Inhaled beta agonist doses used for initial management of asthma exacerbations in children <12 years of age*

Medication	Dose form	0 to <4 years	4 to 11 years	Comments
Metered dose inhaler (MDI)
Albuterol (salbutamol) HFA MDI with spacer (valved holding chamber)	90 mcg/puff	Home management – 2 to 4 inhalations, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 4 to 8 inhalations every 20 minutes for 3 doses^Δ, then up to every 1 hour as needed	Home management – 2 to 4 inhalations, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 4 to 8 inhalations every 20 minutes for 3 doses^Δ, then up to every 1 hour as needed	Differences in potencies exist, but products shown are essentially comparable on a per-puff basis. An increasing use or lack of expected effect indicates diminished control of asthma. Not recommended for long-term daily treatment. Regular use exceeding 2 days/week for symptom control (not prevention of EIB) indicates the need for additional long-term control therapy. Periodically clean mouthpiece as drug may plug orifice. Instructions for use, priming, and cleaning MDI vary by brand. For specific information, refer to UpToDate topic on use of inhaler devices in children, Lexicomp, and patient leaflet included with MDI.
Levalbuterol (levosalbutamol) HFA MDI with spacer (valved holding chamber)	45 mcg/puff	Safety and efficacy not established in children <4 years	Home management – 2 to 4 inhalations, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 4 to 8 inhalations every 20 minutes for 3 doses^Δ, then up to every 1 hour as needed
Dry powder inhaler (DPI)
Albuterol (salbutamol) breath-activated DPI	90 mcg/inhalation	Safety and efficacy not established in children <4 years	Home management – 2 to 4 inhalations, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶	DPI alternative for prophylactic use prior to exercise in older children who are comfortable with and capable of properly using a breath-activated inhaler technique. Use of DPI is not advised as rescue therapy in an acute setting, as some children may be unable to generate sufficient inspiratory flow rate to assure optimal lung deposition of drug. NOTE: DPIs can contain lactose and trace milk proteins (ie, potential allergens). Also refer to information above on albuterol MDI.
Nebulizer solution
Albuterol (salbutamol)	0.63 mg/3 mL 1.25 mg/3 mL 2.5 mg/3 mL 5 mg/mL (0.5%)	Home management – 1.25 to 2.5 mg, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 0.15 mg/kg per dose (minimum 2.5 mg, maximum 5 mg/dose) up to every 20 minutes for up to 3 doses, then 0.15 to 0.3 mg/kg (maximum 10 mg) up to every 30 minutes as needed or switch to continuous therapy if in a critical care setting Critical care setting and severe exacerbation – Continuous nebulizer treatment 0.5 mg/kg per hour (maximum 20 mg per hour) by large-volume nebulizer. Dose may also be determined based upon body weight as follows: 5 to 10 kg – 5 to 7.5 mg per hour 10 to 20 kg – 10 to 12.5 mg per hour >20 kg – 15 to 20 mg per hour	Home management – 2.5 to 5 mg, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 0.15 mg/kg per dose (minimum 2.5 mg, maximum 5 mg/dose) up to every 20 minutes for up to 3 doses, then 0.15 to 0.3 mg/kg (maximum 10 mg) every 30 minutes to 4 hours as needed or switch to continuous therapy if in a critical care setting Critical care setting and severe exacerbation – Continuous nebulizer treatment 0.5 mg/kg per hour (maximum 20 mg per hour) by large-volume nebulizer; weight-based dosing is also an option (refer to 0 to <4 years)	May mix with budesonide suspension, ipratropium solution, or cromolyn sodium solution for nebulization.
Levalbuterol (levosalbutamol)	0.31 mg/3 mL 0.63 mg/3 mL 1.25 mg/0.5 mL 1.25 mg/3 mL	Home management – 0.63 to 1.25 mg, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 0.75 mg/kg per dose (minimum 1.25 mg, maximum 2.5 mg/dose) up to every 20 minutes for up to 3 doses, then 0.075 to 0.15 mg/kg (maximum 5 mg) up to every 30 minutes as needed Critical care setting and severe exacerbation – Continuous nebulizer treatment 0.25 mg/kg per hour (maximum 10 mg per hour) by large-volume nebulizer	Home management – 0.63 to 1.25 mg, can be repeated every 20 minutes for a total of 3 doses, then up to every 4 hours as directed^¶ Acute care setting – 0.75 mg/kg per dose (minimum 1.25 mg, maximum 2.5 mg/dose) up to every 20 minutes for up to 3 doses, then 0.075 to 0.15 mg/kg (maximum 5 mg) up to every 30 minutes as needed Critical care setting and severe exacerbation – Continuous nebulizer treatment 0.25 mg/kg per hour (maximum 10 mg per hour) by large-volume nebulizer	May mix with budesonide suspension, ipratropium solution, or cromolyn sodium solution for nebulization.

Also refer to separate UpToDate topic reviews and table on recommended doses of medications other than inhaled beta agonists to treat children with an acute asthma exacerbation.
Nonselective inhaled agents (ie, epinephrine, isoproterenol, metaproterenol) and orally administered beta₂-agonists are not recommended, due to their potential for excessive cardiac stimulation, especially in high doses. For severely ill children, however, IM or SC epinephrine may be administered for rapid relief.

HFA: hydrofluoroalkane; EIB: exercise-induced bronchoconstriction; IM: intramuscular; SC: subcutaneous.
* Doses are provided for those products that have been approved by the US Food and Drug Administration or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use. Doses shown and strengths (ie, mcg per puff or inhalation) are based upon product descriptions approved in the United States, which may differ from how strengths are described for products available in other countries. Consult local product information before use.
¶ Typically, 2 puffs are used for mild-to-moderate symptoms and 4 puffs for more severe symptoms and/or for patients who are older and/or weigh more. Children (excluding infants) with more severe symptoms may require up to 6 inhalations per dose. Over the course of these 3 short-acting beta agonist treatments, the caregiver can determine (based on action plan or clinician guidance) whether to continue care at home or seek additional medical attention.
Δ The number of inhalations is based up on the severity of respiratory impairment, age and weight of the patient, number of inhalations the patient has already received, and availability of monitoring. When administering an albuterol MDI for acute asthma exacerbation, use of a valved holding chamber (with a mask in children <4 years of age) and careful attention to technique are recommended.

Data from:

National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines (Accessed on October 18, 2021).
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, updated 2021. https://ginasthma.org/reports/ (Accessed on October 18, 2021).

Graphic 134102 Version 6.0

خرید پکیج

Inhaled beta agonist doses used for initial management of asthma exacerbations in children <12 years of age*