Anaphylaxis and asthma

If you took Cooking Fundamentals, you met allergy from the kitchen side. Its lesson 4 told you that heat doesn't remove an allergen, that a trace can be enough, and that taking it off the plate isn't good enough. That lesson was about preventing the reaction. This one is about the minutes after it starts anyway: a colleague whose lips swell after a pastry, a boy stung by a wasp at a football match, a friend whose asthma closes in.

Both conditions come with their own medicine, and usually the person carries it. Your job is to recognise what's happening, get that medicine used without delay, make the call, and get the position right, which for these two is usually opposite. And in anaphylaxis there is a clock, because a second dose may be due.

The US guidance is the AHA and American Red Cross's 2024 first aid guideline, which grades each recommendation.¹ The UK guidance is RCUK's 2025 first aid guideline, the UK adaptation of the European Resuscitation Council's, which prints no grades.²³ For anaphylaxis the UK adds texts written for the person with the allergy and those around them: the MHRA's 2023 advice (the MHRA is the UK's medicines regulator, and it calls the devices AAIs, adrenaline auto-injectors), the NHS anaphylaxis page, and the leaflets that come with the devices.⁶⁷¹¹ Adrenaline is called epinephrine in the US; it is the same drug.

Recognising anaphylaxis

The NHS calls anaphylaxis a life-threatening allergic reaction that happens very quickly, set off by food, medicine or insect stings, usually within minutes of contact.⁷ RCUK's 2025 guideline says to suspect it if someone has:²

• Breathing trouble, from noisy breathing high in the throat (stridor, from swelling in the upper airway) to wheezing lower down.
• Flushing, a rash or hives, cold or clammy skin, or feeling faint.
• Stomach pain, vomiting or diarrhoea.
• A recent exposure to a food they're known to be allergic to, or an insect sting.

The NHS says to call 999 if you think it's anaphylaxis, and its call-999 list names: sudden swelling of the lips, mouth, throat or tongue; struggling to breathe or to swallow; skin, tongue or lips turning blue, grey or pale (on brown or black skin, often easier to see on the palms or soles); sudden confusion, drowsiness or dizziness; a child who is limp or floppy.⁷

Two warnings. ILCOR's good practice statement, unchanged since 2010, is candid: "First aid providers should not be expected to recognize the signs and symptoms of anaphylaxis without repeated episodes of training and encounters with persons with anaphylaxis (good practice statement)."⁴ And RCUK's 2021 anaphylaxis guideline, written for health professionals, says the skin changes may be absent in up to 20% of cases, so no rash does not mean no anaphylaxis.⁵ The same guideline says breathing trouble in anaphylaxis can look like an asthma attack with nothing else to suggest an allergy, and that anaphylaxis should be considered in anyone with sudden breathing difficulty, especially after a food or sting they are known to react to.⁵

Adrenaline first

The AHA/Red Cross guideline's supporting text says strong international consensus, based mainly on observational data, endorses early epinephrine injected into the muscle of the outer thigh as the primary treatment of anaphylaxis, whatever triggered it.¹ RCUK's 2021 guideline says adrenaline works best when given early, and that delay is associated with longer reactions, low blood pressure and deaths.⁵

Why adrenaline. In anaphylaxis, RCUK's 2021 guideline explains, the blood vessels widen, fluid leaks out of them into the tissues, and the airways tighten and swell.⁵ Adrenaline narrows the vessels, reduces the swelling, opens the airways, strengthens the heart's contraction and damps down the release of histamine, one of the chemicals driving the reaction.⁵

Why not an antihistamine. RCUK's 2021 guideline: "Antihistamines are considered a third-line intervention and should not be used to treat Airway/Breathing/Circulation problems during initial emergency treatment."⁵ Its main text says they can help skin symptoms but must not be given in preference to adrenaline, and that most guidelines worry their use delays adrenaline.⁵

The US guideline's anaphylaxis section does not discuss antihistamines; its bee and wasp sting table says over-the-counter antihistamines can be used for local itching (AHA/Red Cross 2024, COR 2a, LOE C-EO). The FDA, in 2024, called epinephrine the only life-saving treatment for anaphylaxis.¹¹³

