Pharmacologic Treatment of Asthma Exacerbations*, †

Short-acting beta-2 agonists‡

AlbuterolAlbuterol

HFA: 90 mcg/puff

Same as adults

4–10 puffs every 20 minutes for 3 doses, then up to 6–10 doses every 1–2 hours

MDI is as effective as nebulized solution if patients can coordinate inhalation maneuver using spacer and holding chamber.

Nebulized solution: 5 mg/mL and 0.63, 1.25, and 2.5 mg/3 mL

0.15 mg/kg (minimum 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

Alternatively, 0.5 mg/kg/hour continuous nebulization (up to 10–20 mg per hour in children < 12 years)

In children > 12 years, up to 10–15 mg/hour

2.5–5 mg every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed

Alternatively, 10–15 mg/hour continuous nebulization

Continuous nebulization is similarly effective compared to episodic nebulization, but it increases frequency of adverse effects.

LevalbuterolLevalbuterol

HFA: 45 mg/actuation

Same as adults

4–8 puffs every 20 minutes for 3 doses, then every 1–4 hours as needed

Levalbuterol is the R-isomer of albuterol.

0.63 mg is equivalent to 1.25 mg racemic albuterol.

Levalbuterol may have fewer adverse effects than albuterol.

Nebulized solution: 0.31, 0.63, 1.25 mg/3 mL, and 1.25 mg/0.5 mL

0.075 mg/kg (minimum 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

1.25–2 mg every 20 minutes for 3 doses, then 1.25–5 mg every 1–4 hours as needed

Alternatively, 5–7.5 mg/hours continuous nebulization

—

Anticholinergics

IpratropiumIpratropium

Nebulized solution: 500 mcg/2.5 mL (0.02%)

MDI: 18 mcg per puff

0.25–0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed

Children: 4–8 puffs every 20 minutes as needed for up to 3 hours

Adolescents: 8 puffs every 20 minutes for up to 3 hours

0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed

Ipratropium should be added to beta-2 agonists and not used as first-line therapy.

It may be mixed in same nebulizer as albuterol.

Dose delivered from MDI is low and has not been studied in exacerbations.

Combination medications

Ipratropium/albuterolIpratropium/albuterol

SMI: 20 mcg ipratroprium and 100 mcg albuterol/puff

—

1 puff every 30 minutes for 3 doses, then every 2–4 hours as needed

Ipratropium prolongs bronchodilator effect of albuterol.

Nebulized solution: 0.5 mg ipratropium and 2.5 mg albuterol in a 3-mL vial

1.5 mL every 20 minutes for 3 doses, then up to 3 hours as needed

3 mL every 30 minutes for 3 doses, then every 2–4 hours as needed

—

Budesonide/formoterolBudesonide/formoterol

HFA: 80 or 160 mcg budesonide and 4.5 mcg formoterol

4 to < 12 years Budesonide 80 mcg/formoterol 4.5 mcg 1 puff as needed for symptom control administered after a few minutes as needed

Maximum daily dose including maintenance and reliever therapy is 8 puffs

≥ 12 years: Budesonide 160 mcg formoterol 4.5 mcg 1 puff as needed for symptom relief after a few minutes as needed to control symptoms

Maximum daily dose is 12 puffs

2 puffs twice a day as needed

Maximum total daily maintenance and rescue (reliever) of 12 puffs (54 mcg)

Additional daily maintenance therapy should be continued even if used as reliever therapy.

Budesonide/albuterolBudesonide/albuterol

HFA: 80 mcg budesonide/90 mcg albuterol

< 18 years: not used

≥ 18 years: 80 mcg budesonide/90 mcg albuterol 2 puffs as needed

Maximum 6 doses or 12 puffs in 24-hour period

—

Systemic glucocorticoids

MethylprednisoloneMethylprednisolone

Tablets: 2, 4, 8, 16, and 32 mg

0–11 years of age: 1–2 mg/kg once a day or in 2 divided doses until symptoms resolve and PEF is at least 80 percent of patient's personal best

40–80 mg day or in 2 divided doses until symptoms resolve and PEF is at least 70 % of patient's personal best

IV has no advantage over oral administration if gastrointestinal function is normal.

Higher doses provide no advantage in severe exacerbations.

The dose is administered once or twice a day until FEV1 or PEF = 50% of predicted or personal best and then lower the dose to twice a day, usually within 48 hours.

Therapy after a hospitalization or ED visit may last 5–10 days in adults and 3–5 days in children.

Tapering the dose is not needed if patients are also given inhaled glucocorticoids.

Injectable suspension: 20 mg/mL, 40 mg/mL, and 80 mg/mL

Solution for injection: 40 mg, 125 mg, 500 mg, 1000 mg, and 2000 mg

0–11 years: 1–2 mg/kg once a day in 2 divided doses until symptoms resolve and PEF is at least 70% of patient's personal best

60–80 mg in 3 or 4 divided doses for 48 hours, then 30–40 mg/day until PEF reaches 70% of personal best

—

PrednisolonePrednisolone

Tablets: 5 mg

Orally disintegrating tablets: 10, 15, and 30 mg

1–2 mg/kg in 1–2 divided doses until PEF is 70% of predicted or personal best

40 to 80 mg once a day or in 2 divided doses until PEF reaches 70% of patient's predicted or personal best

Maximum dose:

< 2 years: 20 mg/day

3–5 years: 30 mg/day

6–11 years: 40 mg/day

Solution: 5, 10, 15, 20 and 25 mg/5 mL

Same as above

Same as above

Same as above

PrednisonePrednisone

Tablets: 1, 2.5, 5, 10, 20, and 50 mg

1–2 mg/kg daily for 5 days

40–60 mg/day in single daily dose or divided every 12 hours for 3–10 days

Maximum dose:

< 2 years: 20 mg/day

3–5 years: 30 mg/day

6–11 years: 40 mg/day

Concentrate: 5 mg/mL

Solution: 5 mg/5 mL

Same as above

Same as above

Same as above