| NHLBI Recommendations for Medication Dosing in Asthma Exacerbation |
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Albuterol nebulizer
- Pediatric (≤ 12 years old)
- 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses then 0.15 – 0.3 mg/kg up to 10 mg every 1–4 hours as needed, or 0.5 mg/kg/hour by continuous nebulization
- Adolescents and adults (≥ 13 years old)
- 2.5 – 5 mg every 20 minutes for 3 doses, then 2.5 – 10 mg every 1–4 hours as needed, or 10 – 15 mg/hour continuously
- Other
- For optimal delivery, dilute aerosols to minimum of 3 mL at gas flow of 6 – 8 L/min. Use large volume nebulizers for continuous administration. May mix with ipratropium
nebulizer solution.
- See albuterol for more
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Albuterol inhaler
- Pediatric (≤ 12 years old)
- 4 – 8 puffs every 20 minutes for 3 doses, then every 1 – 4 hours inhalation maneuver as needed. Use VHC; add mask in children < 4 years.
- Adolescents and adults (≥ 13 years old)
- 4 – 8 puffs every 20 minutes up to 4 hours, then every 1 – 4 hours as needed.
- Other
- In mild-to-moderate exacerbations, MDI plus VHC is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel.
- See albuterol for more
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Ipratropium nebulizer
- Pediatric (≤ 12 years old)
- 0.25 – 0.5 mg every 20 minutes for 3 doses, then as needed
- Adolescents and adults (≥ 13 years old)
- 0.5 mg every 20 minutes for 3 doses then as needed
- Other
- May mix in same nebulizer with albuterol. Should not be used as first-line therapy; should be added to SABA therapy for severe exacerbations. The
addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized.
- See ipratropium for more
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Ipratropium inhaler
- Pediatric (≤ 12 years old)
- 4 – 8 puffs every 20 minutes as needed up to 3 hours
- Adolescents and adults (≥ 13 years old)
- 8 puffs every 20 minutes as needed up to 3 hours
- Other
- Should use with VHC and face mask for children < 4 years. Studies have examined ipratropium bromide MDI for up to 3 hours.
- See ipratropium for more
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Levalbuterol nebulizer
- Pediatric (≤ 12 years old)
- 0.075 mg/kg (minimum dose 1.25 mg) every 20 minutes for 3 doses, then 0.075 – 0.15 mg/kg up to 5 mg every 1 – 4 hours as needed
- Adolescents and adults (≥ 13 years old)
- 1.25 – 2.5 mg every 20 minutes for 3 doses, then 1.25 – 5 mg every 1 – 4 hours as needed
- Other
- Levalbuterol administered in one-half the mg dose of albuterol provides comparable efficacy and safety. Has not been evaluated by continuous nebulization.
- See levalbuterol for more
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Levalbuterol inhaler
- Pediatric (≤ 12 years old)
- 4 – 8 puffs every 20 minutes for 3 doses, then every 1 – 4 hours inhalation maneuver as needed. Use VHC; add mask in children < 4 years.
- Adolescents and adults (≥ 13 years old)
- 4 – 8 puffs every 20 minutes up to 4 hours, then every 1 – 4 hours as needed.
- Other
- In mild-to-moderate exacerbations, MDI plus VHC is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel.
- See levalbuterol for more
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Albuterol 3 mg / Ipratropium 0.5 mg per 3ml nebulizer
- Pediatric (≤ 12 years old)
- 1.5 - 3 mL every 20 minutes for 3 doses, then as needed
- Adolescents and adults (≥ 13 years old)
- 3 mL every 20 minutes for 3 doses, then as needed
- Other
- May be used for up to 3 hours in the initial management of severe exacerbations. The addition of ipratropium to albuterol has not been shown to provide
further benefit once the patient is hospitalized.
- See Duoneb for more
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Albuterol + ipratropium inhaler
- Pediatric (≤ 12 years old)
- 4 – 8 puffs every 20 minutes as needed up to 3 hours
- Adolescents and adults (≥ 13 years old)
- 8 puffs every 20 minutes as needed up to 3 hours
- Other
- Should use with VHC and face mask for children < 4 years
- See Combivent for more
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Corticosteroids (children)
- Drug: Prednisone, Prednisolone, or Methylprednisolone
- Dosing: 1 - 2 mg/kg/day given in 2 divided doses (maximum 60 mg/day). Give until PEF is 70% of predicted or personal best
- Other:
- For outpatient “burst,” use 1 – 2 mg/kg/day (maximum 60 mg/day) for 3 – 10 days
- There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for
intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired.
- The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to
10 days. For corticosteroid courses of less than 1 week, there is no need to taper the dose. For slightly longer courses (e.g., up
to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids.
- Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation.
- See corticosteroids for more
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Corticosteroids (adults)
- Drug: Prednisone, Prednisolone, or Methylprednisolone
- Dosing: 40 – 80 mg/day in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best
- Other:
- For outpatient “burst,” use 40 – 60 mg in single or 2 divided doses for total of 5 – 10 days
- There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for
intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired.
- The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to
10 days. For corticosteroid courses of less than 1 week, there is no need to taper the dose. For slightly longer courses (e.g., up
to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids.
- Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation.
- See corticosteroids for more
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