Albuterol Treatment for Bronchospasm in Asthma and COPD
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 based on clinical response. 1, 2
Acute Exacerbation Dosing
Adults and Children ≥12 Years
- Initial treatment: 2.5-5 mg nebulized every 20 minutes for 3 doses 1, 2
- Maintenance: 2.5-10 mg every 1-4 hours as needed based on severity and response 1, 2
- MDI alternative: 4-8 puffs (90 mcg/puff) every 20 minutes for 3 doses, then every 1-4 hours 1
Children <12 Years
- Initial treatment: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses 1, 3
- Maintenance: 0.15-0.3 mg/kg (up to 10 mg) every 1-4 hours as needed 1, 3
- For children <15 kg requiring <2.5 mg/dose, use 0.5% concentration solution instead of 0.083% 4
Severe Exacerbations (FEV1 or PEF <40%)
- Add ipratropium bromide 500 mcg to albuterol nebulization every 20 minutes for 3 doses 1, 2
- Continue combined therapy hourly or continuously until improvement 1
- In children, use ipratropium 250-500 mcg with albuterol 2
COPD-Specific Dosing
Acute COPD Exacerbations
- Mild exacerbations: 200-400 mcg via MDI 1
- Moderate-severe exacerbations: 2.5-5 mg nebulized every 4-6 hours for 24-48 hours or until clinical improvement 1
- Combined therapy: 2.5-10 mg albuterol with 250-500 mcg ipratropium for poor responders 1
- Adding ipratropium to albuterol provides 26% greater peak FEV1 improvement and 64% greater area under the curve over 8 hours in COPD patients 5
Stable COPD Maintenance
- Standard dosing: 200 mcg (2 puffs) via MDI up to four times daily 1, 2
- Most patients achieve adequate bronchodilation with standard hand-held inhaler doses 1
Administration Technique
Nebulizer Setup
- Dilute to minimum 3 mL total volume with normal saline for optimal delivery 1, 2, 3
- Use gas flow rate of 6-8 L/min 1, 2, 3
- Delivery time should be 5-15 minutes 4
MDI with Valved Holding Chamber
- In mild-to-moderate exacerbations, MDI plus spacer is as effective as nebulized therapy when properly administered 1, 2
- Requires appropriate technique and coaching by trained personnel 1
Critical Safety Considerations
Oxygen vs. Air-Driven Nebulization
- In patients with CO₂ retention and acidosis, drive nebulizer with air, not high-flow oxygen 1, 2
- This prevents worsening hypercapnia in COPD patients 1
Monitoring Requirements
- Monitor heart rate, respiratory rate, oxygen saturation, and work of breathing after each treatment 2, 3
- Watch for tachycardia, tremor, and hypokalemia with frequent or high-dose administration 2, 3
Paradoxical Bronchospasm
- Rare but potentially life-threatening complication requiring immediate recognition 6, 7
- If bronchospasm worsens after albuterol, discontinue immediately and provide oxygen support 6
- True mechanism remains unknown but may involve preservatives or solution components 6
Transition to Discharge
Hospital to Home
- Change to hand-held inhaler 24 hours prior to discharge 1
- Observe for 24-48 hours on hand-held device before discharge 1
- Continue oral corticosteroids as prescribed 1
Warning Signs
- Increasing albuterol use or lack of expected effect indicates worsening disease control and requires immediate reassessment 2, 4
- If previously effective dosing fails to provide usual relief, this signals seriously worsening asthma requiring therapy reassessment 4
When to Add Ipratropium
- Always add ipratropium in severe exacerbations (FEV1 or PEF <40%) 1, 2
- Consider in moderate exacerbations with poor response to albuterol alone 1, 2
- Particularly beneficial in COPD exacerbations requiring hospital admission 2, 5
- Do not use ipratropium as monotherapy—always combine with or add to albuterol 2
- Addition of ipratropium provides no further benefit once patient is hospitalized beyond the emergency department 2