What is the recommended regimen for administering salbutamol (albuterol) and Pulmicort (budesonide) via a nebuliser?

Nebuliser Administration of Salbutamol and Pulmicort (Budesonide)

Recommended Regimen

For acute asthma exacerbations, administer nebulised salbutamol 5 mg (or 0.15 mg/kg in children) every 4-6 hours, and if budesonide is indicated for croup or as adjunctive therapy, give 500 µg nebulised budesonide, which can be administered separately or in combination with salbutamol depending on the clinical scenario. 1

Salbutamol Dosing by Clinical Scenario

Acute Severe Asthma in Adults

• Initial dose: Nebulised salbutamol 5 mg or terbutaline 10 mg, repeated every 4-6 hours if improving 1
• If poor response: Add ipratropium bromide 500 µg to the β-agonist and repeat at 30-minute intervals 1
• Driving gas: Use oxygen whenever possible for nebulisation in acute asthma 1

Acute Severe Asthma in Children

• Dose: Nebulised salbutamol 5 mg or 0.15 mg/kg, repeated 1-4 hourly if improving 1
• If inadequate response: Repeat at 30 minutes after adding ipratropium bromide 250 µg, then continue hourly 1
• Alternative delivery: If nebuliser unavailable, use MDI with spacer: 100 µg per actuation, repeat up to 20 times 1

Chronic Persistent Asthma

• Maintenance dose: Salbutamol 2.5 mg via nebuliser (not the typical 5 mg acute dose) 1
• Important caveat: Nebulised bronchodilators should only be used after formal evaluation demonstrating at least 15% improvement in peak flow from baseline, and only after high-dose inhaled therapy via MDI/spacer has failed 1

Budesonide (Pulmicort) Dosing

Croup

• Dose: Nebulised budesonide 500 µg may reduce symptoms in the first two hours 1, 2
• Duration of effect: Short-lived benefit; no data on longer-term use or ultimate outcome 1
• Combination with epinephrine: Consider nebulised epinephrine 0.5 ml/kg of 1:1000 solution for severe croup, though this is separate from budesonide administration 2

Adjunctive Therapy in Acute Asthma

• Emerging evidence: Budesonide 0.5 mg nebulised with salbutamol three times over 20-minute intervals showed better improvement in PEFR at 40 and 60 minutes compared to salbutamol alone 3
• Mechanism: The corticosteroid effect reduces inflammation and lung swelling, providing additive benefit to bronchodilation 3
• Guideline status: Current British Thoracic Society guidelines note that randomised controlled trials of nebulised corticosteroids in adults with asthma are lacking, and recommend specialist review before prescribing for chronic use 1

Practical Administration Guidelines

Equipment and Technique

• Mouthpiece vs mask: Use a mouthpiece rather than face mask except for infants or young children who cannot tolerate it 1
• Nebuliser type: Standard jet nebulisers with appropriate compressor; ensure adequate flow rate 1
• Equipment maintenance: Change nebuliser equipment every three months; boil durable nebulisers for 5-10 minutes after every 30 uses 1

Combining Medications

• Salbutamol + ipratropium: Can be mixed in the same nebuliser chamber for severe exacerbations 1, 4
• Salbutamol + budesonide: Can be nebulised together (budesonide 0.5 mg with salbutamol) based on recent evidence, though this is not yet standard guideline practice 3
• Timing: Administer treatments every 4-6 hours for maintenance, or more frequently (every 20-30 minutes) in severe acute episodes 1

Critical Safety Considerations

COPD Patients

• Oxygen caution: If the patient has carbon dioxide retention or acidosis, drive the nebuliser with air, not high-flow oxygen, to avoid worsening hypercapnia 1
• Dose: Salbutamol 2.5-5 mg or ipratropium 500 µg every 4-6 hours for acute exacerbations 1

Monitoring and Side Effects

• Systemic effects: Salbutamol causes dose-related tachycardia, tremor, and hypokalaemia; 3 mg may be optimal to balance efficacy with side effects 5
• Cardiovascular: β-agonists may precipitate angina in elderly patients; first treatment should be supervised 1
• Glaucoma risk: Ipratropium may worsen glaucoma; consider mouthpiece use in at-risk patients 1

When to Escalate or Change Therapy

Poor Response Algorithm

1. After initial salbutamol: If inadequate response at 30 minutes, add ipratropium bromide 1
2. Continued poor response: Consider intravenous aminophylline or subcutaneous terbutaline 1
3. Life-threatening features: Transfer to intensive care for continuous nebulisation or mechanical ventilation 1

Transition to Discharge

• Timing: Change to MDI with spacer 24-48 hours before discharge 1
• Observation: Monitor patient on discharge medication before leaving hospital 1
• Education: Ensure proper inhaler technique and understanding of when to seek emergency care 1