Should an MDI Bronchodilator Be Initiated for Acute Bronchitis in a Smoker?
Yes, initiate an albuterol MDI for symptomatic relief in this patient with acute bronchitis, particularly given the smoking history which increases likelihood of bronchospasm. 1, 2
Evidence Supporting Bronchodilator Use in Acute Bronchitis
The research directly addressing this clinical scenario demonstrates clear benefit:
Patients with acute bronchitis treated with albuterol MDI were significantly less likely to be coughing after 7 days compared to placebo (61% vs 91%, P = 0.02). 2
This benefit persisted regardless of smoking status and was independent of antibiotic use. 2
In a separate trial, only 41% of albuterol-treated patients were still coughing at 7 days versus 88% treated with erythromycin (P < 0.05), with benefits observed in both smokers and nonsmokers. 1
The rationale is that pulmonary function tests in acute bronchitis patients resemble those of asthma patients, suggesting reversible bronchospasm as a key component. 1
FDA-Approved Indication
Albuterol is FDA-indicated for "relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm." 3 Acute bronchitis with productive cough and smoking history fits this indication.
Prescribing Details
Dosing:
- Prescribe 2 puffs every 4-6 hours as needed for cough and dyspnea. 4
- Effects peak at 30-60 minutes and last 4-6 hours. 4
- This should be "as-needed" rescue therapy, not scheduled maintenance dosing. 4
Critical Implementation Requirement
You must demonstrate proper MDI technique before the patient leaves—never assume they know how to use it. 4, 5
- 76% of patients make important errors when using MDIs without proper instruction. 4
- Incorrect technique includes failure to activate during inspiration and failure to hold breath after inhalation. 6
- Consider providing a spacer device to reduce coordination requirements and improve drug delivery. 7, 4
Important Contraindication Check
Verify the patient is not taking beta-blockers (including eye drops) before prescribing albuterol. 8
- Beta-blockers like propranolol can cause dangerous bronchoconstriction and block albuterol's therapeutic effect. 8
- If the patient requires both cardiac rate control and bronchodilator therapy, calcium channel blockers (diltiazem, verapamil) are safer alternatives to beta-blockers. 8
When This Approach May Not Apply
This recommendation assumes the patient does not have underlying asthma or COPD requiring maintenance therapy. If the patient has frequent symptoms or known obstructive lung disease, long-acting bronchodilators (LAMAs preferred over LABAs) should be considered instead of or in addition to rescue albuterol. 4