Salbutamol or aminophylline for acute severe asthma: how to choose which one, when and why?

Abstract

Acute, severe exacerbations of asthma present a challenge due to the significant morbidity associated with this presentation. For exacerbations that are refractory to initial treatments with inhaled and oral therapies, there is still doubt about which intravenous therapies are most likely to be helpful. β-2 agonists and aminophylline have differing mechanisms of action that also affect their adverse effects profiles and these are considered. A review of the available randomised control trials suggests that a bolus of intravenous salbutamol may reduce symptoms and hasten recovery. Aminophylline infusions may improve lung function, and in some studies have been shown to improve symptoms, but the evidence is not clear cut. Decisions about which treatment to use should include risk management considerations such as ease of prescription, preparation and administration factors and availability of high-dependency beds.

Methylxanthine use for acute asthma in the emergency department in Japan: a multicenter observational study

“…Methylxanthine is a bronchodilator agent that might also improve respiratory muscle function through increases in mucociliary clearance and actions to stimulate respiration . Methylxanthines could also show anti‐inflammatory and immunomodulatory actions that are associated with apoptosis of granulocytes . These potential mechanisms had supported methylxanthine treatment for patients with acute asthma over decades.…”

Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Research Networks (PERN) study

“…Medications used for acute severe paediatric asthma include IV bronchodilators (such as salbutamol/albuterol [13], terbutaline [14], magnesium [15], or aminophylline [16]), nebulized magnesium [17], inhaled heliox [18], and IV ketamine [19]. Respiratory support with non-invasive and/or invasive ventilation may also be used if there is a poor response to intensive medical treatment [20].…”

“…The guidelines suggest that IV MgSO 4 can be considered for acute severe asthma, and that IV terbutaline may be given to a severely ill child where inhaled therapy is not possible, although there is "no evidence to support the routine use of IV beta 2 -agonists in patients with severe asthma exacerbations" [32]. Thus, there is considerable geographic variation in clinician preference, guidelines, and actual use of IV agents for acute severe paediatric asthma, reflecting the overall paucity of high-quality evidence to inform clinicians [16].…”

British guideline on the management of asthma: SIGN Clinical Guideline 141, 2014

“…In acute severe asthma, the most pressing area for research is to determine which intravenous therapy (salbutamol, aminophylline or magnesium sulfate) should be used as the first-line agent, and at which dose. It has been suggested elsewhere that this choice should be pragmatic at present, taking into account factors such as ease of prescription, preparation and administration, availability of high-dependency beds and nursing preference 3. This and other international guidance suggests considering addition of 150 mg nebulised magnesium sulfate to each dose of inhaled therapy in the first hour of treatment of severe asthma, especially in children with hypoxia (saturations <92% in air) and a short duration of symptoms (<6 h).…”