Respiratory
Asthma and COPD exacerbations
Written 30 September 2026. This date is not a physician-review date.
Why this matters
Wheeze is a sound, not a diagnosis. The dangerous asthmatic patient may have almost no wheeze.
Rapid clinical summary
- A silent chest, exhaustion, and hypoxia in asthma are life-threatening.
- Not every wheeze is asthma, and not every person with COPD is having an exacerbation.
- Oxygen strategy is not identical in asthma and COPD. Numbers are not printed here.
Mechanism
Airways narrow by muscle, inflammation, and secretion. Air trapping raises the work of breathing. When flow is almost gone, the chest goes quiet.
Recognition
Loud wheeze can still be serious. A quiet chest in an exhausted patient is worse.
Typical
- Wheeze
- Tightness
- Cough
- Longer expiration
- A known diagnosis with a trigger
Red flags
- Cannot speak
- Exhaustion
- Silent chest
- Falling consciousness
- Hypoxia
Differential
| Condition | Clue | Trap |
|---|---|---|
| Heart failure | Edema, orthopnea, a cardiac history | Treating ‘cardiac asthma’ as bronchial asthma only |
| Anaphylaxis | Minutes after an allergen, rash, shock | Giving only a bronchodilator and missing adrenaline |
| Pneumothorax | Sudden unilateral pain | Calling it a usual asthma attack |
| Pulmonary embolism | Sudden dyspnea without much wheeze | A past label of COPD that explains every future breath |
Investigations
- Peak flow or spirometry only if the patient can do it safely. Do not delay treatment of a silent chest for a number.
- Chest radiograph if the story could be pneumothorax, pneumonia, or failure.
- Blood gas when the attack is severe or consciousness is falling. Do not wait for a gas before treating obvious life-threatening asthma.
Management
- Immediate
- Treat a life-threatening attack immediately. Do not sedate an exhausted patient. Anaphylaxis, if that is the picture, is intramuscular adrenaline, not a cream.
- Definitive
- Bronchodilation, steroids for an inflammatory attack, treatment of infection when it is actually present, and a review of why this happened. Doses are omitted.
- Monitoring
- Speech, effort, oxygen, and tiring. Improvement in the sound of wheeze can be false reassurance if the patient is more exhausted.
Common pitfalls
- Reading a quiet chest as recovery.
- Sedating breathlessness.
- Using one oxygen habit for both asthma and COPD without thinking.
Exam reasoning
Severity recognition is the usual question. The wrong option is discharge, delay, or a sedative.
Practice this topicOpens original Mahazanaka questions in this subject. If this subject is thin on that track, the session uses what exists.
Visual summary
A quiet chest can be the emergency.
Recognize, reason, prioritize, act safely
- Recognize. How hard is this person working, and is air moving?
- Reason. Asthma, COPD, failure, anaphylaxis, or clot?
- Prioritize. Life-threatening features before a perfect label.
- Act safely. Immediate treatment. No sedation.
Knowledge check
An asthmatic patient is exhausted, barely speaking, saturation 89%, chest quiet. Is the attack resolving?
No citation is attached to this chapter. Nothing here is personal medical advice.