What to do if a patient is still wheezing 2 hours after receiving an albuterol (salbutamol) nebulizer?

Management of Persistent Wheezing After Albuterol Nebulizer Treatment

If a patient is still wheezing 2 hours after receiving an albuterol nebulizer, you should administer a repeat dose of nebulized albuterol, and consider adding ipratropium bromide if the response remains poor. 1

Assessment of Severity

First, quickly assess the severity of the patient's condition:

• Check for features of severe asthma:

  • Inability to complete sentences in one breath
  • Respiratory rate ≥25 breaths/min
  • Heart rate ≥110 beats/min
  • Peak expiratory flow (PEF) ≤50% of predicted or best 1

• Check for life-threatening features:

  • PEF <33% of predicted or best
  • Silent chest, cyanosis, or feeble respiratory effort
  • Bradycardia or hypotension
  • Exhaustion, confusion, or coma 1

Treatment Algorithm

For Patients Without Life-Threatening Features:

1. Administer a repeat nebulized albuterol treatment (5 mg salbutamol or 10 mg terbutaline) 1

2. Monitor response 15-30 minutes after nebulizer treatment 1

3. If response remains poor:

   • Add ipratropium bromide (500 μg) to the nebulized albuterol 1
   • Consider oral corticosteroids (prednisolone 30-60 mg for adults) if not already given 1

4. Continue nebulized treatments every 4-6 hours until PEF >75% of predicted or best and PEF diurnal variability <25% 1

For Patients With Life-Threatening Features:

1. Immediately repeat nebulized albuterol plus ipratropium bromide 1

2. Administer oxygen (40-60%) 1

3. Consider intravenous bronchodilators or assisted ventilation if no improvement 1

4. Arrange urgent hospital admission 1

Special Considerations

• For children with status asthmaticus not responding to intermittent nebulization, continuous nebulization of albuterol (0.3 mg/kg/hr) may be more effective 2

• In COPD exacerbations, combined nebulized treatment (β-agonist with ipratropium bromide) should be considered, especially if the patient has had a poor response to either treatment alone 1

• If the patient has carbon dioxide retention and acidosis, the nebulizer should be driven by air (not high-flow oxygen) 1

Monitoring and Follow-up

• Measure PEF 15-30 minutes after each nebulizer treatment to objectively assess response 1

• Be aware that albuterol's effect typically peaks at approximately 1 hour after administration and can remain close to peak for 2 hours in most patients 3

• Clinically significant improvement in pulmonary function (defined as maintenance of a 15% or more increase in FEV1 over baseline values) typically continues for 3-4 hours in most patients 3

Cautions and Pitfalls

• Be aware of the rare possibility of paradoxical bronchoconstriction with albuterol, which can occur with both metered-dose inhalers and nebulizer solutions 4

• Albuterol increases oxygen consumption (by approximately 48% within 10 minutes), which can last up to 3 hours after administration 5

• If a patient shows no improvement or worsens after repeated albuterol treatments, consider alternative diagnoses or complications such as pneumothorax 1

• For infants and young children with viral-induced wheezing, high-dose inhaled salbutamol may interact with oral prednisolone for better outcomes 6