Drug Doses for Atrovent and Albuterol
Albuterol Dosing
For acute asthma or COPD exacerbations, administer albuterol 2.5-5 mg via nebulizer every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed; or 4-8 puffs via MDI every 20 minutes for 3 doses, then every 1-4 hours as needed. 1
Nebulizer Administration
- Adults and children ≥12 years: 2.5-5 mg every 20 minutes for 3 doses initially, then 2.5-10 mg every 1-4 hours based on clinical response 1
- Children <12 years: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg (up to 10 mg) every 1-4 hours as needed 1
- Continuous nebulization for severe cases: 10-15 mg/hour in adults; 0.5 mg/kg/hour in children 2, 3
- Dilute to minimum 3 mL with normal saline at gas flow of 6-8 L/min 2, 4
MDI Administration
- Adults and children ≥12 years: 4-8 puffs every 20 minutes for up to 4 hours, then every 1-4 hours as needed 1
- Children <12 years: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 1
- Always use with valved holding chamber (VHC); add face mask for children <4 years 1, 2
- MDI plus VHC is as effective as nebulized therapy in mild-to-moderate exacerbations with proper technique 1, 2
Chronic Maintenance (COPD)
- Standard dosing: 200 µg (2 puffs) via MDI up to four times daily for stable disease 1
- Most patients achieve adequate bronchodilation with standard hand-held inhaler doses 1
Ipratropium Bromide (Atrovent) Dosing
For acute exacerbations, administer ipratropium 500 µg via nebulizer every 20 minutes for 3 doses, then as needed; or 8 puffs via MDI every 20 minutes for up to 3 hours. 1
Nebulizer Administration
- Adults: 500 µg (0.5 mg) every 20 minutes for 3 doses, then as needed 1
- Children: 250-500 µg every 20 minutes for 3 doses, then as needed 1
- Can be mixed in same nebulizer with albuterol if used within one hour 5
MDI Administration
- Adults: 8 puffs (18 µg/puff) every 20 minutes as needed for up to 3 hours 1
- Children: 4-8 puffs every 20 minutes as needed for up to 3 hours 1
- Use with VHC and face mask for children <4 years 1
Chronic Maintenance
- Standard dosing: 500 µg (one unit-dose vial) three to four times daily, with doses 6-8 hours apart 5
- Alternative: 40-80 µg (2 puffs) via MDI up to four times daily 1
Combination Therapy
Adding ipratropium to albuterol provides superior bronchodilation compared to either agent alone, particularly during the first 4 hours after administration. 6, 7
Pre-mixed Combination (Albuterol/Ipratropium)
- Nebulizer solution - Adults: 3 mL (containing 2.5 mg albuterol + 0.5 mg ipratropium) every 20 minutes for 3 doses, then as needed 1
- Nebulizer solution - Children: 1.5 mL every 20 minutes for 3 doses, then as needed 1
- MDI - Adults: 8 puffs (each puff = 90 µg albuterol + 18 µg ipratropium) every 20 minutes for up to 3 hours 1
- MDI - Children: 4-8 puffs every 20 minutes for up to 3 hours 1
When to Use Combination
- Should be added to SABA therapy for severe exacerbations 1
- Particularly beneficial in COPD exacerbations requiring hospital admission 1
- Consider for patients with poor response to albuterol alone 1
Critical Clinical Considerations
Acute Exacerbations
- Do not use ipratropium as first-line monotherapy - always combine with or add to SABA 1
- The addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized beyond the emergency department 1
- Studies examining ipratropium MDI are limited to up to 3 hours of use 1
COPD-Specific Warnings
- In patients with CO₂ retention and acidosis, drive nebulizer with air, not high-flow oxygen 1
- For acute COPD exacerbations, use nebulized bronchodilators 4-6 hourly for 24-48 hours or until clinical improvement 1
- Change to hand-held inhaler and observe 24-48 hours before hospital discharge 1