An Overview of Asthma Attacks

If you or your child has asthma, it is important that you recognize and treat the early warning signs of an asthma attack. The symptoms of an asthma attack include wheezing, a sense that you are struggling to breathe, and pale or blue fingers, toes, or lips.

Early management may prevent a trip to the emergency room or admission to the hospital—the effects of an asthma attack can occur rapidly. Respiratory tests can confirm that your breathing problems are caused by an asthma attack. Rescue inhalers are often used to stop it quickly.

Fatal asthma is a significant problem—more than 10 Americans die each day from the effects of asthma. Learn how to recognize an asthma attack and how to reduce your risk of having one.

You may experience asthma attacks frequently, or you may have long periods of time without symptoms. These episodes cause severe physical discomfort and distress. Asthma attacks may come on suddenly and worsen rapidly. Sometimes, they last for only a few minutes, but many do not improve without treatment.

Often, asthma attacks are preceded by an increased frequency of asthma symptoms, but this is not necessarily always the case. If your asthma is not optimally controlled, you may develop signs of an impending asthma attack.

Warning signs of worsening asthma and early signs of an asthma attack include:

• Increased coughing
• Intermittent wheezing
• Mild shortness of breath
• Occasional chest tightness
• Fatigue or shortness of breath with exertion or when performing normal daily activities
• Worsening allergies

An asthma attack is more sudden and severe than the intermittent signs of worsening or poorly controlled asthma.

The effects of an asthma attack may include:

• Wheezing (a whistling sound while breathing in or out)
• Shortness of breath
• Continuous coughing
• Difficulty breathing
• Tachypnea (breathing very fast)
• Shallow breathing
• Retractions (your skin is pulled in as you breathe)
• Chest tightness
• Difficulty speaking in complete sentences
• Pale skin
• Anxiety or a sense of panic
• Difficulty walking due to shortness of breath.
• Cyanosis (blue lips, toes, or fingers)

You may not necessarily experience all of the effects of an asthma attack, but you are sure to notice the symptoms when you have any of them.

Asthma attacks may occur when you have an infection like the common cold or some other kind of viral or bacterial respiratory infection. Likewise, your symptoms may worsen when you breathe a substance that irritates your lungs, such as cigarette smoke, dust, or other possible triggers.

Asthma attacks often occur in response to a trigger, which is usually a harmless substance in the environment. Your immune system may mount an immune response when you are exposed to the trigger—behaving as if the trigger were an infectious microorganism.

Common triggers include:

• Pollen
• Animal dander
• Dust
• Dust mites: Find out what increases your dust mite exposure.
• Mold
• Droppings from cockroaches and other pests
• Extreme weather
• Exercise
• Tobacco smoke
• Medications such as beta blockers and ACE inhibitors

Keep in mind that each person's asthma attacks may be triggered by some, but not all, of these common substances.

If you have a diagnosis of asthma, you are at risk for an asthma attack. A number of different risk factors may increase your chances of developing an asthma attack.

You are at increased risk of a significant asthma attack if you:

• Have had a serious asthma attack in the past
• Required admission to a hospital or intensive care unit to care for your asthma in the last year
• Your asthma attacks seem to creep up on you suddenly without any signs
• Require frequent use of your rescue inhaler
• Have a history of substance abuse
• Have a history of significant mental illness

Asthma attacks are caused by sudden bronchoconstriction (tightening of the bronchi). Your bronchi are passageways through which air enters the lungs. Your immune system can overact and release chemicals into the bloodstream that induce bronchoconstriction, making it difficult for air to enter the lungs.

Asthma attacks are characterized by three distinct features:

• Bronchoconstriction and spasm of the bronchi, which narrows or closes them off, preventing air from entering the lungs
• Excessive mucus in the lungs—which clogs the bronchi, restricting air flow
• Inflammation ​of the air passages, which thickens the bronchi, narrowing the lumen (opening)

Asthma attacks are diagnosed based on your medical history and your symptoms. If it is not clear whether your breathing difficulties are caused by an asthma attack or something else, some diagnostic tests can help differentiate between an asthma attack and other conditions that affect breathing.

Tests you may need when you have an asthma attack include:

Pulse oximeter: A pulse oximeter is a non-invasive test that measures the oxygen saturation in your blood. It is a small device that is placed on your finger, providing a continuous, updated reading. This test is useful in monitoring your oxygen level to help assess whether your condition is improving or worsening. Low oxygen levels indicate a medical emergency.

Spirometry: This is a test that measures how much air you can breathe out into a mouthpiece. It requires your active participation, so you cannot do it if you are in severe respiratory distress.

