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3.1 Bronchodilators

Salbutamol aerosol inhaler, easi-breathe, accuhaler, nebuliser solution, injection
Terbutaline turbohaler
Salmeterol aerosol inhaler, accuhaler
Formoterol turbohaler

QIPP Detail Aid: Salbutamol – Does it really need to be nebulised? 


1. The metered dose inhaler (MDI) remains the most cost-effective delivery system and should be considered for all new patients.

2. Patients with poor aerosol inhalation technique may benefit from the use of a large spacer device such as the "Volumatic", or a breath-actuated device. The most cost-effective of this type of device currently marketed is the Easi-breathe.

3. Salmeterol and formoterol should be used in asthma and COPD in accordance with the recommendations in the British Thoracic Society Guidelines for asthma and COPD. (See BNF)

4. Salmeterol provides an alternative to increasing the dose of inhaled corticosteriods in asthma management. It should be considered in patients with COPD as an alternative to tiotropium or in patients with two or more exacerbations per year

5. Sodium chloride 0.9% is the preferred diluent for nebuliser solutions.

6. Salbutamol and ipratropium nebuliser solutions may be mixed immediately prior to administration for convenience. However, Combivent vials offer an alternative to mixing. See 3.1.4

7. Oral bronchodilators e.g. salbutamol tablets (e.g. Volmax) should only be used where the inhaled route is not an option e.g. in patients who are incapable of using any inhaler device e.g. very elderly or infirm. They may also be considered as a 'therapeutic trial' to ensure the drug is effective.

8. The overall benefits of long-acting b-agonists (LABAs), both as monotherapy and in combination with inhaled corticosteroids (ICS), in the treatment of chronic obstructive pulmonary disease (COPD) continue to outweigh any risks. However, healthcare professionals are reminded that ICS should not be used alone in COPD. A key issue
remains the increased risk of pneumonia associated with the use of ICS in COPD.


3.1.2    Antimuscarinic bronchodilators

Short acting antimuscarinic
Ipratropium aerosol inhaler, nebuliser solution
Long acting antimuscarinic
Tiotropium inhaler (Braltus)
Aclidinium inhaler
Glycopyrronium inhaler
Umeclidinium (Incruse Elipta)
LAMA / LABA combination devices
Aclidinium / formoterol (Duaklir Genuair) 
Indacaterol & glycopyrronium inhaler (Ultibro)
Tiotropium / olodaterol (Spioloto Respimat)


1. Tiotropium should be used as an alternative to salmeteriol (and in place of ipatropium) in pts with COPD who remain uncontrolled on short acting bronchodilators (i.e. step 2 or experience two or more exacerbations per year). It should only be continued if the patient demonstrates a subjective improvment (i.e. perform a two month trial).

2. When using tiotropium to treat chronic obstructive pulmonary disease (COPD), the risk of cardiovascular side effects should be taken into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:

• myocardial infarction in the last 6 months
• unstable or life threatening cardiac arrhythmia
• cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
• hospitalisation for heart failure (NYHA Class III or IV) within the past year

Patients at high risk of cardiovascular events  should have their tiotropium regularly reviewed.

Patients should be advised to report any worsening of cardiac symptoms after starting tiotropium. They should also be reminded not to exceed the recommended once daily dose.

For further detail see Drug Safety Update

Tiotropium (Braltus): risk of inhalation of capsule if placed in the mouthpiece of the inhaler. Reports have been received of patients who have inhaled a Braltus capsule from the mouthpiece into the back of the throat, resulting in coughing and risking aspiration or airway obstruction. Patients should be trained to place the Braltus capsule in the correct chamber of the Zonda inhaler. See Drug Safety update

3. See LAMA pathway here

3.1.3    Theophylline

Aminophylline MR tablets, injection,
Theophylline MR tablets, capsules


1. Bioequivalence of different brands of oral theophylline/aminophylline cannot be guaranteed. Patients should not change brands once stabilised unless plasma level monitoring is carried out. The brand name should always appear on prescriptions and in correspondence.

2. There is a wide inter-individual variation in theophylline/aminophylline dosing requirements.

3. Theophylline/aminophylline clearance can be reduced by impaired cardiac and hepatic function. Cimetidine,ciprofloxacin,diltiazemverapamil,erythromycin,clarithromycin and fluvoxamine can all lead to a serious increase in theophylline blood levels, and so such combinations should be avoided.

4. Theophylline clearance can increase in smokers, heavy drinkers, and with the concurrent use of phenytoin, carbamazepine and rifampicin

5. Slo-phyllin is recommended where a slow-release theophylline preparation is required in paediatrics and in the elderly, as the contents of the capsules may be emptied and administered in fluid.

6.  Link to UKMi document: “How is an iv aminophylline dose converted to an oral dose of aminophylline or theophylline?”

For link to BNF section: 3.1 Bronchodilators

3.1.4    Compound Bronchodilator Preparations

Salbutamol + Ipratropium nebuliser solution


Salbutamol and ipratropium nebuliser solutions may be mixed immediately prior to administration with no extra dilution for convenience. However, Combivent vials offer an alternative to mixing. 

For BNF section link: 3.1.4 Compound bronchodilator preparations 

3.1.5    Inhaler devices

Diskhaler - not recommended for new patients


3.1.6    Other agents

Rofluminast tablets – see notes (link to NICE Ta


Rofluminast is approved for add-on to bronchodilator therapy, is recommended as an option for treating severe chronic obstructive pulmonary disease in adults with chronic bronchitis, only if:

a.the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and

b.the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid

c.Treatment with roflumilast should be started by a specialist in respiratory medicine