Acute asthma in the emergency department
Acute asthma (asthma exacerbation) is a common, potentially life‑threatening ED presentation. Rapid recognition, objective severity assessment, immediate evidence‑based treatment and a structured discharge bundle (including optimisation of anti‑inflammatory therapy and arranged follow‑up) reduce morbidity and mortality.
UK practice should follow the joint NICE/BTS/SIGN pathway (NG244) and guideline (NG245), with ED implementation points from the Royal College of Emergency Medicine and acute resuscitation principles from Resuscitation Council UK.
Initial priorities
- Rapid ABC assessment. If life‑threatening features are present, treat immediately while continuing assessment (see “Life‑threatening asthma”).
- Obtain a focused history including baseline control, recent exacerbations or oral steroid courses, previous ICU/intubation, current inhalers and adherence, recent SABA use, pregnancy, comorbidity and psychosocial factors.
- Perform early objective measures where feasible: pulse oximetry, peak expiratory flow (PEF) compared with predicted or best, and arterial blood gas (ABG) if severe disease or concern for ventilatory failure.
- Continuously reassess after treatment and escalate early to senior, respiratory or critical care teams when response is inadequate.
Why the ED matters
- Confidential enquiries have demonstrated that many asthma deaths are predictable and preventable.
- Key red flags: previous life‑threatening asthma (ICU/intubation), recent hospital/ED attendance, frequent oral steroid courses, poor inhaled corticosteroid (ICS) adherence and heavy SABA use (≥12 SABA inhalers/year).
- The ED is both an opportunity to treat the acute attack and...