High-dose inhaled terbutaline in the management of chronic severe asthma: comparison of wet nebulisation and tube-spacer delivery.

Abstract

Eight patients with chronic severe asthma, poorly controlled by conventional doses of inhaled bronchodilator, were treated with high-dose inhaled terbutaline (4 mg four times daily), via either wet nebulisation of terbutaline respirator solution, or by tube-spacer aerosol, using cannisters delivering 1 mg terbutaline per metered dose. All patients improved objectively and subjectively on these higher dosage regimens during both day and night. A trial of high-dose inhaled beta2 sympathomimetic therapy should be considered in any patient with chronic severe asthma who fails to obtain benefit from standard doses of inhaled bronchodilator.Patients with chronic severe asthma often respond poorly to inhaled bronchodilators in conventional dosage. Such patients are usually very disabled, require frequent hospital admissions, and are commonly prescribed long-term oral corticosteroids. Domiciliary high-dose inhaled bronchodilator therapy, delivered by wet nebulisation, may improve some patients with chronic asthma sufficiently for oral steroids to be discontinued.' However, the air compressors necessary for the domiciliary nebulisation of bronchodilator are expensive and inconvenient. We decided, therefore, to compare the efficacy of high-dose bronchodilator therapy delivered by wet nebulisation and by a new aerosol device, the tube-spacer.2 The tube-spacer was chosen because it achieves higher penetration of aerosol into the lung than does conventional aerosol,3 and also because it may be more effective than conventional aerosol in the management of some patients with asthma.4-6 The tube-spacer is cheaper and more convenient than the wet nebuliser. MethodsEight patients (four male and four female) with chronic severe asthma participated in the study. Mean first second forced expired volume (FEV1) was 0 83 I BTPS (range 0I5-1V61 BTPS).

A more logical approach to asthma

“…Accepting these difficulties in studying truly comparable doses of sympathomimetics by these two routes, Anderson, Goude and Peake (1982) compared 4 8 mg of salbutamol by nebulizer and pressurized aerosol. As with the study of Prior et al (1982), salbutamol was equally effective by either route and well tolerated.…”

“…A similar effect is more cheaply obtained, however, by high doses from the conventional pressurized aerosol; perhaps with further improvement of inhalational efficiency with devices such as the tube spacer. Thus Prior, Nowell and Cochrane (1982) showed significant improvement in patients with poorly reversible airways obstruction when using terbutaline in a dose of 4 mg four times a day by both wet nebulization and a specially prepared high dose pressurized aerosol (1 mg per shot). Only 10% of a pressurized aerosol dose is actually inhaled (Neuman et al, 1980) and only some 12% of drug delivered by wet nebulization reaches the airways.…”

Inhaler devices for the treatment of asthma and chronic obstructive airways disease (COPD)

“…[53][54][55] Twenty three studies in adults showed clinical equivalence for inhaler devices and nebulisers for the main pulmonary outcomes (FEV 1 and PEFR) and no evidence of significant difference in other outcomes. [56][57][58][59][60][61][62][63][64][65][66][67][68][69] Figure 5 shows the standardised mean difference of FEV 1 between nebulisers and hand held inhaler devices for the delivery of β agonists in stable asthma. 54 57-60 62 63 65-67 69-71 Updated searching identified two further studies.…”

Efficacy and Cost Comparisons of Bronchodilatator Administration Between Metered Dose Inhalers with Disposable Spacers and Nebulizers for Acute Asthma Treatment

“…Although greater bronchodilatator response might be expected with a nebulizer due to the higher dose used for nebulization compared with standard measured-dose inhalers, studies comparing delivery of beta agonist with MDI plus a spacer vs. a nebulizer show no difference with respect to clinical response in acute severe asthma and stable chronic asthma (9,(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26). In addition, extrapulmonary sympathetic effects such as tremor, anxiety, and dysrhythmias were found in one study to be more prevalent in patients receiving nebulized medication compared to MDI/spacer-delivered medication (27).…”