How should I manage tremor in a 75‑year‑old patient after nebulising Asthalin (salbutamol) 2.5 mL?

Management of Tremor After Asthalin (Salbutamol) Nebulisation in a 75-Year-Old

Reduce the salbutamol dose to 2.5 mg (from the current dose) or switch to ipratropium bromide 250-500 mcg as first-line therapy, as beta-agonists are especially likely to cause tremor in elderly patients and high doses should be avoided unless absolutely necessary. 1

Immediate Management Strategy

Dose Reduction Approach

• Lower the salbutamol dose to 2.5-3 mg per nebulisation, as this produces satisfactory bronchodilation with fewer systemic side effects including tremor compared to the standard 5 mg dose 2
• Tremor is dose-related with beta-agonists, and reducing the dose is the most direct intervention 3, 4
• If using 2.5 mL respules, verify the concentration—standard Asthalin respules contain 2.5 mg salbutamol in 2.5 mL, which is already an appropriate dose 2

Switch to Anticholinergic Therapy

• Consider switching to ipratropium bromide 250-500 mcg four times daily as first-line therapy, as the response to beta-agonists declines more rapidly than anticholinergics with advancing age 1, 5
• Ipratropium bromide is generally safer in elderly patients and has useful bronchodilator function without causing tremor 3
• Use a mouthpiece rather than face mask when administering ipratropium to avoid acute glaucoma or blurred vision, which are more common in elderly patients 1, 5

Why Tremor Occurs and Expected Course

Mechanism and Risk Factors

• Beta-agonists cause tremor through direct action on skeletal muscle beta-2 receptors, shortening the active state of muscle and leading to incomplete fusion of tetanic contractions 4
• Tremor correlates closely with hypokalaemia induced by beta-agonists 4
• Elderly patients are especially susceptible to tremor from beta-agonists, making this a predictable and common adverse effect in this age group 1

Natural Resolution

• Desensitization of beta-2 receptors occurs during the first few days of regular use, and tremor commonly resolves after the first few doses 4
• If continuing salbutamol, reassure the patient that tremor typically improves with continued use over 3-5 days 4

Combination Therapy Option

Adding Anticholinergic to Reduced-Dose Beta-Agonist

• Combine ipratropium bromide 250-500 mcg with reduced-dose salbutamol (2.5 mg) to optimize bronchodilation while minimizing side effects 5, 3
• This approach allows lower doses of each agent, reducing tremor while maintaining therapeutic efficacy 5
• Start with ipratropium alone and add salbutamol only if response is inadequate after maximizing anticholinergic dose 5

Critical Safety Considerations in This Patient

Cardiac Assessment

• Ensure this patient has been screened for ischemic heart disease, as beta-agonists may precipitate angina in elderly patients 1, 5
• The first treatment with beta-agonists should always be supervised in elderly patients, particularly those with known cardiac disease 1, 5
• Consider ECG monitoring if cardiac history is present or unknown 5, 6

Monitoring for Other Systemic Effects

• Check serum potassium, as hypokalaemia can be aggravated by concomitant diuretics, corticosteroids, or theophyllines 3
• Monitor for tachycardia and blood pressure changes, which may impair quality of life in elderly patients 3

Alternative Delivery Methods

Consider Hand-Held Inhalers

• Assess whether the patient can use a metered-dose inhaler with spacer and tight-fitting face mask, which may deliver lower systemic doses 1, 5
• Alternative devices include breath-activated inhalers or dry powder inhalers if coordination allows 1, 5
• Many elderly patients cannot use metered-dose inhalers due to impaired cognitive function, memory loss, weak fingers, or poor coordination, which is why nebulisers are often necessary 1, 6

Common Pitfalls to Avoid

• Do not continue high-dose salbutamol (5 mg or higher) in elderly patients experiencing tremor, as this prioritizes bronchodilation over quality of life without clear mortality benefit 1
• Do not add theophylline to manage symptoms, as it has a narrow therapeutic index, extensive drug-drug interactions, and increased adverse effects in elderly patients 5, 7, 3
• Do not use face masks for anticholinergic delivery if the patient has glaucoma or prostatism risk 1, 5, 6
• Do not dismiss tremor as insignificant, as even "minor" adverse events can significantly impair quality of life in elderly patients 3