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Chest Physiology Medicines: Inpatient & Outpatient Guide

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1. SHORT-ACTING BETA-2 AGONISTS (SABAs)

• Acute bronchospasm (asthma, COPD exacerbations)
• Exercise-induced bronchoconstriction (EIB)
• Acute severe asthma (inpatient: nebulized salbutamol continuous/intermittent)
• Pre-procedure bronchodilation

• Outpatient: Reliever inhaler, PRN use
• Inpatient: Continuous/frequent nebulization in acute exacerbations, ICU

• Hypersensitivity to drug
• Uncorrected hypokalemia (caution — SABAs worsen hypokalemia)
• Severe tachycardia / tachyarrhythmias (relative)
• Hypertrophic obstructive cardiomyopathy (HOCM)
• Thyrotoxicosis (relative)

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2. LONG-ACTING BETA-2 AGONISTS (LABAs)

• Maintenance therapy in asthma (NEVER as monotherapy — must be combined with ICS)
• COPD maintenance (with or without LAMA)
• Prevention of nocturnal symptoms

• Outpatient: Standard maintenance, combined with ICS or LAMA
• Inpatient: Continued during admission; may be added on discharge

• Asthma monotherapy without ICS (BLACK BOX WARNING — increases asthma mortality)
• Hypersensitivity
• Acute severe asthma attack (use SABA instead)

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3. SHORT-ACTING MUSCARINIC ANTAGONISTS (SAMAs)

• COPD exacerbations (often combined with SABA)
• Acute severe asthma (adjunct)
• Chronic bronchitis
• Rhinorrhea (nasal spray)

• Outpatient: COPD reliever, alternative to SABAs
• Inpatient: Nebulized ipratropium + salbutamol combo (Duovent) in COPD & asthma exacerbations

• Narrow-angle glaucoma (systemic absorption risk)
• Urinary retention / BPH (relative)
• Hypersensitivity to atropine or derivatives

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4. LONG-ACTING MUSCARINIC ANTAGONISTS (LAMAs)

• COPD maintenance (first-line)
• Asthma (add-on in poorly controlled cases, ≥6 years with tiotropium)
• Reduction of COPD exacerbations

• Outpatient: Core of COPD maintenance therapy
• Inpatient: Continue during admission; initiate before discharge if newly diagnosed

• Narrow-angle glaucoma (use with extreme caution)
• Urinary retention / benign prostatic hypertrophy
• Hypersensitivity

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5. INHALED CORTICOSTEROIDS (ICS)

• Persistent asthma (mild–severe) — cornerstone of maintenance
• COPD with frequent exacerbations + eosinophilia (blood eos ≥300/µL)
• COPD-asthma overlap (ACO) — ICS mandatory
• Eosinophilic bronchitis

• Outpatient: Daily maintenance in persistent asthma; stepwise add-on in COPD
• Inpatient: Nebulized budesonide alternative/adjunct to systemic steroids in moderate exacerbations

• Active pulmonary tuberculosis (use with caution — relative CI)
• Untreated fungal/bacterial respiratory infection
• Hypersensitivity

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6. SYSTEMIC CORTICOSTEROIDS

• Acute severe asthma (inpatient IV methylprednisolone)
• COPD acute exacerbation (AECOPD) — oral prednisolone 40 mg/day × 5 days
• Status asthmaticus
• Allergic bronchopulmonary aspergillosis (ABPA)
• Hypersensitivity pneumonitis

• Inpatient: IV methylprednisolone for severe/life-threatening attacks; improves FEV1, oxygenation, reduces hospitalization (GOLD 2025, p. 128, Evidence A)
• Outpatient: Short course oral prednisolone for moderate exacerbations; rescue packs for COPD patients

• Active peptic ulcer disease (relative — use PPI cover)
• Uncontrolled diabetes (relative — monitor glucose)
• Active systemic infections (fungal, TB — relative)
• Osteoporosis (long-term — relative)
• Duration should NOT exceed 5 days in COPD exacerbations (GOLD 2025, p. 128)

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7. METHYLXANTHINES

• Severe refractory asthma (add-on, inpatient IV aminophylline)
• COPD — adjunct when bronchodilators insufficient (low-dose theophylline)
• Neonatal apnea (caffeine/theophylline)
• Central apnea

• Inpatient: IV aminophylline in severe/life-threatening asthma (with continuous ECG monitoring)
• Outpatient: Low-dose oral theophylline in COPD/asthma (declining use due to toxicity)

• Epilepsy / seizure disorders
• Cardiac arrhythmias
• Hyperthyroidism
• Acute peptic ulcer
• GOLD 2025 recommends against methylxanthines in COPD exacerbations due to increased side effect profiles (p. 128, Evidence B)

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8. MUCOLYTICS / EXPECTORANTS

