Nebulisation Regimen with Bronchodilators and Steroids
For acute severe asthma or COPD exacerbations requiring nebulisation, administer nebulised salbutamol 5 mg (or 0.15 mg/kg in children) combined with ipratropium bromide 500 μg every 4-6 hours, driven by oxygen at 6-8 L/min when possible, alongside systemic corticosteroids (prednisolone 2 mg/kg/day for 3 days, maximum 40 mg/day, or hydrocortisone 100 mg IV every 6 hours). 1, 2
Acute Severe Asthma - Adults
Initial Treatment:
- Nebulised salbutamol 5 mg OR terbutaline 10 mg combined with ipratropium bromide 500 μg 1
- Drive nebuliser with oxygen at 6-8 L/min whenever possible 1, 2
- Administer oral prednisolone or IV hydrocortisone 100 mg every 6 hours 1, 2
- Repeat nebulisation every 4-6 hours if improving 1
If Poor Response:
- Repeat combination therapy at 30 minutes, then continue hourly 1
- Consider hospital admission and aminophylline infusion (5 mg/kg loading dose over 20 minutes, then 1 mg/kg/hour) 1
Acute Severe Asthma - Children
Initial Treatment:
- Nebulised salbutamol 5 mg (or 0.15 mg/kg) OR terbutaline 10 mg (or 0.3 mg/kg) 1
- Add ipratropium bromide 250 μg if inadequate response at 30 minutes 1
- Prednisolone 2 mg/kg/day for 3 days (maximum 40 mg/day) or hydrocortisone 100 mg IV every 6 hours 1
- Repeat every 1-4 hours if improving, otherwise hourly 1
COPD Exacerbations
Mild Exacerbations:
- Hand-held inhaler: salbutamol 200-400 μg or terbutaline 500-1000 μg every 4 hours 1
Moderate to Severe Exacerbations:
- Nebulised salbutamol 2.5-5 mg OR terbutaline 5-10 mg every 4-6 hours for 24-48 hours 1
- Ipratropium bromide 500 μg every 4-6 hours 1
- Combined therapy (beta-agonist plus ipratropium) for severe cases or poor response to monotherapy 1
Critical Caveat for COPD:
- Use compressed air (NOT oxygen) as driving gas if patient has CO2 retention and acidosis or if blood gases cannot be measured 1, 2
- Provide supplemental oxygen via nasal cannulae at 4 L/min between treatments if needed 1
Nebulised Steroids (Chronic Management)
Budesonide for Asthma:
- Starting dose: 0.5 mg once daily or 0.25 mg twice daily for patients on bronchodilators alone or inhaled corticosteroids 3
- 0.5 mg twice daily for patients on oral corticosteroids 3
- Use only with compressed air-driven jet nebulisers (not ultrasonic devices) 3
Important Note: Nebulised steroids are primarily for chronic persistent asthma management, not acute exacerbations 1. Acute exacerbations require systemic steroids (oral or IV) 1, 2.
Technical Specifications
Nebuliser Setup:
- Gas flow rate: 6-8 L/min 1, 2
- Volume in chamber: 2.0-4.5 ml (most require only 2-2.5 ml if residual is 0.5 ml) 1
- Treatment duration: 10 minutes for bronchodilators (nebulise until 1 minute after "spluttering" occurs) 1
Delivery Method:
- Use mouthpiece for steroids (prevents facial deposition) and anticholinergics (reduces glaucoma risk) 1, 2
- Use mask for acutely ill patients or young children unable to coordinate 1
Monitoring and Adjustment
Continue Treatment Until:
- Peak expiratory flow reaches >75% predicted with diurnal variability <25% 2
- Clinical improvement sustained for 24-48 hours 1, 2
Frequency Reduction:
- Decrease nebulisation frequency as symptoms improve 1
- Transition to hand-held inhaler 24-48 hours before discharge 1, 2
Critical Pitfalls to Avoid
- Never use oxygen as driving gas in COPD patients with documented CO2 retention - use compressed air instead 1, 2
- Never use water for nebulisation - it causes bronchoconstriction; use 0.9% saline if needed 1
- Avoid ipratropium via mask in patients with glaucoma - use mouthpiece to prevent eye exposure 1, 2
- Do not rely on hospital reversibility tests to predict long-term nebuliser benefit - formal home trials with peak flow monitoring are required 1
- Rinse mouth after nebulised steroids to prevent oral thrush 1