What are the best treatments for wheezing?

Best Treatments for Wheezing

Administer nebulized salbutamol 5 mg (or terbutaline 10 mg) immediately as first-line therapy for any patient presenting with wheezing, using oxygen at 6–8 L/min as the driving gas unless the patient has documented carbon dioxide retention. 1

Immediate Bronchodilator Therapy

• Nebulized beta-agonists are the cornerstone of acute wheezing management, with salbutamol 5 mg or terbutaline 10 mg delivered via nebulizer as the initial intervention. 2, 1
• For pediatric patients, dose salbutamol at 0.15 mg/kg or terbutaline at 0.3 mg/kg. 1
• If a nebulizer is unavailable, deliver salbutamol via metered-dose inhaler with spacer, administering 100 µg per actuation and repeating up to 20 actuations. 1
• Use oxygen as the nebulizer driving gas at 6–8 L/min to maintain adequate oxygenation during treatment. 1

Critical Exception for Hypercapnic Patients

• In patients with documented carbon dioxide retention and acidosis, use compressed air (not oxygen) as the driving gas to prevent worsening hypercapnia. 2, 1
• This applies particularly to COPD patients with severe exacerbations who require hospital admission. 2

Assessment of Severity During Treatment

Recognize severe features that mandate escalation:

• Peak expiratory flow ≤ 50% of predicted value signals severe disease. 2, 1
• Respiratory rate ≥ 25/min, heart rate ≥ 110/min, or inability to complete sentences in one breath indicate severe asthma. 2
• Life-threatening features include PEF < 33% predicted, silent chest, cyanosis, bradycardia, hypotension, exhaustion, confusion, or coma. 2, 1

Escalation for Inadequate Response

Add ipratropium bromide 500 µg to the nebulized beta-agonist when the initial response is insufficient. 2, 1

• Repeat the combination of beta-agonist plus ipratropium every 20 minutes for up to three doses in the first hour if improvement is observed. 1
• For pediatric patients, use ipratropium 250 µg every six hours. 1
• Continue nebulized treatments every 4–6 hours until PEF exceeds 75% of predicted and diurnal variability falls below 25%. 2, 1

Systemic Corticosteroids

• Initiate prednisolone 2 mg/kg/day for three days (maximum 40 mg/day) or hydrocortisone 100 mg IV every six hours to reduce airway inflammation and prevent relapse. 1
• Corticosteroids should be started early in severe cases, as they take 4–6 hours to exert clinical effect. 1

Intravenous Bronchodilators

• If bronchodilator therapy remains ineffective, start aminophylline with a loading dose of 5 mg/kg IV over 20 minutes (omit if already on theophylline), followed by maintenance infusion of 1 mg/kg/hour. 1
• Consider ICU transfer for continuous bronchodilator delivery or mechanical ventilation when deterioration persists. 1

COPD-Specific Management

• For mild COPD exacerbations, use hand-held inhaler delivering salbutamol 200–400 µg or terbutaline 500–1000 µg. 2, 1
• Severe COPD exacerbations require nebulized salbutamol 2.5–5 mg or terbutaline 5–10 mg, or ipratropium 500 µg every 4–6 hours. 2, 1
• Combine beta-agonist with ipratropium 500 µg in severe or poorly responding cases. 2, 1

Long-Term Controller Therapy for Persistent Asthma

Inhaled corticosteroids are first-line anti-inflammatory therapy for patients with persistent asthma (symptoms more than twice weekly). 3

• Long-acting inhaled beta-agonists serve as preferred adjunctive therapy to inhaled corticosteroids in moderate to severe persistent asthma. 3
• Before prescribing long-term nebulized bronchodilator therapy, demonstrate clinically useful bronchodilation with a home trial monitoring peak flow for two weeks on standard treatment, then two weeks on nebulized treatment. 2
• An increase of 15% or more from mean baseline peak flow should be demonstrated before recommending chronic nebulized treatment. 2
• Leukotriene modifiers can be used as maintenance therapy in mild persistent asthma or added to the regimen in moderate to severe cases. 3

Pediatric Considerations

• When tolerated, metered-dose inhaler with spacer (and face mask if required) is preferred over nebulization for children because it is more cost-effective and convenient. 1
• Some infants and young children cannot tolerate a face mask or spacer; in these cases, nebulized therapy remains necessary. 1
• If subcutaneous administration is needed, give terbutaline 2.5 mg subcutaneously. 1

Discharge Planning

• Transition patients to hand-held inhaler therapy at least 24 hours before discharge to confirm stability on outpatient medication. 2, 1
• Continue nebulized treatments until sustained clinical improvement with PEF > 75% of predicted and diurnal variability < 25%. 1
• Ensure patients have a short-acting beta-agonist rescue inhaler and understand when to seek emergency care. 4

Critical Pitfalls to Avoid

• Do not withhold beta-agonists due to elevated heart rate; tachycardia is primarily driven by the severe asthma itself, not the medication. 5
• Do not use oxygen as the nebulizer driving gas in hypercapnic patients; compressed air prevents worsening hypercapnia. 2, 1
• Do not continue repeated nebulizations indefinitely without escalation; after 2–3 treatments without significant improvement, add systemic corticosteroids and consider hospital admission. 1
• Use a mouthpiece rather than mask with ipratropium to minimize glaucoma risk in elderly patients. 5
• Rinse mouth with water after inhaled corticosteroid use to prevent oral thrush. 4

When to Consider Alternative Diagnoses

• In patients with persistent wheezing despite optimal bronchodilator and corticosteroid therapy, consider flexible fiberoptic bronchoscopy to identify anatomic abnormalities, tracheomalacia, bronchomalacia, or lower airway bacterial infection. 1
• Identifying airway malacia is crucial because beta-agonists may adversely affect airway dynamics in these patients. 1
• In adults over 40 years with significant tobacco use and new-onset wheezing, advanced imaging should be considered to evaluate for malignancy. 6