Do regular inhalers need to be stopped or held in asthma patients during an exacerbation requiring regular nebulizers?

Management of Regular Inhalers During Asthma Exacerbations Requiring Nebulizers

Regular maintenance inhalers should NOT be stopped or held during asthma exacerbations requiring nebulizer treatments, but should be continued alongside nebulizer therapy to maintain optimal asthma control. 1

Rationale for Continuing Regular Inhalers

• Maintenance inhalers (particularly those containing inhaled corticosteroids) provide ongoing anti-inflammatory effects that complement the bronchodilation from nebulized treatments
• Discontinuing maintenance therapy during exacerbations may lead to worsening inflammation and delayed recovery
• The British Thoracic Society guidelines support the continued use of controller medications during acute exacerbations 2

Treatment Algorithm During Exacerbations

Initial Management

1. Continue all maintenance inhalers at their regular schedule
2. Add nebulized bronchodilators according to severity:
   • For severe asthma: Salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer every 15-30 minutes as needed 1
   • Add ipratropium bromide 500 μg to nebulized β-agonist if poor initial response 2

Ongoing Management

• Systemic corticosteroids: Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1
• Oxygen therapy: Maintain SaO₂ > 92% 1
• Regular monitoring of vital signs, oxygen saturation, and work of breathing
• Continue maintenance inhalers throughout the exacerbation period

Transitioning Back to Regular Inhalers

When the exacerbation improves:

1. Gradually reduce nebulizer frequency while maintaining regular inhaler schedule
2. Observe for 24-48 hours after complete transition to ensure stability 1
3. Verify proper inhaler technique before discharge

Special Considerations

• Medication delivery: During severe exacerbations, patients may have difficulty using regular inhalers properly due to respiratory distress. In these cases, focus on nebulized therapy initially, but reintroduce regular inhalers as soon as the patient can use them effectively.

• Inhaler technique: Ensure proper technique is maintained or retaught as the patient recovers, as poor technique is a common cause of treatment failure.

• Medication adjustments: The dose of maintenance inhalers generally does not need adjustment during exacerbations, but the frequency of rescue inhalers may increase.

Common Pitfalls to Avoid

• Discontinuing ICS: Never stop inhaled corticosteroids during exacerbations, as this may worsen inflammation and delay recovery
• Relying solely on nebulizers: Nebulizers provide acute relief but don't replace the anti-inflammatory effects of maintenance therapy
• Overuse of SABAs: While nebulized beta-agonists are crucial during exacerbations, excessive use without addressing underlying inflammation can worsen outcomes
• Inadequate monitoring: Patients should be closely monitored for response to therapy and signs of deterioration

By maintaining regular inhaler therapy while adding nebulized treatments during asthma exacerbations, you provide both immediate symptom relief and ongoing control of the underlying inflammatory process, leading to better outcomes and faster recovery.