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 as 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.

Symptoms

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.

Warning Signs

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:

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

During an Asthma Attack

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.

Causes

Asthma attacks can occur when you have a bacterial or viral respiratory infection such as common cold. Likewise, your symptoms may worsen when you breathe in a substance that irritates your lungs, such as cigarette smoke or dust.

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
• Stress
• Dust
• Dust mites
• Mold
• Droppings from cockroaches and other pests
• Weather changes
• 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.

Risk Factors

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
• Require frequent use of your rescue inhaler
• Have a history of substance abuse
• Have a history of significant mental illness

What Happens During an Asthma Attack

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)

Diagnosis

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

Pulse oximeter: A pulse oximeter is a non-invasive test that measures the oxygen saturation in your blood. It is a small device that clips onto a fingertip, 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 test 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 spirometer 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 tests: 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. These can identify severe infections, traumatic injuries, or lung disease.

Ventilation/perfusion test (V/Q scan): This imaging test assesses blood flow and air flow. It can help identify changes seen in asthma. A V/Q scan is also helpful for identifying a pulmonary embolism (PE), which is a blood clot in the 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 that measures oxygen level, blood pH, carbon dioxide level, and bicarbonate level.

Electrocardiogram (EKG): An electrical test that measures heart rate and rhythm, an EKG can help your healthcare providers 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.

Treatment

Because quick treatment is essential, your healthcare provider will prescribe medication for you to use when you have an asthma attack, along with guidelines for when you should get emergency medical attention.

Asthma medication typically is delivered via an inhaler, a small handheld device that allows you to breathe the drug directly into your lungs. Very young children and others who may not be able to manage an inhaler may use a nebulizer, a device that turns medicine into a mist that can be breathed in.

Inhalers

When you are having an asthma attack, inhaled medications can quickly relieve your symptoms. Which medications you use—known as rescue medications—will depend in part on the severity of your asthma and whether you use an inhaled corticosteroid (ICS) regularly to control symptoms.

Your healthcare provider will fine-tune how you should best deal with an asthma attack, of course, but according to recommendations issued by the National Institutes of Health in December 2020 in the event of an impending or in-progress asthma attack:

• People 12 and over with mild persistent asthma who use an ICS daily should use a short-acting beta agonist (SABA).
• Those who do not use an ICS regularly should use a SABA and an ICS concomitantly (one after the other).

Steroids work by reducing inflammation, while SABAs widen bronchi to allow for a freer flow of air. SABAs are anticholinergics that counteract the effects of acetylcholine (a neurotransmitter that stimulates constriction (narrowing) of the bronchi).

Bronchodilators commonly used to treat asthma include:

• Proventil, Ventolin (albuterol)
• Xopenex HFA (levalbuterol)
• Metaproterenol

Steroids commonly used to treat asthma include:

• Qvar (beclomethasone dipropionate)
• Pulmicort, Entocort, Uceris (budesonide)
• Flovent, ArmonAir RespiClick, Ticanase, Ticaspray (fluticasone propionate)
• Triamcinolone
• Aerospan HFA (flunisolide)

When used in response to an asthma attack, inhaled medications are referred to as rescue medications.

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.

Prevention

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.

Peak Flow Meters

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 healthcare provider if your peak flow is declining.

Asthma Attacks and Children

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 it happened. You can also review what actions everyone took, why they helped, and look for ways to improve on it if it occurs again. 

Shallow Breathing

Children and adults who have asthma may be able to use a shallow breathing technique called Buteyko breathing 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.

A Word From Verywell

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.

Knowing how to recognize the signs of worsening asthma is important—this is an indication you should talk to your healthcare provider. They may adjust your asthma medications before an attack happens. The Doctor Discussion Guide below can help you start that conversation.

Asthma Doctor Discussion Guide

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