Shortness of breath with a history of asthma

Any person, 16 years of age and over, presenting with a history of asthma.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Preferably semi-reclined or upright

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment

Intervention

Life-threatening or critical asthma SpO2 less than 90% or clinical cyanosis Bradypnoea indicates respiratory exhaustion Severe respiratory distress or poor respiratory effort Soft or absent breath sounds Unable to speak

Assist ventilation, if clinically indicated Apply oxygen If peri-arrest, give adrenaline 0.5 mg of 1:1000 IM once only Auscultate chest Give with 8–10 L of oxygen via nebuliser: place 2 x 5 mg salbutamol nebules into nebuliser chamber and give via continuous nebulisation – repeat as required and nebulised ipratropium 500 microg (added to salbutamol), every 20 minutes, for 3 doses and give hydrocortisone 100 mg IV/intraosseous, once only Prepare for potential non-invasive ventilation or intubation

Severe asthma SpO2 90–94% Respiratory rate over 25 breaths per minute Paradoxical chest wall movement, chest sucks in when patient breathes in Use of accessory muscle of neck or intercostal muscles or “tracheal tug” during inspiration or subcostal recession, abdominal breathing Can only speak a few words in one breath

Assist ventilation, if clinically indicated If SpO2 is less than 92%, apply oxygen Select: Able to breathe via spacer Unable to breathe adequately via spacer Able to breathe via spacer Give: 12 puffs salbutamol 100 microg/puff MDI via spacer, every 20 minutes, for 3 doses and 8 puffs ipratropium 21 microg/puff MDI via spacer, every 20 minutes, for 3 doses and give: prednisolone 50 mg orally once only or if unable to tolerate oral prednisolone, hydrocortisone 100 mg IV/intraosseous, once only Unable to breathe adequately via spacer Give: with 8–10 L oxygen via nebuliser: nebulised salbutamol 5 mg and ipratropium 500 microg every 20 minutes for 3 doses and give: prednisolone 50 mg orally once only or if unable to tolerate oral prednisolone, hydrocortisone 100 mg IV/intraosseous, once only

Mild or moderate asthma SpO2 over 94% Respiratory rate less than 25 breaths per minute Respiratory distress is not severe Wheeze or normal breath sounds Can finish a sentence in one breath

Give: 12 puffs salbutamol 100 microg/puff MDI via a spacer. Repeat once after 20 minutes, if required and prednisolone 50 mg orally, once only If there is an inadequate response to the treatment, manage as per the next severity box

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones , or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status – last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
Nausea and/or vomiting	If present, see nausea and/or vomiting section
NBM	Consider clear fluids or NBM based on red flags and clinical severity

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete a respiratory focused assessment.

Precautions and notes

Delivery of short-acting beta-agonists via MDI and spacer is equally effective as nebulisation, provided the patient can inhale effectively.

Interventions and diagnostics

Specific treatment

If ineffective respiratory effort, consider non-invasive ventilation (NIV) where available and escalate as per local CERS protocol if required.

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Analgesia

If pain score 1–6 (mild to moderate): give paracetamol 1000 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS.

If chest pain present, consider chest pain protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Radiology

• If life threatening or concern for pneumothorax: CXR

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Pathology

• If severe or life-threatening: FBC, UEC, VBG
• Temp less than 35°C, or 38.5°C and over: take two sets of blood cultures from two separate sites

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au