T Asthalin Pediatric Dosage
For pediatric asthma exacerbations, administer salbutamol 2.5-5 mg via nebulizer (half doses for very young children) combined with ipratropium bromide 100-250 mcg every 20 minutes for 3 doses, then continue ipratropium every 6 hours until improvement begins. 1, 2
Initial Emergency Dosing
Salbutamol Component
- Standard dose: 5 mg via oxygen-driven nebulizer 1
- Very young children: Use half doses (2.5 mg) 1
- Frequency: Every 20-30 minutes for first hour, then every 4 hours if improving 1
- Maximum: 40 mg/day 1
Ipratropium Bromide Component
- Initial dosing: 100-250 mcg nebulized every 20 minutes for 3 doses 1, 2
- Maintenance: Continue every 6 hours until patient shows improvement 1, 2
- Very young children: 100 mcg per dose 1
When to Add Ipratropium
Add ipratropium bromide to salbutamol in the following situations:
- Moderate to severe exacerbations at presentation 2, 3
- No improvement after 15-30 minutes of initial beta-agonist therapy 1, 2
- Life-threatening features present (silent chest, cyanosis, altered consciousness, PEF <33% predicted) 1, 2
The combination therapy significantly reduces hospital admission risk by 21% compared to salbutamol alone (RR 0.79), with the greatest benefit seen in severe exacerbations where admission risk decreases by 27% (RR 0.73) 3. This evidence comes from a 2021 meta-analysis of 55 trials involving 6,396 pediatric patients, representing the highest quality recent evidence for this intervention.
Administration Technique
- Mix both medications in the same nebulizer 2
- Use oxygen-driven nebulizer at 6-8 L/min flow 2
- Dilute to minimum 3 mL total volume for optimal nebulization 2
- For children <4 years: Use spacer with face mask if using MDI 2
Alternative MDI Dosing
If nebulizer unavailable:
- Salbutamol MDI: 4-8 puffs every 20 minutes as needed 1, 2
- Ipratropium MDI: 4-8 puffs (18 mcg per puff) every 20 minutes for up to 3 hours 2
Critical Clinical Caveats
Do not continue ipratropium beyond initial stabilization once hospitalized - the addition provides no additional benefit after the first 3 hours or once the patient is admitted 2. The benefit is primarily in the emergency department setting during acute presentation.
Patients with heavy pre-presentation beta-agonist use (>10 puffs or serum salbutamol >2 mmol/L) show minimal additional benefit from ipratropium 4. However, given the difficulty of assessing this in real-time emergency situations, the combination should still be administered for moderate-severe presentations.
Monitor for response: Reassess peak flow 15-30 minutes after starting treatment 1. If no improvement, increase frequency of nebulized beta-agonist to every 30 minutes and ensure ipratropium is included 1.