For a diagnosed asthmatic patient presenting with breathlessness, the initial treatment would involve administering high doses of a rapid-acting inhaled bronchodilator like salbutamol every 20 minutes for the first hour. If the patient does not see adequate improvement, ipratropium bromide would be added. Systemic corticosteroids like prednisolone would also be prescribed if the exacerbation is severe or not responding to initial bronchodilator therapy, to reduce inflammation and control the attack.

1. Acute Exacerbation Chronic or long
term
•Severe
•Short term
•Also known as attack
•High doses are required
•Mild
•Long term
Suitable therapy:
Nebulisation
Suitable therapy:
MDI + Spacer/ DPI
Asthma
Presentation
Asthma

2. Acute Exacerbation
Exacerbations of asthma (asthma attacks or acute asthma) are
episodes of progressive increase in shortness of breath, cough,
wheezing, or chest tightness, or some combination of these
symptoms.
Severe exacerbations are potentially life threatening, and their
treatment requires close supervision.
Patients with severe exacerbations should be encouraged to
see their physician promptly or, to proceed to the nearest clinic
or hospital that provides emergency access for patients with
acute asthma.
GINA 2006
Asthma

3. Acute asthma
All patients with asthma
irrespective of their
severity; are at a risk of
developing an acute
attack…

4. Acute asthma Symptoms
• Increased Breathlessness / Dysponea
[Difficulty in breathing]
• Increased Wheezing
[Whistling sound while exhaling]
• Increased Cough
[Often at night or after some exertion]
• Chest Tightness

5. Acute Asthma Signs
• Inability to complete a sentence
• Tachycardia [rapid heart beats]
• Tachypnea [rapid breathing]
• Accessory respiratory muscle use [around neck]
• Excessive sweating
• Cyanosis [blue discoloration of skin, lips in acute
severe cases]

6. Who is at risk?
• Previous hospitalization or “casualty visit” for asthma in
past year
• Currently using or have recently stopped using oral
steroids
• Not currently using preventive therapy
• Frequent use of salbutamol /terbutaline
• Emotional/ psychological component of asthma.
These patients require closer attention and
should be encouraged to seek urgent care
early in the course of their attacks.

7. Symptoms Mild- Moderate Severe- life threatening
Breathless On walking or talking At rest
Talks in Sentences / Phrases Words/
Unable to speak
Accessory muscles Usually not Usually
Central Cyanosis Absent Likely to be present
SaO2
[as measured by pulse
oximeter]
91-95%
OR
> 95%
< 90%
Pulse
rate
Adults <100-120 / min > 120 / min
Children <100-200 / min > 200 / min
Acute asthma classification
Refer to hospital
any patient with
features of
acute severe to life
threatening asthma

8. Routes of administration of
anti-asthma drugs
Oral Inhaled Parenteral
Tablets
Syrup
Metered dose inhaler (MDI)
Dry powder inhaler (DPI)
Injections
Nebulizers

9. Nebulizer
Delivers a therapeutic dose
of the drug as an aerosol in
the form of respirable
particles within a short
period, 5-10 mins.

10. Why nebulized therapy.......
• Immediate relief is required which can be achieved only from
inhalation therapy.
• Targeted drug delivery.
• Easy to Use
• When High dose of medications are required.
• Does not require coordination between inspiration and actuation as
it uses normal tidal breathing.
• Patient who does not respond to regular treatment with oral or other
inhaled devices, may benefit.
• Critically ill patients, unable to co-ordinate with other inhaler
devices like MDI or Rotahaler , may benefit.
• Profitable

11. Advantages of nebulized therapy
Over Injectables
Targeted drug delivery
Lesser side effects
Non invasive / Painless
Easy to use
Over Orals
Targeted drug delivery
Lesser side effects
Faster onset of action
Very useful in acute cases

12. Nebulized therapy used for…
• Acute attacks of asthma
• Acute attacks of COPD
• Symptomatic relief of Croup
• Other respiratory diseases presenting with acute
bronchitis
• Rarely, at home, in mild-moderate acute asthma when
the patient can’t use other inhaler devices.
• Infants, children and elderly patients who can’t use other
inhaler devices.

13. Types of nebulizers
• JET Nebulizer
• Ultrasonic Nebulizer

14. JET nebulizer
• Based on compressed air technology.
• Widely used
• Economical
• Any form of liquid can be nebulized (including
suspensions).

15. Ultrasonic Nebulizer
• Based on high frequency sound waves technology.
• Finest mist and better deposition
• Not preferable for suspensions.
• Less noisy
• Costly, thus limits its use.

