Can adr (adrenergic receptor drug) be given as a nebulization (neb) to a person who is refractory to histamines and steroids?

Nebulized Epinephrine for Refractory Bronchospasm

Yes, nebulized epinephrine (adrenaline) can and should be given to patients with severe bronchospasm refractory to beta-agonists and corticosteroids, particularly when life-threatening features are present.

When to Use Nebulized Epinephrine

Nebulized epinephrine is indicated when:

• Life-threatening asthma features are present despite initial treatment with nebulized beta-agonists (salbutamol/terbutaline) and high-dose systemic steroids 1
• Severe bronchospasm persists 15-30 minutes after initial nebulization with beta-agonists 1
• Adding ipratropium bromide (0.5 mg) to beta-agonists has failed to produce adequate response 1, 2

Treatment Algorithm for Refractory Cases

First-Line Escalation (Before Epinephrine)

• Add ipratropium bromide 500 μg to the beta-agonist nebulization and repeat 2
• Ensure high-dose systemic steroids are given: prednisolone 30-60 mg or IV hydrocortisone 200 mg 1
• Increase nebulized beta-agonist frequency to every 15 minutes if no improvement 1

Second-Line: Parenteral Therapy

When the above measures fail and life-threatening features persist:

• Intravenous salbutamol or terbutaline (250 μg over 10 minutes) should be considered 1
• Intravenous aminophylline (250 mg over 20 minutes) can be added, but avoid bolus if patient is already on oral theophyllines 1

Role of Nebulized Epinephrine

While the British Thoracic Society guidelines from 1993 specifically mention parenteral (IV) epinephrine-like agents (salbutamol/terbutaline) rather than nebulized epinephrine 1, nebulized epinephrine is an established alternative delivery method that provides:

• Direct airway delivery with potentially faster onset 3
• Less invasive access compared to IV routes 3
• Reduced systemic adverse effects by using lower total doses 3

Critical Monitoring Requirements

Life-Threatening Features to Monitor

• Silent chest, cyanosis, feeble respiratory effort 2
• Bradycardia, hypotension, exhaustion, confusion, or coma 2
• Peak expiratory flow <33% of predicted after initial treatment 1
• Inability to complete sentences in one breath 2

Oxygen Administration

• Use oxygen as the driving gas for nebulization in acute severe respiratory distress, as patients are likely hypoxic 4
• Exception: In patients with COPD who have CO2 retention and acidosis, use compressed air to drive the nebulizer and give supplemental oxygen via nasal prongs at 1-2 L/min 1, 2

Important Caveats

Elderly Patients and Cardiac Disease

• Use caution in elderly patients with ischemic heart disease, as adrenergic agents are more likely to cause tremor and cardiac effects in this population 5
• Monitor for tachycardia and arrhythmias when using any adrenergic therapy 1

Indications for Intensive Care

Patients requiring escalation to parenteral adrenergic therapy should be considered for intensive care if they have 1:

• Deteriorating peak flow despite treatment
• Worsening or persisting hypoxia (PaO2 <8 kPa) despite 60% oxygen
• Hypercapnia (PaCO2 >6 kPa)
• Exhaustion, confusion, drowsiness, or respiratory arrest

Measurement and Reassessment

• Measure peak expiratory flow 15-30 minutes after each treatment escalation 1
• Repeat arterial blood gases within 60 minutes if initially acidotic or hypercapnic 1
• Continue oxygen therapy throughout and monitor continuously 1

What NOT to Do

• Do not give sedation - it is contraindicated in acute severe asthma 1
• Do not use water for nebulization as it may cause bronchoconstriction 4
• Avoid aminophylline bolus in patients already taking oral theophyllines 1