NHLBI asthma exacerbation treatment recommendations


    • Reference: National Heart, Lung, and Blood Institute (NHLBI) 2007 asthma guidelines
Medication Pediatric (≤ 12 years old) Adult (≥ 13 years old) Other
Albuterol nebulizer

(2.5 mg/0.5 ml)
(2.5 mg/3 ml)
(1.25 mg/3 ml)
(0.63 mg/3 ml)
(5.0 mg/mL concentrate)
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 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 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.
Albuterol inhaler

(Proventil HFA®)
(Ventolin HFA®)
(ProAir HFA®)
(ProAir® RespiClick)
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. 4 – 8 puffs every 20 minutes up to 4 hours, then every 1 – 4 hours as needed. In mild-to-moderate exacerbations, MDI plus VHC is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel.
Ipratropium nebulizer

(0.5 mg/2.5 ml)
0.25 – 0.5 mg every 20 minutes for 3 doses, then as needed 0.5 mg every 20 minutes for 3 doses then as needed 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.
Ipratropium inhaler

(Atrovent HFA®)
4 – 8 puffs every 20 minutes as needed up to 3 hours 8 puffs every 20 minutes as needed up to 3 hours Should use with VHC and face mask for children < 4 years. Studies have examined ipratropium bromide MDI for up to 3 hours.
Levalbuterol nebulizer

(0.31 mg/3 mL)
(0.63 mg/3 mL)
(1.25 mg/3 mL)
(1.25 mg/0.5 ml)
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 1.25 – 2.5 mg every 20 minutes for 3 doses, then 1.25 – 5 mg every 1 – 4 hours as needed Levalbuterol administered in one-half the mg dose of albuterol provides comparable efficacy and safety. Has not been evaluated by continuous nebulization.
Levalbuterol inhaler

(Xopenex HFA®)
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. 4 – 8 puffs every 20 minutes up to 4 hours, then every 1 – 4 hours as needed. In mild-to-moderate exacerbations, MDI plus VHC is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel.
Ipratropium 0.5 mg/
albuterol 3 mg per 3ml

(Duoneb®)
1.5 - 3 mL every 20 minutes for 3 doses, then as needed 3 mL every 20 minutes for 3 doses, then as needed 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.
Ipratropium + albuterol

(Combivent Respimat®)
4 – 8 puffs every 20 minutes as needed up to 3 hours 8 puffs every 20 minutes as needed up to 3 hours Should use with VHC and face mask for children < 4 years