Nebulised Adrenaline: Not Recommended for Asthma or COPD Exacerbations
Nebulised adrenaline should not be used for acute asthma or COPD exacerbations—standard therapy is nebulised beta-agonists (salbutamol 5 mg or terbutaline 10 mg) with or without ipratropium bromide (500 µg), not adrenaline. 1
Why Adrenaline Is Not Standard Therapy
The British Thoracic Society guidelines explicitly recommend nebulised beta-agonists as first-line bronchodilator therapy for both acute asthma and COPD exacerbations, with no mention of adrenaline as a treatment option 1. While older research from 1987 and 1995 showed that nebulised adrenaline (1-2 mg) produced equivalent bronchodilation to salbutamol in acute severe asthma 2, 3, this has not translated into guideline recommendations or clinical practice.
The theoretical advantages of adrenaline's alpha-agonist activity (reducing microvascular leakage and airway edema) did not produce additional clinical benefit beyond standard beta-agonists 2. Importantly, adrenaline is not available in standardized nebuliser formulations for routine respiratory use 1.
Correct Treatment Algorithm for Acute Exacerbations
Acute Severe Asthma
- Initial therapy: Nebulised salbutamol 5 mg or terbutaline 10 mg, driven by oxygen at 6-8 L/min flow rate 1
- Add ipratropium bromide 500 µg if poor response to initial beta-agonist 1
- Repeat treatments every 4-6 hours until peak flow >75% predicted 1
- Concurrent therapy: Oral corticosteroids and supplemental oxygen 1
COPD Exacerbations
- Mild cases: Hand-held inhaler with salbutamol 200-400 µg or terbutaline 500-1000 µg 1
- Moderate-severe: Nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg, or ipratropium 500 µg, given 4-6 hourly 1
- Combined therapy: Beta-agonist (2.5-10 mg) plus ipratropium (250-500 µg) for severe cases with poor response 1
- Critical caveat: Use air-driven nebulisation (not oxygen) if CO₂ retention is present or suspected, with supplemental oxygen via nasal cannulae if needed 1, 4
When Adrenaline IS Appropriate (Non-Nebulised Routes)
Parenteral adrenaline (intramuscular or intravenous) should be considered in life-threatening asthma with imminent respiratory arrest, but this is distinct from nebulised administration 5. Emergency medicine guidelines mention epinephrine for severe exacerbations, but this refers to systemic administration, not nebulisation 5.
Technical Nebulisation Parameters
- Gas flow rate: 6-8 L/min to generate 2-5 µm particles for optimal small airway deposition 1, 4
- Volume: 2.0-4.5 mL in nebuliser chamber 1, 6
- Duration: 10 minutes for bronchodilators, continuing until one minute after "spluttering" 1
- Patient position: Sitting upright with normal tidal breathing 1, 6
Common Pitfalls to Avoid
- Do not use oxygen-driven nebulisers in COPD patients with hypercapnia—this can worsen CO₂ retention; use air-driven nebulisation instead 1, 4
- Do not substitute adrenaline for standard beta-agonists based on older research showing equivalence—guidelines have not adopted this practice 1
- Do not assume nebulisers are superior to properly-used inhalers—hand-held inhalers with spacers achieve equivalent bronchodilation when technique is correct 7