Dosing for Ipratropium Bromide and Albuterol Sulfate Inhalation
For acute asthma or COPD exacerbations in adults, administer 3 mL of the combination nebulizer solution (containing 0.5 mg ipratropium bromide and 2.5 mg albuterol sulfate) every 20 minutes for 3 doses, then as needed; alternatively, use 8 puffs via MDI every 20 minutes for up to 3 hours. 1
Nebulizer Dosing
Adults
- Acute exacerbations: 3 mL of combination solution (0.5 mg ipratropium + 2.5 mg albuterol) every 20 minutes for 3 doses, then as needed 1, 2
- Maintenance therapy: The combination can be administered three to four times daily with doses 6-8 hours apart for stable COPD 3
- Dilute aerosols to a minimum of 3 mL at gas flow of 6-8 L/min for optimal delivery 1
Pediatric Patients (≤12 years)
- Acute exacerbations: 1.5 mL of combination solution every 20 minutes for 3 doses, then as needed 1, 2
- For very young children (including infants), use half doses of approximately 100-125 mcg ipratropium 2
Metered-Dose Inhaler (MDI) Dosing
Adults
- Acute exacerbations: 8 puffs (each puff contains 18 mcg ipratropium + 90 mcg albuterol) every 20 minutes as needed for up to 3 hours 1, 4
- Maintenance therapy: 2 puffs four times daily for stable disease 4, 5
Pediatric Patients
- Acute exacerbations: 4-8 puffs every 20 minutes as needed for up to 3 hours 1, 2
- Must use with valved holding chamber (spacer) and face mask for children <4 years 1
Individual Component Dosing
Ipratropium Bromide Alone
Nebulizer:
- Adults: 0.5 mg every 20 minutes for 3 doses, then as needed 1, 2
- Children: 0.25-0.5 mg every 20 minutes for 3 doses, then as needed 1
- FDA-approved maintenance dosing: 500 mcg three to four times daily, with doses 6-8 hours apart 6
MDI:
- Adults: 8 puffs (18 mcg/puff) every 20 minutes as needed for up to 3 hours 1, 4
- Children: 4-8 puffs every 20 minutes as needed for up to 3 hours 1
Albuterol Sulfate Alone
Nebulizer:
- Adults: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1
- Children: 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
MDI:
- Adults and children: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 1
Critical Clinical Considerations
When to Add Ipratropium
- Do not use ipratropium as first-line monotherapy for acute asthma exacerbations 1, 4
- Add ipratropium to short-acting beta-agonist (SABA) therapy for severe exacerbations, particularly when FEV1 or PEF <40% predicted 1, 2
- Consider adding ipratropium when patients fail to improve after 15-30 minutes of initial beta-agonist therapy 2
Duration of Combination Therapy
- The combination may be used for up to 3 hours in initial management of severe exacerbations 1, 2
- Important caveat: The addition of ipratropium to albuterol has not been shown to provide further benefit once the patient is hospitalized 1, 2
Administration Technique
- MDI with valved holding chamber is as effective as nebulized therapy when administered with appropriate technique and coaching 1, 5
- For nebulizer use, ensure adequate flow rate of 6-8 L/min with oxygen-driven nebulizer 1
- Ipratropium can be mixed in the same nebulizer with albuterol or metaproterenol if used within one hour 6
Evidence for Combination Therapy
- High-dose combination therapy (ipratropium + albuterol) produces 48% greater improvement in FEV1 compared to albuterol alone in acute exacerbations 7
- The combination reduces hospital admission risk by 49% (relative risk 0.51) compared to albuterol alone 7
- Patients with FEV1 ≤30% predicted and symptom duration ≥24 hours benefit most from combination therapy 7
- For stable COPD, combination therapy provides better bronchodilation than either agent alone without increasing adverse effects 3, 8