What is the recommended dose of salbutamol (albuterol) nebulizer for a patient with asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Salbutamol Nebulizer Dosing

For acute severe asthma in adults, use nebulized salbutamol 5 mg every 4-6 hours if improving, or add ipratropium bromide 500 μg if not improving; for acute COPD exacerbations, use salbutamol 2.5-5 mg combined with ipratropium bromide 250-500 μg every 4-6 hours for 24-48 hours. 1

Acute Severe Asthma

Adults

• Initial dose: Salbutamol 5 mg (or terbutaline 10 mg) via nebulizer with oxygen plus oral steroids 2, 1
• Repeat every 4-6 hours if patient is improving 2, 1
• If not improving after initial dose, add ipratropium bromide 500 μg to the salbutamol and repeat at 30 minutes, then continue hourly 2, 1
• Severity indicators requiring this approach: cannot complete sentences, respiratory rate >25/min, heart rate >110/min, peak flow <50% best 2

Children

• Salbutamol 5 mg (or 0.15 mg/kg) or terbutaline 10 mg (or 0.3 mg/kg) 2, 1
• Repeat 1-4 hourly if improving 2, 1
• If not improving, repeat at 30 minutes after adding ipratropium bromide 250 μg, then continue hourly 2
• Severity indicators: cannot talk or feed, respiratory rate >50/min, heart rate >140/min, peak flow <50% predicted 2

Research supports combination therapy, showing that salbutamol plus ipratropium produces a 77% improvement in peak flow versus 31% with salbutamol alone in asthmatic patients, with maximum benefit in those with peak flow <140 L/min 3

Acute COPD Exacerbations

• Salbutamol 2.5-5 mg combined with ipratropium bromide 250-500 μg 1
• Administer every 4-6 hours for 24-48 hours or until clinical improvement 1
• Combination therapy is superior to single-agent therapy, especially in severe cases 1

Research demonstrates that for COPD patients, the peak flow response to salbutamol alone versus combination therapy is nearly identical, unlike in asthma where combination is clearly superior 3

Chronic Persistent Asthma and Stable COPD

Home Nebulizer Therapy

• Start with salbutamol 2.5 mg four times daily for 2-week trial period 2
• If response is poor, escalate to salbutamol 5 mg four times daily (or terbutaline 10 mg four times daily) 2
• Consider adding ipratropium bromide 250-500 μg four times daily 2
• Consider mixture of salbutamol (2.5 or 5 mg) with ipratropium 500 μg four times daily 2

Important caveat: Regular nebulized bronchodilator treatment should only be undertaken after formal evaluation of its benefit and where treatment with hand-held inhalers at appropriate doses (up to 1,000 μg salbutamol four times daily via MDI with spacer) has failed 2, 1

Research shows that 3 mg salbutamol may be an optimal dose for chronic use, producing satisfactory bronchodilation with fewer side-effects related to systemic absorption compared to higher doses 4

Critical Safety Consideration for COPD Patients

Always drive nebulizers with air, not oxygen, in patients with carbon dioxide retention and acidosis to prevent worsening hypercapnia 1

• Provide supplemental oxygen via nasal cannulae at 4 L/min during air-driven nebulization if needed 1
• This is a common and dangerous pitfall that must be avoided 1

Proper Nebulizer Technique

• Patients should sit upright during nebulization 1
• Use gas flow rate of 6-8 L/min to generate particles of 2-5 μm diameter for optimal small airway deposition 5
• Use 2.0-4.5 mL volume of fluid in the nebulizer chamber 1
• Nebulization should take 5-10 minutes, continuing until about one minute after "spluttering" occurs 2, 5
• The first treatment should always be done under supervision 2, 1
• Tap the nebulizer cup towards the end of treatment 2

Additional Common Pitfalls to Avoid

• Never use water for nebulization as it may cause bronchoconstriction 1
• For elderly patients, rarely β-agonists may precipitate angina, so first treatment should be supervised 2
• When using ipratropium in elderly patients, consider using a mouthpiece rather than mask to prevent worsening glaucoma 2, 1
• Proper inhaler technique must be demonstrated and checked periodically before escalating to nebulizer therapy 1