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3.1 Bronchodilators

3.1 Bronchodilators

 3.1.1 Adrenoceptor agonists Selective beta2-agonists

GREEN      Salbutamol 
                   metered dose inhaler (MDI) 100micrograms/inhalation 
                   breath-actuated inhaler 100 microgram/inhalation (Airomir Autohaler®)  
                   breath actuated dry powder  inhaler 100mcg/inhalation (Salbutamol Easyhaler®)
                   breath actuated dry powder inhaler 200mcg/inhalation (Salbutamol Easyhaler®)
                   dry powder inhaler 200 microgram/blister (Ventolin Accuhaler®)  
                   nebuliser solution 2.5mg/2.5ml, 5mg/2.5mL
                   syrup 2mg/5mL
RED           Salbutamol
                   injection 500 microgram/mL
                   solution for intravenous infusion 5mg/5mL
GREEN      Terbutaline
                   dry powder inhaler 500 microgram/inhalation (Bricanyl Turbohaler®)  
                   nebules 5mg/2mL          
Longer acting beta 2  - agonists
Use regularly in addition to inhaled corticosteroids and inhaled bronchodilators for improved control as described in Step 3
of BTS guidelines. Comparative costs for longer acting beta2 - adrenoceptor stimulants are indicated.
Formoterol should only be used in accordance with national and local guidance on the management of asthma or COPD. In 
asthma it should not be used as monotherapy, but be used alongside inhaled corticosteroids as per MHRA advice.
Formoterol metered dose inhaler (MDI) presented as the brand Easyhaler® is the first line long acting beta-2 agonist of choice 
within East Lancashire.
GREEN       Formoterol
                    dry powder for inhaler 12 microgram/inhalation (Easyhaler Formoterol ®)
GREEN       Formoterol 
                    dry powder inhaler 6 microgram/metered inhalation (Oxis Turbohaler®)  
                    dry powder inhaler 12 microgram/metered inhalation (Oxis Turbohaler®) 
Second line option
GREEN       Salmeterol 
                    metered dose inhaler (MDI) 25 microgram/inhalation (Serevent®)
                    dry powder inhaler 50 microgram/blister (Serevent Accuhaler®) 
Third line option for patients with moderate COPD who are having difficulties with either compliance or the inhaler device.
GREEN      Indacaterol  
                   dry powder hard capsule 150, 300 microgram (Onbrez Breezhaler®)
                   Note minimum inspiratory flow rate required 50L/min  

