What Are the Symptoms of Severe Asthma

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Severe asthma symptoms can include wheezing, breathlessness that interferes with your ability to speak, eat, or sleep, and other symptoms like fast heartbeat and blue lips or fingers. When asthma symptoms like these can't be controlled with daily medication, the condition is considered severe.

Severe asthma is usually treated with inhaled corticosteroids and often other long-term medications.

Severe Asthma Symptoms

Verywell / Katie Kerpel

When to Call 911

Call 911 if you or someone else experiences these signs of an asthma emergency:

  • Severe wheezing or trouble breathing
  • Struggling for each breath or can barely speak or cry
  • Fainting
  • Lips or face that are bluish (or grey in people with darker complexions)

Symptoms of a Severe Asthma Attack

Asthma is considered serious or severe if you experience:

  • More frequent attacks: Someone with severe asthma may have frequent episodes of nighttime asthma and breathing difficulties occurring throughout the day. Rescue medication may be needed several times per day.
  • More severe asthma symptoms: People with severe asthma may experience asthma symptoms like wheezing, chest tightness, coughing (especially at night or in the morning), and shortness of breath more intensely than people without mild or moderate asthma.
  • Fatigue: Everyday activities may become more difficult.
  • Rapid breathing: During a severe asthma attack, the chest expands and doesn't return to a regular state even when you breathe out. Breathing becomes very labored with chest retractions that cause the skin to pull in tightly against the chest and ribs (creating a clear outline of the bones), and the nostrils move quickly in and out.
  • Rapid heartbeat: You may feel like your heart is racing.
  • Cyanosis: Your face, lips, or fingernails may turn blue (gray if your skin tone is darker). This happens because your blood lacks oxygen.

In severe asthma, the length of an attack varies depending on what triggered it and how inflamed your airways are. Severe attacks typically last longer than mild ones, with breathing problems persisting for several hours and possibly even a few days.

Can asthma kill you?

In rare cases, severe asthma can be fatal. With the right treatment, however, symptoms can be controlled.

When Is Asthma an Emergency?

There are four stages of asthma severity:

  • Intermittent: Daytime asthma symptoms occur less than twice per week; nighttime asthma symptoms occur less than twice per month. Flare-ups are short, lasting from a few hours to a few days. Flare-ups may be bothersome, but do not interfere with quality of life.
  • Mild persistent: Daytime asthma symptoms occur more than two times per week, but no more than once per day; nighttime asthma symptoms occur more than two times per month. Quality of life may be affected by flare-ups.
  • Moderate persistent: Asthma symptoms occur every day; nighttime symptoms occur more than once per week. Flare-ups occur twice per week or more, and rescue medication is needed every day. Quality of life may be affected by flare-ups.
  • Severe persistent: Daytime asthma symptoms are constant; nighttime asthma symptoms are frequent. Flare-ups occur frequently and interfere with quality of life.

Even a person with intermittent asthma and no history of severe asthma can have an asthma emergency. Call 911 if you or someone else:

  • Has severe wheezing or trouble breathing
  • Seems to be struggling for breath
  • Can barely speak or cry
  • Faints
  • Has a bluish or gray face or lips

Call a healthcare provider or seek medical attention right away if you experience:

  • Wheezing that is not gone after 20 minutes after using a nebulizer or inhaler
  • Breathing that is much faster than normal
  • Non-stop coughing that does not improve with a nebulizer or inhaler
  • Severe chest pain
  • A need to use a nebulizer or inhaler more often than every four hours
  • Fever over 104 F

Take note that some people may not wheeze or cough during an asthma attack. This happens when a person's airways are so restricted that they cannot get air through them at all. In cases like these, symptoms like blue skin or struggling to breathe may be the first signs you notice.

What Are the Causes of Severe Asthma?

Severe asthma may have a number of causes, including:

  • Hypersensitivity: People with severe asthma may be more sensitive to triggers such as dust mites, air pollution, and pet dander.
  • Age and gender: In children, boys are more likely to have severe asthma than girls. The trend switches around puberty, however. As they progress through adolescence, older girls and women are at greater risk for severe asthma.
  • Obesity: Pressure on the chest and abdomen from extra weight may impede breathing. People with a body mass index (BMI) over 30 also tend to respond poorly to medication used to treat asthma, including inhaled corticosteroids. This leads those with mild or moderate asthma to have progressively worse symptoms.
  • Smoking: Smoking causes lung tissue damage and interferes with the respiratory system's ability to keep out irritants, Smokers with asthma are likely to have poorer control over symptoms than people with asthma who don't smoke. This is due to airway inflammation and less sensitivity to corticosteroid medications.
  • Obstructive sleep apnea: People with obstructive sleep apnea (OSA) and asthma are often more overweight than those with asthma only; this may account for more severe asthma symptoms in patients with both conditions.
  • Chronic sinusitis: Chronic sinus inflammation has been directly linked to asthma. Those with frequent sinus infections and perennial allergic rhinitis are more likely to develop some form of asthma. The more serious the inflammation, the greater the severity of asthma.
  • Gastroesophageal reflux disease (GERD): GERD has been associated with uncontrolled asthma because acids from the stomach can be inhaled into the lungs and lead to increased asthma symptoms.
  • Allergic bronchopulmonary aspergillosis: This fungal infection of the lung is caused by hypersensitivity to antigens that colonize the airways.
  • Churg-Strauss syndrome: A rare autoimmune condition, Churg-Strauss syndrome causes inflammation of the blood vessels and primarily affects the lungs.
  • Primary immunodeficiencies: These immune system deficiencies include a wide range of disorders. In adults with asthma, the disorders frequently exacerbate asthma symptoms.

