What is the usual dose of Atrovent (ipratropium bromide)?

Atrovent (Ipratropium Bromide) Usual Dosing

For adults with chronic obstructive pulmonary disease, the usual maintenance dose of ipratropium bromide is 500 mcg (2 puffs of 18 mcg each from MDI, or 1 unit-dose vial via nebulizer) administered 3-4 times daily, with doses spaced 6-8 hours apart. 1

Adult Dosing by Indication

Chronic Maintenance Therapy (COPD/Chronic Bronchitis)

• Nebulizer solution: 500 mcg (one 2.5 mL unit-dose vial) administered 3-4 times daily via oral nebulization, with doses 6-8 hours apart 1
• Metered-dose inhaler (MDI): 2 puffs (36 mcg total) four times daily, with a maximum of 12 inhalations per day 2
• The bronchodilatory effect typically begins within 15 minutes, with peak effect at approximately 1 hour and duration of 3-5 hours 3, 2

Acute Asthma Exacerbations (Adjunctive Therapy)

• Nebulizer: 0.5 mg every 20 minutes for 3 doses, then as needed 4
• MDI: 8 inhalations every 20 minutes as needed for up to 3 hours 4
• Critical caveat: Ipratropium should NOT be used as first-line monotherapy for acute asthma; it must be added to short-acting beta-agonist (SABA) therapy for moderate to severe exacerbations 4, 5

Pediatric Dosing

Children Under 12 Years (Acute Exacerbations)

• Nebulizer: 0.25-0.5 mg every 20 minutes for 3 doses, then as needed 6, 4, 5
• Very young children may use half doses (approximately 100 mcg) 4
• MDI: 4-8 inhalations every 20 minutes as needed for up to 3 hours 4, 5
• For children under 4 years, use with a spacer device and facial mask 4, 7

Children 12 Years and Older

• Use adult dosing: 0.5 mg nebulized every 20 minutes for 3 doses 6

Combination Therapy with Albuterol

Ipratropium can be mixed with albuterol in the same nebulizer if used within one hour 1:

Adults

• Nebulizer: 3 mL of combination solution every 20 minutes for 3 doses, then as needed 4
• MDI: 8 inhalations every 20 minutes as needed for up to 3 hours 4

Children

• Nebulizer: 1.5 mL of combination solution (containing 0.25 mg ipratropium + 1.25 mg albuterol) every 20 minutes for 3 doses 4, 7
• MDI: 4-8 inhalations every 20 minutes as needed for up to 3 hours 4, 5

Important Clinical Considerations

Timing and Context

• After initial management of acute exacerbations, ipratropium may not provide additional benefit once the patient is hospitalized or stabilized 4, 5, 7
• In acute settings, continue every 6 hours after the initial 3 doses until improvement begins 4
• The delayed onset of action (15 minutes) makes it unsuitable as sole therapy for acute bronchospasm 2

Administration Technique

• Use oxygen-driven nebulizer at 6-8 L/min flow 4
• Dilute to minimum of 3 mL for optimal nebulization 4
• Ensure proper mask fit for pediatric patients to maximize delivery 7

Common Pitfalls to Avoid

• Do not use as monotherapy for acute asthma exacerbations 4, 5
• Do not exceed 12 inhalations per day for chronic maintenance therapy 2
• Do not mix with other drugs besides albuterol or metaproterenol without established stability data 1

Adverse Effects

• Generally mild: dry mouth, cough, nausea, dizziness, nervousness 2
• May cause drying of respiratory secretions 7
• Rarely, increased wheezing in some individuals 7