• COPD with chronic productive cough
• Bronchiectasis
• Cystic fibrosis (Dornase alfa)
• Acute bronchitis

• Outpatient: Oral carbocisteine/NAC in COPD, bronchiectasis
• Inpatient: Nebulized NAC; IV NAC for paracetamol overdose

• Active peptic ulcer (carbocisteine)
• Hypersensitivity
• Dornase alfa: not indicated outside cystic fibrosis

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9. LEUKOTRIENE RECEPTOR ANTAGONISTS (LTRAs)

• Mild persistent asthma (add-on or alternative to low-dose ICS)
• Allergic rhinitis + asthma (dual benefit)
• Exercise-induced bronchoconstriction
• Aspirin-exacerbated respiratory disease (AERD)

• Outpatient: Step 2–3 add-on therapy in asthma
• Not typically used inpatient acutely

• Hypersensitivity
• Neuropsychiatric effects (FDA black box: depression, suicidality — especially in children)
• Not for acute attacks

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10. BIOLOGICS / MONOCLONAL ANTIBODIES

• Severe uncontrolled allergic asthma (Omalizumab — high IgE, aeroallergen sensitized)
• Severe eosinophilic asthma (Mepolizumab, Benralizumab — eos ≥300/µL)
• Severe asthma with T2 inflammation (Dupilumab, Tezepelumab)
• COPD with eosinophilic phenotype (Dupilumab — FDA-approved 2024)

• Outpatient: Specialist clinic, subcutaneous injections
• Inpatient: Not used acutely

• Acute asthma attack (ineffective acutely)
• Hypersensitivity to the biologic
• Active parasitic (helminth) infection (Omalizumab relative CI)

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11. PHOSPHODIESTERASE-4 (PDE4) INHIBITORS

• Severe COPD (FEV1 <50%) with chronic bronchitis phenotype and frequent exacerbations
• Add-on to LABA/LAMA when exacerbations persist

• Outpatient only (maintenance)

• Moderate-to-severe hepatic impairment
• Depression / suicidal ideation
• Pregnancy / breastfeeding
• Underweight patients (causes weight loss)

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12. NON-INVASIVE VENTILATION (NIV) / OXYGEN THERAPY

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COMBINATION THERAPY CHART

COPD — Drug Combination Ladder (GOLD 2025)

DISEASE SEVERITY / EXACERBATION RISK ──────────────────────────────────────►

┌─────────────────┬──────────────────────────────────────────────────────────────────────────────────┐
│   COPD GROUP    │  PREFERRED COMBINATION THERAPY                                                   │
├─────────────────┼──────────────────────────────────────────────────────────────────────────────────┤
│  Group A        │  SABA (PRN) or SAMA (PRN)                                                        │
│  (Low symptoms, │  → Monotherapy only                                                               │
│  low risk)      │  e.g., Salbutamol MDI PRN                                                        │
├─────────────────┼──────────────────────────────────────────────────────────────────────────────────┤
│  Group B        │  LAMA alone  OR  LABA alone  OR  LABA + LAMA                                     │
│  (More symptoms,│  e.g., Tiotropium  OR  Indacaterol                                                │
│  low risk)      │  OR Umeclidinium/Vilanterol (LAMA+LABA fixed-dose)                               │
├─────────────────┼──────────────────────────────────────────────────────────────────────────────────┤
│  Group E        │  LABA + LAMA  (first-line, all patients)                                         │
│  (High          │  If eos ≥300/µL  OR  ACO features → LABA + LAMA + ICS (TRIPLE)                  │
│  exacerbation   │  e.g., Budesonide/Glycopyrronium/Formoterol (Breztri)                            │
│  risk)          │  OR Fluticasone furoate/Umeclidinium/Vilanterol (Trelegy)                        │
│                 │  + Add Roflumilast if FEV1<50% + chronic bronchitis                              │
│                 │  + Add Azithromycin (macrolide prophylaxis) in ex-smokers                        │
└─────────────────┴──────────────────────────────────────────────────────────────────────────────────┘

COPD Combination Drugs (Named Products)

Key GOLD 2025 Principle (p. 98): LABA+ICS alone is discouraged in COPD. If ICS is indicated, the preferred regimen is LABA+LAMA+ICS triple therapy, which is superior to LABA+ICS in reducing exacerbations, improving lung function, and may reduce mortality. (Evidence A)

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ASTHMA — Stepwise Combination Therapy (GINA 2024)

Asthma Combination Drugs (Named Products)

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Head-to-Head: COPD vs. Asthma Combination Strategy

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Sources: Global Strategy for Prevention, Diagnosis and Management of COPD 2025 Report (GOLD), pp. 98, 128 | GINA 2024 | Harrison's Principles of Internal Medicine | BTS/SIGN Asthma Guidelines