The MHRA says an auto-injector "should be used without delay if anaphylaxis is suspected, even if in doubt about the severity of the event".⁶ Keep its scope: the doubt is about how severe a suspected reaction is. Its reason is that the risks of delay outweigh the possible risks of adrenaline that turns out not to have been needed.⁶ The device leaflets say: if in doubt, use it.¹¹

In the US, the guideline's first anaphylaxis recommendation is that a person with an autoinjector available should use it (AHA/Red Cross 2024, COR 1, LOE B-NR), and its background says they're prescribed to be used at the first sign of a reaction.¹

Who gives it

People get this wrong both ways: anyone may inject anyone, or only the trained may touch the device.

• In the US: the person should use their own autoinjector (AHA/Red Cross 2024, COR 1, LOE B-NR), and "A first aid provider should assist a person experiencing anaphylaxis to use their autoinjector if assistance is required." (AHA/Red Cross 2024, COR 1, LOE C-EO)¹ EpiPen's US label: for use by the person or their caregiver, and anyone who may give it should understand how to use it.¹²
• In the UK: RCUK's step says adrenaline is given "either self-administered or by trained individuals". Its general principle is "only use equipment and medications you have been trained to use", except that the emergency services may direct you to use equipment you haven't had in-depth training on (RCUK 2025).² St John Ambulance tells a first aider to help them use it, or give the injection themselves straight away, following the instructions.⁹ The MHRA: for use by the patient or the patient's carer. EpiPen's UK leaflet: designed to be used easily by people without medical training.⁶¹¹

This course's reading: in both countries the device is the person's own, it goes in at once, and you help as much as they need. If they can't use it at all, St John tells a UK first aider to do it.⁹ RCUK does not say how its exception for equipment the emergency services direct you to use applies to an auto-injector, so this course will not say it for them. In the US the furthest any text here goes is the AHA's "assist"; this course found no US text on a stranger giving the injection. The call handler will be on speaker by then: ask, and do what they say.

The call

• In the US: the guideline's third recommendation is to activate the emergency response system for anyone with anaphylaxis (AHA/Red Cross 2024, COR 1, LOE C-EO).¹ EpiPen's US label says to get emergency help right away, even after using it.¹²
• In the UK: RCUK's list puts the 999 call first and says adrenaline should be given as soon as possible (RCUK 2025).² The MHRA, the NHS and the leaflets, which speak to the person with the allergy, put the injection first and the call straight after, saying "anaphylaxis".⁶⁷¹¹

The orders differ on paper and agree in practice: none of these texts delays adrenaline for the call, or skips the call because the adrenaline worked. With two of you, lesson 1's tactic applies: one helps while the other calls.

The devices

An adrenaline auto-injector is a spring-loaded pen that pushes a hidden needle into the thigh muscle when it is pressed firmly against it. The MHRA names two in the UK, EpiPen and Jext, each with a leaflet (EpiPen, Jext); for the US this lesson uses the EpiPen label.⁶¹¹¹²

Three seconds against ten is the detail people get wrong, and EpiPen's US label warns that if it isn't held long enough it might not deliver the right dose.¹² The rule for every device, including ones that change after this lesson: follow the instructions printed on the device, which the NHS says are on the side of the injector.⁷

The Jext leaflet and EpiPen's US label both warn never to put a thumb or hand over the needle end. Adrenaline injected by accident into a finger or hand may reduce or stop the blood flow there, and EpiPen's US label says to go straight to the nearest emergency room if it happens.¹¹¹² Each device is one dose, and the US label tells caregivers to hold a young child's leg firmly before and during the injection, to lower the risk of injury.¹²

Nasal sprays exist now too, neffy in the US and EURneffy in the UK, each with a lower dose for children from 15 kg.¹²¹⁴ neffy's label puts any second dose in the same nostril with a new spray, "starting 5 minutes after the first dose", and the FDA approved it on studies of blood levels in healthy adults, not a trial in people having a reaction.¹²¹³

