.
• Life-threatening or near-fatal asthma.

IV magnesium sulphate should only be used following consultation with senior medical staff.

Intravenous aminophylline

IV aminophylline is not likely to result in any additional bronchodilation in the context of acute asthma compared to standard care with inhaled bronchodilators and steroids. Side effects such as arrhythmias and vomiting are increased if IV aminophylline is used.²

IV aminophylline should only be administered by senior medical staff and/or in a critical care context.

Antibiotics

Antibiotics should not be routinely prescribed in the context of acute asthma unless there is evidence of concurrent underlying infection.²

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Circulation

Clinical assessment

Pulse

Patients with acute asthma may be tachycardic, particularly if beta-agonists have been administered.

Blood pressure

Hypotension is a highly concerning feature of life-threatening asthma.

Capillary refill time

Capillary refill time may be prolonged in life-threatening asthma.

Fluid balance assessment

Calculate the patient’s fluid balance:

• Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
• Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.

Investigations and procedures

Intravenous cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below (unless already performed to administer IV drugs to treat a breathing problem).

See our intravenous cannulation guide for more details.

Blood tests

Collect blood tests after cannulating the patient including:

• FBC: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
• U&Es
• LFTs
• CRP: to screen for evidence of inflammation (e.g. pneumonia).

Interventions

Intravenous fluids

Hypovolaemic patients require fluid resuscitation:

• Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
• Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (i.e. persistent hypotension).

See our fluid prescribing guide for more details on resuscitation fluids.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Disability

Clinical assessment

Consciousness

In the context of asthma, a patient’s consciousness level may be reduced secondary to hypoxia or hypovolaemia.

Assess the patient’s level of consciousness using the AVPU scale:

• Alert: the patient is fully alert, although not necessarily orientated.
• Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
• Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
• Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Pupils

Assess the patient’s pupils:

• Inspect the size and symmetry of the patient’s pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
• Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology.

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Investigations and procedures

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia). 

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.

Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting a CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. 

Clinical assessment

Inspection

Inspect for evidence of anaphylaxis such as an urticarial rash and angioedema.

Look for potential allergens (e.g. an intravenous antibiotic infusion).

Review the output of the patient’s catheter and any surgical drains.

Assess the patient’s calves for erythema, swelling and tenderness which may suggest a deep vein thrombosis.

Temperature

Assess the patient’s temperature: fever may indicate an infective cause underlying the acute exacerbation of asthma.

Investigations

If a DVT is suspected, calculate the patient’s DVT Wells score to determine if an ultrasound scan or D-dimer test should be performed to confirm or exclude the presence of a DVT.

Interventions

Removal of allergen

If a potential allergen is identified and you suspect allergic aetiology remove the allergen (e.g. stop the antibiotic infusion).

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Reassess ABCDE

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.

Use an effective SBARR handover to communicate the key information effectively to other medical staff.

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Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Revisit history taking to identify risk factors for asthma and explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.

See our history taking guides for more details.

Review

Review the patient’s notes, charts and recent investigation results.

Review the patient’s current medications and check any regular medications are prescribed appropriately.

Document

Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details.

Discuss

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

• Are any further assessments or interventions required?
• Does the patient need a referral to HDU/ICU?
• Does the patient need reviewing by a specialist?
• Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.

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References

1. British Thoracic Society/SIGN guidelines. Management of Acute Asthma in Adults. Available from: [LINK].
2. NICE Clinical Knowledge Summary. Acute asthma exacerbation. Available from: [LINK].

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