Asthma Attack: When to Go to the ER (Adults and Children)

It started with a night-time cough after a simple cold, then the blue inhaler started getting used more than usual. Now it's the middle of the night, the chest is tight, breathing is short, and there's one question: is the inhaler enough, or do we need to go now? Most asthma attacks can be managed at home with a clear plan. But asthma can shift from uncomfortable to dangerous quickly, and recognising that moment is what keeps people safe.

What are the signs of an asthma attack?

In an asthma attack, the airways narrow, swell and fill with mucus, so air struggles to get through. An attack can come on suddenly over minutes, or build slowly over hours or days. The common signs:

• Wheezing, or a cough that's getting worse, especially at night or early in the morning.
• Chest tightness that keeps getting worse.
• Faster breathing, and a feeling you can't catch your breath.
• Needing your reliever more than usual, or finding its effect doesn't last.
• In children: complaining of a tummy ache, stopping play, or struggling to feed or eat.

One important caution: a very severe attack may produce no wheeze at all, because so little air is moving that it can't make the sound. A quiet chest with obvious breathlessness is a danger sign, not a sign of improvement.

What to do during an asthma attack

If you have a written asthma action plan from your doctor, follow it first — it's tailored to you and your medicines. If you don't, and you use a standard blue reliever inhaler (salbutamol), these are the steps the NHS recommends:

1. Sit up straight — don't lie down — try to stay calm, and loosen any tight clothing.
2. Take one puff of your reliever every 30 to 60 seconds, up to 10 puffs. A spacer helps the medicine reach the lungs, and is essential for children.
3. If you feel worse at any point, or you don't feel better after 10 puffs, call 911.
4. If the ambulance hasn't arrived within 10 minutes and you still feel unwell, repeat step 2.

If you use a combination inhaler that acts as both preventer and reliever (sometimes called MART or AIR), the number of puffs is different — follow what your doctor wrote in your plan, and call 911 if you're not improving. And even if the attack settles completely, see a doctor on the same day or within 48 hours: an attack means your asthma needs reviewing.

When is an asthma attack life-threatening?

Call 911 straight away — don't wait to finish the 10 puffs — for any of these:

• Too breathless to speak in full sentences, or to eat or sleep.
• Your reliever isn't helping, or only helps for a few minutes.
• Blue or grey lips, face or fingertips. On darker skin this may be easier to see on the gums, inside the lips and under the nails.
• Drowsiness, confusion, exhaustion or dizziness.
• Fainting or collapse.
• A quiet chest with obvious breathlessness.

Danger signs in children

• The skin between or under the ribs, or at the base of the neck, sucking in with each breath, or the tummy pulling in.
• Nostrils flaring with each breath, or grunting as they breathe out.
• Unable to talk, cry normally or feed.
• Unusually quiet, tired or floppy — a child who suddenly goes quiet during an attack may be exhausted, not better.

If a child has wheezing together with a fever and seems very unwell, an infection may be involved rather than asthma alone — and either way they need to be assessed.

Autumn asthma triggers in Amman

Autumn in Amman brings several asthma triggers at the same time, which is why many parents notice their child's asthma getting worse in these weeks:

• Viral infections with the return to school: colds and flu spread quickly in classrooms and are one of the most common triggers of asthma attacks in children. Doctors in many countries see a rise in asthma attacks in the weeks after the school year starts.
• Dust: dry, dusty days and dust storms irritate the airways. On those days, limit time outdoors and keep windows closed.
• Heater smoke and tobacco: as nights cool, kerosene, gas and wood heaters (the sobba) come back out, and their smoke and fumes irritate the lungs — as does cigarette and argileh smoke indoors. Keep rooms ventilated, and never smoke near a child with asthma.
• Cold air, damp and mould in poorly ventilated homes through the winter.

The heater carries another risk besides asthma: if more than one person in the same room has a headache, dizziness and nausea, think of carbon monoxide first — see our guide to carbon monoxide poisoning symptoms from heaters. And for telling flu, RSV and COVID apart and knowing when to see a doctor, read our guide to autumn viruses in Amman.

Asthma attack or severe allergic reaction?

Wheezing and breathlessness can be part of anaphylaxis. If wheezing starts after a food, a medicine or an insect sting, or comes with swelling of the lips, tongue or throat, hives or dizziness, treat it as anaphylaxis: use an adrenaline auto-injector if there is one, then the reliever, and call 911. More in our guide to anaphylaxis signs and when to go to the ER.

How to give a child their inhaler during an attack

Children usually can't time pressing the inhaler with breathing in, so most of the dose ends up in the mouth and throat. That's why a spacer is used, with a face mask for very young children. Shake the inhaler, fit it into the spacer, place the mouthpiece between the child's lips or the mask snugly over nose and mouth, press one puff, and let them breathe through the spacer for about five breaths before the next puff. Stay calm — children pick up on your worry — and sit them upright on your lap. If the child is crying hard or fighting it and the medicine isn't getting in, or they aren't improving, don't delay calling 911.

How to lower the risk of the next attack

• Take your preventer inhaler every day as prescribed, even when you feel well.
• If you need your reliever three or more times a week, your asthma isn't controlled — see your doctor.
• Ask for a written asthma action plan, and give a copy to your child's school along with an inhaler and spacer.
• Check your inhaler technique with a doctor or pharmacist, and make sure the inhaler is in date and not empty.
• Ask your doctor about a yearly flu vaccine for you or your child with asthma.

Urgent care or the ER?

For any life-threatening sign, call 911 — the ambulance crew starts treatment on the way, and you shouldn't drive yourself while struggling to breathe. If symptoms improve with the inhaler but keep coming back, or your asthma has been sliding with a cold, urgent care sees walk-ins around the clock, with on-site X-ray and laboratory. If the inhaler isn't enough or you're worried, go to the emergency department.

Sources

• NHS — Asthma Attacks
• NHS — Asthma
• CDC — Asthma
• World Health Organization — Asthma