What is the appropriate treatment for audible wheezing?

Treatment for Audible Wheezing

Immediately administer nebulized salbutamol 2.5-5 mg (or terbutaline 10 mg) as first-line treatment for audible wheezing, regardless of the underlying cause, because the benefit of treating bronchospasm outweighs the risks of delayed treatment. 1

Immediate Management Algorithm

First-Line Bronchodilator Therapy

• Administer nebulized salbutamol 5 mg (or 0.15 mg/kg in children) OR terbutaline 10 mg (or 0.3 mg/kg in children) immediately 2, 3
• Drive the nebulizer with oxygen at 6-8 L/min flow whenever possible to maintain adequate oxygenation 2, 3
• Exception: Use compressed air (not oxygen) as the driving gas if the patient has documented CO2 retention and acidosis to avoid worsening hypercapnia 2, 3
• Alternative delivery: MDI with spacer can deliver salbutamol 100 μg per actuation, repeated up to 20 times, if nebulizer unavailable 2, 3

Assess Severity While Treating

Look for severe asthma features that require escalation 2, 3:

• Inability to complete sentences in one breath
• Respiratory rate ≥25/min (adults) or >50/min (children)
• Heart rate ≥110/min (adults) or >140/min (children)
• Peak expiratory flow (PEF) ≤50% predicted
• Use of accessory muscles of breathing

Look for life-threatening features requiring immediate intensive care consideration 2, 3:

• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma
• PEF <33% predicted

Escalation Protocol for Poor Response

Add Anticholinergic Therapy

• If inadequate response after initial beta-agonist, add ipratropium bromide 500 μg to the nebulizer with salbutamol and repeat 2, 3, 4
• For children, use ipratropium 250 μg six hourly 2
• Caution: Avoid eye exposure with face masks as ipratropium can cause pupil dilation, blurred vision, or precipitate narrow-angle glaucoma 5

Repeat Dosing Strategy

• Repeat nebulized beta-agonist (with or without ipratropium) every 20 minutes for up to 3 doses in the first hour if the patient shows improvement 4
• Continue treatments every 4-6 hours until PEF >75% predicted and diurnal variability <25% 2, 3
• In severe cases with ongoing symptoms, treatments can be given hourly 4

Add Systemic Corticosteroids

• Administer prednisolone 2 mg/kg/day for 3 days (maximum 40 mg/day) OR hydrocortisone 100 mg IV every 6 hours 2, 3
• Systemic steroids are essential for reducing airway inflammation and preventing relapses 6

Further Deterioration

• Start aminophylline infusion: Loading dose 5 mg/kg IV over 20 minutes (omit if already on theophylline), then 1 mg/kg/hour maintenance 2
• Consider transfer to intensive care for continuous bronchodilator therapy or mechanical ventilation 2

Monitoring Parameters

Clinical Response Assessment

• Measure PEF before and after each treatment to objectively assess bronchodilator response 3
• Monitor respiratory rate, oxygen saturation, degree of wheezing, and dyspnea 1
• SpO2 <94% indicates increased severity; SpO2 ≤92% carries 6.3-fold greater risk for requiring additional treatment 7

Cardiovascular Monitoring

• Monitor heart rate and blood pressure before and 30 minutes after each treatment 1
• Expected pharmacologic effects include tachycardia, increased systolic blood pressure, decreased diastolic blood pressure, and potential hypokalemia—these are not reasons to withhold treatment 1

Special Considerations

When Wheezing Persists Despite Optimal Bronchodilator Therapy

• Consider flexible fiberoptic bronchoscopy to identify anatomic abnormalities, tracheomalacia, bronchomalacia, or lower airway bacterial infection 3
• Identifying airway malacia is critical because beta-agonists may worsen airway dynamics in these patients 3

COPD Exacerbations

• For mild exacerbations: Use hand-held inhaler with salbutamol 200-400 μg or terbutaline 500-1000 μg 2
• For severe exacerbations: Nebulized salbutamol 2.5-5 mg or terbutaline 5-10 mg OR ipratropium 500 μg every 4-6 hours 2, 4
• Consider combination therapy (beta-agonist with ipratropium 500 μg) in severe cases or poor response 2, 4

Pediatric Considerations

• Metered dose inhaler with spacer (and face mask if needed) is preferred over nebulizer when tolerated, as it is cheaper and more convenient 2
• Some infants and children cannot tolerate face masks and spacers, requiring nebulizer use 2
• If subcutaneous route needed: Terbutaline 2.5 mg subcutaneously 2

Discharge Planning

• Transition to hand-held inhaler therapy at least 24 hours before discharge to ensure stability on discharge medication 2, 3
• Continue nebulized treatments until clinical improvement is sustained and PEF >75% predicted with diurnal variability <25% 2, 3
• Decrease frequency of bronchodilators as symptoms improve 2

Critical Pitfalls to Avoid

• Never delay bronchodilator treatment while attempting to differentiate cardiac from pulmonary causes of wheezing—bronchospasm itself is life-threatening 1
• Do not continue repeated nebulizations indefinitely without escalating care; if no significant improvement after 2-3 treatments, add systemic corticosteroids and consider hospital admission 4
• Avoid using oxygen as driving gas in hypercapnic patients; use compressed air instead 2, 3
• Do not use ipratropium without proper face mask fit to prevent eye exposure and associated complications 3, 5