Acute Asthma Exacerbation vs Poor Control
How to assess asthma severity at the pharmacy counter, when to call 999, when to refer to a GP, and when emergency supply or supply via Patient Group Direction (PGD) is appropriate.
Why this matters
Asthma affects around 5.4 million people in the UK, and community pharmacists regularly encounter patients during both acute exacerbations and periods of worsening day-to-day control. These situations require different responses. A patient with acute severe or life-threatening asthma needs 999 immediately. A patient whose symptoms are deteriorating over days or weeks needs same-day GP review rather than repeated purchases of reliever inhalers.
Key severity markers are peak expiratory flow (PEF), oxygen saturation, visible work of breathing, and the ability to complete a sentence. A silent chest, where there is almost no air entry despite obvious respiratory effort, is a very high-risk sign. In contrast, patients with a mild exacerbation who respond well to salbutamol via a spacer may be managed via emergency supply or supply under a Patient Group Direction (PGD), with clear safety netting, provided follow-up is arranged.
Red flags vs more likely benign
| Feature | More likely benign | Red flag ⚠ |
|---|---|---|
| Wheeze | Audible, bilateral wheeze without distress | Silent chest with minimal air entry despite respiratory effort |
| PEF | Above 75 percent of best or predicted | Below 50 percent: acute severe. Below 33 percent: life-threatening |
| Speech | Able to speak in full sentences | Unable to complete sentences in one breath |
| Oxygen saturation (SpO2) | 95 percent or above on air | Below 92 percent on air: life-threatening, requires emergency oxygen and 999 |
| Reliever use | Occasional use with stable control | Using reliever more than three times per week: poor control, GP review needed |
| Night symptoms | Sleep undisturbed | Waking at night more than once a week with wheeze or cough |
| Response to salbutamol | Clear improvement within 15 to 20 minutes | No improvement or worsening after 5 to 10 puffs via spacer: call 999 |
| Consciousness | Alert and oriented | Confusion, reduced consciousness or collapse: pre-arrest signs |
What to do in pharmacy
Key takeaways
- A silent chest in an asthmatic patient is a pre-arrest sign. Call 999 immediately.
- PEF below 33 percent is life-threatening. PEF between 33 and 50 percent is acute severe. Neither is suitable for emergency supply or pharmacist-managed supply without urgent clinical assessment.
- Patients using a reliever inhaler more than three times per week have poorly controlled asthma and need GP review and an updated asthma action plan. Do not simply supply additional relievers.