Albuterol Rescue Inhaler Dosing for a 42 kg Child
For a 42 kg child with asthma, administer albuterol 2 puffs (180 mcg total) via metered-dose inhaler (MDI) with a large volume spacer as needed for symptom relief, which can be repeated every 4-6 hours for maintenance or every 20 minutes for up to 3 doses during acute exacerbations. 1
Delivery Method
- MDI with large volume spacer is the preferred delivery device for children, as it is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects 1, 2
- Use a mouthpiece rather than face mask unless the child cannot tolerate it 1
- Most children cannot achieve proper coordination for unmodified MDI use without a spacer device 2
Routine Rescue Dosing
- Standard dose: 2 puffs (90 mcg per puff = 180 mcg total) every 4-6 hours as needed for symptom relief 1
- This weight-based approach applies across pediatric age groups for routine rescue use 2
Acute Exacerbation Dosing
For acute asthma exacerbations, the dosing algorithm is more aggressive:
- Initial treatment: 4-8 puffs via MDI with spacer every 20 minutes for up to 3 doses in the first hour 2, 3
- Alternative: Give one puff every few seconds until improvement occurs (maximum 20 puffs) 1
- After initial stabilization, continue 4-6 puffs every 4 hours as symptoms improve 2
Proper Spacer Technique
- Actuate the MDI into the spacer 2
- Have the child breathe in one puff through the spacer 2
- Repeat until the appropriate number of puffs are inhaled 2
When to Escalate Treatment
Add systemic corticosteroids immediately if:
- The child fails to respond to 2-3 doses of albuterol within the first hour 1, 2
- Peak expiratory flow remains <50% predicted after initial treatment 1
- Respiratory rate >50/min, pulse >140/min, or oxygen saturation <92% 2
Dose: Prednisolone 1-2 mg/kg orally (maximum 40 mg) as a single dose, which for a 42 kg child would be 42-84 mg, but capped at the 40 mg maximum 1
Critical Pitfalls to Avoid
- Do not delay systemic corticosteroids while giving repeated albuterol doses alone if the child has failed initial treatment 2
- Underuse of corticosteroids is specifically identified as a leading cause of preventable asthma mortality 2
- Do not use antibiotics unless bacterial infection is confirmed, as viral respiratory infections are the most common trigger 2
- Ensure proper inhaler technique before escalating therapy, as poor technique often mimics treatment failure 2
Monitoring Response
- Reassess clinical status 15-30 minutes after each bronchodilator dose 2, 3
- If no improvement after 3 doses in the first hour, add ipratropium bromide 4-8 puffs to each albuterol dose 2, 3
- Seek immediate medical care if the child cannot complete sentences in one breath, appears exhausted or confused, or has persistent tachycardia/tachypnea 2
Emerging Evidence
Recent research suggests that combination albuterol-budesonide rescue inhalers reduce severe exacerbations by 26% compared to albuterol alone in patients with moderate-to-severe asthma 4, 5, though this is currently FDA-approved only for adults ≥18 years 5. This represents a paradigm shift toward addressing both bronchoconstriction and inflammation during acute symptoms 5, 6.