In their excellent article on asthma exacerbations,1 Aldington Beasley, ask “…why there is such a huge discrepancy between the management of severe asthma recommended by evidence based guidelines, and that observed in clinical practice”.

Although the guidelines are in fact quite simple and straightforward, I think that non-specialist junior physicians in the emergency department are confused by the apparent complexity of, for example, fig 3 from their article reproduced from the British Thoracic Society guidelines, especially when faced with an extremely unwell patient with asthma.

For a number of years, I have taught a very simple “6 P rule” for the assessment of asthma:

• PEFR—baseline and response to first nebuliser.

• Pulse, >120 (it is not due to salbutamol).

• pO₂ (measure and then titrate oxygen against O₂ saturation).

• Panic (ie, ability to speak/respiratory rate).

• Paradox (patients cannot sustain this for long).

• Pneumothorax (make sure the trachea is central until you can obtain a chest x ray; and do not allow anyone to put in a subclavian line).

This is the basic information needed to assess severity, and decide on management, and it is more easily taught and remembered than a complex figure.