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What Can Cause Asthma Exacerbation

When To Call 911

Of these, rhinoviruses account for 60% to 70% of all viral-induced asthma cases, with the majority of remaining cases linked to influenza viruses and RSV. However, it is unclear how these different viral infections trigger asthma.

Most scientists agree that there is not a simple cause-and-effect relationship. What follows are a few hypotheses as to why viral-induced asthma occurs.

Assessment Of Ventilatory Status

In patients with acute asthma exacerbations, frank ventilatory failure is unusual. Signs of severe respiratory distress, such as excessive use of accessory muscles, extreme tachypnea, or abdominal paradox, warrant the initiation of ventilatory assistance. Arterial blood gases showing normocapnia in a patient with severe respiratory distress should also cause alarm because patients reach a crossover point as they fail, when they can no longer sustain hyperventilation but have not become sufficiently fatigued to retain CO2. These patients should be monitored closely so that noninvasive ventilatory aids can be initiated promptly in order to avert the need for invasive ventilation with its attendant potential complications.

Advice For Friends And Family

It’s important that your friends and family know how to help in an emergency.

It can be useful to make copies of your personal asthma action plan and share it with others who may need to know what to do when you have an attack.

You can photocopy your existing plan, or you could download a blank personal asthma action plan from Asthma UK and fill it in for anyone who might need a copy.

Or you could take a photo of your action plan on your phone, so you can show or send it to others easily.

Page last reviewed: 19 April 2021 Next review due: 19 April 2024

When Should Steroids Be Administered Iv Or Oral

In patients presenting with a mild to moderate exacerbation, give oral corticosteroids if the patient does not have an immediate response to inhaled beta-agonists or if there is a history of recent steroid use. All patients with a severe exacerbation should receive oral corticosteroids, preferably within the first hour of presentation. IV steroids should be reserved for those patients with respiratory arrest or failure. Oral steroids have been found to be equally effective to IV steroids in several studies.

How Do Healthcare Providers Diagnose Asthma

Asthma Infographic Elements Detail About Of Asthma ...

Your healthcare provider will review your medical history, including information about your parents and siblings. Your provider will also ask you about your symptoms. Your provider will need to know any history of allergies, and other lung diseases.

Your healthcare provider may order a chest X-ray, blood test or skin test. Your provider may order . This test measures airflow through your lungs.

What Causes Asthma Symptoms To Flare Up

Your asthma can flare up for different reasons. If you’re allergic to dust mites, pollens or molds, they can make your asthma symptoms get worse. Cold air, exercise, fumes from chemicals or perfume, tobacco or wood smoke, and weather changes can also make asthma symptoms worse. So can common colds and sinus infections. Gastroesophageal reflux can also cause flare-ups. You can help yourself by paying attention to the way these things affect your asthma. Your doctor might test you to find out if you’re allergic to something. Then your doctor can help you avoid the things that bother your asthma.

The Difference Between Poorly Controlled Asthma And Asthma Exacerbations

The most commonly used definition of an asthma exacerbation requires not an event of a particular character but the management of it, whether that be hospitalisation, emergency room presentation or a course of oral corticosteroids . Such an exacerbation can be an extension of the pattern of disease in ongoing poor control or an independent event. It is clear that some patients have excellent current control of asthma with minimal or no symptoms, and yet have sudden and severe exacerbations. Viral infections have been implicated in such events. At the other extreme, some patients have unrecognised or ineffectively managed asthma, and have extreme variability in symptoms and lung function. In these cases, exacerbations may be recorded not necessarily for the deepest fluctuations in lung function or for specific patterns of asthma worsening, but for those occasions where medical advice was sought and treatment given.

One particularly challenging aspect of asthma exacerbations is the differentiation between inadequate treatment regimens leading to episodic symptomatic asthma and catastrophic failures in asthma control in response to various stimuli, i.e. an exacerbation.

Blood Oxygen Level Tests

During a severe asthma attack, it may be necessary to check the level of oxygen in your blood. This can be done using a pulse oximeter. A pulse oximeter is a small device thats placed on the end of your finger. The test takes a few seconds to complete and can even be performed at home.

Shop for a to use at home.

Most of the time, asthma exacerbations can be managed at home or with a visit to your doctor. The asthma plan you developed with your doctor can help you manage your symptoms and acute attacks.

