Moderate asthma attack in OPD
Measure peak flow, give salbutamol through a spacer and prednisolone, check inhaler technique, and send home only if peak flow is above 75%.
A 22-year-old woman has been wheezy for 2 days after a cold. She can talk in full sentences. Peak flow 300 L/min (her best is 480, so 62%). Pulse 98, RR 20, SpO₂ 97%. She uses her salbutamol inhaler "only when bad" (about 5 times a week) and has no preventer. Her inhaler technique: she breathes in before pressing the canister.
How do you treat her today, and what does she leave with so this doesn't happen again?
- Grade severityPeak flow, speech, pulse, RR, SpO₂. Look for severe and life-threatening features.
- Severe or life-threatening featuresTreat in the emergency department, not OPD. See asthma guide.
- Salbutamol by spacer4 puffs, then 2 puffs every 2 minutes up to 10 puffs.
- Prednisolone40–50 mg daily for at least 5 days.
- Reassess at 15–30 minutesPeak flow, symptoms, observations.
- Preventer for everyone with an attackInhaled steroid, technique checked with a spacer.
- Written action planPeak flow zones, when to step up, when to come in. Follow-up within 2 working days.
- Any severe or life-threatening feature
- Not improving after spacer treatment
- Previous ICU admission or near-fatal attack
- Pregnant
- Attack despite high-dose preventer
- Night-time or late presentation with poor social support
- Severe asthma looking deceptively calm
- Pneumothorax
- Pneumonia
- Anaphylaxis
- Poor adherence and wrong technique
- Over-reliance on salbutamol
| Moderate | Peak flow 50–75% of best or predicted, normal speech |
| Severe | Peak flow 33–50%, RR 25 or more, pulse 110 or more, can't finish sentences |
| Life-threatening | Peak flow below 33%, SpO₂ below 92%, silent chest, cyanosis, exhaustion, confusion, arrhythmia, low BP |
| Salbutamol via spacer | 4 puffs, then 2 every 2 minutes, up to 10 puffs |
| Prednisolone | 40–50 mg once daily for at least 5 days, no taper |
| Discharge | Peak flow above 75% of best after treatment and stable for an hour |
Check every dose against a current drug reference and your hospital protocol.
On this page
How severe?
- Treat in OPD
- spacer, prednisolone, review
- Emergency department
- oxygen-driven nebulisers, steroids, senior
- Emergency now
- call senior and ICU
Assessment
- Peak flow: best of 3, compared with the patient's best (or predicted for height, age and sex).
- Speech: full sentences, phrases, words.
- Observations: RR, pulse, SpO₂, BP.
- Chest: wheeze, air entry, silent areas.
- History: trigger (cold, dust, smoke, pollen, exercise), how often reliever used, night waking, previous admissions or ICU, current inhalers and adherence, technique.
Treatment in OPD
- Salbutamol via spacer4 puffs, then 2 puffs every 2 minutes, up to 10 puffs. One puff at a time, 5 breaths after each.
- Prednisolone40–50 mg now, then daily for at least 5 days.
- Reassess at 15–30 minutesPeak flow, symptoms, observations.
- Not improving or worseEmergency department.
- ImprovingPeak flow above 75%: home with a plan.
A spacer works as well as a nebuliser for mild and moderate attacks, and teaches the patient how to use it at home.
Before she goes home
| Item | Detail |
|---|---|
| Preventer | Inhaled steroid for everyone who has an attack or uses their reliever 3 or more times a week |
| Technique | Check with a spacer; watch the patient do it |
| Spacer | Large-volume spacer (or a cut plastic bottle if nothing else) |
| Prednisolone | Finish 5 days |
| Action plan | Written, with peak flow zones and when to step up or come in |
| Triggers | Smoke (cigarettes, huqqa, chulha), dust, pollen, cold air, pets |
| Follow-up | Within 2 working days, then asthma review |
Inhaler technique (metered-dose with spacer)
- Shake the inhaler and attach it to the spacer.
- Breathe out gently, away from the spacer.
- Seal lips around the mouthpiece.
- Press once, then breathe in and out slowly 5 times (or one slow deep breath and hold 10 seconds).
