What is the treatment for wheezing?

Treatment of Wheezing

For acute wheezing, administer nebulized albuterol 2.5-5 mg (or 0.15 mg/kg in children) combined with ipratropium bromide 500 μg, driven by oxygen at 6-8 L/min, repeated every 20 minutes for three doses, plus systemic corticosteroids (prednisolone 40-60 mg for adults or 2 mg/kg/day for children). 1, 2, 3

Initial Assessment and Severity Stratification

Before initiating treatment, rapidly assess for life-threatening features including silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma. 2 Evaluate for severe asthma indicators: inability to complete sentences in one breath, respiratory rate ≥25/min, heart rate ≥110/min, and peak expiratory flow (PEF) ≤50% predicted. 2, 4

Important caveat: Not all wheezing is asthma or bronchiolitis—consider alternative diagnoses including airway malacia, vascular rings, foreign bodies, or mass lesions, particularly if there is poor response to standard bronchodilator therapy. 5, 6

Acute Pharmacologic Management

First-Line Bronchodilator Therapy

• Nebulized albuterol 2.5-5 mg (adults) or 0.15 mg/kg (children weighing ≥15 kg) administered over 5-15 minutes. 1, 3
• Add ipratropium bromide 500 μg to the nebulizer for combination therapy, which provides superior bronchodilation in acute settings. 1, 2, 4
• Use oxygen as the driving gas at 6-8 L/min whenever possible to ensure adequate oxygenation during treatment. 2, 4
• Repeat this combination every 20 minutes for up to three doses in the first hour if needed. 1, 4

Alternative delivery method: Metered-dose inhaler (MDI) with spacer is equally effective—administer albuterol 100 μg per actuation, up to 20 puffs (total 2000 μg), which is clinically equivalent to nebulized therapy and may be easier to use. 2, 7

Systemic Corticosteroids (Essential Component)

• Adults: Prednisolone 40-60 mg orally daily or hydrocortisone 100 mg IV every 6 hours. 1, 2
• Children: Prednisolone 2 mg/kg/day (maximum 40 mg/day) for 3 days. 1, 2
• Corticosteroids should be administered early in acute exacerbations to reduce inflammation and prevent progression. 1, 2

Ongoing Management Protocol

• Continue nebulized treatments every 4-6 hours until PEF >75% predicted and diurnal variability <25%. 2, 4
• Monitor peak flow measurements before and after each treatment to assess response. 2
• If poor initial response after three doses, repeat the albuterol-ipratropium combination and consider escalation of care. 2, 4
• Measure arterial blood gases if hospital admission is required to assess for hypercapnia or acidosis. 2

Management of Persistent Wheezing Despite Standard Therapy

For infants and children with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, consider airway survey via flexible fiberoptic bronchoscopy with bronchoalveolar lavage (BAL). 1, 2

Rationale for Bronchoscopy

• Approximately 33% of patients with persistent wheezing have identifiable anatomic abnormalities (tracheomalacia, bronchomalacia, vascular rings) that cause symptoms. 1
• 40-60% of infants with persistent wheezing have positive BAL cultures indicating lower airway bacterial infection, and 20-30% will improve with targeted antibiotic therapy. 1
• Critical insight: Beta-agonists may paradoxically worsen symptoms in children with airway malacia by causing dynamic airway collapse, making diagnosis essential. 1, 2

This recommendation is conditional with very low quality evidence, as bronchoscopy requires sedation and carries procedural risks, though complications are rare in reported case series. 1

Critical Pitfalls to Avoid

• Do not use oxygen as driving gas in patients with documented CO2 retention and acidosis—use compressed air instead to prevent worsening hypercapnia. 2, 4
• Avoid ipratropium in patients with glaucoma risk without using a mouthpiece to prevent ocular exposure. 2
• Do not prescribe nebulized corticosteroids (budesonide) for acute wheezing—these lack evidence for acute exacerbations and are reserved only for severe persistent asthma under specialist supervision. 8
• Do not continue nebulization until complete dryness—stop about one minute after "spluttering" occurs (typically 5-10 minutes total) to avoid unnecessarily prolonged treatment. 4, 3
• Avoid empiric food avoidance in wheezing infants without eczema, as trials show no benefit for wheezing outcomes. 1

Transition and Discharge Planning

• Continue nebulized treatments until clinical improvement is sustained. 2
• Transition to MDI therapy at least 24 hours prior to discharge to ensure the patient can maintain stability on outpatient regimen. 2
• If a previously effective dosage regimen fails to provide usual relief, this signals seriously worsening disease requiring immediate reassessment. 3