Symptoms like breathlessness, coughing, and wheezing are hallmark signs of asthma. But not everyone experiences asthma and asthma symptoms in the same way.
A diagnosis of asthma is categorized as mild, moderate, or severe depending on the severity of the symptoms, how often the symptoms occur, and how well they respond to treatment, says Maria R. Streck, MD, an allergist and immunologist at Ben Sawyer Primary Care in Mount Pleasant, South Carolina, which is part of the Medical University of South Carolina Health System.
For any category of asthma, symptoms can either be intermittent (meaning sometimes the person experiences symptoms and other times they do not) or persistent (meaning the person always experiences symptoms), Dr. Streck explains.
Anyone with asthma is at risk of having an asthma attack (sometimes also called an “asthma exacerbation” or “flare-up”), when the muscles around the airways contract and the airways produce more mucus, which narrows the bronchial tubes through which we breathe, according to Mayo Clinic. Other asthma symptoms (like coughing, wheezing, shortness of breath, and tightening of the chest) tend to worsen during an asthma attack.
An asthma attack may be considered minor if symptoms get better with home treatment; an attack is considered severe when they do not. Anyone with asthma can experience a severe asthma attack.
Even if someone has baseline mild asthma, they can have a severe exacerbation or attack, says Streck. “Sometimes people with a mild case of asthma that is generally very well-controlled can have attacks that are very severe,” she says.
There are three main components to an asthma attack, says Streck.
- The smooth muscles that line the airways clamp down.
- The airways swell and become inflamed.
- Mucus production in the airways increases.
An attack is severe if it is difficult to control and manage with at-home treatment.
Many things can lead to a severe asthma attack, says Streck. And, generally, the same types of triggers that lead to severe asthma attacks lead to milder ones.
An attack can be a response to an exposure to something or the environment around you, says Streck. Irritants like heavy perfumes, a bonfire, or cleaning chemicals can trigger an asthma attack. “For some people with exercise-induced asthma, exercise or exertion can sometimes bring it on,” says Streck.
“For patients with allergies, if they get around triggers like a cat or a dog or pollen, that can cause an asthma attack,” she says. Cold weather can also bring on an episode. “A viral infection or an upper respiratory infection can trigger a severe asthma attack,” she adds.
Many people with asthma can go about their daily activities normally, but if a severe exacerbation occurs, it may require hospitalization or turn into a life-threatening emergency, notes the Mayo Clinic.
When you’re diagnosed with asthma, your doctor should create and review with you an asthma action plan of what to do if symptoms flare up, such as using a rescue inhaler or a nebulizer, according to the Centers for Disease Control and Prevention. If symptoms don’t go away soon or get worse, you should seek immediate medical attention.
Several signs may indicate that you are having a severe asthma attack. Remember that asthma attacks can look and feel different depending on the individual, and not every person may experience every symptom, according to the National Institutes of Health. Here we review the most common symptoms of a severe attack, and what each might feel or look like.
Severe Wheezing
Wheezing is often a sound you can’t hear — it’s more of a noise doctors pick up with a stethoscope, says Streck. “If a person is audibly wheezing, meaning across the room you can hear the noise, that’s a sign of a severe asthma attack,” she says. “Typically, wheezing occurs when the person is breathing out, so on expirations; but in a severe attack, they can also be making that noise when they’re sucking in air,” she says.
This noise is caused by the inflammation and narrowing of airways, according to MedlinePlus.
A Coughing Fit — Coughing That Won’t Stop
In a coughing fit brought on by a severe asthma attack, the person can’t catch their breath — they just keep coughing, says Streck. “They can’t clear their throat to make it better. The cough just keeps going,” she says. It’s more of a staccato type of cough that can sound tight and dry, she says.
Rapid Breathing
Breathing can become more rapid when an asthma attack becomes more severe. “When this occurs, a person can’t control their rate of breathing; they’re just trying to breathe fast to compensate,” says Streck. The rapid rate is the result of the person just wanting to get air in, she says.
Fast breathing with chest retractions can be a medical emergency, according to the Asthma and Allergy Foundation of America. Retraction is something that is quickly visible to clinicians when the patient’s shirt is pulled up, Streck says, as the skin sucks in between or around the chest and rib bones when the patient inhales.
Feelings of Panic or Anxiety
As breathing becomes more difficult, anxiety can set in, says Streck. When you’re lacking oxygen to your brain, it’s natural to start to feel panicked, she says. Stress and anxiety are also common triggers for an asthma attack, according to the Cleveland Clinic.
Chest Tightness or Pressure
Patients will sometimes feel tight pressure on their chest during a severe asthma attack, says Streck. “For some people, it can feel as though someone is standing on their chest,” she says.
Difficulty Talking
In a severe asthma attack, difficulty with breathing and continuous coughing can make it hard for the person get a full sentence out, says Streck. “They can have pressured speech as they try to get words out because they just can’t breathe,” she says.
Blue Lips or Fingernails
In a very severe attack, someone’s lips or fingernail beds might turn blue, says Streck.
When you’re having a hard time getting enough oxygen, the oxygen will first go to the organs that are vital to life, she says. “The heart, lungs, and brain are still trying to get the oxygen as much as possible. Your fingernails and your lips can start turning blue because they’re not getting the oxygen like they’re supposed to,” says Streck. “If this happens, it’s a severe sign that a person is not doing well. They’re not getting enough oxygen in their extremities.”
Pale, Sweaty Face
If someone’s face appears pale and sweaty during a severe asthma attack, it can be related to the fact that they’re not getting enough oxygen, says Streck. “The color drains from their face as a result,” she says.
Jon E. Stahlman, MD
Medical Reviewer
Jon E. Stahlman, MD, has been a practicing allergist for more than 25 years. He is currently the section chief of allergy and immunology at Children’s Healthcare of Atlanta's Scottish Rite campus and the senior physician at The Allergy & Asthma Center in Atlanta. He served as the president of the Georgia Allergy Society, has been named a Castle Connolly Top Doctor, and was listed as a Top Doctor by Atlanta magazine. His research interests include new therapies for asthma and allergic rhinitis as well as the use of computerized monitoring of lung function.
He received his bachelor's and medical degrees from Emory University. He completed his pediatric residency at Boston Children’s Hospital and his fellowship in allergy and clinical immunology at Harvard University’s Boston Children’s Hospital and Brigham and Women’s Hospital. After his training, Dr. Stahlman conducted two years of clinical research at Boston Children’s Hospital and was part of the faculty at Harvard Medical School, where he taught medical students and allergy and immunology fellows.
Stahlman is board-certified and recertified in allergy and clinical immunology. He served as a principal investigator on phase 2 through 4 studies that are responsible for most of the U.S. Food and Drug Administration–approved therapies for allergies and asthma available today.
Outside of the office, he centers his interests around his wife and three daughters, coaching soccer for many years, and his hobbies include cycling and triathlons.
Becky Upham
Author
Becky Upham has worked throughout the health and wellness world for over 25 years. She's been a race director, a team recruiter for the Leukemia and Lymphoma Society, a salesperson for a major pharmaceutical company, a blogger for Moogfest, a communications manager for Mission Health, a fitness instructor, and a health coach.
Upham majored in English at the University of North Carolina and has a master's in English writing from Hollins University.
Upham enjoys teaching cycling classes, running, reading fiction, and making playlists.