What is the recommended dose of salbutamol (albuterol) for acute asthma exacerbation in pediatric patients?

Salbutamol Dosing for Acute Asthma Exacerbation in Pediatric Patients

For acute asthma exacerbations in children, administer salbutamol 2.5 mg (age ≤2 years) or 5.0 mg (age >2 years) via nebulizer every 20 minutes for up to 3 doses in the first hour, or alternatively 4-8 puffs via MDI with spacer every 20 minutes for 3 doses. 1, 2, 3

Delivery Method Selection

Nebulized Salbutamol (Preferred in Severe Exacerbations)

• Dosing: 2.5 mg for children ≤2 years or 5.0 mg for children >2 years, administered every 20 minutes for up to 3 doses over the first hour 1, 4
• After initial treatment, continue nebulized salbutamol every 4 hours as needed based on clinical response 2
• For severe exacerbations requiring continuous therapy, nebulized salbutamol can be given continuously then at 30 min, 1 h, 2 h, 3 h, and 4 h intervals according to need 4

MDI with Spacer (Equally Effective Alternative)

• Dosing: 4-8 puffs (400-800 mcg) every 20 minutes for up to 3 doses 2, 5, 3
• Each puff delivers 100 mcg of salbutamol; 10-20 puffs provides 1-2 mg total dose, approximating the 2.5-5 mg nebulized dose 5
• MDI with large volume spacer is strongly recommended by all major guidelines and may result in lower admission rates, particularly in more severe exacerbations, with fewer cardiovascular side effects 1, 2
• This method is equally effective to nebulization and is the preferred delivery device for children who can cooperate 2, 6

Dosing Variability Across Guidelines

Important caveat: International guidelines show significant variability in salbutamol dosing recommendations, ranging from 2-10 puffs (200-1000 μg) via MDI-spacer, with timing administration ranging from 20-30 minutes for the first hour 1. Despite this variability, the most commonly reported and evidence-based approach is the 4-8 puffs every 20 minutes protocol for acute management 2, 5, 3.

Home Management Protocol (Yellow Zone)

• Administer 4-8 puffs of salbutamol via MDI with spacer every 20 minutes for up to 3 doses (total 12-24 puffs over one hour) 5
• Start oral prednisone 1-2 mg/kg (maximum 60 mg) immediately when yellow zone symptoms appear 5
• Reassess the child 15-30 minutes after each bronchodilator dose 5
• If no improvement after 3 doses or if red flag symptoms develop, seek immediate medical attention 5

Intravenous Salbutamol (Severe Cases Only)

• Loading dose: 15 mcg/kg IV over 10 minutes (maximum 750 mcg) for children with severe acute asthma not responding to initial nebulized therapy 4, 7
• This can be followed by continuous infusion if needed in PICU settings 7
• Important note: A 2022 randomized controlled trial found no additional clinical benefit of adding a loading dose to continuous infusion in PICU patients, though it remains an option for severe cases 7

Concurrent Essential Therapy

• Systemic corticosteroids must be given immediately upon recognition of acute severe asthma: oral prednisolone 1-2 mg/kg (maximum 60 mg) or IV hydrocortisone 200 mg every 6 hours if unable to take oral medications 2, 3
• Add ipratropium bromide 100-250 mcg to nebulizer every 20 minutes for 3 doses if initial beta-agonist treatment fails or in severe exacerbations 2, 3
• Administer high-flow oxygen via face mask to maintain oxygen saturation >92% 1, 2

Monitoring and Reassessment

• Repeat peak expiratory flow measurement 15-30 minutes after starting treatment 2
• Maintain continuous pulse oximetry with target >92% 2
• Chart PEF before and after β-agonist administration at least 4 times daily 2

Common Pitfalls to Avoid

• Do not delay systemic corticosteroids while continuing repeated doses of salbutamol alone—failure to respond to 2 doses within 24 hours signals treatment failure requiring escalation 2
• Ensure proper inhaler technique and age-appropriate device before escalating therapy, as inadequate technique is a common cause of treatment failure 2, 5
• Do not exceed the recommended frequency of administration—more frequent administration or larger number of inhalations beyond the protocol is not recommended 8
• The inhaler must be properly cleaned and dried thoroughly at least once weekly to prevent medication buildup and blockage 8

Hospital Admission Criteria

• Persistent features of severe asthma after initial treatment 2
• Peak expiratory flow remaining <50% predicted 15-30 minutes after nebulization 2
• Inability to complete sentences in one breath, pulse >110 bpm, or respiratory rate >25/minute persisting after treatment 5
• Child appears exhausted, drowsy, or confused 5