Albuterol Continuous Nebulizer Dosing
For continuous nebulization in severe asthma exacerbations, use 10-15 mg/hour for adults or 0.5 mg/kg/hour for children (maximum 10 mg/hour). 1, 2
Adult Dosing Protocol
Standard continuous nebulization delivers 10-15 mg/hour of albuterol for adults with severe respiratory distress. 1, 2 This represents the evidence-based recommendation from the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines. 1
Administration Technique
- Dilute aerosols to a minimum of 3 mL at gas flow of 6-8 L/min 1, 2
- Use large volume nebulizers specifically designed for continuous administration 1
- Oxygen is the preferred driving gas when available 3
When to Use Continuous vs. Intermittent Therapy
Continuous nebulization should be reserved for patients with severe exacerbations who remain in distress after initial intermittent treatments. 1 The standard approach begins with intermittent dosing: 2.5-5 mg every 20 minutes for 3 doses, then escalate to continuous therapy if inadequate response. 1, 2
Research evidence supports this approach: patients with peak flows ≤200 L/min showed significantly better improvement with continuous nebulization (10 mg over 2 hours) compared to intermittent therapy, with lower admission rates (11/35 vs 19/34, p=0.03). 4 However, patients with less severe disease (peak flow >200 L/min) showed no benefit from continuous therapy. 4
Pediatric Dosing Protocol
Children require 0.5 mg/kg/hour by continuous nebulization, with a maximum of 10 mg/hour. 1, 2 This weight-based approach ensures appropriate dosing while avoiding excessive beta-agonist exposure.
Pediatric Evidence
A prospective randomized trial in children with impending respiratory failure demonstrated that continuous nebulization at 0.3 mg/kg/hour resulted in faster resolution (median 12 hours vs 18 hours, p=0.03) and shorter hospital stays (median 80 hours vs 147 hours, p=0.043) compared to intermittent therapy. 5 The study used 0.3 mg/kg/hour, but current guidelines recommend up to 0.5 mg/kg/hour for severe cases. 1
Dose Comparison: High vs. Standard Continuous Rates
The evidence does not support using doses higher than 10-15 mg/hour in adults. 6, 7 A randomized controlled trial comparing 15 mg/hour vs 7.5 mg/hour continuous nebulization found no difference in peak flow improvement at 1 hour (45 L/min vs 51 L/min, mean difference 6.8 L/min, 95% CI -11 to 24.9) or admission rates (65% vs 70.9%). 6
Another study found that standard-dose continuous treatment (2.5 mg continuously over 1 hour, repeated) produced equivalent FEV1 improvement (1.02 L) to high-dose continuous treatment (7.5 mg continuously, 1.07 L improvement) with fewer side effects. 7
Critical Adjunctive Therapy
Add ipratropium bromide to the nebulizer solution for moderate to severe exacerbations. 2 Use 0.5 mg every 20 minutes for 3 doses in adults, or 0.25-0.5 mg in children. 1, 2 The medications can be mixed in the same nebulizer solution. 1
Administer systemic corticosteroids early - methylprednisolone 125 mg IV or prednisone 40-60 mg orally for adults. 2, 8 For children, use 1-2 mg/kg/day (maximum 60 mg/day). 2
Monitoring Requirements
Clinical Parameters to Track
- Measure FEV1 or peak flow every 30-60 minutes during continuous therapy 8, 7
- Monitor heart rate, blood pressure, and respiratory rate continuously 1, 7
- Watch for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retractions, worsening fatigue, PaCO2 ≥42 mmHg 1
Safety Monitoring
- Check serum potassium levels, as hypokalemia can occur with high-dose therapy 7
- Monitor for tachycardia and tremor 2, 7
- One study reported potassium drops were more pronounced with high-dose therapy, though clinically significant hypokalemia (<3.0 mmol/L) was rare 7
Common Pitfalls to Avoid
Do not delay intubation once deemed necessary while attempting continuous nebulization. 1 Intubation of severely ill asthmatic patients is difficult and complications increase with delay. 1
Do not use continuous nebulization as first-line therapy for mild-to-moderate exacerbations. 4 Begin with intermittent dosing (2.5-5 mg every 20 minutes for 3 doses) and escalate only if response is inadequate. 1, 2
Ensure proper equipment setup - failure to use large-volume nebulizers or inadequate dilution results in suboptimal drug delivery. 1
Duration of Continuous Therapy
Continue high-dose therapy beyond 2 hours if needed, as studies demonstrate continued significant improvement through 4 hours. 8 One study showed FEV1 doubled from baseline over 4 hours with continued statistically significant improvement from 120 to 240 minutes (p<0.0001). 8
Reassess every 1-2 hours and consider transitioning to intermittent therapy (2.5-10 mg every 1-4 hours) once the patient shows sustained improvement. 1, 2