How to Write an Albuterol Nebulizer Order
For adults, order albuterol nebulizer solution 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed; for children, order 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg every 1-4 hours as needed. 1
Standard Order Components
Adult Dosing
- Initial treatment: Albuterol 2.5-5 mg via nebulizer every 20 minutes for 3 doses 1
- Maintenance: 2.5-10 mg every 1-4 hours as needed based on clinical response 1
- Severe exacerbations: Consider continuous nebulization at 10-15 mg/hour 2
Pediatric Dosing
- Weight-based: 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses 1, 3
- Maintenance: 0.15-0.3 mg/kg every 1-4 hours as needed 1, 3
- Severe cases: Continuous nebulization at 0.5 mg/kg/hour 3, 4
- Children <15 kg: Use 0.5% solution instead of 0.083% for doses less than 2.5 mg 5
Administration Specifications
Solution Preparation
- Dilution: Dilute to a minimum of 3 mL total volume with normal saline for optimal nebulization 1, 2, 3
- Standard concentration: 0.083% solution (2.5 mg/3 mL) requires no dilution 5
- Gas flow rate: 6-8 L/min 1, 2
- Driving gas: Use oxygen when available, especially in hypoxic patients 3, 4
Treatment Duration
- Each nebulization treatment should last approximately 5-15 minutes 5
- Continue until no more mist is formed in the nebulizer chamber 5
Severity-Based Ordering Algorithm
Mild-to-Moderate Exacerbations
- Start with 2.5 mg every 20 minutes for 3 doses 1, 2
- Reassess after initial 3 doses 1
- If improving, transition to every 1-4 hours as needed 1
- Alternative: MDI with spacer (4-8 puffs every 20 minutes) is equally effective with proper technique 1, 2
Severe Exacerbations (FEV1 <40% predicted)
- Use higher doses: 5 mg every 20 minutes for adults 1
- Add ipratropium: 0.5 mg for adults, 0.25-0.5 mg for children to first 3 doses 1, 2
- Consider continuous nebulization if inadequate response after 1 hour 2, 6
- Continuous dosing provides greater FEV1 improvement than intermittent dosing in severe obstruction 6
Sample Order Format
"Albuterol 2.5 mg via nebulizer with 3 mL normal saline at 6-8 L/min oxygen flow, administer every 20 minutes × 3 doses, then every 1-4 hours as needed for wheezing/dyspnea"
For severe cases: "Albuterol 5 mg + ipratropium 0.5 mg via nebulizer with normal saline at 6-8 L/min oxygen flow, administer every 20 minutes × 3 doses, then albuterol alone every 1 hour as needed"
Critical Monitoring Parameters
During Treatment
- Monitor heart rate, respiratory rate, and oxygen saturation before and after each treatment 1
- Watch for tachycardia, tremor, and hypokalemia, especially with frequent or high-dose administration 2, 3, 4
- Reassess clinical response after each dose cycle 1, 2
Response Assessment
- Measure FEV1 or peak flow if possible 1
- Response to initial treatment is a better predictor of hospitalization need than initial severity 2, 4
- Most patients (72%) with severe asthma require cumulative doses of 7.5 mg to achieve maximal bronchodilation 7
Common Pitfalls to Avoid
- Underdosing severe exacerbations: Standard 2.5 mg doses may be insufficient; 50% of hospitalized asthmatics require higher doses 7
- Omitting dilution: Always dilute to at least 3 mL for proper nebulization 1, 3
- Wrong gas flow rate: Flow rates below 6 L/min result in suboptimal delivery 1, 2
- Forgetting ipratropium: Should be added to first 3 doses in moderate-to-severe cases 1, 2
- Continuing ipratropium after hospitalization: No additional benefit once admitted 1