ANZCOR Guidelines

ANZCOR Guidelines > First Aid for Medical Conditions > Guideline 9.2.5 – First Aid for Asthma


Guideline 9.2.5 – First Aid for Asthma

Next review November 2025

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To whom does this guideline apply? 

This guideline applies to adults and children.

Who is the audience for this guideline?

This guideline is for use by bystanders, first aiders and first aid training providers.

Summary of Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) makes the following recommendations for the first aid treatment of acute asthma:

  1. Follow the person’s Asthma Management Plan [Good Practice Statement].
  2. If no Asthma Management Plan in place, start treatment with reliever medications following the Asthma First Aid Plan as soon as practicable [Good Practice Statement].
  3. If the person does not improve within 5 minutes, or is having a severe asthma attack, send for an ambulance [Good Practice Statement].





Australian and New Zealand Committee on Resuscitation


Personal Protective Equipment





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Asthma is a disorder of the smaller airways of the lungs. People with asthma have sensitive airways which can narrow when exposed to certain triggers, leading to difficulty in breathing. This is known as an acute exacerbation of asthma, or asthma attack.1-3

Three main factors cause the airways to narrow:2

  1. The muscle around the airway tightens (bronchoconstriction).
  2. The inside lining of the airways becomes swollen (inflammation).
  3. Extra mucus (sticky fluid) may be produced.

In asthma, symptoms are made worse by triggers. Every person’s asthma is different and not all people will have the same triggers. Triggers are more likely to provoke asthma in those with poorly controlled asthma.  Triggers can include:3-5

  • respiratory infection
  • irritants (e.g. cigarette, woodfire or bushfire smoke, perfumed or cleaning products)
  • inhaled allergens (e.g. dust mites, mould spores, animal dander, grass/tree pollen)
  • cold air, exercise, laughing/crying
  • non steroidal anti-inflammatory agents (e.g. aspirin, ibuprofen)
  • sulfite additives (food preservatives)
  • food allergy – while usually accompanied by other symptoms such as rash or vomiting, isolated severe asthma may occur as the only presentation
  • food colourings and flavours
  • emotional triggers such as stress.

Recognising an Asthma Attack

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Asthma can be recognised by the following signs and symptoms:1-4

  • a dry, irritating, persistent cough, particularly at night or early morning, with exercise or activity
  • chest tightness
  • shortness of breath
  • wheeze (high pitched whistling sound during breathing).

Signs and symptoms of a severe asthma attack include some or all of the following:

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  • gasping for breath (with or without wheeze)1, 3, 6
  • inability to speak more than one or two words per breath1, 3, 6
  • severe chest tightness1, 3, 6
  • ‘sucking in’ of the throat and rib muscles, use of shoulder muscles or bracing with arms to help breathing1, 3, 6
  • blue discolouration around the lips1, 3, 6
  • pale and sweaty skin1, 3, 6
  • distress and anxiety1, 3, 6
  • decreased level of consciousness1, 3, 6
  • little or no improvement after using reliever medication/s1, 3, 6
  • symptoms rapidly getting worse or using reliever more than every two hours.1, 3, 6


As well as the above symptoms, young children may appear restless, unable to settle or become drowsy. They may have problems eating or drinking due to shortness of breath and may experience vomiting.


An asthma attack can take anything from a few minutes to a few days to develop.  Other conditions can mimic asthma, but asthma is the common cause particularly in a person known to have asthma.7 If the person has a history of anaphylaxis and is carrying an epinephrine (adrenaline) autoinjector (e.g. EpiPen™ and Anapen™), consider this possibility and treat according to ANZCOR Guideline 9.2.7.


Managing an Asthma Attack

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Many people with asthma have personal Asthma Action Plans which have a series of steps to follow if they are experiencing an asthma attack. If a person has an Asthma Action Plan, follow the plan.8, 9 

If there is no Asthma Action Plan in place or you are unable to locate an action plan then use the Asthma First Aid Plan below (refer to section 3.1).

If a person is experiencing any signs of severe asthma (refer to section 2.1) send for an ambulance immediately and then continue to follow the person’s Asthma Action Plan/Asthma First Aid Plan till the ambulance arrives.

If a severe allergic reaction is suspected, follow First Aid Management of Anaphylaxis (refer to ANZCOR Guideline 9.2.7).

*Many fatal cases of food-induced anaphylaxis occur in those with asthma.10 In persons with asthma known to be at risk from anaphylaxis where it is uncertain whether the person is suffering from asthma or anaphylaxis, it is appropriate to administer an epinephrine (adrenaline) auto-injector first followed by asthma reliever medication. The harm of not treating anaphylaxis outweighs the risk of unnecessary epinephrine (adrenaline) administration [Good Practice Statement].

If at any time the person becomes unresponsive and is not breathing normally, commence resuscitation following the Basic Life Support Flowchart (refer to ANZCOR Guideline 8).


Asthma First Aid Plan

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Australia (4 x 4 x 4)1

New Zealand (6 x 6 x 6)11


Sit the person comfortably upright. Be calm and reassuring. Do not leave the person alone.



Without delay give four separate puffs of a reliever inhaler*. The medication is best given one puff at a time via a spacer device.12 Ask the person to take four breaths from the spacer after each puff of medication.