However, acute exacerbations often result in a trip to the emergency room. Emergency treatment may include:

  • inhaled beta-2 agonists, such as
  • corticosteroids, such as fluticasone

An acute exacerbation requires close monitoring. Your doctor may repeat diagnostic tests several times. You wont be discharged until your lungs are functioning adequately. If your breathing continues to be labored, you may have to be admitted for a few days until you recover.

You may need to take corticosteroids for several days following the exacerbation. Your doctor may also recommend follow-up care.

Summary And Next Steps

Much is already known about asthma exacerbation risk and prevention. Currently, medical history, biomarkers, environmental assessments, and technology have allowed for more personalization of asthma care for the prevention of asthma exacerbations than ever before. Further study into the underlying mechanisms for asthma exacerbations and gene-environmental interactions will provide for further personalization in the future. Future steps to further personalize asthma therapy includes the further elucidation of genetic-environmental interaction risk factors for exacerbations including the role of the human rhinovirus receptor in asthma exacerbations,114 proteomics,115 and metabolomic116 and microbiome117,118 evaluations. This expanding understanding of exacerbation risk could be harnessed into more precise, and possibly even real-time exacerbation prediction, as has been envisioned.119 However, in the meantime, providers can utilize currently available information to predict asthma exacerbations, including demographic information, asthma history , markers of lung function, biomarkers including allergen sensitization, FeNO and eosinophils, and indoor and outdoor environmental exposures.

Jennifer Dunnick MD, MPH, … Jerri A. Rose MD, in, 2018

Allergies Can Cause Asthma

Allergies with asthma is a common problem. Eighty percent of people with asthma have allergies to things in the air, like tree, grass, and weed pollens; mold; animal dander; dust mites; and cockroach droppings. In one study, children with high levels of cockroach droppings in their homes were four times more likely to have childhood asthma than children with low levels. An allergy to dust mites is another common asthma trigger.

If you have asthma thatâs hard to control, see an allergist to find out if you have allergies. Treating your allergies with medication and avoiding your triggers can help lower the odds of a severe asthma attack.

Food And Food Additives Trigger Asthma

Food allergies can cause mild to severe life-threatening reactions. They rarely cause asthma without other symptoms. If you have food allergies, asthma can be part of a severe, life-threatening reaction called . The most common foods associated with allergic symptoms are:

  • Eggs
  • Salads
  • Fresh fruits

Food preservatives can trigger isolated asthma, especially sulfite additives, like sodium bisulfite, bisulfite, sodium metabisulfite, potassium metabisulfite, and sodium sulfite, which are commonly used in food processing or preparation.

Aspirin And Other Drugs That May Trigger Asthma

Carol DerSarkissian, MD

Many people with have sensitivities to certain drugs that can precipitate an asthma attack . If you have , you need to be aware of which may be triggers. You do not need to avoid these medications unless you know they are asthma triggers for you. If these medications have never triggered your , it is still best to take the medications with caution because a reaction can occur at any time.

Below is a list of the most common medications known to trigger symptoms of asthma. However, if you are prescribed any medication that you think may be causing your asthma to worsen, discuss it with your doctor.

Aspirin Sensitivity, Asthma, and Nasal Polyps. Some people with asthma cannot take aspirin or NSAIDs because of whatâs known as Samterâs — a combination of asthma, aspirin sensitivity, and nasal polyps. Nasal polyps are small growths that form inside the nasal cavity.

This aspirin sensitivity occurs in about 30% to 40% of those who have asthma and nasal polyps. Many people with Samter’s triad have nasal symptoms, such as runny nose, postnasal drip, and congestion, along with asthma symptoms, such as wheezing, , and shortness of breath. Talk to your doctor about options other than aspirin and NSAIDs if you have this.

Management Of Acute Asthma Exacerbations

5 Causes of Asthma

SUSAN M. POLLART, MD, MS; REBEKAH M. COMPTON, MSN, FNP-C; and KURTIS S. ELWARD, MD, MPH, University of Virginia Health System, Charlottesville, Virginia

Am Fam Physician. 2011 Jul 1;84:40-47.

 Patient information: See related handout on how to treat an asthma attack, written by the authors of this article.

In 2005, the prevalence of asthma in the United States was nearly 8 percent , and approximately 4 percent of Americans experienced an asthma attack., There have been many advances in medical therapy to prevent the worsening of asthma symptoms, including an improved understanding of asthma etiology, identification of risk factors for asthma exacerbations, and evidence supporting the benefits of written asthma action plans.

