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The Malaysian Thoracic Society.
Recommendations on Inhalational Therapy during the COVID-19 Pandemic [5 April
2020] |
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Dose conversion from nebuliser
therapy to MDI + VHC a
a) MDI+VHC = Metered-dose inhaler with valved holding chamber b) Respiratory therapist contacts physician if prescribed
nebulizer dose differs from those listed or if response to MDi is considered
inadequate c) For patients who can perform a slow, deep inhalation and
hold their breath for 5-10 seconds on command d) For patients <4 years or who are unable to perform a
slow, deep inhalation or hold their breath for 5-10 seconds on command e) Not recommended in children, for whom there are no data on
the use of ipratropium delivered by MDI+VHC. The combined product (Combivent,
Boehringer Ingelheim) contains albuterol 90 mcg (as sulfate salt) and
ipratropium bromide (18 mcg) per puff. |
Hendeles et al. Replacement of
nebulizer therapy by an albuterol inhaler and valved holding chamber. Am J
Health-Syst Pharm. 2005; 62. |
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Salbutamol MDI vs nebulizer < 6 year old: 6 x 100 mcg puff
= 2.5 mg Salbutamol nebules. > 6 year old: 12 x 100 mcg puff
= 5.0 mg Salbutamol nebules. |
Paediatric Protocols for Malaysian
Hospitals, 4th Edition, 2019 |
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·
For
adults seen and assessed for acute asthma, this review found no significant
differences between the two delivery methods. Consequently, the choice of
delivery method should reflect patient preference, practice situations and
formal economic evaluation ·
In
children, no outcomes were significantly worse with the spacers, and the
available evidence suggests that in most cases nebulisers could be replaced
with spacers to deliver beta2-agonists in acute asthma. Moreover, other
observed benefits (time spent in emergency department, oxygenation and side
effects) may favour the groups treated with metered-dose inhaler (MDI) and
spacer. ·
The
experimental method adopted in many of the studies was to give repeated
treatments at short intervals (e.g. one respule via a nebuliser or four puffs
of a MDI via a spacer every 10 to 15 minutes). The number of
treatments required was adjusted to the individual patient's response,
overcoming the uncertainty of dosage delivery from different devices. Tidal
breathing is easier for adults and children using a spacer for acute asthma,
but each puff should be inhaled from the spacer before the next puff is
delivered into the spacer. Current evidence is therefore based upon titrated
treatment regimens and this should be considered when implementing any change
in practice. ·
The
studies excluded people with life-threatening asthma; therefore, the results
of this meta-analysis should not be extrapolated to this patient population |
Cates CJ, Welsh EJ, Rowe BH.
Holding chambers (spacers) versus nebulisers for beta-agonist treatment of
acute asthma. Cochrane Database of Systematic Reviews 2013, Issue 9. Art.
No.: CD000052. |
Lexi-Drugs
Multinational
In Adults:
|
Drug |
Dx |
Metered Dose Inhaler Dose |
Nebulisation Solution |
|
Salbutamol* |
Moderate to severe
exacerbations (in primary or acute care settings) |
(90 mcg/actuation) 4-8 puffs every 20
mins for 3 doses, then taper as tolerated (e.g. 2-4 puffs every 1-4 hrs PRN).
For extremely severe exacerbations, some experts suggest up to 10 puffs for the initial doses [GINA 2019]. High doses are typically administered in a monitored setting. |
2.5-5 mg every 20 mins
for 3 doses, then taper as tolerated (e.g. 2.5-5 mg every 1-4 hrs PRN). For critically ill patients, 10-15 mg may be administered by continuous nebulization over 1 hr via special apparatus [Fanta 2019b]. |
|
Fenoterol |
Severe exacerbation of
asthma |
(100 mcg/inhalation) 4 puffs every 10 mins
or 8 puffs every 20 mins for up to 4 hrs, then every 1-4 hrs PRN [Cruz 2012 ;
PCDT 2013] |
2.5-5 mg (10-20 drops)
inhaled via nebulisation every 20 mins for 3 doses, the 2.5-10 mg (10-40
drops) every 1-4 hrs PRN [Cruz 2012 ; PCDT 2013] |
|
Ipratropium* |
Acute asthma (moderate
to severe exacerbations) |
MDI: 8 inhalations
(136 mcg) every 20 minutes as needed for up to 3 hours (NAEPP 2007). |
0.5 mg (500 mcg, one
unit-dose vial) every 20 minutes for 3 doses, then as needed (NAEPP 2007). |
*For severe exacerbations, salbutamol is used in combination with an inhaled short-acting muscarinic antagonist, and nebulised treatments are generally preferred. [Hess 2019]
However, In patients with coronavirus disease 2019 (COVID-19)
who require bronchodilator therapy for asthma or chronic obstructive pulmonary disease
symptoms, the use of pressurized-metered dose inhalers as opposed to nebulized
delivery is preferred. Nebulized delivery may increase the transmission of
particles (SARS-CoV2) into the environment and potentially decrease the expiratory circuit filter life (AARC 2020).
