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 disease1-6. 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 emphysema1,2,7,8. Revefenacin (Yupelri®) is FDA-approved as a maintenance therapy for COPD1,2,9. A nebulized formulation of the long acting antimuscarinic anticholinergic agent glycopyrrolate (Lonhala Magnair®) was approved by the FDA in 2017 for the long-term maintenance treatment of airflow obstruction in patients with COPD1,2,10. 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 agents1,2,11. 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 exacerbations12. 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 exacerbations.13 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 bronchodilator1,2,14. 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 Sympathomimetics1-6
| Treatment Indication |
Drug Name |
Dosage Strength |
Maximum Recommended Dosage |
| Bronchospasm in reversible obstructive airway disease (e.g., asthma) |
Racemic albuterol (various generics) |
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) |
| Bronchospasm in reversible obstructive airway disease (e.g., asthma) |
Levalbuterol (Xopenex®, generics) |
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 needed12
Table 2. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Monotherapy: Short-Acting Anticholinergics1,2,11
| Treatment Indication |
Drug Name |
Dosage Strength |
Maximum Recommended Dosage |
| Chronic obstructive pulmonary disease (COPD) |
Ipratropium (various generics) |
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 Sympathomimetics1,2,7,8
| Treatment Indication |
Drug Name |
Dosage Strength |
Maximum Recommended Dosage |
| Chronic obstructive pulmonary disease (COPD) |
Arformoterol (Brovana®, generic) |
15 mcg/2 ml |
15 mcg twice daily by nebulization |
| COPD |
Formoterol (Perforomist®, generic) |
20 mcg/2 ml |
20 mcg twice daily by nebulization |
Table 4. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Monotherapy: Long-Acting Anticholinergics1,2,9,10
| Treatment Indication |
Drug Name |
Dosage Strength |
Maximum Recommended Dosage |
| Chronic obstructive pulmonary disease (COPD) – maintenance therapy |
Glycopyrrolate (Lonhala® Magnair®) |
25 mcg/ mL |
25 mcg twice daily by nebulization! |
| COPD – maintenance therapy |
Revefenacin (Yupelri®) |
175 mcg/3 ml |
175 mcg once daily |
Legend:
- ! Lonhala® Magnair® is approved for use with the Magnair® nebulization system10
Table 5. Maximum Recommended Nebulized Bronchodilator Dosages in Adults: Combination Therapy1,2,14
| 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