In persons older than two years with asthma, neither the injectable nor the intranasal influenza vaccine increases the likelihood of an asthma exacerbation in the period immediately following vaccination. However, one study of infants found an increase in wheezing and hospital admissions after intranasal influenza vaccination. Seasonal influenza vaccine does not reduce the risk of developing an asthma exacerbation. Influenza vaccination appears to improve asthma-related quality-of-life in children during influenza season.

Gaps In Knowledge And Care

The key messages for the nonventilatory management of asthma in adults in the emergency department are presented in , and .

Box 4: Key messages for subsequent care of patients with acute asthma*

Gaps in knowledge exist in several areas, representing opportunities for future research in the assessment and management of acute asthma.

Research is needed into ways of identifying the specific phenotype of asthma that is associated with high risk for potentially fatal asthma. Sudden asphyxic asthma may represent a particular phenotype, and efforts are needed to better characterize this relatively rare occurrence and its risk factors. Although it is known that poor preventive management of asthma predisposes people to poor asthma control and heightens the risk of death from asthma, novel methods for monitoring the adequacy of anti-inflammatory control of asthma should be developed and simplified for widespread use. This might entail the development of serologic markers, simplified management of cytologic examination of induced sputum, or reliable and practical methods of analyzing exhaled breath condensate.

Can Current Therapeutic Regimens Prevent Virus

There is no doubt that the reductions observed in asthma morbidity and mortality observed over the last 20 years are the result of better therapeutic management; however, the real question is, are asthma therapeutics effective in virus-induced exacerbations? Large studies have shown that even low-dose inhaled corticosteroids reduce exacerbations and the risk of death from asthma . For example, in comparison to no treatment, 100 g budesonide twice daily resulted in a 60% reduced risk of having a severe exacerbation in the OPTIMA trial . The addition of a long-acting 2-agonist to ICS further reduces the frequency , severity and duration of exacerbations. Studies such as these were not designed to identify the cause of the exacerbation; however, as viruses are thought to cause 50% of all exacerbations, it is reasonable to assume that some reduction in the incidence of virus-induced exacerbations would occur. None of these studies specifically identified whether improved asthma management does one or more of the following: 1) reduces the rate of respiratory viral illnesses; 2) reduces the rate at which respiratory viral infections trigger a sequence of inflammatory events that will result in an exacerbation; or 3) reduces the severity of symptoms or lung function such that the episode does not require exacerbation-defining medical intervention.

Management Of Acute Asthma Episodes

Asthma exacerbations occur frequently and may occur even in the context of regular use of long-term controller therapy. Most exacerbations, especially those which are mild in nature, can generally be managed without difficulty at home. However, success in outpatient care of acute asthma demands excellent preparation, including a written set of instructions to help guide the patient and his/her family. The Asthma Action Plan is the central component for home asthma management. Patients must be instructed as to the early and accurate recognition of changes in asthma status, as early intervention is likely to lessen the severity and rate of progression of the episode. An algorithm which serves as the basis for the action plan and allows for telephone triage and recommendations is shown in Figure 34-3.

Carlos A. CamargoJr., in, 2018

What Is An Asthma Action Plan

Your healthcare provider will work with you to develop an asthma action plan. This plan tells you how and when to use your medicines. It also tells you what to do if your asthma gets worse and when to seek emergency care. Understand the plan and ask your healthcare provider about anything you dont understand.

After An Asthma Attack

You should see a GP or asthma nurse within 48 hours of leaving hospital, or ideally on the same day if you did not need hospital treatment.

About 1 in 6 people treated in hospital for an asthma attack need hospital care again within 2 weeks, so it’s important to discuss how you can reduce your risk of future attacks.

Talk to a doctor or nurse about any changes that may need to be made to manage your condition safely.

For example, the dose of your treatment may need to be adjusted or you may need to be shown how to use your inhaler correctly.

