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Nebulised salbutamol or nebulised adrenaline for wheeze in anaphylaxis

Three Part Question

In [patients with anaphylaxis] is [nebulised salbutamol better than nebulised adrenaline] at [reducing wheeze]?

Clinical Scenario

A 33 year school teacher arrives in the Emergency Department following a trip to the local botanical gardens. She has breathing difficulty with extensive expiratory wheeze and a florrid urticarial rash. She was given salbutamol by nebulizer in the ambulance. She continued to wheeze in the Emergency Department and was given intra-muscular adrenaline. You wonder whether nebulised adrenaline would have worked for her wheeze as this was an acute allergic reaction/anaphylaxis and not asthma.

Search Strategy

Medline 1950 - February week 4 2009, using the Ovid interface
"((((anaphyla$.MP.) OR (allerg$.MP.) OR (hypersensitivity)) AND ((wheeze) OR (respirator$.MP.) OR (breath$.MP.))) AND ((adrenalin$.MP.) OR (salbutamol$.MP.) OR (epinephrin$.MP.) OR (salmeterol))) AND (nebulise$.MP.)"

Search Outcome

36 papers were found but none answered the specific question


There were no papers comparing nebulised salbutamol to nebulised adrenaline in the treatment of wheeze or respiratory difficulty in patients with an acute allergic reaction. Theoretically this could be subjected to a randomised controlled trial. Given the clinical urgency of bronchospasm in acute allergic reactions this is unlikely to happen.

Clinical Bottom Line

Patients with severe (life-threatening) acute allergic reactions should be treated with intramuscular adrenaline according to the Resuscitation Council Guidelines (2008).