Pediatric Albuterol Dosing for Asthma Exacerbation
For pediatric asthma exacerbations, the recommended albuterol dosing via MDI is 4-12 puffs with a valved holding chamber every 20-30 minutes for the first hour, then adjusted based on response. 1
Dosing by Administration Method
Metered-Dose Inhaler (MDI)
- Children <15 kg: 4-8 puffs via MDI with valved holding chamber every 20 minutes for 3 doses, then as needed 2, 1
- Children ≥15 kg: 4-12 puffs via MDI with valved holding chamber every 20-30 minutes for 3 doses, then as needed 1
- Always use a spacer with valve and face mask for children under 10 kg 1
Nebulizer
- Children <15 kg: 0.15 mg/kg (minimum dose 1.25 mg) every 20 minutes for 3 doses, then 0.075-0.15 mg/kg every 1-4 hours as needed 2
- Children ≥15 kg: 2.5 mg every 20 minutes for 3 doses, then every 4-6 hours as needed 2, 1, 3
- For children weighing <15 kg who require <2.5 mg/dose, use 0.5% albuterol solution instead of 0.083% 3
Treatment Approach Based on Exacerbation Severity
Mild Exacerbations
- 4-12 puffs via MDI with valved holding chamber every 20-30 minutes for 3 doses 1
- Reassess after initial treatment
Moderate to Severe Exacerbations
- 3 treatments of albuterol administered every 20-30 minutes 2, 1
- Consider adding ipratropium bromide for patients with incomplete or poor response 1, 4
- Ipratropium has been shown to significantly reduce hospitalization rates in children with severe asthma exacerbations (37.5% vs 52.6%) 4
- For severe cases, consider continuous nebulization at 0.5 mg/kg/hour (up to 20 mg/hour) 1, 5
Monitoring and Safety Considerations
- Monitor respiratory rate, work of breathing, and oxygen saturation in all children 1
- Continuous monitoring is essential for patients receiving high doses or continuous nebulization 1
- Watch for potential side effects:
- Cardiac effects (tachycardia)
- Electrolyte disturbances (hypokalemia)
- Tremor, hyperactivity, and vomiting 6
Important Clinical Pearls
- Approximately 60-70% of patients will respond sufficiently to initial 3 doses to be discharged 1
- High-dose albuterol (0.15 mg/kg) has been shown to be more effective than low-dose (0.05 mg/kg) in improving lung function and reducing hospitalization rates in severe asthma, without significant differences in side effects 6
- Continuous nebulization (0.3 mg/kg/hr) has similar efficacy and safety to intermittent nebulization (0.15 mg/kg every 30 minutes) but may be more efficient in terms of healthcare provider time 7
- Research has not identified an optimal weight-based dose of continuous albuterol, with doses ranging from 0.07-3.2 mg/kg/hr showing similar outcomes 5
Administration Tips
- Dilute albuterol in a minimum of 2-3 mL of saline solution for adequate nebulization 1
- Administer the entire contents of one sterile unit-dose vial (3 mL of 0.083% solution) by nebulization over approximately 5-15 minutes 3
- If a previously effective dosage regimen fails to provide relief, seek medical advice immediately as this may indicate worsening asthma requiring reassessment 3
Remember that albuterol dosing should be adjusted based on clinical response, with close monitoring for both efficacy and potential side effects.