Do regular inhalers need to be held when initiating salbutamol (albuterol) and ipratropium nebulizer therapy?

Management of Regular Inhalers When Initiating Nebulizer Therapy

Regular inhalers do not need to be held when initiating salbutamol and ipratropium nebulizer therapy, as they provide complementary bronchodilation through different delivery methods. 1

Rationale for Continuing Regular Inhalers

• The British Thoracic Society (BTS) guidelines do not recommend discontinuing regular inhaler therapy when initiating nebulizer treatment 1
• Nebulizers are typically used in acute settings when higher doses of medication are needed or when patients cannot effectively use hand-held inhalers due to severity of symptoms 2

Appropriate Use of Nebulizers vs. Inhalers

Indications for Nebulizer Use

• Acute severe asthma or COPD exacerbations where patients cannot effectively use inhalers 1
• When large drug doses are needed for symptom control 1
• When coordinated breathing is difficult in acutely ill patients 1
• In patients where hand-held inhalers have been found ineffective despite proper technique 1

Dosing Guidelines for Nebulized Therapy

• For adults with severe symptoms: salbutamol 5 mg or terbutaline 10 mg, repeated every 4-6 hours 1
• For combined therapy: add ipratropium bromide 500 μg to the β-agonist 1, 2
• For children: salbutamol 5 mg (or 0.15 mg/kg) or terbutaline 10 mg (or 0.3 mg/kg) 1

Clinical Considerations

Acute Exacerbations

• In severe exacerbations, nebulized therapy is often used as a rescue treatment while maintaining regular inhaler therapy 2
• The BTS recommends administering nebulized salbutamol at 2.5-5 mg every 4-6 hours for 24-48 hours or until clinical improvement rather than back-to-back treatments 2

Transition of Care

• Before hospital discharge, patients should transition from nebulized treatment back to hand-held inhaler therapy 2
• Patients should be observed for 24-48 hours after this transition to ensure stability 2

Special Populations

Elderly Patients

• In elderly patients with glaucoma, consider using a mouthpiece rather than a mask when administering ipratropium bromide to prevent exacerbation of glaucoma 1
• β-agonists may rarely precipitate angina in elderly patients, so first treatment should be supervised 1

Common Pitfalls to Avoid

• Do not use oxygen to drive nebulizers in COPD patients with carbon dioxide retention and acidosis; use compressed air instead 2
• Do not administer back-to-back nebulizations as this may increase side effects without providing additional clinical benefit 2
• Do not discontinue regular preventative treatment even when using a nebulizer for acute symptoms 1

Monitoring During Nebulizer Therapy

• Monitor for side effects such as tachycardia, tremor, and hypokalemia, which may be more pronounced with higher or more frequent dosing 2
• For patients ill enough to require hospital admission, measure arterial blood gas tensions 2