A spirometry measures forced vital capacity, which is a measure of how much air you can breathe out (after inhaling as much air as you can). It also measures forced expiratory volume, which is a measure of how much air you can breathe out in one minute. When these values are lower than normal, it is a sign of impaired respiratory function.

Imaging test: You may need to have an imaging test, such as an x-ray, computerized tomography (CT), or magnetic resonance imaging (MRI), to assess your lungs and the surrounding structures. This can identify severe infections, traumatic injuries, or lung disease.

Ventilation/perfusion test (V/Q scan): This is an imaging test used to assess blood flow and air flow. It can help identify changes seen in asthma. A V/Q scan is also helpful in identifying a pulmonary embolism (PE), which is a blood clot in the blood vessels that supply the lungs. This is a medical emergency that can cause respiratory distress similar to that of an asthma attack.

Arterial blood gas: This is a minimally invasive blood test in which blood is drawn from your artery. This test measures oxygen level, blood pH, carbon dioxide level, and bicarbonate level.

In addition to providing more information than a pulse oximeter, arterial blood gas is a more accurate reading of blood oxygen saturation than a pulse oximeter—but the blood sample must be sent to a lab, and the results can take between 10 to 30 minutes.

Electrocardiogram (EKG): An electrical test that measures heart rate and rhythm, an EKG can help your doctors assess whether you have a heart problem. Sometimes, a heart attack can cause shortness of breath that is similar to that of an asthma attack.

Because quick treatment is essential, your doctor will prescribe treatments for you to use when you have an asthma attack. And your doctor will also give you guidelines for when you should get emergency medical attention.

Asthma attacks are usually treated with inhalers. These medications are taken with a device called a nebulizer. You use this device to breathe in the medication. Your medical team will show you how to use a nebulizer at home.

When you are having an asthma attack, inhaled medications can quickly relieve the episode.

Bronchodilators are fast-acting medications that widen the bronchi, allowing air to move into the lungs. They are anticholinergics that counteract the effects of acetylcholine (a neurotransmitter that stimulates constriction (narrowing) of the bronchi).

Bronchodilators commonly used in the treatment of asthma include:

• Proventil, Ventolin (albuterol)
• Xopenex (levalbuterol)
• Alupent (metaproterenol)

Steroid inhalers are used to reduce the inflammation when you are having an asthma attack. Steroids commonly used in the treatment of asthma include:

• Qvar (beclomethasone dipropionate)
• Pulmicort, Entocort, Uceris (budesonide)
• Flovent, ArmonAir RespiClick, Ticanase, Ticaspray (fluticasone propionate)
• Azmacort (triamcinolone acetonide)
• Aerobid (flunisolide)

These inhaled medications are often referred to as rescue medications. You may be instructed to use a bronchodilator and an inhaled steroid when you have an asthma attack.

If you need to be seen in the hospital during your asthma attack, you will likely have a nasal cannula placed on your nose for delivery of oxygen. Sometimes, oral steroids are used during an asthma attack, although this is not as common as inhaled medications.

Preventing asthma attacks is a key component to staying healthy when you have asthma. This means recognizing the warning signs of an impending attack, avoiding triggers when possible, and using a peak flow meter to monitor your respiratory function at home.

A peak flow meter is a simple device that you can use at home, school, work, or just about anywhere. You can breathe into the device, and it measures your peak expiratory flow rate (PEFR), which is how quickly you can breathe out after taking in a full breath.

You should regularly check your PEFR and keep a diary with the values. If your numbers are declining, this is often a sign that your asthma is getting worse. You should talk to your doctor if your peak flow is declining.

If your child has asthma, it's important to teach them about symptoms that can lead to an attack. This will help your child alert you (or their babysitter, teacher, or coach) if they start to feel an asthma attack coming on.

Another thing you can do is review what happened during an asthma attack once your child is safe and everyone has calmed down. Talk about what they felt and help them understand why that happened. You can also review what actions everyone took, why they helped, and look for ways to improve on it if it occurs again. 

Children and adults who have asthma may be able to use deep breathing exercises such as Buteyko to reduce the severity of an asthma attack. While it will not eliminate your need for a rescue inhaler, it can make the episode more manageable.

Asthma attacks can be terrifying. Fortunately, these episodes generally improve with medical treatment. Be sure to have a plan in place in case you suddenly have an asthma attack.

Recognizing the signs of worsening asthma is important. When your asthma is worsening, you should talk to your doctor, who may adjust your asthma medications before an attack happens. You can use our Doctor Discussion Guide below to help you start that conversation.