Subcutaneous terbutaline as an alternative to metered-dose inhalers for asthma during the COVID-19 pandemic.

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In a well-written and informative article, Whittle et al1 “Respiratory Support for Adult Patients with COVID-19,” correctly recommend against using nebulizer therapy for asthmatics and suggests metered-dose inhalers. During the COVID-19 epidemic, asthmatics will continue to have exacerbations, frequently requiring emergency room care in a physician's office, urgent care center, or emergency department of a hospital. It is recommended that asthmatic patients continue to be managed according to asthma guideline recommendations.2 Nebulizer use is discouraged unless essential during a pandemic because nebulized therapy is more likely to aerosolize SARS-CoV-2 and increase risk of contagion. As such, asthma therapy delivered by a metered-dose inhaler would be more appropriate in the healthcare setting.3 Nevertheless, some patients are so tight that using a metered-dose inhaler, even with a spacer, might be problematic, particularly if they have uncontrolled coughing, have severe life-threatening asthma, or those who are uncooperative or unable to follow directions required for the metered-dose inhaler, even with a spacer. A recent article4 demonstrated that, in a prospective study, 85 asthmatic patients treated with subcutaneous terbutaline significantly improved after already receiving multiple albuterol treatments with either nebulized aerosols or albuterol metered-dose inhalers. Advantages of terbutaline over epinephrine include: (1) a more pronounced effect with a longer duration of action on forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC),5 and (2) preferred over epinephrine in pregnancy.6 Terbutaline is inexpensive and readily accessible, even though a previous survey of physicians in the Cleveland area reveal that 98% of physicians rarely or never use subcutaneous terbutaline for an exacerbation of asthma.7 From a colleague in New York City reading about my work with terbutaline, “This is great! Not only that, but the feasibility of subcutaneous terbutaline as an administration route during a high-volume/war-like situation is underappreciated.” Additionally, the American College of Allergy, Asthma, and Immunology (ACAAI) has reported that some areas around the country are experiencing shortages in albuterol inhalers as a result of an increased demand, because hospitals are using inhalers rather than nebulizers to treat COVID-19 patients.8 Finally, although metered-dose inhalers frequently work, the use of subcutaneous terbutaline would obviate the need for these inhalers or aerosols.