Asthma is a progressive disease. If it's not treated properly, it can develop into a more serious condition. If you do not take preventive measures, you could suffer from frequent asthma attacks, which can cause the lungs to change. This can lead to severe asthma or other lung diseases.

Asthma Doctor Discussion Guide

Get our printable guide for your next healthcare provider's appointment to help you ask the right questions.

Doctor Discussion Guide Old Woman

How Is Severe Asthma Diagnosed?

Severe asthma is not the same as uncontrolled asthma. The two can be distinguished by some key factors:

Severe Asthma
  • Symptoms cannot be controlled with typical medication dosages

  • Adjustments in treatment not successful in controlling symptoms

Uncontrolled Asthma
  • Mild or moderate asthma in which symptoms are not well-managed with your current medication plan

  • Should improve with treatment changes

If you see your healthcare provider with symptoms of severe asthma, they will likely adjust your asthma treatment plan to see if you improve. If your symptoms do not subside, it's an indication your asthma has become severe.

Your healthcare provider will check your overall pulmonary function as severe asthma often reduces lung function. Poor lung function can be determined by spirometry or another pulmonary function test (PFT). These breathing tests generally focus on your forced expiratory volume (FEV), forced vital capacity ratio or how much air you can exhale into a spirometer in one second out of total exhaled air.

Is severe asthma a disability?

A person with a physical or mental impairment that severely limits major life activities is considered disabled Under the Americans with Disabilities Act (ADA). Severe asthma is one of the many conditions included under this definition.

How Is Severe Asthma Treated?

To be properly treated for severe asthma, you may need to consult with several specialists, including a pulmonologist, otolaryngologist (ear, nose, throat doctor), and an allergist.

A combination of treatments is often used to manage severe asthma. These may include:

  • Corticosteroids: Inhaled corticosteroids (ICS) are a first-line treatment to reduce inflammation and symptoms. Severe asthma often requires courses of stronger oral corticosteroids.
  • Beta-2 (β2) agonists: Both short-acting beta-agonists (SABAs) and long-acting beta-agonists (LABAs) may be used to help relieve bronchial muscle spasms. LABAs should always be used in combination with ICS.
  • Anticholinergics: These medications relax the airway muscles to counter bronchoconstriction and enable you to breathe more easily.
  • Biologics: These are medications made from living organisms. To treat severe asthma, they target specific cells or chemical messengers to reduce inflammation and the overactive immune system responses that trigger asthma.
  • Immunotherapy: Allergy shots can reduce sensitivity to allergens, which can then reduce severe asthma symptoms in many people.

Sometimes severe asthma does not improve with treatment. This causes a condition that healthcare providers previously labeled "status asthmaticus"—what's now more commonly referred to as acute severe asthma. Characterized by low oxygen and elevated carbon dioxide levels in the blood, acute severe asthma can lead to respiratory failure and requires emergency medical attention.

If asthma symptoms do not improve after the use of a rescue inhaler, you should seek immediate treatment in an emergency room.

Other Treatments

Conditions such as allergies, nasal polyps, or sinus problems may also contribute to your asthma symptoms. If you have severe asthma, you should be evaluated and appropriately treated for these conditions.

Allergies, in particular, can greatly exacerbate asthma symptoms and should be managed appropriately. Immunotherapy (allergy shots) may be recommended.

Triggers such as exercise or allergies must be identified and avoided. Also, obesity can make asthma worse, so weight management may be an appropriate part of your treatment plan.

Non-medical treatment such as physiotherapy may be beneficial in conjunction with the above. A physiotherapist may teach you different ways of breathing, how to change your breathing patterns, relaxation techniques, or ways to modify your exercise routine so that you can still participate in physical activity despite your breathing problems.

How to Cope With Severe Asthma

Severe asthma can significantly impact your quality of life. Chronic breathing issues may make it hard to work and enjoy leisure activities. Those with severe asthma are at greater risk of hospitalization compared to those with mild or moderate asthma.

It's important, therefore, to work closely with your healthcare provider to ensure you are appropriately following the treatment plan so you can maximize your tolerance for activity safely and effectively.

Also, consider consulting with a therapist to avoid depression, which is a common issue that people with severe asthma face.

Individuals with significant community and family support tend to have better treatment outcomes than those who lack these important resources. Seeking therapy and other support groups, like those online, can make a big difference in your mood and day-to-day ability to cope.

Summary

Asthma is considered severe when symptoms cannot be controlled by avoiding triggers or using daily allergy medications. During an asthma attack, symptoms may include wheezing, trouble breathing, and blue or grey-tinged skin; some people having an asthma attack cannot cough or wheeze at all.

Although there is no cure for severe asthma, with treatment you can still live a normal life. The first-line treatment for severe asthma is oral or inhaled corticosteroids. A combination of treatments may be prescribed depending on your symptoms.

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Daniel More, MD

By Daniel More, MD
Daniel More, MD, is a board-certified allergist and clinical immunologist. He is an assistant clinical professor at the University of California, San Francisco School of Medicine and formerly practiced at Central Coast Allergy and Asthma in Salinas, California.