X2.2.1 Inhaled bronchodilators for treatment of exacerbations

Inhaled bronchodilators are effective treatments for acute exacerbations (NHLBI/WHO Workshop Report, April 2001),(Siafakas et al., 1995),(American Thoracic Society, 1995),(British Thoracic Society, 1997, Moayyedi et al., 1995, Fernandez et al., 1994) [evidence level I]

In exacerbations of COPD, the immediate bronchodilator effect is small, but may result in significant improvement in clinical symptoms in patients with severe obstruction.

Studies of acute airflow limitation in asthma indicate that beta-agonists are as effectively delivered by metered dose inhaler and spacer as by nebuliser. (Cates et al., 2006) The applicability of this evidence to patients with COPD is unknown. There is evidence in patients with a COPD exacerbation that a dry powder inhaler delivering eformoterol is as effective in improving lung function as a metered dose inhaler delivering salbutamol, with or without a spacer device.(Selroos et al., 2009) An adequate dose should be used. The dose equivalent to 5 mg of salbutamol delivered by nebuliser is 8–10 puffs of 100mcg salbutamol by metered dose inhaler and spacer. Limited evidence indicates dry powder inhalers are as effective as other delivery devices for the administration of short-acting bronchodilators in the setting of acute exacerbations of COPD (Selroos et al., 2009). Airflow in the nebuliser should be 6 L per minute or higher to achieve an appropriate aerosol, but using high- flow oxygen should be avoided as this may worsen carbon dioxide retention. High doses of beta-agonists may induce hypokalaemia and predispose to cardiac arrhythmias.