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Acute exacerbations of asthma and COPD are often initially managed with inhaled beta2-agonists (salbutamol), inhaled anticholinergics (ipratropium bromide), steroids and O2. In severe cases, treatment adjuncts such as MgSO4 IV, Salbutamol IV, Aminophylline IV and Adrenaline may be considered. Administration of salbutamol has traditionally been via nebulisation, but we will consider burst therapy as an alternative here as well.
Salbutamol nebulisation:
- nebulised in saline/sterile water (1 - 2ml)
- 2.5mg (<5yrs) or 5mg (>5yrs)
- repeat at 30min to 1hour interval, then 2 - 4hourly until recovered
Ipratropium nebulisation:
- may be combined in nebuliser with Salbutamol
- 250mcg (<5yrs) or 500mcg (>5yrs) every 20min for 3 doses
- then 2 puffs (<5yrs) or 4 puffs (>5yrs) every 6h
Salbutamol burst therapy:
- Metered dose inhaler (MDI) 100mcg
- Spacer device recommended
- Bursts -> 6 puffs/dose (<5yrs) or 12 puffs/dose (>5yrs)
- about 4 breathes between each puff
- repeat every 20min for an hour (3 doses in total) & reassess after each dose
- then give burst doses prn
- if subsequent bursts are required at <2hourly intervals consider admission, adjunct treatments and alternative diagnoses
Ipratropium burst therapy:
- MDI 21mcg
- Spacer device recommended
- Bursts -> 4 puffs per dose (<5yrs) or 8 puffs per dose (>5yrs)
- repeat bursts every 20min for an hour (3 doses in total)
- then 2 puffs (<5yrs) or 4 puffs (>5yrs) every 6h
Burst therapy vs nebuliser:
- Burst therapy is generally just as effective as nebulisation with the advantages of being faster, more targeted, cheaper and not requiring electricity or special equipment
- Nebulisation takes longer to deliver medication and patients may need to sit still for 10 or more minutes
- Nebulisation has more facial and oropharyngeal deposition of medication resulting in at best 10% reaching the lungs. This may result in side effects such as tachycardia and tremors.
- Nebulisation however is preferred where patients struggle to co-ordinate taking a deep breathes through a spacer.
- Burst therapy is therefore a useful initial approach before switching to nebulisation if it's ineffective
This information is for academic purposes only and opinions are likely to differ. Please always refer to your local guidelines and protocols for recommended clinical practices.
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(HRE)
