Early recognition
Usually, a person with asthma knows about their condition and may have their inhaler with them. The person may be able to indicate they are having an asthma attack. They are usually found in an upright position; sometimes sitting leaning forward.
The person may experience:
• difficult or laboured breathing accompanied by wheezing and coughing
• shortness of breath, or a feeling of suffocation or tightness in the chest
• rapid breathing and elevated heart rate
• altered mental status including becoming anxious, confused or unresponsive.
First aid steps
1. Help the person into a comfortable position. Reassure them.
2. Help the person to use their inhaler. Loosen any tight clothing.
3. Access EMS immediately if:
a. the person has no inhaler and the attack lasts for several minutes b. the inhaler is ineffective within a few minutes
c. the person is experiencing severe breathing difficulties d. the person’s lips, ears, fingers or toes turn a bluish colour
e. the person has a change in mental status, such as becoming confused or unresponsive f. their breathing becomes slow, less noisy, or if the person is getting tired.
4. If properly trained and access to supplementary oxygen is available, give it to the person as needed.
(See Oxygen administration.)
5. Stay with the person and continue to observe them, keeping them calm and comfortable until the attack is over. Depending on the person’s prescription, they may use their inhaler again before medical help arrives.
Local adaptation
• In contexts that do not have inhalers or supplemental oxygen readily available, help the person be calm, for example by sitting near an open window as this may help their breathing.
Access help
Access help if the person’s mental state is affected as they may become Unresponsive. In a critical case, cardiac arrest may occur, and the person may stop breathing.
NOTE
• If the person is near to something that may be causing the attack (e.g., a dusty environment) help them to move away from the trigger.
• If the person uses a spacer device, help them to fit the device to their inhaler as this may help the person to breathe in their medication more effectively. Spacers are especially useful for young children but may be used by adults too.
• If the person becomes unresponsive open their airway and check for breathing. See Unresponsiveness.
Education considerations
Context considerations
• Administration of an inhaler or other medication should be guided by local laws and regulations.
First aid educators may need to vary their education according to the context.
• In both high and low resource settings, a person with asthma may not have an inhaler with them.
Allow learners to practise what to do when there isn’t an inhaler available. This may include actions to calm the person or help them breathe easier, such as loosening clothing and sitting up. You may also move the person away from the trigger causing the asthma attack (such as smoke).
• In areas where EMS services are extremely limited or non-existent, individuals should learn strategies that can help to ease breathing until the attack passes.
• Check legal restrictions that govern the help first aid providers can give and educate within these. If necessary, include these laws in the educational content.
Learner considerations
• Consider whether learners need to understand:
> how to recognise someone is having an asthma attack
> how to help someone use an inhaler
> when and if to repeat the dose of inhaler
> when and how to use a spacer device
> how to administer supplementary oxygen.
• There is limited evidence that schoolteachers are under-prepared for asthma attacks and could therefore be identified as an important audience for this topic (Neuharth-Pritchett & Gretch, 2001).
• Asthma attacks can be fatal, so working with health promotion teams and local clinics can help assess community members for potential asthma and needed prescriptions.
Facilitation tips
• Spend time exploring how a first aid provider may help to calm someone having an asthma attack, as this may help their breathing.
• Administration of inhalers by first aid providers requires education in recognition and medication use depending on the method being used and availability of equipment.
• Discuss different types of inhalers, or other equipment such as spacers, and how to either administer the inhaler or help a person use it.
• Learners should have the opportunity to practise the steps they would use in helping someone having an attack (Espinoza et al., 2009).
Scientific foundation
Systematic reviews
Evidence summaries from the Centre for Evidence-based Practice (CEBaP) were drawn upon to develop these guidelines, as well as evidence review work by the International Liaison Committee on Resuscitation (ILCOR).
