Salbutamol and Ipratropium Nebulizers for Pediatric Cough
Salbutamol and ipratropium nebulizers should NOT be used for treating nonspecific cough in children, as there is no evidence supporting their benefit for cough without underlying airway obstruction. 1
When These Nebulizers ARE Indicated
These bronchodilators are reserved specifically for acute severe asthma exacerbations, not for cough as an isolated symptom. 1
Recognition of Acute Severe Asthma in Children Requiring Treatment:
- Too breathless to talk or feed 1
- Respiratory rate >50 breaths/min 1
- Heart rate >140 beats/min 1
- Peak expiratory flow (PEF) <50% predicted 1
Life-Threatening Features:
- PEF <33% predicted or poor respiratory effort 1
- Cyanosis, silent chest, fatigue or exhaustion 1
- Agitation or reduced level of consciousness 1
Treatment Protocol for Acute Severe Asthma in Children
Initial Treatment:
- Salbutamol 5 mg (or 0.15 mg/kg) via oxygen-driven nebulizer (half doses in very young children) 1
- High flow oxygen via face mask 1
- Intravenous hydrocortisone 1
- Add ipratropium 100-250 mcg nebulized 6 hourly 1
If Patient Improves:
- Continue high flow oxygen 1
- Prednisolone 1-2 mg/kg daily (maximum 40 mg) 1
- Nebulized β-agonist 4 hourly 1
If NOT Improving After 15-30 Minutes:
- Continue oxygen and steroids 1
- Give nebulized β-agonist more frequently, up to every 30 minutes 1
- Add ipratropium to nebulizer and repeat 6 hourly until improvement starts 1
Evidence Quality and Clinical Nuances
For Acute Severe Asthma:
The British Thoracic Society guidelines establish that ipratropium should be added when initial salbutamol therapy fails to produce improvement within 15-30 minutes. 1 The combination produces significant additional improvement in FEV1 and FVC, with median duration of 15% improvement in FEV1 extending to 5-7 hours compared with 3-4 hours for β-agonist alone. 2
A 2021 meta-analysis of 55 studies involving 6,396 participants demonstrated that ipratropium + salbutamol significantly reduced hospital admission risk (RR 0.79; 95% CI 0.66-0.95) compared to salbutamol alone, with the most pronounced benefit in severe asthma exacerbations (RR 0.73; 95% CI 0.60-0.88). 3
For Nonspecific Cough:
The 2006 ACCP guidelines explicitly state: "there is no evidence to support using β2-agonists in children with acute cough and no evidence of airflow obstruction" and "there is also no evidence to support the use of anticholinergic agents for the treatment of nonspecific cough in children." 1
A systematic review confirmed that inhaled salbutamol showed no benefit in chronic cough without airway obstruction. 1
Critical Pitfalls to Avoid
Do NOT Use These Medications For:
- Isolated cough without signs of airway obstruction 1
- Mild asthma episodes (use hand-held inhalers instead: salbutamol 200-400 mcg four hourly) 1
- Cough attributed to gastroesophageal reflux disease (GERD treatment should follow GERD-specific guidelines, not bronchodilator therapy) 1
Dosing Errors to Avoid:
One study found that frequent low doses of salbutamol (0.075 mg/kg every 30 minutes) were associated with increased vomiting (RR 2.5) without additional bronchodilation benefit compared to hourly high doses (0.15 mg/kg every 60 minutes). 4 Therefore, stick to the established protocols above rather than more frequent lower dosing.
Administration Considerations:
- Ipratropium can worsen glaucoma; use mouthpiece rather than face mask when possible to prevent eye exposure 1
- If using face mask, ensure proper fit to avoid leakage around mask that could cause eye exposure, temporary blurring of vision, or pupil enlargement 2
- Ipratropium can be mixed with salbutamol in the nebulizer if used within one hour, but not with other drugs 2