Combined Nebulization of Levosalbutamol and Budesonide
Yes, levosalbutamol and budesonide can be safely mixed and administered together in the same nebulizer for asthma management. 1
Compatibility and Administration
Budesonide suspension is explicitly compatible with albuterol (salbutamol), levalbuterol (levosalbutamol), and ipratropium nebulizer solutions in the same nebulizer, as confirmed by the American Academy of Allergy, Asthma, and Immunology. 1
Only jet nebulizers should be used because ultrasonic nebulizers are ineffective for budesonide suspensions. 1
Oxygen should be used as the driving gas whenever possible in acute severe asthma, as patients are likely hypoxic; otherwise use an electrical compressor or compressed air. 2, 3
Dosing Recommendations
For Levosalbutamol:
- Standard dose is 0.63 mg/3 mL for infants under 1 year with wheezing. 1
- For acute severe asthma in older children and adults, doses range from 2.5-5 mg salbutamol equivalent (levosalbutamol at half the dose provides equivalent bronchodilation). 2, 4
For Budesonide:
- 0.25-0.5 mg (low dose) for infants and young children, can increase to >0.5-1.0 mg (medium dose) if needed. 1
- 500 μg is the typical dose for respiratory distress in older children and adults. 3
Clinical Context and Rationale
Systemic corticosteroids remain the gold standard for treating the inflammatory component of acute asthma exacerbations, with effects appearing in 6-12 hours. 2
Nebulized budesonide provides additional acute benefit when added to systemic steroids and nebulized bronchodilators, particularly improving spirometric indices in the emergency setting. 5
Levosalbutamol (the R-isomer) provides equivalent bronchodilation to racemic salbutamol at half the dose, with potentially fewer adverse effects like tachycardia, as the S-isomer may have pro-inflammatory effects. 4, 6, 7
Administration Technique
For children under 4 years, use a face mask that fits snugly over nose and mouth. 1
Avoid nebulizing in the eyes and wash face after each treatment to prevent local side effects like oral thrush. 1
Patients should rinse their mouth after treatment to minimize risk of candidiasis. 3
Treatment Frequency
In acute severe asthma, repeat nebulized treatments every 4-6 hours until peak flow >75% predicted and diurnal variability <25%. 2
For chronic persistent asthma requiring regular nebulized therapy, treatments are typically given 2-4 times daily depending on severity. 2
Important Caveats
Budesonide is the only inhaled corticosteroid with FDA approval for children under 4 years, though safety and efficacy in infants under 1 year is not fully established and requires careful monitoring. 1
There is no evidence that levosalbutamol should be favored over albuterol in terms of major clinical outcomes, though it may cause less tachycardia. 2, 6
For recurrent or persistent wheezing, monitor response carefully; if no clear benefit is observed within 4-6 weeks, consider alternative therapies or diagnoses. 1
In many cases, a metered-dose inhaler with spacer may be as effective and more cost-effective than nebulization, particularly for stable patients. 2, 3