3.1.2 Antimuscarinic bronchodilators

For relieving bronchoconstriction in COPD as an alternative to beta2 -agonists. Ipratropium is a short acting muscarinic antagonist 
whilst Tiotropium is long acting. Tiotropium is an option at step 2 of the local guidelines in those patients with persistant
GREEN      Ipratropium bromide 
                   metered dose inhaler (MDI) 20micrograms/inhalation
                   nebuliser solution 250micrograms/mL
GREEN      Tiotropium inhaler (Braltus®  Zonda inhaler) 
                  (Braltus 10 microgram per delivered dose inhalation powder, hard capsule) 
Add on maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease
Note:  Ipratropium should be discontinued when tiotropium is introduced.
GREEN     Tiotropium Spiriva®  Respimat   ®
N.B. Braltus is the preferred Tiotropium product.The Tiotropium Respimat is restricted for use in COPD patients to those who have poor 
         manual dexterity and difficulty using the Handihaler®  
Add on maintenance bronchodilator treatment in adult patients with Asthma who meet all of the following criteria:
          >     persistent airflow limitation demonstrated by an FEV¹ <80% predicted and a ratio of FEV¹/FVC  <70% and
          >     currently treated with the maintenance combination of inhaled corticosteroids (>800 micrograms budesonide/day or
                 equivalent*) and long acting ß² agonists and 
          >     experienced one or more severe exacerbations in the previous year. 
Second line ONLY where Tiotropium is not appropriate, not tolerated or there is difficulty using the device.  
Glycopyrronium bromide inhaler is available in a new device which requires lower inspiratory rate and enables visual compliance.
GREEN      Glycopyrronium bromide, inhaler (Seebri Breezhaler®) 
3rd line ONLY where Tiotropium is not tolerated or there is difficulty using the device. 
GREEN      Aclidinium bromide, inhalation powder (Eklira Genuair®)
3rd line option when Tiotropium is not tolerated or the device cannot be used effectively
Long acting Antimuscarinic bronchodilators in combination with Long-Acting Beta² agonists (LAMA/LABA)
GREEN     Tiotropium  and  olodaterol 
                  (Spiolto® Respimat 2.5 microgram/2.5 microgram, inhalation solution) 
Spiolto® Respimat is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic
obstructive pulmonary disease (COPD).
GREEN    Glycopyrronium bromide 85mcg/Indacterol maleate 43mcg inhalation powder 
                 capsule device.  (Ultibro®Breezhaler dry powder inhaler)
GREEN    Aclidinium  and fomoterol 
                 (Duaklir® Genuair 340 micrograms /12 micrograms inhalation powder)
Duaklir Genuair is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic 
obstructive pulmonary disease (COPD)    
Triple combination inhaler (ICS + LAMA +LABA)
Trimbow® inhaler  - link to guideline
First line use in Patient Group D, where patient requires Triple Therapy (LAMA+LABA+ICS) (single combination inhaler, dose 2 puffs 
(Use reserved for patients who have failed to achieve or maintain an adequate response to an appropriate course of dual
GREEN   Beclomethasone 87mcg, formoterol fumarate 5mcg, glycopyrronium bromide 9mcg 
               (Trimbow®pMDI)   (dose = 2 puffs twice daily)

3.1.3 Theophylline

Used for reversible airways obstruction. Narrow margin between therapeutic and toxic dose. Prescribe oral preparations by brand 
GREEN      Theophylline (Uniphyllin®) tablets m/r 200mg, 300mg, 400 mg      
Other preparations 
AMBER     Aminophylline tablets 225mg, 350mg 
RED           Aminophylline injection 25mg/ml, 10mL ampoule 
RED           Caffeine citrate oral solution 50mg/5mL (unlicensed) 
RED           Caffeine citrate intravenous injection 10mg/2mL (NICU only) (unlicensed) 
Note: caffeine 10mg = caffeine citrate 20mg.
To avoid confusion these preparations must always be prescribed as CAFFEINE CITRATE.

3.1.4 Compound bronchodilator preparations

In COPD, salbutamol alone should be used first line
GREEN     Combivent® nebuliser solution - (ipratropium 500 microgram & salbutamol 2.5mg/ 2.5ml vial)

3.1.5 Peak flow meters, inhaler devices and nebulisers

Patients who require a spacer device for the first time with Allen & Hanbury inhalers (e.g. Ventolin® and Serevent® brands) should
be prescribed a Volumatic spacer device.  Aerochamber® is an alternative for other inhalers brands as it is less bulky and fits all 
If you are prescribing any spacer device to a patient for the first time, these patients should be monitored frequently in the normal
way for the emergence of or worsening of symptoms of disease or adverse effects. Any patients who are switched to a different 
device should be regarded in the same way as new patients, and the same careful monitoring is required.
For inhaled ß2 agonist bronchodilators the most frequent signs of toxicity are headache, tremor and palpitations; for inhaled 
corticosteroids the most serious concern from over exposure is adrenal suppression and particularly when high doses are 
administered to children and adolescents.
GREEN      Nebuchamber® 
GREEN      Volumatic® 
GREEN      AeroChamber Plus® 
GREEN      Pari Vortex®
GREEN      Space Chamber Plus®
GREEN      Compact Space Chamber Plus®
GREEN      AeroChamber® Plus Flow-Vu anti-static device


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