What is the proper use of a rescue inhaler, such as albuterol (salbutamol), for acute asthma symptoms or Chronic Obstructive Pulmonary Disease (COPD) exacerbations?

Rescue Inhaler Use for Acute Asthma and COPD Symptoms

For acute asthma symptoms or COPD exacerbations, use a short-acting beta-2 agonist (SABA) such as albuterol 2-4 puffs (180-360 mcg) via metered-dose inhaler (MDI) with spacer, or 2.5-5 mg via nebulizer, repeated every 20 minutes for up to 3 doses initially, then every 1-4 hours as needed based on symptom severity. 1

Initial Dosing Strategy

Mild-to-Moderate Exacerbations

• Albuterol MDI with spacer: 4-8 puffs (360-720 mcg) every 20 minutes for 3 doses 1
• MDI with spacer is equally effective as nebulizer therapy when used with proper technique 1
• After initial 3 doses, continue every 1-4 hours as needed based on response 1

Severe Exacerbations (Asthma)

Severity indicators: Cannot complete sentences, respiratory rate >25/min, heart rate >110/min, peak flow <50% predicted 1

• Nebulized albuterol 5 mg (or terbutaline 10 mg) every 20 minutes for 3 doses 1
• If inadequate response after initial doses, add ipratropium bromide 500 mcg to the beta-agonist 1
• Continuous nebulization (10-15 mg/hour) may be more effective than intermittent dosing in severe cases 1
• Must be combined with oxygen and systemic corticosteroids 1

COPD Exacerbations

• Nebulized albuterol 2.5-5 mg or terbutaline 5-10 mg every 4-6 hours 1
• For severe COPD exacerbations, adding ipratropium bromide to beta-agonists has not shown additional benefit (unlike in asthma) 1
• Use air-driven nebulizers (not oxygen) if CO2 retention is present to avoid worsening hypercapnia 1

Proper Inhalation Technique

MDI with Spacer

• Actuate during slow, deep inhalation (3-5 seconds) 1
• Hold breath for 10 seconds after inhalation 1
• Use valved holding chamber (spacer) with face mask for children <4 years 1
• Mouth washing and spitting after use reduces systemic absorption 1

Nebulizer

• Fill chamber with 2-5 ml total volume (dilute with 0.9% saline if needed to reach 4 ml minimum) 1
• Continue nebulization until approximately 1 minute after "spluttering" occurs (typically 5-10 minutes) 1
• Tap nebulizer cup toward end of treatment 1
• Use mouthpiece rather than face mask when possible to avoid nasal deposition, though breathless patients may prefer mask 1

Frequency and Duration Adjustments

After Initial Treatment

• If good response: Continue every 4-6 hours until peak flow >75% predicted and diurnal variability <25% 1
• If poor response: Repeat nebulized treatment within minutes or use continuous nebulization 1
• Lack of response to repeated treatments indicates need for escalation (hospital admission, possible ventilatory support) 1

Transition to Maintenance

• Switch from nebulizer to hand-held inhaler once condition stabilizes, as this permits earlier hospital discharge 1
• Observe patients for 24-48 hours after switching to MDI before discharge 1

Critical Safety Considerations

Oxygen Administration

• Always provide supplemental oxygen with nebulizer treatments in acute severe asthma 1
• Nebulizers require 6-8 L/min flow rate 1
• Beta-agonists may initially worsen oxygen saturation due to ventilation-perfusion mismatch 1

Special Populations

• Elderly patients: First treatment should be supervised as beta-agonists may rarely precipitate angina 1
• Glaucoma risk: Use mouthpiece rather than face mask with ipratropium to avoid ocular complications 1
• Pregnant women: Maintain oxygen saturation >95% 1

Common Pitfalls to Avoid

• Do not use SABA as monotherapy for long-term asthma control - regular daily use is not recommended 1
• Do not stop inhalation at the moment of actuation - this is a common error that reduces drug delivery 1
• Do not use intravenous beta-agonists routinely - they offer no advantage over inhaled therapy and cause more systemic side effects 1
• Increasing SABA use (>2 days/week for symptom relief) indicates inadequate disease control and need for intensified anti-inflammatory therapy 1

Equipment Maintenance

• Replace disposable components (tubing, nebulizer cup, mask/mouthpiece) every 3-4 months 1
• Service compressors annually 1
• If nebulization is slow, disassemble and wash equipment; if still inefficient, use spare nebulizer and seek medical help 1