16. Parts of the Nebulizer
Nebulizer system consists of the following parts.
Tubing nebulization
Chamber
Mask/Mouthpiece
Compressor
• The compressor is the portable pump which provides power
for nebulizer.
• The nebulizer is the small chamber into which the liquid
medicine is put and through which the air is blown to make a
mist.

17. Important Aspects
Fill Volumes
• Ideal volume of the drug
to be put in the
nebulization chamber is
usually 2-4 ml

18. Important Aspects
Nebulization Time
• Time from starting
nebulization until
continuous nebulization
has ceased
• For bronchodilators it
should be <10 mins.

19. Important Aspects
Nebulization End point
• Patients should be
nebulize for about a
minute after ‘spluttering’
occurs
• Residual volume of 0.5 to
1 ml will always remain in
the nebulizer

20. Important Aspects
Driving gas flow rate
• Most jet nebulizers work
at a flow rate of 6-8 l/min
• Oxygen can be used if a
compressor is not
available.

21. Important Aspects
Breathing pattern of patient
• Steady normal breathing
• Occasional deep breath

22. Important Aspects
OR
Face Masks Mouthpiece
Prefer When Patient is …
•Too critical
•Unconscious
•Pediatric
Prefer When Patient is …
• Comfortable enough to hold the
mouthpiece
• Receiving anticholinergics
• Receiving Steroids
Do not talk while being nebulized

23. Management of mild / moderate
acute asthma
After brief history* and physical
examination…
*Rule out beta blocker or NSAID [aspirin] use, check for exposure
to strong trigger

24. Rapid Acting Bronchodilators
• Repeated administration of rapid-acting inhaled beta2-
agonists.
E.g. Salbutamol or Levosalbutamol respules /MDI
• Every 20 min for first 3 doses
• After the first hour, the dose of beta2-agonist required will
depend on the severity of the exacerbation.

25. Rapid Acting Bronchodilators
• Treatment should also be titrated depending upon the
individual patient response.
• No evidence to support the routine use of IV beta2
agonists.
NEBULIZED [Respules/
Respirator solution]
MDI + SPACER
Salbutamol
[Asthalin]
Adult 2.5-5 mg Adult 8-12 puffs per hour
Child 1.25 -2.5 mg Child 4-6 puffs per hour
Levosalbutamol
[Levolin]
Adult 0.63-1.25 mg Adult 4-6 puffs per hour
Child 0.31-0.63 mg Child 2-3 puffs per hour

26. • Many patients will be able to monitor their PEF after the
initiation of increased bronchodilator therapy.
• No additional medication is necessary if the rapid-acting
inhaled beta2-agonist produces a complete response
(PEF returns to greater than 80% of predicted or
personal best) and the response lasts for 3 to 4 hours.
Rapid Acting Bronchodilators

27. Additional bronchodilators
• In case of poor response to beta2 agonist therapy; add
nebulized ipratropium bromide.
• Available In Combination As Duolin Respules
• Ipratropium +beta2 agonist combination:
– Greater bronchodialation
– Shorter duration of admission
– Faster recovery
Bronchodilators Adults Children
Ipratropium 250 – 500 mcg 250 mcg

28. Duolin LD
The Dual Action Bronchodilator
Brand Composition Pack
Duolin Respules Levosalbutamol 0.63 mg + Ipratropium bromide
500 mcg/ 2.5 ml
2.5 ml
Brand Volume of solution Dosage - adults and adolescents (above
12 years of age)
Duolin Respules 1 Respule 1 respule 3-4 times a day

29. If patient has…
• Reduced distress
• Able to complete sentence
• Near normal Pulse rate/ respiratory rate
• No use of accessory muscles
• Improved Oxygen saturation
[>95%=Child / >90%=Adult]
Consider sending home

30. Steroids in acute asthma

31. CHRONIC INFLAMMATION
Time
ACUTE
INFLAMMATION
Structural changes Airway
remodeling
What happens in acute asthma?

32. When?
• Initial bronchodilator therapy fails improvement
• Attack in patient already on oral steroids.
• Previous attacks required oral steroids.
Systemic Steroids
GINA 2008
Age Daily dose of prednisolone Treatment up to
<2 years 10 mg 3 days or until recovery
2-5 years 20 mg 3 days or until recovery
>5 years 30-40 mg 3 days or until recovery
adults 40-50 mg at least 5-7 days/until recovery