- Wait 30 seconds, repeat for each puff.
- Rinse the mouth after steroid inhalers.
Long-term control
- Reliever alone is not enough for anyone with regular symptoms or attacks.
- Inhaled steroid (beclometasone, budesonide) daily, or a combination inhaler as a preventer and reliever per guideline.
- Step up if not controlled; step down after 3 months of good control.
- Check adherence and technique before increasing treatment.
Treatment doses
Common mistakes
- Sending a patient home without a preventer.
- Not checking technique (most patients use inhalers wrongly).
- Missing severe features because the patient is quiet.
- Giving antibiotics for a viral trigger.
- Prescribing a long taper of prednisolone unnecessarily.
- Not arranging follow-up.
Frequently asked questions
How do you treat a moderate asthma attack?
Salbutamol via spacer (up to 10 puffs), prednisolone 40–50 mg daily for 5 days, then reassess. Discharge with a preventer, inhaler technique check and a written action plan.
Is a spacer as good as a nebuliser?
Yes, for mild and moderate attacks a spacer works as well as a nebuliser.
When does an asthma attack need the emergency department?
Peak flow below 50%, RR 25 or more, pulse 110 or more, unable to finish sentences, SpO₂ below 92%, a silent chest, exhaustion or confusion.
Who needs a preventer inhaler?
Anyone who has had an attack, uses their reliever 3 or more times a week, or wakes at night with asthma.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A woman with asthma has peak flow 62% of best and speaks in full sentences. How severe is the attack?
Answer: Moderate. Moderate: 50–75% of best without severe features.
- Severe: Needs 33–50%.
- Near-fatal: Needs raised CO₂.
- Life-threatening: Needs below 33% or other features.
- Mild only: 50–75% is moderate.
2. What steroid treatment is given for a moderate asthma attack?
Answer: Prednisolone 40–50 mg for 5 days. Oral prednisolone 40–50 mg daily for at least 5 days.
- Prednisolone 60 mg tapering over 6 weeks: Unnecessary.
- IV hydrocortisone for all: Oral works as well if swallowing.
- Inhaled steroid only: Oral steroid needed.
- Single 5 mg dose: Too little.
3. Before discharge after an asthma attack, which is most important?
Answer: Inhaled steroid preventer. Every patient with an attack should be on an inhaled steroid, use a spacer and have a plan.
- Antibiotics for all: Not routine.
- Montelukast only: Inhaled steroid first.
- Stop salbutamol: No.
- Chest X-ray for all: Not routine.
4. Which corticosteroid has strong glucocorticoid activity but almost no mineralocorticoid activity, making it suitable for cerebral oedema?
Answer: Dexamethasone. Dexamethasone (and betamethasone) are potent, long-acting glucocorticoids with negligible salt retention, used for cerebral oedema around tumours, fetal lung maturation and suppression tests. Fludrocortisone is used for its mineralocorticoid effect (Addison's). Hydrocortisone has both effects.
- Fludrocortisone: Mainly mineralocorticoid.
- Hydrocortisone: Both effects; used for replacement.
- Aldosterone: The natural mineralocorticoid.
- Prednisolone in high doses: Has some mineralocorticoid activity.
5. To prove medical negligence, which elements must be shown?
Answer: Duty, breach, harm and causation. Negligence requires: the doctor owed a duty of care, fell below the accepted standard (often judged against what a responsible body of doctors would do), the patient suffered harm, and the breach caused that harm. A known complication without a breach is not negligence.
- Breach and harm only: Harm must also be caused by the breach.
- Duty and breach only: Without resulting harm there is no negligence claim.
- Harm and causation only: A breach of a duty of care must also be shown.
- Duty, harm and intent to harm: Negligence does not require intent.
References and dose sources
- BTS/SIGN/NICE NG245 — Asthma
- Salbutamol dosing: Drugs.com: Albuterol (salbutamol) dosage (see also our salbutamol dose page)
- Prednisolone dosing: Drugs.com: Prednisolone dosage (see also our prednisolone dose page)
- Beclometasone (inhaled) dosing: Drugs.com: Beclomethasone dosage (see also our beclometasone (inhaled) dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.