Continuous Nebulisation for Severe Respiratory Distress

Key Recommendations by Clinical Context

The British Thoracic Society recommends that continuous nebulisation should be reserved for very severe asthma attacks in patients monitored in intensive care settings, as it remains under evaluation and is not superior to frequent intermittent nebulisation for most acute severe presentations 1, 2
For severe acute asthma, the standard approach is to administer nebulised β-agonist (salbutamol 5 mg or terbutaline 10 mg) initially, repeated every 20 minutes for the first hour if needed, according to the British Thoracic Society 1, 2
The British Thoracic Society suggests that for poor response, ipratropium bromide 500 μg should be added to the β-agonist 1, 3
Continuous nebulisation dosing for terbutaline is 1-3 mg/hour and for salbutamol is 0.3 mg/kg hourly (maximum 10 mg/hour), as recommended by the British Thoracic Society 1, 2

The British Thoracic Society recommends standard intermittent dosing for COPD exacerbations, with nebulised salbutamol 2.5-5 mg or terbutaline 5-10 mg at 4-6 hourly intervals 4, 5, 6
For severe COPD exacerbations with poor response, the British Thoracic Society suggests combining β-agonist with ipratropium bromide 0.25-0.5 mg 4, 5
The British Thoracic Society advises driving nebulisers with compressed air (not oxygen) if PaCO₂ is raised and/or respiratory acidosis is present, and oxygen can be given simultaneously via nasal prongs at 1-2 L/min to prevent desaturation 4, 5, 6

The British Thoracic Society recommends considering continuous nebulisation for very severe attacks requiring intensive care monitoring, patients not responding adequately to frequent intermittent dosing, and early experience with this method is encouraging but still under evaluation 1, 2, 7
The British Thoracic Society suggests that metered dose inhaler with spacer may be as effective and cheaper than nebulisation for acute exacerbations, though not yet widely undertaken 1, 2, 7