Stop me if you’ve heard this one before – there’s a drug shortage of a critical therapy. This time is might be more pressing than most because we are running critically low on the bottles of albuterol that are used to compound continuous treatments. There is not a shortage of metered dose inhalers and nebules (the small single dose ampules). But, you can imagine a scenario where downstream effects of one shortage will lead to others. So what should we do?

Don’t give albuterol when you don’t think it will work or when the evidence suggests the likely benefit is low

Albuterol is not recommended for bronchiolitis. This is well described in the literature and part of several key guidelines. This goes for RSV or the current pathogen causing some of the wheezing in the United States – Enterovirus D68 (don’t forget about COVID-19 and other viruses too – ok fine, everything causes wheezing). You’ll need to brush up on your anticipatory guidance and be sympathetic to parents who are worried about their infants with bronchiolitis/lower respiratory tract infections and explain why their children wheeze and work hard to breathe, and how it is different than asthma. Obviously this is good practice even when there isn’t a shortage.

Use inhalers instead of nebulizers especially in mild to moderate asthma

Metered dose inhalers with a spacer (even for kids as small as 2 years) are equivalent to nebulizer treatments in all key metrics. This was well described in recent Cochrane Database systemic reviews. The equivalent amount in “3 back-to-back treatments” can be given via neb or metered dose inhaler MDI (4-8 puffs). 4-6 puffs via MDI with spacer is equivalent to one neb in the cooperative patient. It is important to note that MDI with spacer can deliver a smaller particle size and thus reach the airways more effectively, whereas nebs are easier to deliver during a sicker or less cooperative patient’s tidal ventilation. In a 2013 Cochrane review of 39 RCTs in children an adults comparing nebs to inhaler the authors noted no difference in admission rates. There was a shorter length of stay in the ED for children with MDI + spacer (33 min shorter mean LOS – 95% CI -43 to -24 min). Finally, in children the pulse rate and risk of tremor was lower for MDI + spacer.

Don’t just park a patient on continuous albuterol, and use additional treatments

There will be severe asthmatics that need continuous albuterol – however you should already be regularly reassessing them to see if the therapy is making a difference. Use IV magnesium for bronchodilation (it can also reduce the risk of admission), and consider additional IV therapies such as theophylline or terbutaline. You can also decrease the concentration of continuous albuterol that you’re giving.

And don’t forget about ipratropium – Short acting anticholinergics work synergistically with beta agonists to relieve bronchospasm. A Cochrane review of 23 child and adult trials showed decreased risk for hospitalization in severe exacerbations (RR 0.72, 95% CI 0.59 to 0.87) but not mild or moderate (test for difference between subgroups P = 0.02) when ipratropium was added to the three initial beta agonist treatments. SABA + SAAC also improve PEF more than albuterol alone. Furthermore there is a decreased ED return visits (RR 0.80, 95% CI 0.66 to 0.98) and finally, a slightly higher risk of adverse events (OR 2.03, 95% CI 1.28 to 3.20) (tremor, tachycardia) for SABA + SAAC.

Change your order sets to remove nebs and/or favor MDI

This may take a bit of a lift, but if you have a widely used order set removing a treatment that is in short supply can curtail its use along with timely messaging.

If you have a device like the Aerogen you can use it instead of a traditional nebulizer

Aerogen is a respiratory device that can deliver the equivalent amount of 3 back to back nebs in a single treatment through delivery of a much smaller particle size. If it is available in your facility you can use it in lieu of the 3 back to back nebs.

References

Bonini M, et al.. Beta₂-agonists for exercise-induced asthma. Cochrane Database Syst Rev. 2013 Oct 2;(10):CD003564. doi: 10.1002/14651858.CD003564.pub3. PMID: 24089311.

Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta‐agonist treatment of acute asthma. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD000052. DOI: 10.1002/14651858.CD000052.pub3. Accessed 19 August 2022.

Griffiths B, et al. Combined inhaled anticholinergics and short‐acting beta₂‐agonists for initial treatment of acute asthma in children. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD000060. DOI: 10.1002/14651858.CD000060.pub2.

Edit: Thank you Indi Trehan for catching a typo in the first sub-heading. I have edited the text to remove a misspelling and include that Enterovirus D68 is causing some of the wheezing seen in the US right now. Post-publication peer review FTW!