What is the treatment for wheezing?

Treatment of Wheezing

For acute wheezing, administer nebulized albuterol 5 mg (or 0.15 mg/kg) or terbutaline 10 mg (or 0.3 mg/kg), with oxygen as the driving gas whenever possible, and add systemic corticosteroids (prednisolone 2 mg/kg/day for 3 days, max 40 mg/day, or hydrocortisone 100 mg IV every 6 hours). 1

Acute Severe Wheezing/Asthma

Initial Assessment and Treatment

Severity indicators requiring immediate treatment: 1

• Unable to complete sentences in one breath
• Respiratory rate ≥25/min (adults) or ≥50/min (children)
• Heart rate ≥110/min (adults) or ≥140/min (children)
• Peak expiratory flow (PEF) ≤50% predicted or best

First-line bronchodilator therapy: 1

• Nebulized salbutamol 5 mg or terbutaline 10 mg (adults)
• Nebulized salbutamol 5 mg (0.15 mg/kg) or terbutaline 10 mg (0.3 mg/kg) (children)
• Repeat every 20-30 minutes initially if improving, then 4-6 hourly 1
• Oxygen should drive the nebulizer at 6-8 L/min whenever possible 1

Alternative delivery method: 1

• MDI with spacer: salbutamol 100 mcg per actuation, repeat up to 20 times
• Research supports that high-dose albuterol via MDI plus spacer (50 mcg/kg) is equivalent to nebulization (150 mcg/kg) and better tolerated in children 2

Escalation for Poor Response

If inadequate response after initial bronchodilator: 1

• Add ipratropium bromide 250-500 mcg nebulized to the beta-agonist
• Continue combination therapy every 30-60 minutes as needed
• Consider hospital admission

Systemic corticosteroids (mandatory for acute severe wheezing): 1

• Prednisolone 2 mg/kg/day for 3 days (maximum 40 mg/day), OR
• Hydrocortisone 100 mg IV every 6 hours

Life-threatening features requiring ICU consideration: 1

• PEF <33% predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, exhaustion, confusion, or coma
• Consider aminophylline IV: 5 mg/kg loading dose over 20 minutes (omit if already on theophylline), then 1 mg/kg/hour infusion 1

Chronic/Persistent Wheezing

Stepwise Approach

For chronic persistent wheezing, optimize hand-held inhaler therapy first before considering nebulizers: 1

• Try salbutamol 200-400 mcg QID or terbutaline 500-1000 mcg QID via MDI
• If inadequate, increase to salbutamol 1000 mcg QID and/or ipratropium 160-240 mcg QID 1

Nebulized therapy for chronic asthma (Step 4 or above only): 1

• Should only be prescribed after demonstrating ≥15% improvement in peak flow over baseline during a 2-week home trial 1
• Typical doses: salbutamol 2.5 mg QID or terbutaline 5 mg QID, with or without ipratropium 250-500 mcg 1

Regular inhaled corticosteroids are superior to PRN bronchodilators alone: 3

• Regular beclomethasone 400 mcg BID plus PRN salbutamol resulted in 69.6% symptom-free days vs 61.0% with PRN salbutamol alone (P=0.034) 3
• However, PRN combination beclomethasone/salbutamol may be an alternative with similar efficacy but lower cumulative steroid dose 4, 3

Persistent Wheezing Despite Treatment

Diagnostic Evaluation

For infants/children with persistent wheezing despite bronchodilators and corticosteroids, consider flexible bronchoscopy with: 1

• Airway survey to identify anatomic abnormalities (found in ~33% of cases, with >90% showing improvement either spontaneously or with surgical correction)
• Bronchoalveolar lavage (BAL) to identify bacterial infection (positive in 40-60% of cases, with 20-30% improving with antibiotic treatment)

Important caveat: Beta-agonists may worsen airway dynamics in infants with airway malacia, so identification of this condition changes management 1

Special Populations

Preschool Children (1-4 years)

• Nebulized albuterol 2.5 mg (0.15 mg/kg) is standard 5
• Children <15 kg require dose adjustment using 0.5% solution rather than 0.083% 5
• Spacer devices are better tolerated and equally effective 2

Brittle Asthma

• Patients with sudden severe attacks require high-dose beta-agonist by nebulizer (salbutamol 5 mg or terbutaline 10 mg) 1
• Should have written treatment plan agreed with specialist 1

Elderly Patients

• Beta-agonists may precipitate angina; first treatment should be supervised 1
• Use mouthpiece rather than mask with ipratropium to avoid glaucoma exacerbation 1

Common Pitfalls

• Do not use ribavirin for RSV bronchiolitis—it does not reduce hospital stay, oxygen need, or ventilation requirements 1
• Avoid empiric food avoidance in infants without eczema—no evidence supports this for wheezing 1
• Do not continue ineffective therapy—if previously effective treatment fails, this signals worsening disease requiring reassessment 5
• Ensure proper nebulizer technique—treatment should take 5-15 minutes; if slower, check equipment 1, 5