What's the next step for a patient with bronchial asthma who remains wheezing after receiving three doses of salbutamol (albuterol), one dose of budesonide (Pulmicort), and 250mg of hydrocortisone?

Management of Persistent Wheezing in Bronchial Asthma After Initial Treatment

For a patient with bronchial asthma who remains wheezing despite three doses of salbutamol, one dose of budesonide, and 250 mg of hydrocortisone, the next step should be adding ipratropium bromide 500 μg to the nebulized β-agonist (salbutamol). 1, 2

Assessment of Current Status

Before proceeding with additional treatment, quickly reassess:

• Severity indicators:
  • Ability to speak in sentences
  • Respiratory rate (>25/min indicates severe asthma)
  • Heart rate (>110/min indicates severe asthma)
  • Oxygen saturation
  • Peak expiratory flow (PEF) if available (<50% predicted indicates severe asthma)

Treatment Algorithm

1. Add ipratropium bromide 500 μg to the next salbutamol nebulization

   • Most studies show that nebulized ipratropium leads to faster recovery in patients with severe asthma when combined with nebulized β-agonist 1
   • Can be mixed in the nebulizer with salbutamol if used within one hour 3

2. Continue oxygen therapy

   • Maintain high-flow oxygen via face mask
   • Target oxygen saturation >94%

3. Repeat combined nebulization (salbutamol + ipratropium)

   • If no improvement after 30 minutes, repeat the combined nebulization
   • Continue hourly nebulizations as needed 1

4. Consider hospital admission

   • If features of acute severe asthma persist after initial treatment
   • If PEF <33% of predicted/best after treatment
   • If unable to maintain oxygen saturation >92% on supplemental oxygen

Medication Dosing

Medication	Dose	Frequency
Salbutamol	5 mg	Every 15-30 minutes as needed
Ipratropium bromide	0.5 mg	Every 6 hours

Important Considerations

• Monitor response closely: Reassess after each nebulization treatment for improvement in wheezing, respiratory rate, and oxygen saturation

• Avoid common pitfalls:

  • Underestimating severity - each emergency consultation should be regarded as potentially acute severe asthma until proven otherwise 2
  • Delaying additional treatment - benefits of medications may take time to appear 2
  • Inappropriate discharge - ensure patient meets all discharge criteria before leaving hospital 2

• Administration technique: When using ipratropium:

  • Connect nebulizer to compressor
  • Have patient sit in comfortable, upright position
  • Use mouthpiece or face mask (avoid leakage around mask as it may cause temporary vision blurring) 3
  • Continue treatment until no more mist is formed (about 5-15 minutes)

If the patient fails to respond to the addition of ipratropium bromide or shows signs of deterioration, consider:

1. Initiating aminophylline infusion
2. Consulting for ICU admission if respiratory failure develops
3. Considering mechanical ventilation if necessary

The British Thoracic Society guidelines emphasize that most patients with severe asthma respond to combined nebulized β-agonist and ipratropium therapy when administered appropriately 1.