What is the recommended dosage of continuous albuterol (salbutamol) treatment for pediatric patients?

From the Guidelines

Continuous albuterol treatment for pediatric patients should start with 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed, or 0.5 mg/kg/hour by continuous nebulization, as recommended by the most recent guidelines 1.

Key Considerations

• The dose can be titrated based on clinical response and side effects, with a maximum dose of 10 mg every 1-4 hours as needed.
• For continuous nebulization, a dose of 0.5 mg/kg/hour is recommended, with a maximum dose of 10 mg/hour.
• The medication should be diluted in normal saline to create a total volume of 3 mL, depending on the delivery system.
• Continuous treatment requires cardiorespiratory monitoring due to potential side effects including tachycardia, hypokalemia, and tremors.
• Vital signs should be checked every 1-2 hours, and serum potassium and glucose levels should be monitored, especially in prolonged therapy.

Mechanism of Action

Continuous albuterol works by providing consistent bronchodilation through beta-2 adrenergic receptor stimulation, which relaxes bronchial smooth muscle.

Transition to Intermittent Treatment

As the patient improves, transition to intermittent treatments (typically 2.5-5 mg every 4-6 hours) should occur before discharge.

Important Notes

• Only selective beta2-agonists are recommended, and for optimal delivery, dilute aerosols to a minimum of 3 mL at gas flow of 6-8 L/min.
• Use large volume nebulizers for continuous administration, and may mix with ipratropium nebulizer solution 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm

The recommended dosage for continuous albuterol treatment in pediatrics is 2.5 mg administered three to four times daily by nebulization for children weighing at least 15 kg. For children weighing less than 15 kg, albuterol inhalation solution, 0.5% should be used instead of albuterol inhalation solution, 0.083%. The treatment can be continued as medically indicated to control recurring bouts of bronchospasm 2.

From the Research

Continuous Albuterol Treatment for Pediatrics Dosage

• The dosage of continuous albuterol for pediatrics can vary, with some studies suggesting a range of 2.5-20 mg/hr 3.
• A study published in 2015 found that high-dose continuous albuterol nebulization (75 or 150 mg/hr) was associated with a low rate of subsequent mechanical ventilation and fairly short PICU length of stay without significant toxicity 3.
• Another study published in 2021 found that there was no difference in adjusted length of stay or adjusted duration of continuous albuterol therapy among different weight-based dosage quintiles, ranging from 0.07-0.29 mg/kg/h to >0.76-3.2 mg/kg/h 4.
• A 2020 study compared two continuous nebulized albuterol doses (10 vs. 25 mg/h) and found that the lower dose was associated with lower fluid bolus resuscitation without increased adjunctive therapies 5.
• The safety and effectiveness of using a modified pediatric asthma score (PAS) to initiate/stop continuous albuterol as part of a score-based, RT-driven asthma pathway were evaluated in a 2022 study, which found that the use of this pathway was safe and effective in the PICU and step-down unit 6.
• A 2019 study implemented an RT-driven continuous albuterol weaning protocol using the Pediatric Asthma Severity Score (PASS) and found that it did not decrease the duration of continuous albuterol without increasing adverse events 7.

Key Findings

• The optimal dosage of continuous albuterol for pediatrics is not well established, with different studies suggesting different ranges and dosages.
• High-dose continuous albuterol nebulization may be associated with a low rate of subsequent mechanical ventilation and fairly short PICU length of stay without significant toxicity.
• Weight-based dosage quintiles may not be associated with differences in adjusted length of stay or adjusted duration of continuous albuterol therapy.
• Lower doses of continuous albuterol may be associated with lower fluid bolus resuscitation without increased adjunctive therapies.
• The use of a modified pediatric asthma score (PAS) to initiate/stop continuous albuterol as part of a score-based, RT-driven asthma pathway may be safe and effective in the PICU and step-down unit.