Asthma First Aid

05

M.A.M.I.  —  Clinical Resources

Asthma First Aid

Protocol AS-01  ·  Reviewed 13 July 2026  ·  Next review July 2027

Sit them upright. Never lie them down.

Australian asthma first aid follows one rhythm — four puffs, four breaths, four minutes — and it is repeated until the person improves or the ambulance arrives. If you are not certain the problem is asthma, give the reliever anyway. It is unlikely to cause harm.

Immediate escalation

Call 000 straight away if

  1. The person cannot speak in full sentences, or is gasping.
  2. The lips or face are turning blue or grey.
  3. Symptoms are severe from the outset, or worsen quickly.
  4. The chest is silent — no wheeze, and no air moving.
  5. The person is exhausted, confused, or collapsing.
  6. There is no reliever available.
  7. There is no improvement after two rounds of the four-minute cycle.
  8. You are in any doubt at all.
01

The four-minute cycle

Four puffs · Four breaths · Four minutes

4
Puffs

Of the blue or grey reliever. One puff at a time, into a spacer.

4
Breaths

From the spacer after each single puff. Then the next puff.

4
Minutes

Wait, and reassess. No improvement, repeat the cycle.

  1. Sit them upright

    Upright, and leaning slightly forward if that helps. Never lie them down — it makes breathing harder. Stay calm, and stay with them. Do not leave them alone to find the puffer.

  2. Follow their Action Plan if they have one

    If the person has a written Asthma Action Plan, it takes precedence over this protocol.

  3. Give four separate puffs

    Shake the puffer. One puff into the spacer. Four breaths from the spacer. Repeat until four puffs have been given. Shake, one puff, four breaths — four times. Without a spacer: one puff, one slow deep breath, hold as long as is comfortable, repeat.

  4. Wait four minutes

    Reassess. Speech, colour, effort, wheeze.

  5. No improvement — give four more puffs

    Exactly as before.

  6. Still no improvement — call 000

    Tell the operator it is an asthma emergency. Keep giving four puffs every four minutes until the ambulance arrives. Do not stop because you have made the call.

  7. If they stop breathing or become unresponsive

    Start CPR and follow the ANZCOR Basic Life Support flowchart.

Not everyone uses a blue or grey reliever.

Some people use a Bricanyl Turbuhaler, and others use an anti-inflammatory reliever containing budesonide and formoterol. These have different first aid steps and are not given through a spacer. Know what your patient carries, and check the National Asthma Council first aid chart for the device in front of you.

The one that gets missed

Asthma, or anaphylaxis?

Anaphylaxis causes bronchospasm. It produces wheeze and breathing difficulty that is clinically indistinguishable from an asthma attack — and while you wait to see whether the reliever works, the reaction is progressing.

If someone with known asthma and a known allergy has sudden breathing difficulty — wheeze, persistent cough, or a hoarse voice — give the adrenaline device first, then the reliever. Do this even if there are no skin symptoms at all.

The puffer does not treat anaphylaxis. Adrenaline does, and it is safe when the diagnosis is uncertain.

Anaphylaxis protocol
02

Do and do not

The errors that cause harm

Do
  • Sit the person upright.
  • Stay with them, and stay calm.
  • Give the reliever even if you are unsure it is asthma — it is unlikely to harm.
  • Use a spacer whenever one is available.
  • Give one puff at a time, with four breaths after each.
  • Keep the cycle going while waiting for the ambulance.
  • Give adrenaline first where anaphylaxis is possible.
Do not
  • Do not lie the person down.
  • Do not leave them alone.
  • Do not use a preventer inhaler — brown, orange or purple. It does nothing in an attack.
  • Do not fire four puffs in one go. One at a time, four breaths each.
  • Do not wait for a wheeze. A silent chest is worse, not better.
  • Do not stop the cycle once you have called 000.

Scope and limitations

This protocol is an educational resource for practitioners. It is a guide only. It does not replace clinical judgement, your clinic's own emergency procedures, an individual patient's written Asthma Action Plan, or nationally accredited first aid certification (HLTAID011 Provide First Aid). Reading this document does not confer competence in first aid or resuscitation.

Sources

  • National Asthma Council Australia — First Aid for Asthma chart, and the device-specific first aid charts.
  • ANZCOR Guideline 9.2.5 — First Aid for Asthma.
  • ANZCOR Guideline 8 — Cardiopulmonary Resuscitation, Basic Life Support flowchart.
  • ASCIA — Acute Management of Anaphylaxis (2026), for the asthma and allergy overlap.

The 4×4×4 sequence is the Australian recommendation. New Zealand guidance differs. Where this document differs from the current National Asthma Council or ANZCOR guidance, that guidance prevails — confirm the current version at nationalasthma.org.au and anzcor.org.

Clinical review. Reviewed by Dr Larissa Miller, Cosmetic Physician, on 13 July 2026. Next scheduled review July 2027. Protocols are reviewed at least annually and after any incident.

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