33. Budecort
Nebulised Steroid control in Difficult Asthma

34. Brand Composition Pack
Budecort
0.5 mg Respules
Budesonide 0.5 mg/2 ml 2 ml
Budecort
1 mg Respules
Budesonide 1 mg/2 ml 2 ml
Brand Dosage Adults Dosage Children
Budecort
0.5 mg
Respules
Initiating dose: 1-2 mg
twice daily
Maintenance dose:
0.5 mg –1 mg twice
daily
Initiating dose:
0.5-1 mg twice daily
Maintenance dose:
0.25 – 0.5mg twice
daily
Budecort
1 mg Respules

35. Combination of Bronchodilator &
Steroid
• Makes available both bronchodilator and steroids
• Targets different aspects of asthma, salbutamol
reverses the bronchoconstriction and budesonide
takes care of inflammation
• Reduces nebulisation time.
Budesal: (Salbutamol + Budesonide)

36. Budesal
The First Anti inflammatory corticosteroid +
Bronchodilator Nebulised Therapy

37. The First Anti inflammatory
corticosteroid + Bronchodilator
Nebulised Therapy
Brand Composition Pack
Budesal 0.5 mg Respules Salbutamol 2.5 mg +
Budesonide 0.5 mg
2.5 ml
Budesal 1 mg Respules Salbutamol 2.5 mg +
Budesonide 1 mg
2.5 ml
Brand Volume of
solution
Dosage Adults Dosage
Children
Budesal
0.5 mg
Respules
1-2
respules
1-2 respules(1
mg) twice daily
or 1 respule
thrice daily
1-2 respules(0.5
mg) twice daily
or 1 respule
thrice daily
Budesal 1 mg
Respules
1-2
respules

38. High dose rapid acting bronchodilator*
Salbutamol (Asthalin)/ levosalbutamol (Levolin)
Partial / no response…
Add ipratropium
In severe cases, one can directly start with duolin
Partial / no response…
Initiate Steroid therapy
Further treatment depends on severity of acute asthma & response to the initial treatment.
Summary so far…

39. If patient has…
• No distress
• Able to complete sentence
• Near normal Pulse rate/ respiratory rate
• No use of accessory muscles
• Oxygen saturation [>95%=Child / >90%=Adult]
• Improved lung function [greater than 80% of predicted or
personal best]
Consider sending home

40. If patient has…
• Poor Response to Therapy
• Severe symptoms
• Drowsiness
• Cyanosis
• Also if already, High Risk Patient
Refer to hospital / ICU….

41. Other bronchodilators…
Theophylline
• Much less effective than Salbutamol + Ipratropium
• Injectible should be used in hospital settings only, with
monitoring serum levels.
• Mainly used as an add on therapy for prevention.
[long acting oral preparation]
Adrenaline
• Not routinely indicated for asthma attacks; mainly
indicated for anaphylaxis.

42. Do’s
• Never delay transfer to hospital/ICU if necessary
• Try to check pulse oximeter saturations at every step
• Ensure the patient who has been hospitalized is
discharged with regular ICS.
• Ensure patient has written asthma action plan.
• Prevent future acute asthma attacks by prescribing
regular treatment with inhaled corticosteroid
[MDI/ DPI].

43. The story of asthma treatment
Traditional treatment
Occasional Relievers
Ideal treatment
Regular Controllers
i.e. ICS

44. Follow up after hospital discharge
• Review within 48 hours
• Monitor symptoms and PEF
• Check inhaler technique
• Modify treatment according to severity
• Follow up with chest physician at regular interval

45. Good Nebulizer practice: Cleaning
• Disassemble.
• Wash in warm water with detergent at least once a day.
• Carefully dry.
• The nebulizer should be run empty for a moment or two
before the next use.

46. Respule
• A “respule” is an ampoule containing the liquid drug to
be nebulized.
• It contains drug, which is prediluted and hence can be
used directly.
• The respule should be broken and the liquid drug
should be pored into the nebulization chamber.
• Respules are for inhalation use only.
• The solution should not be injected or swallowed.

47. Respirator Solution
• Respirator solution contains the drug to be nebulized in
concentrated form.
• Dilute the drug concentrate in a ratio of 1 part of drug
solution: 3 parts of normal saline (0.9% sodium chloride).
• Care should be taken that after diluting the fill volume
should not exceed of 2-4 ml.
• It is not recommended to use distilled water or tap water
contains certain elements which itself could irritate the
airways.

48. A diagnosed asthmatic
breathless patient
comes to your clinic ……
What would be your line of treatment ?????