What is the recommended dose of albuterol (bronchodilator) via nebulizer for an 18-month-old patient?

Albuterol Nebulizer Dosing for an 18-Month-Old

For an 18-month-old child, administer 0.075 mg/kg (minimum dose 1.25 mg) of albuterol via nebulizer every 20 minutes for 3 doses during acute exacerbations, then 0.075-0.15 mg/kg every 1-4 hours as needed. 1

Weight-Based Dosing Calculation

• Calculate the dose: For an average 18-month-old weighing approximately 11 kg, the calculated dose would be 0.075 mg/kg × 11 kg = 0.825 mg 1
• Apply the minimum dose: Since this calculated dose falls below the minimum recommended dose of 1.25 mg, administer the minimum dose of 1.25 mg per treatment 1
• This weight-based approach from the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines ensures safe and effective dosing for young children 1

Initial Treatment Protocol for Acute Exacerbations

• First hour: Administer 1.25 mg every 20 minutes for 3 doses 1
• Maintenance dosing: After initial treatment, give 1.25 mg every 1-4 hours as needed based on clinical response 1
• Severe exacerbations: For continuous nebulization in critically ill children, use 0.5 mg/kg/hour (approximately 5.5 mg/hour for an 11 kg child) 2

Preparation and Administration

• Dilution: Use the 1.25 mg/0.5 mL or 1.25 mg/3 mL formulation, diluting to a minimum total volume of 3 mL with normal saline for optimal aerosol delivery 2
• Flow rate: Set nebulizer gas flow at 6-8 L/min to deliver the medication over approximately 5-15 minutes 2, 3
• Face mask requirement: Children under 4 years of age require a face mask with valved holding chamber for proper delivery 1

Important Clinical Considerations

FDA-Approved Dosing Context

• The FDA label states that children weighing <15 kg who require <2.5 mg/dose should use albuterol inhalation solution 0.5% instead of 0.083% 3
• However, the NAEPP guidelines provide more specific weight-based dosing that supersedes this general FDA recommendation for acute exacerbations 1

Alternative to Nebulizer

• MDI with spacer: For mild-to-moderate exacerbations, a metered-dose inhaler with valved holding chamber can be equally effective as nebulized therapy when proper technique is used 1, 4
• This requires 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 1

Adjunctive Therapy

• Ipratropium bromide: For severe exacerbations, add 0.25-0.5 mg ipratropium to the albuterol nebulizer every 20 minutes for 3 doses 1
• This combination should only be used in the emergency department or initial hospital setting, as additional benefit has not been demonstrated once hospitalized 1

Monitoring and Safety

• Assess clinical response after each treatment, including respiratory rate, work of breathing, oxygen saturation, and auscultation 2
• Monitor for side effects: Watch for tachycardia, tremor, and hypokalemia, especially with frequent dosing 2
• Escalation criteria: If a previously effective dosage fails to provide relief, this signals seriously worsening asthma requiring immediate reassessment 3

Common Pitfalls to Avoid

• Do not automatically use 2.5 mg (the standard adult/older child dose) in toddlers—this exceeds the weight-based recommendation and increases unnecessary side effects 1
• Do not use levalbuterol at the same mg dose as albuterol—levalbuterol is administered at one-half the mg dose (0.0375 mg/kg, minimum 0.63 mg) for comparable efficacy 1
• Do not continue ipratropium beyond initial stabilization once the child is admitted to the hospital, as no additional benefit has been demonstrated 1