Which way up

The ERC's one-line summary is broader, "Ensure that the person remains in a seated or lying position", but its evidence text gives the same split as RCUK's.³

The US side, in this course's reading: the same guideline's shock section, which lesson 9 taught, says that for a person in shock with no trauma or injury, raising the feet about 6 to 12 in from lying on their back may be reasonable (AHA/Red Cross 2024, COR 2b, LOE C-LD). It does not name anaphylaxis, and this course leaves it there.¹

Why lying down? With the vessels wide and leaking, less blood flows back to the heart and it fills poorly (RCUK 2021). Getting up makes that worse: "Changes in posture from supine to standing or sitting upright have been associated with cardiovascular collapse and death during anaphylaxis."⁵ Supine means lying on your back. For a person whose circulation is failing, keeping them flat, legs raised or not, "will maximise venous return", the blood coming back to the heart through the veins, and so what the heart can pump out.⁵ The same guideline says someone whose problem is mainly breathing, with the circulation holding up, may prefer to be half sitting, which is the UK's sitting-up exception.⁵

The ERC labels its posture advice "(expert opinion)", and RCUK's 2021 guideline rests its posture sentence on two published papers about deaths, which this course hasn't read.³⁵ There is no trial: it's a firm instruction on thin evidence, and the US anaphylaxis section's silence is an absence, not a finding that posture does not matter. Lesson 9 raised the legs for shock to help blood reach the vital organs, and the MHRA gives that reason here too: lying down with the legs raised helps blood reach the heart and vital organs.⁶

The second dose

The US guideline's supporting text estimates that 7% to 18% of people with anaphylaxis need more than one dose, and that most who had a second improved after it.¹ ILCOR, whose review both countries build on, keeps its 2015 suggestion of a second dose by autoinjector for adults and children with severe anaphylaxis not relieved by the first (weak recommendation, very low certainty evidence).⁴ The countries differ on when.

The UK rule is a clock: five minutes, no better, second dose, and the ERC says the same.³ The US guideline's rule has two conditions, no response and help still more than 5 to 10 minutes away, graded 2b, "may be considered", on nonrandomised evidence. Neither guideline gives a reason for its timing, so this course will not supply one. Follow the country you're in. Either way you need the time of the first dose. This course's suggestion is to say the time aloud when it goes in; the Jext leaflet says to tell the healthcare professional the injection has been given.¹¹

If they stop responding

If the person stops responding and is not breathing normally, it's lesson 2: CPR, with the call handler coaching you, and the AED as soon as one arrives (lessons 3 to 5). Slow, noisy or gasping breathing is not normal. If they stop responding but are breathing normally, quietly and regularly, it's lesson 7's recovery position, which is what EpiPen's UK leaflet says for an unconscious person, watching the breathing the whole time.¹¹

The office kitchen in Des Moines

A box of pastries arrives at an office in Des Moines. A colleague with a peanut allergy eats half of one, then stops. Within minutes her lips are swelling, she's wheezing, and she says her throat feels tight. Her auto-injector is in her bag under the desk, and her hands are shaking too much to get it out.

Recognise. A known allergy, a recent exposure, lip swelling and wheeze: RCUK's list fits, and no rash is needed to decide.²⁵

Call and fetch. One colleague calls 911 on speaker (AHA/Red Cross 2024, COR 1) and says what it is.¹ You get the bag.

The device. You find it, check it's hers, and help her use it in her outer thigh, through her clothes, following the steps printed on its side, with everyone's fingers clear of the orange needle end. The guideline's first recommendation is written for her, and its second for you: assist if assistance is required (COR 1).¹¹² It's an EpiPen, so it's held for 3 seconds. Someone says the time aloud: 10:14.

Position. She's wheezing and wants to sit on the floor against the wall. The US guideline's anaphylaxis section has no posture instruction; its general positioning text presumes an alert person will choose the position that best helps their breathing.¹ Nobody walks her to a chair by the window: the UK texts would keep her off her feet, and nothing in the US texts disagrees.

Watch. At 10:19 she's no better: the swelling is the same and the wheeze is worse. The call handler says the crew is still about 15 minutes away. She has a second device.

