Introduction

Asthma is a chronic condition that causes the airways in the lungs to become narrow and inflamed, resulting in difficulty breathing, particularly when symptoms worsen. 

Around one in eleven children and young people in the UK suffer from asthma.¹ Due to hectic schedules, peer pressure, and fluctuating hormones, managing asthma during teenage years can be challenging. 

Asthma symptoms may suddenly get worse at times, known as asthma exacerbation. These can be serious if not treated quickly. 

This article focuses on managing asthma exacerbations. We will go through immediate treatment strategies, when to seek emergency help, and ways teenagers can manage their asthma effectively. 

What is an acute asthma exacerbation?

How asthma works 

Asthma is a long-term condition that affects the airways in your lungs. These airways are tubes that carry air in and out when you breathe. In asthma, two main things happen: the airways become inflamed, meaning they swell and produce extra mucus, and the muscles around them tighten, known as bronchospasm.² Together, these changes result in making the airways narrower than normal, so less air can pass through.³ 

What happens during an exacerbation?

An acute asthma exacerbation is the sudden worsening of symptoms and lung function from a patient’s usual state, usually requiring a change in treatment.⁴ In asthma, the airways are more sensitive than normal. The airways can get easily irritated by a number of things, known as “triggers”. 

Common triggers include allergens (such as dust or pollen), cigarette smoke, air pollution, exercise, respiratory infections, and weather changes. Exposure to any of these triggers may lead to inflammation and bronchospasm as explained above. This can lead to the characteristic symptoms of asthma:⁵

• Shortness of breath
• Chest tightness
• Wheezing
• Coughing

An asthma exacerbation can feel like trying to breathe through a straw for a few minutes. No matter how hard you blow air out or suck air in, it can feel like there is not enough air getting into your lungs.

Why teenagers face unique challenges

Research shows that all of the physical, emotional, and social shifts in teens can make asthma tough to manage.⁶ These changes may alter how well teens deal with symptoms and follow treatment plans.⁷ This can cause poorer health outcomes compared to other age groups.

Immediate treatment strategies

Recognising an exacerbation

When you have an asthma exacerbation, your airways are much tighter than usual. As mentioned earlier, this causes difficulty in moving air in and out of your lungs.. Peak flow meters check how quickly you can breathe out air, you might see that your peak flow readings are lower than normal.. If your peak flow readings drop, this could mean your asthma is getting worse, even before severe symptoms appear.

During an exacerbation, you may notice you are using your reliever inhaler more often; you may also experience trouble sleeping, shortness of breath, a tight chest, a cough, and/or wheezing.⁸ It is important to recognise the early warning signs of acute asthma exacerbations to be able to act quickly, as waiting may lead to rapid worsening of your symptoms. 

Using a reliever inhaler 

Reliever/rescue inhalers, such as Salbutamol or Terbutaline, work by relaxing the muscles around the airways, helping to open them up so air can pass into and out of the lungs more easily. They are used to ease breathlessness, a tight chest, or wheezing. They work quickly, providing short-term symptom relief, taking as little as five minutes to feel the inhaler’s initial effect, and can last up to 4 hours.⁹

Spacer devices

Spacer devices fit onto your inhaler to make it easier to breathe in the medicine. When you are short of breath, using your inhaler properly can be tough. A spacer holds the medicine, allowing you to inhale it more slowly and deeply. Making sure that more medicine reaches your lungs instead of getting stuck in your mouth or throat. With a spacer, the medicine can work better and can help to improve your breathing quickly during an exacerbation.¹⁰ 

Oral corticosteroids

During an asthma exacerbation, your lung airways become irritated and swollen. While reliever inhalers work to open the airways up quite quickly, they don’t help to treat the underlying inflammation. That is where oral corticosteroids (e.g. prednisolone) come in. They work over a few hours to calm the airway inflammation and help you breathe more easily.

These medicines are typically taken as daily tablets for a short course, usually lasting three to five days. For most people, taking these tablets is just as effective as getting the medicine through a drip in the hospital. They are safe when used for short courses, and can often prevent an exacerbation from getting worse. 

Corticosteroids also help your body respond better to inhalers by making the lungs more sensitive to bronchodilators (your reliever medication). That is why they are an important part of early treatment during an asthma exacerbation.¹¹

Inhaled corticosteroids (ICS): do you still need them during an exacerbation?

Inhaled corticosteroids (ICS) are usually used daily to reduce airway inflammation and to help prevent asthma flare-ups. As mentioned earlier, oral corticosteroids are prescribed during an exacerbation for a few days to quickly reduce inflammation. 

Although both ICS and oral corticosteroids work in the same way by calming airway inflammation, they are used differently. Steroid tablets work quickly to control flare-ups, while inhaled corticosteroids are used regularly to keep asthma stable over time. Using both together during an asthma exacerbation can support a quicker and more stable recovery.¹²

When to seek emergency help

Recognising when to seek help during an asthma flare-up is really important. There are certain signs that mean you should get medical advice quickly. They are:¹³

• Breathing rapidly and feeling unable to get air into your lungs 
• Wheezing and/or a lot of coughing
• Severe or worsening chest tightness 
• Difficulty talking or walking 
• Turning pale 
• Sweating 
• Feeling anxious 
• Lips or nails turning blue 

You might have some or all of these signs, but if any appear, it is key to get emergency help right away. 

Hospital treatment 

What happens when you arrive?

A medical team of nurses and doctors will assist you upon your arrival. They will quickly determine the severity of your exacerbation. They will use a stethoscope to listen to your chest and assess your breathing. They will monitor your vital signs closely, including your oxygen levels, heart rate, and blood pressure. To measure how well air is moving in and out of your lungs, you may also be asked to measure your peak flow. All of this aids the medical staff in determining what treatment you need and how closely you should be monitored. 

Medications and interventions used 

• Oxygen therapy: if your oxygen levels are low, you may be given oxygen to help your body get the oxygen it needs
• Nebulisers: If your asthma gets worse, a nebuliser can be used to give you a strong bronchodilator medicine to help relax your airways and make breathing easier. A nebuliser turns liquid medicine into a fine mist that you breathe in through a mask
• Corticosteroids: as mentioned earlier, if the exacerbation is more severe, you may be prescribed steroid tablets called prednisolone. In more serious cases, these can also be given through a vein (intravenously) in a hospital to act more quickly
• Antibiotics: if your exacerbation is caused by a bacterial infection, you may be prescribed antibiotics. However, if it is due to a virus, antibiotics will not help and usually are not given

If your symptoms are not improving as quickly as your team would like or they are severe, they may try other treatments, like:

• Magnesium: magnesium given intravenously, can help to open your airways and ease wheezing
• Aminophylline: this medication helps open your airways by relaxing the muscles around them. It is given as a drip over at least one to two days continuously. Once you’re feeling better, you might be switched to a tablet form

FAQs

When should I use my reliever inhaler?

Once you notice signs like wheezing or chest tightness, use your inhaler to help open your airways to make breathing easier.

What should I do if my asthma exacerbation does not get better? 

If your symptoms aren’t getting better after using your inhaler or you start to feel worse, call your GP or get emergency help. 

Will I get help after leaving the hospital? 

Yes, your team will make sure you leave with clear advice and check how you are using your inhaler, so you feel more confident managing your asthma or any future exacerbations.

Summary

Asthma exacerbations can be serious; however, they can be controlled with the right care and attention. Avoiding triggers, using medications correctly, and recognising symptoms early can help prevent exacerbations from getting worse. It is important to know when to get emergency help to stay safe and recover quickly. Getting regular check-ups and support from healthcare professionals can contribute positively to effective asthma management.