Bronchodilator Resuscitation in the Emergency Department Part 2 of 2: Dosing Strategies

Abstract

Patients presenting to the ED with severe exacerbation of airway obstruction require a more aggressive treatment strategy than the standard doses and frequency of β agonists recommended by the manufacturer. Up to 70% of patients with severe airway obstruction will respond to increasing doses of bronchodilators (up to 1.0-2.4 mg/h of albuterol via MDI/HC and 5.0-30 mg/h via nebulizer), whereas approximately 30% of patients do not respond sufficiently and require hospitalization. Aggressive dosing with bronchodilators for 30 minutes improves the ability to predict which patients will require admission, compared to predictions made before starting treatment.

The advantage of high-dose β agonist administration appears to be greatest in patients with the most severe airway obstruction. Patients with moderate airway obstruction may gain less additional benefit from higher than standard doses of β agonists, but the risk of adverse effects with high doses of albuterol in this population is only slightly higher than with lower doses. Titrating the dose of bronchodilator to response of the individual patient may be the best strategy for resuscitating these patients.