The football tournament in Harrogate

A 14-year-old at a youth tournament in Harrogate is stung by a wasp on the neck. Within minutes he's blotchy, his face is swelling and he's short of breath. He uses his own EpiPen at 10:02 with his coach's help while a parent calls 999, and he's laid down. By 10:08 he feels much better and wants to get up and rejoin his team. A visiting coach from the US says, "He's fine now. Let him walk it off."

Whose rules. They are in England, so the UK's, the rules the call handler will use.

Position. He stays lying down. The MHRA's sentence fits this moment exactly: "do not stand up even if someone encourages you to".⁶ The visiting coach isn't breaking a US rule, because the US guideline's anaphylaxis section has no posture rule; in England the UK texts apply, and on this point they are explicit.

Second dose. He has improved, so the five-minute rule does not call for one (RCUK 2025; MHRA 2023).²⁶ But the second device stays in someone's hand: St John says repeat doses can be given at five-minute intervals if symptoms return.⁹

"Fine" at six minutes. The leaflets say to call even if symptoms improve, and that the person needs hospital observation because the reaction may happen again later.¹¹ So the ambulance comes, and he goes with it, lying down. RCUK says to remove the trigger if you can; after a wasp there's usually no sting left in the skin, since wasps have smooth stingers.²¹

Asthma

The NHS says asthma symptoms happen when the airways become swollen and narrower, and describes an attack as severe symptoms that make it hard to breathe and can be life-threatening; St John says that in an attack the muscles of the air passages go into spasm.⁸⁹ St John's signs include a tight chest, speaking in short sentences or a whisper, a grey-blue tinge to the lips, earlobes and nailbeds, and, in a severe attack, exhaustion.⁹

The NHS tells someone having an attack to "sit up straight" and try to stay calm; Asthma + Lung UK says to sit up, and St John to sit them down comfortably.⁸¹⁰⁹ In anaphylaxis the UK sources keep a person lying down unless breathing is hard; in asthma, sitting up is the rule.

Helping with their own reliever is where the countries agree.

• In the US: first aid providers should help a person with asthma who's having difficulty breathing to use their own prescribed bronchodilators, the guideline's word for relievers, as needed (AHA/Red Cross 2024, COR 1, LOE B-R). An inhaler with a spacer, or a nebuliser, is reasonable in preference to an inhaler alone (COR 2a, LOE B-R), and an improvised spacer if there is no commercial one (COR 2a, LOE B-R).¹
• In the UK: a first aider should help a person with asthma who is having breathing trouble to use their own reliever inhaler, with a spacer if one's available (RCUK 2025).²

Three words from those lines. A metered dose inhaler is the ordinary puffer, giving a measured dose with each press. A spacer is an add-on for it (the research the AHA cites calls spacers holding chambers), and a nebuliser is a machine; the AHA's text says inhalers with spacers work as well as nebuliser machines.¹ ILCOR's weak suggestion speaks only to trained first aid providers (ILCOR 2025, unchanged since 2015); RCUK's asthma step carries no training condition.⁴²

The AHA's supporting text says a spacer, used with a metered dose inhaler, improves the delivery of the medicine to the lungs; St John says the inhaler is more effective with one, especially for young children.¹⁹ Without one: "Improvised spacers made with a 500-mL (≈16 oz) plastic cold drink bottle or a 150-mL (≈5 oz) disposable paper cup appear to provide drug delivery similar to that achieved with commercial spacer devices".¹ No text read here shows how to set one up, so ask the person, or a parent, who may know.

Is it safe to help? The AHA's text says salbutamol (albuterol in the US), a bronchodilator, causes no clinically significant change in heart rate, blood pressure or potassium.¹ ILCOR adds that it isn't known whether first aiders can correctly identify an asthma attack, or whether relievers could harm someone whose breathing trouble has another cause, which is one reason the person's own diagnosis and inhaler matter.⁴

How many puffs

The US guideline says "as needed" and gives no count, and this course found no US source that does.¹ UK public advice gives two schedules, depending on the inhaler.