Are Corticosteroids Effective Or Ineffective During Virus

Corticosteroids are known to improve asthma symptoms and decrease exacerbations; however, virus-induced exacerbations can occur in ICS-treated asthma in patients who are well controlled . Clearly, a component of specific virus-induced inflammation is not controlled by stable ICS therapy. Whether ICS have no effect on virus-induced asthma deterioration is much less clear. In patients using budesonide/formoterol maintenance and either terbutaline, formoterol or formoterol/budesonide as a reliever, the exacerbation rate after the onset of reported cold symptoms was reduced by as-needed budesonide/formoterol compared with as-needed formoterol reliever . Even in that setting, there is potential confounding by an effect of the additional as-needed ICS on residual eosinophilic airway inflammation rather than viral mechanisms.

When the dose of ICS used in asthma is considered, there is no benefit from doubling ICS dose for treatment of exacerbations and this approach is now considered insufficient for the management of asthma . A recent study by Oborneet al. extended this finding and evaluated the efficacy of quadrupling the usual dose of ICS at the first symptoms of a cold; however, this approach did not reduce exacerbations in comparison to placebo.

Flu & People With Asthma

People with asthma are at high risk of developing serious flu complications, even if their asthma is mild or their symptoms are well-controlled by medication. People with asthma can develop swollen and sensitive airways, and flu can cause further inflammation of the airways and lungs. Flu infections can trigger asthma attacks and a worsening of asthma symptoms. Flu also can lead to pneumonia and other acute respiratory diseases. In fact, adults and children with asthma are more likely to develop pneumonia after getting sick with flu than people who do not have asthma. Asthma is the most common medical condition among children hospitalized with flu and one of the more common medical conditions among hospitalized adults. For information about underlying health conditions in reported flu hospitalizations, see the FluView Interactive application.


What is Asthma?

What To Do If You Have An Asthma Attack


If you think you’re having an asthma attack, you should:

  • Sit upright and try to take slow, steady breaths. Try to remain calm, as panicking will make things worse.
  • Take 1 puff of your reliever inhaler every 30 to 60 seconds, up to a maximum of 10 puffs.
  • If the ambulance has not arrived within 15 minutes, repeat step 2.
  • Never be frightened of calling for help in an emergency.

    Try to take the details of your medicines with you to hospital if possible.

    If your symptoms improve and you do not need to call 999, get an urgent same-day appointment to see a GP or asthma nurse.

    This advice is not for people on SMART or MART treatment. If this applies to you, ask a GP or asthma nurse what to do if you have an asthma attack.

    What Is Asthma Exacerbation

    Asthma attacks or asthma exacerbations can be acute or subacute episodes during which your airways become swollen. When this happens, the muscles around your airways contract excessively, and the cells inside your airways produce disproportionate amounts of mucus. These changes cause your airways to become narrow, making it difficult for you to breathe properly.

    The severity of asthma attacks is highly variable, and treatment will depend on how bad your symptoms are and how often you experience them. Minor asthma attacks may often be managed at home, whereas severe asthma exacerbations require urgent medical assistance and can even be life-threatening.

    Asthma commonly affects children, but adults can also develop the condition, especially when theyre exposed to specific allergens. Women can be more susceptible to adult-onset asthma during certain stages of life, such as pregnancy, , or menopause.

    The symptoms of an asthma attack include:

    • Difficulty breathing
    • Wheezing when you exhale
    • Low readings in a peak flow meter

    The symptoms caused by an asthma attack can vary greatly from one patient to the next. Different factors, from the medications youre taking to seasonal allergies, can even cause varying symptoms for the same patient.

    The exact causes of an asthma attack cant always be determined, but certain factors can increase your risk of having an asthma exacerbation, such as:

    A Difficult Specific Problem: Treatment Of The Exacerbating Phenotype

    Acute asthma exacerbations cause considerable morbidity, sometimes death; however, they are not a feature of all children with asthma. Asthma lung attacks have been associated with an accelerated decline in lung function in children not prescribed ICS. Acute asthma lung attacks cannot be abolished completely. Acute asthma lung attacks and loss of baseline control are not the same thing; loss of baseline control is characterized by wide diurnal peak expiratory flow variation, while acute asthma lung attacks are characterized by a steep decline in peak flow, with no increased variability.193 Children may have good control, but still have attacks,194 and increasing the interval medications merely increases the risk of side effects. However, poor control195 and previous severe attacks195,196 both predict a high risk of future acute attacks.

