Salbutamol and Ipratropium Dosing for Children
Salbutamol (Albuterol) Dosing
For acute asthma exacerbations in children, administer salbutamol 0.15 mg/kg (minimum 2.5 mg) via nebulizer every 20 minutes for 3 doses, then 0.15-0.3 mg/kg every 1-4 hours as needed, or alternatively 4-8 puffs (90 mcg/puff) via MDI with spacer every 20 minutes for 3 doses. 1
Weight-Based Dosing for Nebulization
- Children <20 kg: 2.5 mg per dose 1
- Children >20 kg: 5 mg per dose 1, 2
- Very young children requiring acute treatment: Use half the standard dose (1.25 mg) 1
MDI with Spacer Dosing (Preferred Method)
- Acute exacerbations: 4-8 puffs (90 mcg/puff) every 20 minutes for 3 doses, then every 1-4 hours as needed 1
- MDI with spacer is equally effective as nebulization and may result in lower admission rates, particularly in severe exacerbations, with fewer cardiovascular side effects 3
- Always use a large volume spacer with face mask for young children who cannot tolerate a mouthpiece 1
Administration Technique
- Dilute salbutamol in 2-3 mL of saline solution for adequate nebulization 1
- Use oxygen as the preferred gas source at 6-8 L/min flow rate for optimal nebulizer delivery 1, 3
- For continuous nebulization in severe cases: 0.5 mg/kg per hour up to 10-15 mg/hour 1
Maximum Dosing
- Maximum daily dose: 40 mg/day during acute exacerbations 1
- For routine use via MDI: maximum 8-12 puffs per 24 hours 2
Ipratropium Bromide Dosing
Add ipratropium 100-250 mcg to nebulized salbutamol when initial beta-agonist treatment fails or in moderate to severe exacerbations. 3
Specific Dosing Recommendations
- Standard dose: 250 mcg per dose for children aged 6-14 years 4
- Alternative dosing: 100 mcg nebulized every 6 hours 3
- Administer with salbutamol at 20-minute intervals for first 3 doses 4
Evidence for Combination Therapy
- The combination of salbutamol plus ipratropium provides superior bronchodilation compared to salbutamol alone, with greater improvement in clinical status and lung function 5
- Hospitalization rates are significantly reduced with combination therapy (18.4% vs 43.8% with salbutamol alone) 5
- The effect is more pronounced in severe asthma crises and works independently of age 5
Clinical Monitoring
- Assess respiratory rate, heart rate, oxygen saturation, and work of breathing during administration 1
- Maintain oxygen saturation >92% during treatment 1, 3
- Reassess clinical response 15-30 minutes after each dose 1, 3
- Repeat peak expiratory flow measurement 15-30 minutes after starting treatment 3
Special Populations
Infants with Chronic Lung Disease
- For ventilator-dependent infants: 200 mcg salbutamol via MDI and spacer can improve compliance and resistance 6
- Use face mask rather than mouthpiece for optimal drug delivery in infants 6
- Response to bronchodilators is variable in this population; consider infant lung function testing to identify responders 6
Children Under Age 6 with URI
- Preoperative nebulized salbutamol (2.5 mg for <20 kg, 5 mg for >20 kg) administered 30 minutes before general anesthesia reduces perioperative respiratory adverse events by approximately 50% 1
Common Pitfalls to Avoid
- Do not delay systemic corticosteroids while continuing repeated doses of salbutamol alone; if the patient fails to respond after 2 doses, escalate care immediately 3
- Do not use nebulization alone when MDI with spacer is available and appropriate, as MDI may be more effective with fewer side effects 3, 7
- Avoid the syringe method or uni/bidirectional adaptor methods for delivering salbutamol via artificial airways; use direct method or spacer instead 8
- Cardiac concerns about salbutamol are largely unfounded; standard dosing does not significantly affect heart rate, and treatment should not be withheld due to tachycardia or underlying heart disease 9