Asthma + Lung UK gives the same schedules.¹⁰ AIR is an anti-inflammatory reliever, used only when symptoms come; MART, maintenance and reliever therapy, is one inhaler used every day and also when symptoms come.⁸ St John's page says its asthma attack advice "is not for patients on a Maintenance and Reliever Therapy (MART) plan."⁹ Neither the NHS nor Asthma + Lung UK says why the slower schedule stops at six, and this course will not guess.

The NHS adds that if the person's asthma action plan gives a different maximum for an attack, follow the plan, and St John says a person on MART will know which inhaler to use and may carry a written plan.⁸⁹ Ask them, and look for the plan, before you count.

When to call

• In the UK: 999 if they feel worse at any time, are no better after the maximum dose, or have no inhaler (the NHS; Asthma + Lung UK). If they're no better after 10 minutes and no ambulance has come, they take the inhaler again up to the same maximum, and Asthma + Lung UK says to call 999 again if that does not help.⁸¹⁰ Asthma + Lung UK, speaking to the helper: call 999 if they don't feel better, or if you're worried at any point.¹⁰ St John also calls for a severe attack that is getting worse or exhausting them, or is their first.⁹ The NHS tells the person not to drive themselves to A&E.⁸
• In the US: the guideline's asthma section gives no call rule, and this course found no US public page with one. Its text on assessing an ill person says any abnormality in breathing should be treated as an emergency that prompts a call to EMS.¹

After an attack that settles without an ambulance, the NHS says to see a GP within 2 days, and Asthma + Lung UK to ask for an urgent same-day appointment.⁸¹⁰ If they stop responding, it is as for anaphylaxis: breathing normally, lesson 7; not breathing normally, lesson 2.

At school

Both countries have made room for a school's own supply.

• In the UK: since 1 October 2014 UK schools may buy a salbutamol inhaler without a prescription, for a child with asthma who cannot reach their own, and since 1 October 2017 schools in England may buy adrenaline auto-injectors the same way, for children at risk of anaphylaxis whose own device is not available or is not working. Both are permissions; this course read only the summary of each.¹⁶
• In the US: the School Access to Emergency Epinephrine Act of 2013 gives states a preference for certain federal asthma grants if they require every public elementary and secondary school to let trained staff give epinephrine to any student reasonably believed to be having an anaphylactic reaction, and to keep a supply.¹⁷ The Act requires nothing of schools itself; the details are state law, which this course did not read.

What people get wrong

"Try an antihistamine first, and use the pen if it gets worse." Adrenaline first, even if in doubt about severity (MHRA 2023); antihistamines are third line (RCUK 2021).⁶⁵

"He's better now, so he can get up." Stay lying down (MHRA 2023; the NHS); getting up has preceded collapse and death (RCUK 2021).⁶⁷⁵

"One auto-injector is enough." Carry two (MHRA 2023); 7% to 18% need more than one dose (AHA/Red Cross 2024).⁶¹

"All auto-injectors are held for ten seconds." EpiPen 3, Jext 10. Follow the device.¹¹¹²

"Either anyone can inject it, or only the trained may." The person uses their own, a first aider assists (AHA/Red Cross 2024), RCUK names the person or trained individuals, and St John tells a UK first aider to do it if the person can't.¹²⁹

"Ten puffs of any inhaler." Ten is for a blue reliever; AIR and MART are up to 6, and the person's plan comes first (the NHS).⁸

Practice

Where to learn more with your hands

A page can't give you the device in a shaking hand, the click, and the count while someone is frightened. The NHS tells people with an allergy to practise with a trainer injector from the company that makes theirs, and to teach friends, family and colleagues how and when to use it.⁷ Lesson 16 lists where to find a class. No video has been watched against the guidance and no device photograph checked for its licence, so none is shown.

Connections

Lesson 2 decides when either emergency has become a cardiac arrest, and lesson 7's recovery position is for the person who stops responding but keeps breathing normally. Lesson 12 met RCUK's training principle over aspirin; it comes back here for adrenaline.

Lesson 14 covers seizures, low blood sugar and poisoning, where whether anything goes in by mouth depends on whether the person is fully awake.