In Paediatrics:
|
Drug |
Dx |
Metered Dose Inhaler Dose |
Nebulisation Solution |
|
Salbutamol* |
Asthma, acute
exacerbation (in emergency care or hospital) |
Oral inhalation: (90 mcg/actuation) Infants and Children: Limited data available
in ages <4 years: 4-8 puffs every 20 minutes for 3 doses then every 1-4
hours (GINA 2018; NAEPP 2007). Adolescents: 4-8 puffs every 20
minutes for up to 4 hours, then every 1-4 hours (NAEPP 2007)
|
Infants and Children: Nebulization: Limited
data in ages <2 years: Intermittent: 0.15
mg/kg/dose (minimum dose: 2.5 mg/dose) every 20 minutes for 3 doses then
0.15-0.3 mg/kg/dose, not to exceed 10 mg/dose every 1 to 4 hours (NAEPP 2007) Continuous nebulization: Dosing regimens variable; optimal dosage not established: ·
Weight based: NIH Guidelines: 0.5 mg/kg/hour (NAEPP 2007) Alternate dosing: Limited data available: 0.3 mg/kg/hour has been used safely in the treatment of severe status asthmaticus in children (Papo 1993); higher doses of 3 mg/kg/hour ± 2.2 mg/kg/hour in children (n=19, mean age: 20.7 months ± 38 months) resulted in no cardiotoxicity (Katz 1993) ·
Fixed dose (Krebs 2013): Limited data available: <20 kg: 10 mg/hour ≥20 kg: 20 mg/hour
Adolescents: NIH Guidelines (NAEPP
2007): ·
Intermittent: 2.5-5 mg every 20 minutes for 3 doses then 2.5-10
mg every 1 to 4 hours as needed ·
Continuous: 10 to 15 mg/hour Alternate dosing (Krebs 2013): Limited data available: <20 kg: 10 mg/hour ≥20 kg: 20 mg/hour
|
|
Fenoterol |
Severe exacerbation of
asthma |
(100 mcg/ inhalation) Children (Ages not specified): 1 puff per 2 to 4 kg of body
weight (maximum: 10 puffs) every 20 minutes for 3 doses
|
Children (Ages not
specified): 0.07 to 0.15 mg/kg/dose (maximum:
5 mg [20 drops]/dose) every 20 minutes for 3 doses (Cruz 2012; PCDT 2013).
|
|
Ipratropium |
Asthma, acute
exacerbation |
Children: 4 to 8 puffs every 20
minutes as needed for up tp 3 hours
Adolescents: 8 puffs every 20
minutes as needed for up to 3 hours
|
Children 0.25 to 0.5 mg (250 to 500 mcg) every 20
minutes for 1 hour (ie, 3 doses), then as needed. In trials, the usual reported dose is 0.25 mg (250 mcg) and reported interval range is every 1 to 8 hours typically with an increasing dosing interval as patient improves. Some trials continued combination SABA/ipratropium therapy for duration of hospitalization (up to 49 hours) although trials have not demonstrated additional benefit with extended use (Vézina 2014) Adolescents: 0.5 mg (500 mcg) every 20 minutes for 3
doses, then as needed |
# Ipratropium has NOT been shown to provide further benefit (e.g. after first 24 hrs) once the patient is hospitalised (GINA 2018; Vezina 2014)
Written on 16.06.2020 ; Updated on 12.10.2020 [J. Ho]
British National
Formulary for Children (BNFC)
Severe or life-threatening asthma
By inhalation or nebulised solution
|
|
1
month – 4 years |
5–
11 years |
12-17
years |
|
Salbutamol (give via oxygen-driven nebuliser if
available) |
2.5 mg every 20-30 mins or when required |
2.5-5 mg every 20-30 mins or when required |
5 mg every 20-30 mins or when required |
|
Ipratropium |
250 mcg every 20-30 mins for the first 2
hrs, then 250 mcg every 4-6 hrs as required |
500 mcg every 4-6 hrs as required |
|
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