What is the recommended dosing for albuterol (salbutamol) inhalation solution for nebulization in treating acute bronchospasm or asthma exacerbations?

Albuterol Inhalation Solution for Nebulization Dosing

Acute Asthma Exacerbations

For adults with acute asthma exacerbations, administer 2.5-5 mg of albuterol nebulizer solution every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed. 1, 2, 3

Initial Treatment Phase (First Hour)

Adults:

• 2.5-5 mg every 20 minutes for 3 doses 1, 2, 3
• Dilute aerosols to minimum of 3 mL at gas flow of 6-8 L/min 1, 2
• Delivery should occur over approximately 5-15 minutes 4

Children:

• 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses 1, 2
• Children weighing <15 kg who require <2.5 mg/dose should use 0.5% concentration instead of 0.083% 4

Ongoing Treatment (After Initial 3 Doses)

Adults:

• 2.5-10 mg every 1-4 hours as needed based on response 1, 2

Children:

• 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed 1

Continuous Nebulization for Severe Exacerbations

Adults:

• 10-15 mg/hour continuously 1, 2, 3
• Use large volume nebulizers for continuous administration 1

Children:

• 0.5 mg/kg/hour by continuous nebulization 1, 2

Maintenance Dosing (Non-Acute)

For routine bronchospasm control, the FDA-approved dosing is 2.5 mg administered three to four times daily by nebulization for adults and children weighing at least 15 kg. 4

Critical Adjunctive Therapy

Add ipratropium bromide 0.5 mg (adults) or 0.25-0.5 mg (children) to albuterol every 20 minutes for 3 doses in moderate to severe exacerbations. 1, 2, 5

• May mix ipratropium directly in the same nebulizer with albuterol 1
• This combination significantly reduces hospitalization rates in severe exacerbations 2

Administer systemic corticosteroids early: prednisone 40-60 mg daily for adults or 1-2 mg/kg/day (maximum 60 mg/day) for children. 2, 5

Alternative: Levalbuterol (R-albuterol)

Levalbuterol provides comparable efficacy at half the milligram dose of racemic albuterol. 1, 2

Adults:

• 1.25-2.5 mg every 20 minutes for 3 doses, then 1.25-5 mg every 1-4 hours as needed 1, 2

Children:

• 0.075 mg/kg (minimum dose 1.25 mg) every 20 minutes for 3 doses, then 0.075-0.15 mg/kg up to 5 mg every 1-4 hours as needed 1, 2

Important Clinical Considerations

Reassessment Strategy

• Response to treatment is a better predictor of hospitalization need than initial severity. 2, 5
• Reassess after initial 3 doses using subjective symptoms, physical examination, and FEV₁ or peak flow measurements 5

Monitoring for Complications

• Watch for signs of impending respiratory failure: inability to speak in full sentences, altered mental status, intercostal retractions, worsening fatigue, and PaCO₂ ≥42 mm Hg 1, 5
• Monitor for beta-agonist toxicity: tachycardia, tremor, and hypokalemia, especially with frequent or high-dose administration 2, 5

Common Pitfalls to Avoid

• Higher doses than recommended (>15 mg/hour continuous) offer no advantage over standard dosing and increase side effects 6
• Do not delay intubation once deemed necessary in patients with impending respiratory failure 1
• Ipratropium should not be used as first-line monotherapy but added to SABA for moderate-severe cases 1
• Once hospitalized, adding ipratropium has not shown further benefit beyond initial ED treatment 1

Special Populations

• For life-threatening exacerbations remaining severe after 1 hour of intensive treatment, consider IV magnesium sulfate (2 g over 20 minutes for adults, 25-75 mg/kg up to 2 g for children). 2, 5