Go deeper

• MHRA, Adrenaline auto-injectors (AAIs): new guidance and resources for safe use, 27 June 2023. Read in full.
• Resuscitation Council UK, Emergency treatment of anaphylaxis, May 2021. For health professionals; the clearest account of why posture matters. Read in part: the summary and the sections on posture, recognition, adrenaline, antihistamines and bronchodilators.

Sources

1. E. K. Hewett Brumberg, M. J. Douma and colleagues, "2024 American Heart Association and American Red Cross Guidelines for First Aid", Circulation 150, 2024, e519 to e579 . Read level: full, direct, from the Internet Archive capture 20260329073336, re-read on 2026-09-25; Tables 18, 22 and 26 from archived copies of the publisher's images.
2. Resuscitation Council UK, 2025 Resuscitation Guidelines: First aid, 27 October 2025 . Read level: full, direct; the key points, "Expectations of a first aid provider", "Anaphylaxis" and "Asthma" sections re-read on 2026-09-25.
3. T. Djärv, J. Rogers, F. Semeraro and colleagues, "European Resuscitation Council Guidelines 2025 First Aid", Resuscitation 215 (suppl 1), 2025, 110752 . Read level: full, direct, on the publisher's page.
4. T. Djärv, M. J. Douma and colleagues for the ILCOR First Aid Task Force, "2025 International Consensus on First Aid Science With Treatment Recommendations", Circulation 152, 2025 . Read level: full, direct, from the accepted manuscript on ilcor.org; the recognition and second-dose statements checked against the typeset text at ahajournals.org. The asthma recommendation and its scoping review are paraphrased from the manuscript.
5. Resuscitation Council UK, Emergency treatment of anaphylaxis: Guidelines for healthcare providers, May 2021 . Written for health professionals. Read level: the summary in full, direct; the main guideline in part, the sections on posture, recognition, adrenaline, antihistamines and bronchodilators.
6. MHRA, Adrenaline auto-injectors (AAIs): new guidance and resources for safe use, Drug Safety Update, 27 June 2023 . Read level: full, direct; re-read on 2026-09-25.
7. NHS, Anaphylaxis, last reviewed 21 June 2023, next review due 21 June 2026 . Read level: full, direct, 2026-09-25.
8. NHS, Asthma, last reviewed 7 April 2025 . Read level: full, direct, 2026-09-25.
9. St John Ambulance, Anaphylaxis, clinically reviewed 25 April 2025, and Asthma attack, clinically reviewed 28 April 2025 . Read level: full, direct; both re-read on 2026-09-25.
10. Asthma + Lung UK, Asthma attacks . Read level: full, direct, 2026-09-25.
11. Patient information leaflets from the UK's electronic medicines compendium: EpiPen 0.3 mg, last revised July 2026, and Jext 300, last revised September 2023 . Read level: full, direct, both 2026-09-25.
12. US prescribing information and patient instructions on DailyMed: EpiPen and EpiPen Jr (Viatris) and neffy (ARS Pharmaceuticals) . The EpiPen prescribing information, patient information and instructions for use, and neffy's dosage section, read on 2026-09-25.
13. US Food and Drug Administration, FDA Approves First Nasal Spray for Treatment of Anaphylaxis, 9 August 2024 . Read level: full, direct, 2026-09-25.
14. Anaphylaxis UK, EURneffy nasal adrenaline spray approved by MHRA, 24 July 2025, and Lower dose EURneffy approved by MHRA for younger children, 30 June 2026. **Read level: full, direct**, both 2026-09-25.
15. R. S. Pumphrey, "Lessons for management of anaphylaxis from a study of fatal reactions", Clinical and Experimental Allergy 30, 2000, 1144 to 1150 . Read level: abstract only (PubMed 10931122), re-read on 2026-09-25.
16. Department of Health and Social Care, Using emergency adrenaline auto-injectors in schools, 20 September 2017, and Emergency asthma inhalers for use in schools, 2014 . Read level: the summary paragraph of each page only.
17. School Access to Emergency Epinephrine Act, Public Law 113-48, 13 November 2013 . Read level: full text, direct, 2026-09-25.