What are the recommended dosages of ipatropium bromide and albuterol for a 22-month-old patient?

Dosing for Ipratropium Bromide and Albuterol in a 22-Month-Old

For a 22-month-old child with acute asthma exacerbation, administer ipratropium bromide 100-125 mcg (half the standard pediatric dose) via nebulizer combined with albuterol, given every 20 minutes for 3 doses, then every 6 hours as needed until improvement begins. 1

Ipratropium Bromide Dosing

Age-Appropriate Dose Reduction

• Use half doses of approximately 100-125 mcg via nebulizer for very young children under 2-3 years of age, as specifically recommended by the British Thoracic Society guidelines 1
• The standard pediatric dose of 0.25-0.5 mg (250-500 mcg) applies to children over 2-3 years, but must be reduced by half for toddlers in this age range 1, 2
• Research from 1987 confirms that for children under 2-3 years, the maximum dose should be 125 mcg delivered as nebulized solution 3

Administration Schedule

• Give ipratropium every 20 minutes for the first 3 doses as adjunctive therapy to beta-agonists 1, 2
• After initial 3 doses, continue every 6 hours until improvement begins 1
• Can be mixed with albuterol in the same nebulizer solution 1, 2

Delivery Technique

• Must use nebulizer with spacer and face mask for children under 4 years of age 1
• Use oxygen-driven nebulizer at 6-8 L/min flow rate 1
• Dilute to minimum of 3 mL total volume for optimal nebulization 1

Albuterol Dosing

Nebulized Albuterol

• Standard pediatric dosing is weight-based at 0.15 mg/kg per dose 4
• For a typical 22-month-old (approximately 11-13 kg), this translates to roughly 1.65-1.95 mg per dose
• Administer every 20 minutes for 3 doses initially, then as needed 1, 2

Combination Product (If Using Pre-Mixed)

• For children, use 1.5 mL of combination nebulizer solution (containing 0.25 mg ipratropium + 1.25 mg albuterol per 1.5 mL) every 20 minutes for 3 doses, then as needed 1, 2
• This provides the appropriate half-dose of ipratropium for this age group

Critical Clinical Considerations

When to Add Ipratropium

• Add ipratropium to albuterol therapy in moderate to severe exacerbations at presentation 1
• Add if child is not improving after 15-30 minutes of initial beta-agonist therapy 1
• Add if life-threatening features present (silent chest, cyanosis, altered consciousness) 1

Important Caveats

• Ipratropium should NOT be used as first-line monotherapy—it must be added to short-acting beta-agonist (SABA) therapy 1, 2
• May be used for up to 3 hours in initial management of severe exacerbations 1, 2
• Addition of ipratropium to albuterol has not shown additional benefit once patient is hospitalized 1, 2
• Always administer systemic corticosteroids (2 mg/kg prednisone/prednisolone) concurrently for acute exacerbations 1, 5

Safety Monitoring

• Use oxygen-driven nebulizer to maintain oxygen saturation ≥90% 1
• Monitor for mild anticholinergic effects (dry mouth), though these are typically minimal with inhaled administration 1
• Heart rate increases are generally mild with combination therapy 4