What is the recommended dosage of salbutamol (albuterol) and Pulmicort (budesonide) via nebuliser in a General Practice (GP) setting for acute asthma exacerbations and chronic asthma management?

Nebulised Salbutamol and Budesonide Dosing in General Practice

Acute Asthma Exacerbations

For acute severe asthma in the GP setting, administer nebulised salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebuliser, with repeat dosing every 20 minutes for the first hour if needed, followed by 4-6 hourly treatments until clinical improvement. 1

Initial Assessment and Severity Markers

Before initiating treatment, assess for features of severe asthma 1, 2:

• Severe asthma features: Cannot complete sentences in one breath, respiratory rate ≥25/min, heart rate ≥110/min, peak expiratory flow (PEF) ≤50% predicted or best 1, 2
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1, 2

Salbutamol Dosing Protocol for Acute Exacerbations

Initial treatment 1, 2, 3:

• Administer 5 mg salbutamol via nebuliser (or terbutaline 10 mg) 1
• Use oxygen (40-60%) as the driving gas whenever possible 1, 2
• If oxygen unavailable, use electrical compressor or compressed air 3
• Nebulisation should take approximately 5-10 minutes, continuing until about one minute after "spluttering" occurs 3

Response assessment and repeat dosing 1, 2, 3:

• Monitor response 15-30 minutes after nebuliser treatment 1, 2, 3
• If poor response or severe features persist, add ipratropium bromide 500 μg to the nebulised salbutamol 1
• The combination of salbutamol and ipratropium provides superior bronchodilation compared to salbutamol alone, particularly when baseline PEF is below 140 L/min 4, 5
• Repeat nebulised treatments every 4-6 hours until PEF >75% predicted and PEF diurnal variability <25% 1

Concurrent systemic corticosteroids 1, 2:

• Give prednisolone 30-60 mg orally or hydrocortisone 200 mg intravenously 1, 2
• Underuse of corticosteroids is a common factor in preventable asthma deaths 2

Hospital Admission Criteria from GP Setting

Arrange immediate hospital admission if 1:

• Any life-threatening features present 1
• Features of acute severe asthma persist after initial treatment, especially PEF <33% 1
• Attack occurs in afternoon/evening, recent nocturnal symptoms, recent hospital admission, or previous severe attacks 1

Chronic Asthma Management

Nebulised Salbutamol for Chronic Persistent Asthma

Nebulised bronchodilators in chronic asthma should only be prescribed after specialist assessment and documented objective benefit, typically at Step 4 or above of asthma management. 1

Assessment requirements before prescribing 1:

• Patient must be assessed by a respiratory physician or appropriately trained specialist/GP 1
• Conduct home trial monitoring peak flow for up to two weeks on standard treatment, then two weeks on nebulised treatment 1
• Peak flows measured twice daily before nebulisation (morning and evening) 1
• Additional peak flow measurement 30 minutes after morning treatment 1
• Demonstrate ≥15% increase from mean baseline peak flow (measured over at least five days) before recommending treatment 1

Chronic dosing 1:

• Usual dose: 2.5 mg salbutamol or 5 mg terbutaline 1
• For ipratropium bromide: 250-500 μg 1

Brittle Asthma

For patients with sudden severe attacks despite little preceding instability 1:

• Require high-dose β-agonist treatment, often by nebuliser 1
• Dose: salbutamol 5 mg or terbutaline 10 mg 1

Nebulised Budesonide (Pulmicort)

Current Evidence and Recommendations

Nebulised corticosteroids including budesonide should only be prescribed after review by a respiratory specialist, as there is limited evidence for their use in adults with asthma. 1

The British Thoracic Society guidelines explicitly state there are no published randomised controlled trials of nebulised corticosteroids' effectiveness in adults with asthma at the time of guideline publication 1. Their potential use is limited to allowing steroid-dependent asthmatic patients to reduce maintenance doses of oral corticosteroids, but this requires specialist supervision 1.

FDA-Approved Dosing for Budesonide Inhalation Suspension

For children 12 months to 8 years (per FDA labeling) 6:

• Previous therapy with bronchodilators alone: 0.5 mg once daily or 0.25 mg twice daily 6
• Previous therapy with inhaled corticosteroids: 0.5 mg once daily or 0.25 mg twice daily, up to 0.5 mg twice daily 6
• Previous therapy with oral corticosteroids: 0.5 mg twice daily 6
• For symptomatic children not responding to non-steroidal therapy, starting dose of 0.25 mg once daily may be considered 6
• If once-daily treatment inadequate, increase total daily dose and/or administer as divided dose 6

Important limitations 6:

• Not indicated for relief of acute bronchospasm 6
• For use via compressed air-driven jet nebulisers only (not ultrasonic devices) 6
• Once asthma stability achieved, titrate dose downwards 6

Critical Safety Considerations

Nebuliser Operation 3

• Most nebulisers work effectively with drug volumes of 2-5 mL 3
• If residual volume >1.0 mL, make up drug volume with 0.9% sodium chloride to minimum of 4.0 mL 3
• Patients should tap nebuliser cup toward end of treatment for maximum medication delivery 3

Special Populations 3

• COPD patients with CO₂ retention: Drive nebuliser with air, not high-flow oxygen 3
• Elderly patients: β-agonists may rarely precipitate angina; first treatment should be supervised 3

Post-Treatment Care 1

• Advise patients to rinse mouth following inhalation to reduce risk of oral candidiasis 6
• Ensure follow-up within 24-48 hours after acute exacerbation 1
• Modify treatment according to chronic asthma management guidelines 1