What is the recommended nebulisation therapy for inpatient management of Chronic Obstructive Pulmonary Disease (COPD) or bronchial asthma?

Nebulisation Therapy for Inpatient COPD or Bronchial Asthma

For acute severe asthma in adults, administer nebulised salbutamol 5 mg (or terbutaline 10 mg) plus oxygen and oral steroids every 4-6 hours; if inadequate response, add ipratropium bromide 500 µg to the β-agonist and repeat treatments. 1 For acute COPD exacerbations, use nebulised salbutamol 2.5-5 mg (or terbutaline 5-10 mg) combined with ipratropium bromide 250-500 µg every 4-6 hours for 24-48 hours, driven by air (not oxygen) if CO2 retention is present. 1, 2

Acute Severe Asthma - Inpatient Protocol

Severity Criteria for Adults

• Cannot complete sentences in one breath 1
• Respiratory rate ≥25/min 1
• Heart rate ≥110/min 1
• Peak expiratory flow (PEF) ≤50% predicted or best 1

Initial Treatment Regimen

• Nebulised β-agonist: Salbutamol 5 mg OR terbutaline 10 mg 1
• Drive nebuliser with oxygen at 6-8 L/min flow rate 1
• Concurrent oxygen supplementation: If oxygen cylinders cannot provide 6-8 L/min, use electrical compressor for nebulisation and provide simultaneous oxygen via nasal cannulae at 4 L/min 1
• Oral corticosteroids must be given concurrently 1
• Frequency: Repeat every 4-6 hours if improving 1

Poor Response Protocol

• Add ipratropium bromide 500 µg to the β-agonist if inadequate response to initial treatment 1
• Repeat combined nebulised treatment (β-agonist + ipratropium) 1
• Continue 4-6 hourly until PEF >75% predicted and PEF diurnal variability <25% 1
• Consider hospital admission and intravenous bronchodilators or assisted ventilation if still poor response 1

Life-Threatening Features Requiring Escalation

• PEF <33% predicted 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, or coma 1

Acute COPD Exacerbations - Inpatient Protocol

Severity Assessment

• Mild exacerbations: Use hand-held inhalers (salbutamol 200-400 µg or terbutaline 500-1000 µg) 1
• Severe exacerbations: Cyanosis, respiratory rate >25/min, cannot complete sentences, reduced activity 1

Nebulisation Regimen for Severe Cases

• Combined therapy is superior: Nebulised salbutamol 2.5-5 mg (or terbutaline 5-10 mg) PLUS ipratropium bromide 250-500 µg 1, 2
• Frequency: Every 4-6 hours for 24-48 hours or until clinical improvement 1, 2
• Duration: Continue until patient is improving clinically 1

Critical Safety Consideration for COPD

Always drive nebulisers with air, NOT oxygen, in patients with CO2 retention and acidosis or when arterial blood gases cannot be measured. 1, 2 This prevents worsening hypercapnia. If supplemental oxygen is needed, provide it via nasal cannulae during air-driven nebulisation. 2

• Measure arterial blood gases in all patients requiring hospital admission 1
• If CO2 retention and acidosis present, use air-driven nebulisation 1, 2
• A 24% Venturi mask is suitable between treatments 1

Technical Nebulisation Parameters

Equipment Setup

• Gas flow rate: 6-8 L/min to generate particles 2-5 µm diameter for optimal small airway deposition 1, 2
• Drug volume: 2-5 mL; if residual volume >1.0 mL, dilute with 0.9% sodium chloride (never water) to minimum 4.0 mL 1
• Patient position: Sit upright during nebulisation 2

Nebulisation Duration

• Continue until approximately one minute after "spluttering" occurs 1
• Expected duration: 5-15 minutes 1, 3
• Do NOT use "dryness" as endpoint 1
• Tap nebuliser cup toward end of treatment 1

Drug Compatibility

• Ipratropium bromide can be mixed with albuterol (salbutamol) or metaproterenol in the nebuliser if used within one hour 3
• Do not mix with other drugs - stability and safety not established 3

Special Populations

Children with Acute Severe Asthma

• Severity criteria: Cannot talk or feed, respiratory rate >50/min, heart rate >140/min, PEF <50% predicted 1
• Treatment: Nebulised salbutamol 5 mg (or 0.15 mg/kg) OR terbutaline 10 mg (or 0.3 mg/kg) 1
• Frequency: Repeat 1-4 hourly if improving 1
• Poor response: Add ipratropium bromide 250 µg at 30 minutes, continue hourly 1

Elderly Patients

• Treatment regimens same as above for both asthma and COPD 1
• First treatment must be supervised as β-agonists may rarely precipitate angina 1
• Use mouthpiece rather than mask when administering ipratropium to avoid worsening glaucoma 1

Transition to Discharge

Conversion Protocol

• Change to hand-held inhaler 24-48 hours before discharge 1, 2
• Observe patient for 24-48 hours on hand-held inhalers before discharge 1
• First nebuliser treatment should always be supervised 1

Common Pitfalls to Avoid

• Never use water for dilution - use only 0.9% sodium chloride to avoid bronchoconstriction 2
• Do not routinely use oxygen to drive nebulisers in COPD due to CO2 retention risk 1, 2
• Avoid mask leakage with ipratropium as direct eye contact may cause pupil enlargement, blurred vision, or precipitate narrow-angle glaucoma 3
• Do not rely on nebulisers as monotherapy - always combine with systemic corticosteroids in acute asthma 1
• Ipratropium as single agent has not been adequately studied for acute COPD exacerbations; combination with β-agonists is preferred 3