Posture
An evidence summary from 2019 identified three experimental studies, involving people with chronic obstructive pulmonary disease, obese people with obstructive sleep apnoea or obesity hypoventilation syndrome, or people with chronic heart failure, comparing different positions to relieve dyspnoea. There is limited evidence in favour of arm bracing and sitting. It was shown that arm bracing resulted in a statistically significant decrease of Borg dyspnoea score, compared to leaning forward while standing or erect standing. A statistically significant change of Borg dyspnoea score, standing erect compared to leaning forward while standing, could not be demonstrated. It was shown that a sitting position resulted in a statistically significant decrease in Borg dyspnoea
Cold humidified air
CEBaP developed an evidence summary on inhaling cold air in case of shortness of breath in 2019, but no relevant studies were identified.
Calmly breathing or breathing exercises
A 2019 evidence summary from CEBaP identified a relevant systematic review from 2018 containing eight randomized controlled trials with 197 patients with chronic obstructive pulmonary disease. There is limited evidence neither in favour of calmly breathing or breathing exercises nor not using these methods.
A statistically significantly increased exercise capacity or a decreased level of dyspnoea during pursed-lip breathing, compared to normal breathing, could not be demonstrated in seven studies. On the other hand, it was shown in one study that pursed-lip breathing resulted in a statistically significant increase in exercise capacity, compared to no pursed-lip breathing. Furthermore, it was shown in five studies that pursed-lip breathing resulted in a statistically significantly decreased minute ventilation, breathing rate and an increased tidal volume, inspiratory time and respiratory cycle duration, compared to no pursed-lip breathing. Finally, a statistically significant increase in tidal volume, inspiratory capacity and blood oxygenation during pursed-lip breathing, compared to no pursed-lip breathing, could not be demonstrated in five studies. Evidence is of very low certainty and results cannot be considered precise due to limited sample sizes and a lack of data.
Bronchodilator inhalers
ILCOR conducted a systematic review on bronchodilator use in 2015, which identified eight randomised controlled trials, two observational studies and one meta-analysis. Two randomised controlled trials showed an improved time to resolution of symptoms (e.g. wheezing, dyspnoea) and six randomised controlled trials and two observational studies showed improved therapeutic endpoints (e.g. oxygenation, ventilation). No studies were identified on the effect on time to resumption of usual activity, or on harm to the person. In three randomised controlled trials and an observational study, a difference in complications could not be shown when using inhalers compared to placebo. Evidence is of very low certainty and results cannot be considered precise.
Inhalers with spacers
A 2019 CEBaP evidence summary about the use of inhalers with spacers identified two Cochrane systematic reviews on the use of inhalers with spacers.
The first Cochrane systematic review revealed that there is limited evidence from eight randomised controlled trials in favour of using inhalers with spacers for medication administration. It was shown that the use of inhalers with spacers resulted in a statistically significant increase in final peak expiratory flow, 15-minute rise in expiratory flow, 15-minute rise in forced expiratory volume, and a statistically significant decrease in pulse rate and improvement of blood gasses, compared to nebulizers. However, a statistically significant decrease in hospital admission, rise in pulse rate, development of tremor, rise in respiratory rate and deterioration of blood gasses, and a statistically significant increase in 30 min rise in forced expiratory volume and 30 min rise in peak expiratory flow could not be demonstrated. Evidence is of low certainty, and results cannot be considered precise due to limited sample sizes, low numbers of events and wide confidence intervals.
The second Cochrane systematic review indicated that there is limited evidence from six randomised controlled trials neither in favour of using home-made spacers nor commercially available spacers for medication administration. A statistically significant decrease in hospital admission, clinical score, heart rate or need for additional treatment when using home-made spacers compared to commercially available spacers, could not be demonstrated. A statistically significant increase in peak expiratory flow rate or oxygen saturation when using home-made versus commercial spacers, could also not be demonstrated. Evidence is of low certainty, and results cannot be considered precise due to limited sample sizes, low numbers of events and wide confidence intervals.