What Are the Symptoms of Severe Asthma

Asthma is a chronic respiratory disease that causes narrowing of the airways, shortness of breath, and difficulty breathing. Asthma symptoms can usually be controlled by avoiding triggers and taking daily medications. When these options are not enough to manage symptoms, the condition is considered severe.

Severe asthma is usually treated with inhaled corticosteroids and often other long-term medications. If rescue medication fails to control an asthma attack, or if there are other symptoms like severe trouble breathing or skin that appears blue or grey, call 911 immediately.

This article explains the symptoms of severe asthma along with what causes it. It also covers how severe asthma is diagnosed and treated, and how to cope with the condition.

What Are the Symptoms of Severe Asthma?

Symptoms of asthma may include:

• Wheezing
• Chest tightness
• Shortness of breath
• Wet or dry cough, especially at night or early morning

These symptoms can be more intense and frequent in people with severe asthma.

Severe asthma can also cause more serious breathing problems, including:

Rapid breathing

• 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).
• Nostrils move quickly in and out.

More frequent breathing problems

• Nighttime asthma episodes are common.
• Breathing difficulties occur throughout the day.
• Rescue medication is needed several times per day.

Short- and long-term complications

• Heart rate races.
• Face, lips, and fingernails turn blue (cyanosis) because your blood lacks oxygen.
• Lung function is reduced.
• Everyday activities become more difficult.

The amount of time an attack lasts varies depending on what triggered it and how inflamed your airways are. Severe attacks last longer than mild ones, though, with breathing problems persisting for several hours and, possibly, even a few days.

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 levels 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 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)

Call a healthcare provider or seek medical attention right away if there is:

• 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 be caused by hypersensitivity to triggers such as:

• Tobacco smoke
• Dust mites
• Outdoor air pollution
• Cockroaches, mice, and other pests
• Pet dander
• Mold

Asthma attacks can also be triggered by:

• Physical exercises
• Some medications, such as aspirin, NSAIDs (like Ibuprofen and Naproxen), and beta-blockers
• Thunderstorms and high humidity
• Breathing in cold, dry air
• Fragrances
• Foods that are high in a preservative called sulfite, including dried fruits and vegetables, wine and beer, bottled lime and lemon juice, shrimp, packaged potatoes, and pickled foods
• Acid reflux
  
• Fast breathing (hyperventilation) caused by strong emotions

Certain factors are known to increase the risk of developing severe asthma, particularly:

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.

While researchers believe sex hormones play an important role in the chances of developing severe asthma, it is not clearly understood how or why.

Obesity

Obesity also increases the likelihood that you will develop severe asthma. Again, the reason extra weight raises the risk for severe asthma is unknown. However, studies have found factors related to obesity that seem to play a role:

• Pressure on the chest and abdomen from extra weight may impede breathing.
• Fat tissue produces inflammation that affects the airways and may contribute to severe asthma.
• People with a body mass index (BMI) over 30 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 negatively impacts everyone, whether they have asthma or not. Because it causes lung tissue damage and interferes with the respiratory system's ability to keep out irritants, it's especially problematic for people with hypersensitivity.

If you have asthma and smoke, you are likely to have poorer control over your symptoms than a non-smoker with asthma. According to research, this is due to airway inflammation and less sensitivity to corticosteroid medications.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder in which your upper airway becomes blocked during sleep. It can cause snoring, choking, or gasping for air.

One meta-analysis suggested that OSA and asthma frequently coexist. Patients with asthma who also have OSA were found to be more obese than those with asthma only; this may account for more severe asthma symptoms in patients with both conditions. It is unclear whether treatment of OSA has an independent effect on asthma severity 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.

In one study, about 33% of those with moderate or severe persistent rhinitis were also diagnosed with asthma. The more serious the inflammation, the greater the severity of asthma.

Gastroesophageal Reflux Disease (GERD)

GERD is a chronic disorder of the digestive system in which the esophageal doesn't completely close, allowing stomach acid to come back up the digestive tract. With GERD, stimulation of the vagal nervous system in the esophagus by refluxed acid and inflammation causes airway constriction and asthma symptoms.

GERD has been associated with uncontrolled asthma because those acids from the stomach can be inhaled into the lungs and lead to increased asthma symptoms. If your asthma symptoms are not being well managed, your healthcare provider may recommend trying GERD medications.

Other Diseases

Less common diseases that may play a role in severe asthma include:

• 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 deficiencies of the immune system include a wide range of disorders. In adults with asthma, the disorders frequently exacerbate asthma symptoms.

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How Is Severe Asthma Diagnosed?

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

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.

Differential Diagnoses

Sometimes, asthma symptoms aren't caused by asthma at all, which is why asthma medications don’t work. For instance, vocal cord dysfunction (VCD) is a medical condition that mimics asthma but is caused by the vocal cords closing over the airway, leading to shortness of breath and wheezing-like sounds.

Your healthcare provider should consider a VCD diagnosis if you are suffering from uncontrollable asthma symptoms. This diagnosis is best made using nasal endoscopy.

In other instances, you may have asthma and may begin to show signs of severe asthma. These symptoms are not always due to asthma progression; they may be caused by another condition. Upper respiratory tract infections and rhinosinusitis are the most common illnesses that can produce symptoms that mimic severe asthma in people who already have mild or moderate asthma.

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.

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. The first-line treatment for severe asthma is oral or inhaled corticosteroids. A combination of treatments may be prescribed depending on your symptoms.

Although there is no cure for severe asthma, with treatment you can still live a normal life. The key is being aware of your asthma triggers, actively avoiding them, and making sure your medications are up-to-date and being used properly. If you are doing these things and asthma continues to interfere with your daily activities, be sure to let your healthcare provider know.

A Word From Verywell

If you experience asthma symptoms daily and rescue medication is needed several times a day, or if you have frequent asthma flare-ups that require urgent care, emergency room visits, or hospitalizations, you may have severe uncontrolled asthma. Contact your healthcare provider if your asthma symptoms are not well controlled. Severe, uncontrolled asthma can be treated effectively with high-dose inhaled corticosteroids, LABAs, anticholinergics, and biologics.

— JURAIRAT J. MOLINA, MD, MEDICAL EXPERT BOARD