Without delay give six separate puffs of a reliever inhaler*. The medication is best given one puff at a time via a spacer device.12 Ask the person to take six breaths from the spacer after each puff of medication.

If a spacer is not available, simply use the inhaler.  Use the person’s own inhaler if possible. If not, use the first aid kit inhaler if available or borrow one from someone else.



Wait four minutes. If there is little or no improvement give another four puffs.

Wait six minutes. If there is little or no improvement give another six puffs.



If there is still no improvement, send for an ambulance immediately.


Keep giving four puffs every four minutes until the ambulance arrives.

Keep giving six puffs every six minutes until the ambulance arrives.


*The most common reliever inhaler is salbutamol (Ventolin ®, Asmol ®, Zempreon ® (grey/blue inhaler).  If a person has a different reliever you should use this instead.8, 13, 14


No harm is likely to result from giving a reliever inhaler to someone without asthma [Good Practice Statement].


If oxygen is available, it should be administered by a person trained in its use, following Use of Oxygen in Emergencies (refer to ANZCOR Guideline 9.2.10) [Good Practice Statement]. 


Diagrams for the use of devices

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Regional differences in recommended dose and intervals

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There are differences in first aid treatment recommendations between Australia and New Zealand.1, 11  Additionally, treatment recommendations for the clinical management of acute asthma by health professionals are different again.  Evidence from scientific literature does not suggest any ideal reliever type, reliever dosage or dosage interval for managing acute asthma in a first aid setting.8, 14-18


In Australia, the National Asthma Council Australia recommends taking 4 puffs every 4 minutes (4 x 4 x 4) whereas in New Zealand, the Asthma and Respiratory Foundation NZ recommend taking 6 puffs every 6 minutes (6 x 6 x 6).1, 11


Both the 2015 and 2021 International Consensus on First Aid Science did not provide any update on dosage or interval between doses for asthma management.18, 19 This guideline is not intended to contradict current recommendations of peak asthma bodies in Australia or in New Zealand – the ANZCOR recommended treatment in 3.1 accounts for these regional differences.


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  1. Asthma First Aid: Asthma and Respiratory Foundation of New Zealand; [Available from:
  2. Living with Asthma: Asthma and Respiratory Foundation New Zealand; [Available from:
  3. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention.; 2022.
  4. About Asthma: Asthma Australia; [Available from:
  5. Common asthma triggers: Asthma and Respiratory Foundation New Zealand; [Available from:
  6. Australian Asthma Handbook: National Asthma Council Australia; [1.1:[Available from:
  7. First Aid for Asthma: National Asthma Council Australia; [Available from:
  8. Craig SS, Craig SS, Dalziel SR, Powell CVE, Graudins A, Babl FE, et al. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane library. 2020;2020(8):CD012977.
  9. Kessler KR. Relationship Between the Use of Asthma Action Plans and Asthma Exacerbations in Children With Asthma: A Systematic Review. Journal of asthma & allergy educators. 2011;2(1):11-21.
  10. Burks AWMD, Tang MMP, Sicherer SMD, Muraro AMDP, Eigenmann PAMD, Ebisawa MMDP, et al. ICON: Food allergy. Journal of allergy and clinical immunology. 2012;129(4):906-20.
  11. Asthma First Aid: Asthma New Zealand; [Available from:
  12. Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ open research. 2018;4(2):65.
  13. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention.; 2021.
  14. Griffiths B, Ducharme FM, Griffiths B. Combined inhaled anticholinergics and short‐acting beta2‐agonists for initial treatment of acute asthma in children. Cochrane library. 2013;2013(9):CD000060-CD.
  15. Kearns N, Maijers I, Harper J, Beasley R, Weatherall M. Inhaled Corticosteroids in Acute Asthma: A Systemic Review and Meta-Analysis. The journal of allergy and clinical immunology in practice (Cambridge, MA). 2020;8(2):605-17.e6.
  16. Kirkland SW, Vandenberghe C, Voaklander B, Nikel T, Campbell S, Rowe BH, et al. Combined inhaled beta‐agonist and anticholinergic agents for emergency management in adults with asthma. Cochrane library. 2017;2017(1):CD001284-CD.
  17. Long D, Bendall J, Bower A. Out-of-hospital administration of corticosteroids to patients with acute asthma: A case study and literature review. Journal of Emergency Primary Health Care. 2008;6.
  18. Singletary EM, Zideman DA, De Buck EDJ, Chang W-T, Jensen JL, Swain JM, et al. Part 9: First Aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation (New York, NY). 2015;132(16 Suppl 1):S269-e1.
  19. Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, et al. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Resuscitation. 2021;169:229-311.

About this guideline

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Search date/s

September 2021 and January 2023



P All adults and children experiencing (symptoms consistent with) an acute exacerbation of asthma

I Any first aid intervention

C No intervention

O Mortality, hospitalisation, worsening of symptoms

S Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort observational studies)

Must include English abstract

T > 2010,


Scoping search of published literature (see worksheet)

Primary reviewers:

Lakshmi Sunderasan, Finlay Macneil

Other consultation

Kevin Nation


July 2023

Guidelines superseded:

ANZCOR Guideline 9.2.5 First Aid for Asthma November 2016

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