Loading Dose for Ventolin and Atrovent in Asthma with Pneumonia and Potential Influenza
For a patient with asthma exacerbation complicated by pneumonia and potential influenza, administer albuterol (Ventolin) 2.5-5 mg plus ipratropium (Atrovent) 0.5 mg via nebulizer every 20 minutes for 3 doses as the loading regimen. 1, 2
Initial Loading Protocol
Standard Adult Dosing
- Albuterol: 2.5-5 mg nebulized every 20 minutes for 3 doses 1, 2
- Ipratropium: 0.5 mg nebulized every 20 minutes for 3 doses 1, 2
- The combination (Duoneb) can be used as 3 mL every 20 minutes for 3 doses in adults 1
Pediatric Dosing
- Albuterol: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses 1, 2
- Ipratropium: 0.25-0.5 mg every 20 minutes for 3 doses 2
- For children, Duoneb 1.5 mL every 20 minutes for 3 doses 1
Critical Timing Considerations
Ipratropium should only be given with the first 3 doses of albuterol during the initial 3 hours of treatment. 1 This is a crucial point that is often missed—continuing ipratropium beyond the initial loading period provides no additional benefit once the patient is stabilized or hospitalized. 1
The combination of ipratropium plus albuterol provides significantly greater improvement in lung function compared to albuterol alone during acute exacerbations, with one study showing a 25% absolute reduction in hospital admissions when ipratropium was added to the initial treatment. 3
Alternative Delivery Method (MDI with Spacer)
For mild-to-moderate exacerbations, metered-dose inhaler with valved holding chamber is equally effective: 1, 2
- Albuterol MDI: 4-8 puffs every 20 minutes for 3 doses 1, 2
- This requires proper technique with a spacer device 1
- Children <4 years should use a face mask with the spacer 2
Severity-Based Approach
The loading dose remains the same regardless of pneumonia or influenza, as these are treated as severe exacerbations requiring combination therapy: 1
- Severe exacerbations warrant the full combination regimen from the outset 1
- Research shows that 72% of hospitalized asthmatics required cumulative doses of 7.5 mg albuterol to achieve maximum bronchodilation 4, supporting the use of higher initial dosing in severe cases
- However, one study found no advantage to routinely using 7.5 mg over 2.5 mg every 20 minutes 5, which is why guidelines recommend the 2.5-5 mg range
Essential Concurrent Therapy
All patients must receive systemic corticosteroids concurrently with bronchodilators: 1, 2
Common Pitfalls to Avoid
- Do not continue ipratropium beyond the initial 3 doses—it provides benefit only during the first 3 hours 1
- Do not routinely use antibiotics unless bacterial pneumonia is confirmed 2
- Monitor for beta-agonist toxicity including tachycardia, tremor, and hypokalemia, especially with high-dose administration 2
- Avoid aggressive hydration in older children and adults, methylxanthines, chest physiotherapy, mucolytics, or sedation 2
Post-Loading Maintenance
After the initial 3 loading doses (first hour of treatment): 1, 2