Bronchodilators & Nebulized Therapy
Drug Indication Adult Dose Pediatric Dose Frequency / Administration Notes Salbutamol Asthma, COPD exacerbation 2.5–5 mg 2.5 mg (<5 yr), 5 mg (≥5 yr) Every 20 min × 3, then q2–4h First-line bronchodilator 4–10 puffs 4–10 puffs Every 20 min × 3 As effective as neb if technique adequate Ipratropium (Atrovent) Moderate–severe asthma, COPD 0.5 mg 0.25–0.5 mg Every 20 min × 3 (initial) Add-on with SABA Combivent Severe asthma, COPD exacerbation 1 neb 1 neb Every 20 min × 3, then q2–4h Preferred combination in ED Budesonide neb (Pulmicort) Asthma (bridge, pediatrics) 0.5–1 mg 0.5–1 mg Every 6–12 h If systemic steroids delayed Nebulized Adrenaline (1:1000) Croup, stridor Max 5 mL 0.5 mL/kg (max 5 mL) Repeat q20–30 min if needed For upper airway edema only
💊 Systemic Corticosteroids
Drug Adult Dose Pediatric Dose Duration Notes Oral Prednisolone 40–50 mg once daily 1mg/kg/day (max 40–50 mg) 5–7 days Start early IV Hydrocortisone 100 mg q6–8h 4 mg/kg q6h As indicated If unable to take orally IV Methylprednisolone 40–60 mg q6–12h 1–2 mg/kg q6–12h As indicated Alternative to hydrocortisone
⚡ Second-Line Therapy – IV Magnesium Sulfate
Parameter Adults Children Notes Indication Severe / life-threatening asthma Severe pediatric asthma After failure of neb + steroids Dose 1.2–2 g IV 25–50 mg/kg (max 2 g) Single dose Administration Infuse over 20 min Infuse over 20–30 min Avoid rapid bolus Adverse Effects Flushing, nausea, hypotension Same Monitor blood pressure
*Rapid IV bolus magnesium sulfate can cause sudden cardiovascular and neuromuscular side effects because magnesium is a potent vasodilator and calcium antagonist . Full article
🚨 Second-Line / Escalation – IV Salbutamol (β-Agonist Infusion)
Parameter Adults Children Notes Indication Life-threatening / refractory asthma Severe pediatric asthma not responding to neb + MgSO₄ ICU-level therapy Starting Dose 5 mcg/min 0.5–1 mcg/kg/min Start low, titrate every 10–20 min Maximum Dose Up to 10 mcg/min Up to 2 mcg/kg/min Use infusion pump only Administration Continuous IV infusion Continuous IV infusion ❌ Avoid IV bolus Monitoring ECG, HR, BP, K⁺ ECG, HR, BP, K⁺, lactate Risk of tachycardia, hypokalaemia Adverse Effects Tremor, arrhythmia, hypokalaemia Same + lactic acidosis Stop if significant arrhythmia
🔥 Third-Line Therapy – IV Aminophylline
Parameter Adults Children Notes Indication Refractory asthma (selective) More commonly used Not routinely recommended Loading Dose 5–6 mg/kg IV over 20–30 min Same (weight-based) If no recent theophylline Maintenance 0.5–0.7 mg/kg/hr Age & weight adjusted Continuous infusion Target Level 10–20 mcg/mL 10–20 mcg/mL Serum monitoring required Risks Arrhythmias, seizures, vomiting Same Many drug interactions