    In older children, the combination of respiratory viral infection, and both sensitization and exposure in the home to high allergen levels, is strongly predictive of asthma lung attacks.83 They are typically characterized by mixed eosinophilic and neutrophilic, or pure neutrophilic inflammation.197â199 At the other extreme, really high-dose allergen exposure can cause acute asthma lung attacks ; thunderstorm asthma at least is characterized by airway eosinophilia.200

    Alexandre T. Rotta, … Howard Eigen, in, 2011

    Who Can Get Asthma

    Anyone can develop asthma at any age. People with allergies or people exposed to tobacco smoke and secondhand smoke are more likely to develop asthma.

    Statistics show women tend to have asthma more than men, and asthma affects Black Americans more frequently than other races.

    When a child develops asthma, healthcare providers call it childhood asthma. If it develops later in life, its adult-onset asthma.

    Children do not outgrow asthma. They may have fewer symptoms as they get older, but they could still have an asthma attack. Your childs healthcare provider can help you understand the risks.

    Side Effects Of Relievers And Preventers

    Relievers are a safe and effective medicine, and have few side effects as long as they are not used too much. The main side effects include a mild shaking of the hands ,  and muscle cramps. These usually only happen with high doses of reliever inhaler and usually only last for a few minutes.

    Preventers are very safe at usual doses, although they can cause a range of side effects at high doses, especially with long-term use.

    Using a spacer can help prevent these side effects, as can rinsing your mouth or cleaning your teeth after using your preventer inhaler.

    Your doctor or nurse will discuss with you the need to balance control of your asthma with the risk of side effects, and how to keep side effects to a minimum.

    When To Seek Emergency Medical Care

    Anyone experiencing any of the following emergency warning signs of flu sickness, including people with asthma, should seek medical attention right away.

    People experiencing these warning signs should obtain medical care right away.

    In children

    • Fast breathing or trouble breathing
    • Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
    • Ribs pulling in with each breath
    • Chest pain
    • Severe muscle pain
    • Dehydration
    • Not alert or interacting when awake
    • Seizures
    • In children less than 12 weeks, any fever
    • Fever or cough that improve but then return or worsen
    • Worsening of chronic medical conditions

    In adults

    • Difficulty breathing or shortness of breath
    • Persistent pain or pressure in the chest or abdomen
    • Persistent dizziness, confusion, inability to arouse
    • Seizures
    • Fever or cough that improve but then return or worsen
    • Worsening of chronic medical conditions

    These lists are not all inclusive. Please consult your medical provider for any other symptom that is severe or concerning.

    Susceptibility To Viral Infection

    People with asthma do not appear to be more likely to develop symptomatic colds than nonasthmatic individuals, but they are more likely to develop lower respiratory tract symptoms and these symptoms are more prolonged. While this may represent the effect of virus infection on asthmatic inflammation, it may also indicate an increased susceptibility to virus infection in asthmatics. Traditionally, antiviral responses have been characterised by a Th1 phenotypic response with raised levels of IFN and recruitment of CD8 cells. This is in contrast to the Th2 response thought to be dominant in asthma, with increased levels of IL4, IL5 and IL13. Subjects infected with RV who have a Th2 characteristic response, as seen by a lower ratio of IFN to IL5 in sputum, were less efficient at clearing the virus. Infection of peripheral blood monocytes from subjects with atopic asthma and nonatopic controls with RV also showed differential responses. Nonasthmatic PBMCs responded with vigorous release of IFN and IL12, while this response was lower in asthmatic PBMCs which had higher levels of the antiinflammatory cytokine IL10 and a small increase in IL4 levels .

    Symptoms Of An Asthma Attack

    Signs that you may be having an asthma attack include:

    • your symptoms are getting worse
    • your reliever inhaler is not helping
    • you’re too breathless to speak, eat or sleep
    • your breathing is getting faster and it feels like you cannot catch your breath
    • your peak flow score is lower than normal
    • children may also complain of a tummy or chest ache

    The symptoms will not necessarily occur suddenly. In fact, they often come on slowly over a few hours or days.

    What Should I Do If I Have A Severe Asthma Attack


    A severe asthma attack needs immediate medical care. The first step is your rescue inhaler. A rescue inhaler uses fast-acting medicines to open up your airways. Its different than your normal maintenance inhaler, which you use every day. You should only use the rescue inhaler in an emergency.

    If your rescue inhaler doesnt help or you dont have it with you, go to the emergency department if you have:

    • Anxiety or panic.
    • Bluish fingernails, bluish lips or gray or whitish lips or gums .
    • Chest pain or pressure.


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