What is the treatment for wheezing?

Treatment of Wheezing

For acute wheezing, administer nebulized salbutamol 5 mg (or 0.15 mg/kg in children) combined with ipratropium bromide 500 μg using oxygen as the driving gas at 6-8 L/min, and initiate systemic corticosteroids immediately. 1, 2

Acute Severe Wheezing Management

Initial Assessment

• Identify life-threatening features: silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1, 2
• Assess severity markers: inability to complete sentences in one breath, respiratory rate ≥25/min, heart rate ≥110/min, peak expiratory flow (PEF) ≤50% predicted 1, 2
• PEF <33% predicted indicates life-threatening asthma requiring immediate escalation 1

First-Line Pharmacologic Treatment

Nebulized Bronchodilators:

• Salbutamol 5 mg (or 0.15 mg/kg) OR terbutaline 10 mg (or 0.3 mg/kg) via nebulizer 1, 2
• Add ipratropium bromide 250-500 μg to the nebulizer solution for combination therapy 1, 2
• Use oxygen as driving gas at 6-8 L/min whenever possible (avoid in CO2 retention with acidosis—use compressed air instead) 1, 2
• Repeat every 20 minutes for 3 doses initially, then every 4-6 hours as needed 1, 2

Alternative Delivery Method:

• MDI with spacer is equally effective: salbutamol 100 μg per actuation, repeat up to 20 times (total 2000 μg), or terbutaline 250 μg per actuation, repeat up to 20 times 1, 2, 3
• This approach is easier to use and better tolerated by children 3

Systemic Corticosteroids (mandatory):

• Prednisolone 2 mg/kg/day for 3 days (maximum 40 mg/day) OR 1, 2
• Hydrocortisone 100 mg IV every 6 hours 1, 2

Escalation for Poor Response

• Continue nebulized treatments every 4-6 hours until PEF >75% predicted and diurnal variability <25% 1, 2
• Consider aminophylline IV: loading dose 5 mg/kg over 20 minutes (omit if already on theophylline), then 1 mg/kg/hour infusion 1
• For brittle asthma with sudden severe attacks, use higher doses: salbutamol 5 mg or terbutaline 10 mg via nebulizer 1

Chronic/Persistent Wheezing Management

Step-Up Approach for Inadequate Control

When standard inhaler therapy fails:

• Optimize hand-held inhaler doses first: salbutamol 200-400 μg four times daily or ipratropium 40-80 μg four times daily 1
• If insufficient, increase to salbutamol 1000 μg four times daily and/or ipratropium 160-240 μg four times daily 1

Home Nebulizer Therapy (Step 4 or above):

• Trial nebulized salbutamol 2.5 mg four times daily or terbutaline 5 mg four times daily for 2 weeks 1
• Document peak flow twice daily before nebulization plus 30 minutes after morning treatment 1
• Require ≥15% increase from baseline peak flow to justify continued nebulizer use 1
• If beneficial, consider higher doses: salbutamol 5 mg or terbutaline 10 mg four times daily, or add ipratropium 250-500 μg 1

FDA-Approved Dosing for Maintenance

Albuterol nebulized solution:

• Adults and children ≥15 kg: 2.5 mg (one 3 mL vial of 0.083% solution) three to four times daily 4
• Children <15 kg: use 0.5% solution for doses <2.5 mg 4
• Deliver over 5-15 minutes via nebulizer 4

Persistent Wheezing Despite Optimal Therapy

Diagnostic Bronchoscopy Indications

When wheezing persists despite bronchodilators, inhaled corticosteroids, and systemic corticosteroids:

• Perform flexible fiberoptic bronchoscopy with airway survey to identify anatomic abnormalities (tracheomalacia, bronchomalacia, vascular rings) found in approximately 33% of cases 1, 2
• Obtain bronchoalveolar lavage (BAL) to detect lower airway bacterial infection present in 40-60% of persistent wheezers 1
• 20-30% of children will improve with antibiotic treatment of BAL-confirmed infection 1

Critical caveat: Identifying airway malacia prevents inappropriate β-agonist use, as these medications may worsen airway dynamics in malacia 1, 2

Special Populations

Preschool Children with Recurrent Wheezing

• Regular inhaled corticosteroids (beclomethasone 400 μg twice daily) are most effective for frequent wheezing 5
• As-needed combination beclomethasone 250 μg/albuterol 100 μg is as effective as regular beclomethasone with lower cumulative steroid dose in mild asthma 6

Infants with Bronchiolitis

• Ribavirin is NOT recommended—does not reduce hospital stay, oxygen need, or ventilation requirement 1

Monitoring and Discharge Criteria

• Continue nebulized treatments until sustained clinical improvement with PEF >75% predicted 1, 2
• Transition to hand-held inhaler at least 24 hours before discharge to ensure stability 2
• If previously effective regimen fails, reassess immediately as this indicates worsening disease 4

Key Pitfalls to Avoid

• Never use oxygen as driving gas in documented CO2 retention with acidosis—use compressed air 2
• Avoid ipratropium in glaucoma risk without mouthpiece to prevent eye exposure 2
• Do not empirically avoid allergenic foods in infants without eczema—no evidence of benefit for wheezing 1
• Recognize that more frequent administration or higher doses than recommended are not beneficial and may cause harm 4