Frequency of Nebulized Atrovent (Ipratropium Bromide) in Severe Asthma Exacerbation
In severe asthma exacerbations, administer ipratropium bromide 0.5 mg (500 mcg) via nebulizer every 20 minutes for the first 3 doses, then transition to every 4-6 hours as needed until clinical improvement. 1, 2
Initial Intensive Phase (First Hour)
Give ipratropium 0.5 mg every 20 minutes for 3 doses combined with high-dose beta-agonist therapy during the first hour of treatment. 1, 2 This aggressive initial approach is specifically recommended for:
- Patients with FEV1 or PEF <40% predicted 1
- Patients not responding to initial beta-agonist therapy alone 2
- Patients with life-threatening features (silent chest, cyanosis, altered consciousness) 2
The National Asthma Education and Prevention Program (NAEPP) Expert Panel specifically endorses multiple high doses (0.5 mg nebulizer solution or 8 puffs by MDI) added to beta-agonist therapy to increase bronchodilation and reduce hospitalizations, particularly in severe airflow obstruction. 1
Maintenance Phase (After Initial 3 Doses)
After the first hour, continue ipratropium every 4-6 hours until clinical improvement begins. 1, 2 The British Thoracic Society guidelines recommend continuing nebulized treatments 4-6 hourly until PEF >75% predicted normal and PEF diurnal variability <25%. 1
For pediatric patients, the American Academy of Allergy, Asthma, and Immunology recommends continuing ipratropium every 6 hours after the initial 3 doses until improvement begins. 2
Important Clinical Caveats
Ipratropium can be mixed with albuterol in the same nebulizer if used within one hour, which simplifies administration during the acute phase. 3 The combination has been shown to produce greater bronchodilation than beta-agonist alone, with a mean 55 mL improvement in FEV1 at 45 minutes. 4
Discontinue ipratropium once the patient is hospitalized and stabilized, as the addition of ipratropium to albuterol has not been shown to provide further benefit beyond the emergency department setting. 2, 5 The primary utility is in the first 3 hours of acute management. 2, 5
Do not use ipratropium as first-line monotherapy—it must always be added to short-acting beta-agonist therapy, never used alone. 2, 5
Dosing Specifics
- Adults: 0.5 mg (500 mcg) per dose via nebulizer 1, 2
- Children <12 years: 0.25-0.5 mg per dose via nebulizer 2, 5
- Very young children: Use half doses (approximately 100-125 mcg) 2
The FDA-approved standard maintenance dosing of 500 mcg three to four times daily with 6-8 hours between doses applies only to chronic COPD management, not acute asthma exacerbations. 3