What are the recommended doses and dosing frequencies of Atrovent (ipratropium bromide) for adults and children using a metered‑dose inhaler, nebulizer, and nasal spray?

Atrovent (Ipratropium Bromide) Dosing Guidelines

For acute asthma or COPD exacerbations in adults, administer 0.5 mg via nebulizer every 20 minutes for 3 doses, then as needed; for children, use 0.25–0.5 mg via nebulizer on the same schedule. 1

Metered-Dose Inhaler (MDI) Dosing

Adults

• Maintenance therapy: 2 puffs (36 mcg total; 18 mcg per puff) four times daily 2, 3
• Acute exacerbations: 8 inhalations every 20 minutes as needed for up to 3 hours 1, 2
• Maximum daily dose should not exceed 12 inhalations for maintenance 3

Children

• Acute exacerbations: 4–8 puffs every 20 minutes as needed for up to 3 hours 1, 4
• Must use with valved holding chamber (spacer) and face mask for children under 4 years 1, 4

Nebulizer Solution Dosing

Adults

• Acute exacerbations: 0.5 mg every 20 minutes for 3 doses, then every 4–6 hours as needed 1, 4
• Chronic COPD maintenance: 250–500 mcg four times daily 4
• Optimal dose for stable COPD is 0.4 mg (400 mcg), which provides peak bronchodilation at 1–2 hours with effects lasting 6.5 hours 5

Children (6–12 years)

• Acute exacerbations: 0.25–0.5 mg every 20 minutes for 3 doses, then every 6 hours until improvement begins 1, 2, 4

Young Children (under 3 years)

• Maximum dose: 125 mcg (half the standard pediatric dose) via nebulizer 4, 6
• For infants and toddlers under 25 months, 125 mcg delivered via metered-dose aerosol with spacer and mask is as effective as nebulization 7
• Preterm infants: Doses exceeding 20 mcg may produce side effects; use with extreme caution 6

Nasal Spray Dosing

Allergic and Nonallergic Rhinitis

• 0.03% concentration: Approved for patients 6 years and older for perennial rhinitis 1
• 0.06% concentration: Approved for patients 5 years and older for common cold-associated rhinorrhea 1

Children Aged 2–5 Years

• Common cold: 84 mcg per nostril three times daily for 4 days 8
• Allergies: 42 mcg per nostril three times daily for 14 days 8

Combination Therapy with Albuterol

Adults

• Nebulizer: 3 mL solution (containing 0.5 mg ipratropium + 2.5 mg albuterol) every 20 minutes for 3 doses, then as needed 1, 2, 4
• MDI: 8 puffs (each puff contains 18 mcg ipratropium + 90 mcg albuterol) every 20 minutes for up to 3 hours 1, 4

Children

• Nebulizer: 1.5 mL every 20 minutes for 3 doses, then as needed 1, 2, 4
• MDI: 4–8 puffs every 20 minutes for up to 3 hours with spacer and mask if under 4 years 1, 4

Critical Clinical Considerations

When to Add Ipratropium

• Add to short-acting beta-agonist (SABA) therapy in moderate-to-severe exacerbations at presentation 9
• Add when patients fail to improve after 15–30 minutes of initial SABA therapy 4, 9
• Add when FEV₁ or peak expiratory flow is less than 40% predicted 9
• Add in presence of life-threatening features (silent chest, cyanosis, altered consciousness) 4

Duration of Use in Acute Settings

• May be used for up to 3 hours in initial emergency department management of severe exacerbations 1, 4
• The addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized 1, 4
• Discontinue after acute phase; do not use for long-term asthma maintenance 9

Administration Technique

• Nebulizer flow rate: Use oxygen-driven nebulizer at 6–8 L/min to maintain oxygen saturation ≥90% 4
• Minimum nebulizer volume: Dilute to at least 3 mL total volume for optimal delivery 1, 4
• Ipratropium can be mixed with albuterol in the same nebulizer 1, 4

Combination with Intranasal Corticosteroids

• Concomitant use of ipratropium nasal spray 0.03% with intranasal corticosteroid is more effective than either drug alone for rhinorrhea without increased adverse events 1

Common Pitfalls to Avoid

• Never use ipratropium as monotherapy for acute asthma—it must be combined with a SABA due to delayed onset of action (15 minutes vs. seconds for beta-agonists) 9, 3
• Do not delay systemic corticosteroid administration while awaiting ipratropium effect 9
• Do not continue ipratropium beyond the acute phase unless there is COPD or specific indication 9
• Ipratropium is approved only for rhinorrhea treatment, not for nasal congestion, although one pediatric study showed modest congestion benefit 1
• Most common adverse effects are mild: epistaxis (9% vs. 5% with saline), nasal dryness (5% vs. 1% with saline), dry mouth, and mild respiratory secretion changes 1, 9

Safety Profile

• Excellent safety profile with minimal systemic absorption due to quaternary ammonium structure 1, 9
• Does not alter physiologic nasal functions (sense of smell, ciliary beat frequency, mucociliary clearance) 1
• Well tolerated in children as young as 2 years without serious or systemic anticholinergic effects 8
• Paradoxical decreases in FEV₁ (less than 10%) observed in isolated patients with cystic fibrosis 1