Can Albuterol Be Given to This 21-Month-Old Child?
Yes, albuterol should be administered to this 21-month-old child (12.2 kg) with oxygen saturation of 91%, provided the clinical presentation is consistent with bronchospasm from asthma or reactive airway disease rather than viral bronchiolitis. 1
Critical Diagnostic Distinction
The decision to use albuterol hinges entirely on the underlying diagnosis:
- If this is asthma/reactive airway disease with wheezing: Albuterol is indicated and should be given immediately 1, 2
- If this is RSV bronchiolitis: Albuterol is contraindicated and provides no benefit 3
The oxygen saturation of 91% indicates moderate hypoxemia requiring urgent bronchodilator therapy if the etiology is reversible bronchospasm. 1
Appropriate Dosing for This Patient
Weight-Based Calculation
For a 12.2 kg child with acute bronchospasm:
- Nebulized albuterol dose: 0.15 mg/kg = 1.83 mg 1
- However, the minimum dose is 2.5 mg regardless of weight-based calculation 1, 2
- Therefore, administer 2.5 mg (one full 3 mL vial of 0.083% solution) via nebulizer 2
Initial Treatment Protocol
- Give 2.5 mg albuterol every 20 minutes for 3 doses 1
- Reassess oxygen saturation, respiratory rate, work of breathing, and clinical score after each dose 1
- If inadequate response after 3 doses, consider continuous nebulization (0.3 mg/kg/hr = 3.66 mg/hr for this child) 4
Alternative Delivery Method
Metered-dose inhaler (MDI) with spacer is equally effective and may be preferred:
- Dose: 4-8 puffs (90 mcg/puff) = 360-720 mcg total 1
- Administer every 20 minutes for 3 doses, then every 1-4 hours as needed 1
- MDI with valved holding chamber provides equivalent bronchodilation to nebulizer in mild-to-moderate exacerbations with less treatment time 1, 5
Mandatory Concomitant Therapy
Do not give albuterol alone for a child with 91% oxygen saturation:
- Supplemental oxygen to achieve SpO₂ ≥90% 1
- Oral corticosteroids (prednisolone 1-2 mg/kg, maximum 40 mg) should be given immediately, not after assessing bronchodilator response 1, 6
- For this 12.2 kg child: prednisolone 12-24 mg orally as a single dose 6
When to Add Ipratropium
For moderate-to-severe exacerbations (which this child has, given the 91% saturation):
- Add ipratropium bromide 0.25 mg to each albuterol nebulization 1
- Mix ipratropium and albuterol in the same nebulizer cup 1
- Continue combined therapy every 20 minutes for 3 doses, then hourly until improvement 1
Critical Pitfalls to Avoid
Do Not Use Albuterol If This Is Bronchiolitis
- The American Academy of Pediatrics explicitly recommends against albuterol for RSV bronchiolitis in infants 3
- Clinical clues favoring bronchiolitis over asthma: first wheezing episode, age <12 months, viral prodrome, crackles more prominent than wheezes, lack of atopic history 3
- If bronchiolitis is suspected, supportive care only—no bronchodilators 3
Do Not Underdose
- Children <15 kg still require the minimum 2.5 mg dose, not a reduced dose 2
- The FDA label explicitly states children <15 kg requiring <2.5 mg should use the 0.5% solution for accurate dosing, but in acute exacerbations, the full 2.5 mg minimum applies 2
Do Not Delay Corticosteroids
- Corticosteroids must be given at the same time as the first albuterol dose 6
- Waiting to see if albuterol works before giving steroids wastes critical time 6
Monitor for Adverse Effects
- Albuterol increases oxygen consumption by 48.6% within 10 minutes, lasting up to 3 hours 7
- Expect tachycardia (significant increase at 10 minutes, 1 hour, and 2 hours post-dose) 7
- Watch for tremor and hypokalemia with repeated dosing 1
Disposition Criteria
This child likely requires hospitalization based on:
- Oxygen saturation ≤92% is a strong predictor of prolonged bronchodilator therapy (OR 2.6-6.6) 8
- If still requiring albuterol more frequently than every 4 hours after initial treatment, admit 8
- Probability of hospitalization is 91.8-99% if ≥3 risk factors present (low SpO₂, high clinical score, frequent dosing interval) 8