Short-acting, nebulized beta2-adrenergic bronchodilators are FDA-approved for use in the relief of acute, potentially recurrent bronchospasm in patients with reversible obstructive airway disease1-5. Long-acting, nebulized beta2-adrenergic agents are FDA-approved for use as maintenance therapy in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema1,6,7. Revefenacin (Yupelri) is FDA-approved as maintenance therapy for COPD1,8. The anticholinergic, ipratropium, is FDA-approved to manage bronchospasm associated with exacerbations of COPD, including bronchitis and emphysema, either as monotherapy or in combination with beta adrenergic agentsXXX .1,9 While not FDA-approved, the Expert Panel 3 guidelines from the National Heart Lung and Blood Institute document benefit when multiple ipratropium doses are administered adjunctively with beta2-agonists in the emergency department to manage more severe acute asthma exacerbations10. Additionally, the Global Initiative for Asthma (GINA) guidelines state that ipratropium may be considered a potential alternative bronchodilator for routine relief of asthma symptoms, and it may be used in combination with a short acting beta2-adrenergic agonist in the emergency treatment of moderate to severe exacerbations11. Ipratropium/racemic albuterol combination therapy is FDA-approved for use as second-line therapy in adult COPD patients who continue to experience bronchospasm with an aerosol bronchodilator and require a second bronchodilator1,2,12.
Recommended adult dosages are summarized in Tables 1-5. Patient profiles with dosages exceeding these recommendations will be reviewed.
Table 1. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Monotherapy: Short-Acting Sympathomimetics1-5| Drug Name | Treatment Indication | Dosage Strength | Maximum Recommended Dosage |
|---|
| Racemic albuterol (various generics) | Bronchospasm in reversible obstructive airway disease (e.g., asthma) | 2.5 mg/3 mL; (0.083%); 2.5 mg/0.5 mL (0.5%) | 2.5 mg four times daily by nebulization* (maximum dose per day: 10 mg) |
| Levalbuterol (Xopenex, generics) | Bronchospasm in reversible obstructive airway disease (e.g., asthma) | 0.31 mg/3 ml; 0.63 mg/3 ml; 1.25 mg/3 ml; 1.25 mg/0.5 ml | 1.25 mg three times daily by nebulization^ |
Legend:
- *Manufacturers of racemic albuterol state that more frequent administration or higher doses not recommended; however, in severe asthma exacerbations, the National Asthma Education and Prevention Program Expert Panel (NAEPPEP) recommends racemic albuterol doses of 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 by continuous nebulization12
- ^For acute asthma exacerbations, NAEPPEP recommends levalbuterol doses of 1.25-2.5 mg every 20 minutes for 3 doses, then 1.25-5 mg every 1-4 hours as needed10
Table 2. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Monotherapy: Short-Acting Anticholinergics1-9| Drug Name | Treatment Indication | Dosage Strength | Maximum Recommended Dosage |
|---|
| Ipratropium (various generics) | Chronic obstructive pulmonary disease (COPD) | 500 mcg/2.5 ml (0.02%) | 500 mcg four times daily, with doses 6 hours apart |
Table 3. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Monotherapy: Long-Acting Sympathomimetics1,6,7| Drug Name | Treatment Indication | Dosage Strength | Maximum Recommended Dosage |
|---|
| Arformoterol (Brovana, generic) | Chronic obstructive pulmonary disease (COPD) | 15 mcg/2 ml | 15 mcg twice daily by nebulization |
| Formoterol (Perforomist, generic) | COPD | 20 mcg/2 ml | 20 mcg twice daily by nebulization |
Table 4. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Monotherapy: Long-Acting Anticholinergics1,8| Drug Name | Treatment Indication | Dosage Strength | Maximum Recommended Dosage |
|---|
| Revefenacin (Yupelri) | COPD – maintenance therapy | 175 mcg/3 ml | 175 mcg once daily |
Table 5. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Combination Therapy1,12| Treatment Indication | Drug Name | Dosage Strength | Maximum Recommended Dosage |
|---|
| Bronchospasm associated with chronic obstructive pulmonary disease (COPD) for patients requiring a second bronchodilator | Ipratropium/ racemic albuterol (generic) | 0.5 mg/3 mg# per 3 ml | 3 ml 6 times per day^ |
Legend:
- # 2.5 mg racemic albuterol base
- ^ For moderate asthma exacerbations, NAEPPEP recommends ipratropium/albuterol doses of 3 mL (ipratropium bromide 0.5mg/ albuterol base 2.5 mg) every 4-6 hours in the emergency setting. For severe asthma exacerbations, NAEPPEP recommends ipratropium/albuterol doses of 3 mL (ipratropium bromide 0.5mg/ albuterol base 2.5 mg) every 20 minutes for 3 doses, then as needed for up to 3 hours in the emergency setting12
