What is the first line treatment for bronchoconstriction?

From the Guidelines

The first-line treatment for bronchoconstriction is a short-acting beta-2 agonist (SABA) such as albuterol (salbutamol), typically administered via metered-dose inhaler at a dose of 2 puffs (90 mcg per puff) every 4-6 hours as needed, or via nebulizer at 2.5-5 mg per treatment. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of rapid relief of bronchoconstriction symptoms 1.

Key Points for Treatment

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation of bronchoconstriction 1.
• For acute episodes, treatment can be repeated every 20 minutes for up to three doses if necessary.
• These medications work rapidly (within minutes) to relax bronchial smooth muscle by stimulating beta-2 adrenergic receptors, which increases cyclic AMP and leads to bronchodilation.
• Albuterol is preferred due to its quick onset of action (5-15 minutes), relatively specific action on bronchial tissue, and limited side effects at standard doses.

Additional Considerations

• Patients should be instructed to use proper inhaler technique, including shaking the inhaler, exhaling fully before use, and holding their breath for 10 seconds after inhalation to maximize medication delivery to the airways.
• For patients with persistent symptoms, additional controller medications such as inhaled corticosteroids may be needed, but SABAs remain the cornerstone of immediate bronchoconstriction relief.
• The use of face masks might promote humidification and prevent water loss, attenuating exercise-induced bronchoconstriction (EIB) 1.

Diagnosis and Prevention

• Diagnosis of EIB is made by using exercise or hyperosmolar surrogate challenges, such as EVH or mannitol.
• If pulmonary function test (PFT) results are normal, then exercise challenge or surrogate hyperosmolar challenge, such as with mannitol or EVH, should be performed.
• Management of EIB is based on the understanding that EIB susceptibility varies widely among asthmatic patients, as well as those who do not have other features of asthma.

From the FDA Drug Label

When beginning STIOLTO RESPIMAT, patients who have been taking inhaled, short-acting beta2-agonists on a regular basis (e.g., four times a day) should be instructed to discontinue the regular use of these drugs and use them only for symptomatic relief of acute respiratory symptoms. When prescribing STIOLTO RESPIMAT, the healthcare provider should also prescribe an inhaled, short-acting beta2-agonist and instruct the patient on how it should be used

The first line treatment for bronchoconstriction is an inhaled short-acting beta2-agonist.

• Key points:
  • Use for symptomatic relief of acute respiratory symptoms
  • Prescribe in addition to STIOLTO RESPIMAT
  • Instruct patient on proper use 2

From the Research

First Line Treatment for Bronchoconstriction

The first line treatment for bronchoconstriction typically involves the use of short-acting beta2-agonists (SABAs) as needed for symptom control 3. However, in patients with persistent asthma, a combination product of fluticasone propionate and salmeterol (FSC) has been shown to be more effective than montelukast in reducing symptoms of bronchoconstriction and improving lung function 4, 5.

Comparison of Treatment Options

Studies have compared the efficacy of FSC with montelukast in patients with asthma who are symptomatic on short-acting beta2-agonists alone. The results show that FSC provides significantly greater improvements in lung function, symptom control, and quality of life compared to montelukast 4, 5. Additionally, the combination of FSC has been shown to be more effective than the addition of montelukast to low-dose inhaled corticosteroids in improving asthma control 5.

Potential Adverse Effects

However, it's important to note that SABAs can cause paradoxical bronchoconstriction in some patients, which is an unexpected constriction of the airways in response to the medication 3. This phenomenon is thought to be caused by the excipients in the inhaler formulation, which can trigger airway hyperresponsiveness in patients with allergically inflamed airways.

Key Findings

• FSC is more effective than montelukast in reducing symptoms of bronchoconstriction and improving lung function in patients with persistent asthma 4, 5.
• The combination of FSC is more effective than the addition of montelukast to low-dose inhaled corticosteroids in improving asthma control 5.
• SABAs can cause paradoxical bronchoconstriction in some patients, which can be managed by switching to an anticholinergic inhaler or removing excipients from the inhaler formulation 3.
• Montelukast may provide greater protection against exercise-induced bronchoconstriction and permit a greater and more rapid rescue bronchodilation with a short-acting beta2-agonist compared to salmeterol 6.