What is the proper dosing and administration for an albuterol (albuterol sulfate) nebulizer treatment?

How to Order Albuterol Nebulizer

For adults, order albuterol nebulizer solution 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed; for children, order 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then every 1-4 hours as needed. 1

Standard Dosing Protocol

Adults

• Initial treatment: 2.5-5 mg every 20 minutes for 3 doses 1
• Maintenance: 2.5-10 mg every 1-4 hours as needed 1
• Severe exacerbations: 10-15 mg/hour by continuous nebulization 1, 2

Pediatric Patients

• Weight-based dosing: 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses 1, 3
• Maintenance: 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed 1
• Severe exacerbations: 0.5 mg/kg/hour by continuous nebulization 1, 3
• Children weighing <15 kg requiring <2.5 mg/dose should use 0.5% concentration instead of 0.083% 4

Routine Maintenance (Non-Acute)

• Adults and children ≥15 kg: 2.5 mg (one 3 mL vial of 0.083% solution) three to four times daily 4
• Children <5 years for routine therapy: 0.63 mg/3 mL via nebulizer 5

Preparation and Administration

Solution Preparation

• Dilute to minimum 3 mL total volume with normal saline for optimal aerosol delivery 1, 3, 5
• Use gas flow of 6-8 L/min 1, 2
• Treatment should take approximately 5-15 minutes 4

Equipment Setup

• Use jet nebulizers with compressed air or oxygen as driving gas 5
• Large-volume nebulizers are required for continuous administration 1
• For children, use properly fitted face mask covering nose and mouth 5

Adding Ipratropium for Severe Cases

For moderate to severe exacerbations, add ipratropium bromide to albuterol in the same nebulizer. 1, 2

• Adults: 0.5 mg ipratropium every 20 minutes for 3 doses 1
• Children: 0.25-0.5 mg ipratropium every 20 minutes for 3 doses 1
• Can mix both medications in the same nebulizer 1
• Ipratropium should not be used as first-line therapy alone 1

Alternative: MDI with Spacer

For mild-to-moderate exacerbations, MDI with valved holding chamber is equally effective as nebulized therapy when proper technique is used. 1, 2, 6

• Adults: 4-8 puffs (90 mcg/puff) every 20 minutes for up to 4 hours 1
• Children: 4-8 puffs every 20 minutes for 3 doses 1, 5
• Requires appropriate administration technique and coaching 1
• Use face mask for children <4 years 1

Monitoring Requirements

Clinical Response Assessment

• Reassess after each treatment cycle 2, 5
• Monitor for tachycardia, tremor, and hypokalemia with frequent dosing 3, 2, 5
• Response to treatment is a better predictor of hospitalization need than initial severity 2, 5

Signs of Treatment Failure

• Inability to speak 1
• Altered mental status 1
• Intercostal retractions 1
• Worsening fatigue 1
• PaCO2 ≥42 mm Hg 1

Common Pitfalls to Avoid

• Do not use ultrasonic nebulizers - they are ineffective for albuterol solutions 5
• Do not skip dilution - undiluted solutions may not nebulize properly 1, 3
• Do not delay adding ipratropium in severe cases - it significantly reduces hospitalization rates 2
• Do not continue nebulizer therapy beyond 3 hours for ipratropium - additional benefit has not been shown once hospitalized 1
• Higher doses than 2.5 mg every 20 minutes show no routine advantage in most patients 7

Levalbuterol Alternative

Levalbuterol can be used at half the milligram dose of albuterol with comparable efficacy. 1, 2

• Adults: 1.25-2.5 mg every 20 minutes for 3 doses 1, 2
• Children: 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses 1
• Has not been evaluated for continuous nebulization 1