Is 3mL of nebulized (neb) albuterol (salbutamol) an appropriate dose for a 23-month-old child with asthma?

Albuterol Dosing for a 23-Month-Old with Asthma

No, 3 mL of nebulized albuterol is not a dose—it is the volume of diluent; the appropriate dose for a 23-month-old child with asthma is 0.15 mg/kg (minimum 2.5 mg) of albuterol diluted in 3 mL of normal saline for acute exacerbations, or 0.63 mg diluted in 3 mL for routine maintenance therapy. 1, 2

Understanding the Confusion: Volume vs. Dose

• The "3 mL" refers to the total volume of liquid in the nebulizer cup, not the amount of albuterol medication 1, 3
• Albuterol nebulizer solutions come in various concentrations (0.63 mg/3 mL, 1.25 mg/3 mL, 2.5 mg/3 mL, or 5 mg/mL concentrate that requires dilution) 1
• For optimal nebulization, the total volume should be diluted to a minimum of 3 mL at a gas flow of 6-8 L/min 1, 3, 2

Weight-Based Dosing for Acute Exacerbations

For a 23-month-old experiencing an acute asthma exacerbation:

• Calculate the dose as 0.15 mg/kg (with a minimum dose of 2.5 mg) 1, 2
• A typical 23-month-old weighs approximately 11-13 kg, which would calculate to 1.65-1.95 mg
• However, use the minimum dose of 2.5 mg since the calculated dose falls below the established minimum 1, 2
• Administer every 20 minutes for the first 3 doses, then every 1-4 hours as needed based on clinical response 1, 3
• This 2.5 mg dose should be diluted to a total volume of 3 mL with normal saline 1, 2

Routine Maintenance Dosing

For routine bronchodilator therapy (not acute exacerbation):

• Use 0.63 mg/3 mL nebulizer solution, which is FDA-approved for children under 5 years 2
• This lower dose represents the safest starting point for routine therapy in young children 2

Severe Exacerbations Requiring Escalation

• For moderate-to-severe exacerbations, add ipratropium bromide 0.25 mg to the first 3 albuterol doses 1, 3, 2
• For life-threatening cases requiring continuous nebulization, use 0.5 mg/kg/hour 3, 2
• The British Thoracic Society recommends half doses in very young children for severe attacks (which would be 2.5 mg from the standard 5 mg adult dose) 1

Critical Administration Technique

• Always use a properly fitted face mask that covers both nose and mouth snugly 2
• Use oxygen as the driving gas when available, particularly in hypoxic patients 2
• Only use jet nebulizers; ultrasonic nebulizers are ineffective for albuterol solutions 2

Alternative: MDI with Spacer

• For mild-to-moderate exacerbations, an MDI with valved holding chamber (spacer) and face mask can be equally effective as nebulized therapy 3, 2
• Administer 4-8 puffs (90 mcg/puff = 360-720 mcg total) every 20 minutes for 3 doses 1, 2
• This requires proper technique and coaching by trained personnel 1, 3

Monitoring and Safety Considerations

• Monitor closely for adverse effects including tachycardia, tremor, hypokalemia, and hyperglycemia, especially with frequent dosing 2, 4
• Response to treatment is a better predictor of hospitalization need than initial severity 3, 2
• Reassess after each treatment cycle with subjective response, physical findings, and clinical scoring 1, 3
• Watch for signs of deterioration: inability to feed, respiratory rate >50 breaths/min, pulse >140 beats/min, poor respiratory effort, or reduced consciousness 1

Common Pitfall to Avoid

The most critical error is confusing the 3 mL volume with the actual medication dose. Always verify the concentration of your albuterol solution and calculate the appropriate milligram dose based on the child's weight, then dilute to 3 mL total volume if needed. 1, 2