Glycopyrrolate Nebulization in Children
For status asthmaticus/bronchospasm in children, nebulized glycopyrrolate should be dosed at 0.25 mg every 20 minutes for up to 3 doses in children <12 years old, and 0.5 mg every 20 minutes for up to 3 doses in children ≥12 years old, using a 0.25 mg/mL nebulized solution. 1
Dosing Specifications
Age-Based Dosing for Bronchospasm
- Children <12 years: 0.25 mg nebulized every 20 minutes for up to 3 doses 1
- Children ≥12 years: 0.5 mg nebulized every 20 minutes for up to 3 doses 1
- Solution concentration: 0.25 mg/mL 1
Administration Details
- Can be mixed with albuterol for combined nebulization 1
- Should NOT be used as first-line therapy - reserve as adjunct to β-agonists 1
- Administer via oxygen-driven nebulizer in acute settings 1
Clinical Context and Positioning
When to Use Nebulized Glycopyrrolate
Glycopyrrolate nebulization is indicated specifically as an adjunct to β-agonists for status asthmaticus or severe bronchospasm 1. The American Academy of Pediatrics guidelines position this as second-line therapy after initial β-agonist treatment has been initiated 1.
Comparison with Ipratropium
While the guidelines specifically address glycopyrrolate dosing, note that ipratropium bromide (250 mcg nebulized six hourly) is more commonly referenced in pediatric asthma guidelines 1. Both are anticholinergic agents, but ipratropium has more established use patterns in acute pediatric asthma 1.
Important Clinical Caveats
Anticholinergic Side Effects
- Monitor for dry mouth, constipation, and urinary retention 2
- Behavioral changes can occur in 18-36% of patients on chronic anticholinergic therapy 2
- Glycopyrrolate has poor blood-brain barrier penetration, resulting in limited central nervous system effects compared to other anticholinergics 3
Duration of Action
Research demonstrates that inhaled glycopyrrolate provides prolonged bronchodilation lasting 8-30 hours in asthma patients, significantly longer than ipratropium 4, 5. However, in acute settings, the guideline-recommended dosing interval remains every 20 minutes for up to 3 doses 1.
Secretion Management Considerations
Despite glycopyrrolate's antisialogogue properties, it does not reduce perioperative respiratory adverse events in children with upper respiratory infections when given for secretion control 6. This finding suggests its primary utility in pediatrics is for bronchodilation rather than secretion management in the acute respiratory setting 6.
Alternative Delivery Systems
Metered-dose inhalers with spacers are preferred over nebulizers when feasible, as they are cheaper and more convenient 1. However, nebulizers remain necessary for children who cannot tolerate spacers or face masks, or in acute severe presentations 1.
Practical Algorithm for Acute Asthma
- First-line: High-flow oxygen + nebulized β-agonist (salbutamol 5 mg or 0.15 mg/kg) 1
- Add glycopyrrolate if inadequate response: 0.25 mg (age <12 years) or 0.5 mg (age ≥12 years) every 20 minutes × 3 doses 1
- Consider systemic corticosteroids concurrently (prednisolone 2 mg/kg/day, max 40 mg) 1
- Escalate to aminophylline infusion if continued deterioration 1