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Add-on treatment options for acute asthma
Agent Recommended use in acute Administration and dosage Notes

Inhaled ipratropium Second-line bronchodilator if Via pMDI Adults and children Use spacer (plus
bromide inadequate response to 21 mcg/actuation 6 years and over: mask, if patient
salbutamol every 20 minutes 8 puffs cannot use
for rst hour Children 0–5 years: mouthpiece)
Repeat every 4– 4 puffs
6 hours for
24 hours


Via nebuliser Adults and children If salbutamol is
every 20 minutes 6 years and over: delivered by
for rst hour 500 mcg nebule nebuliser, add to
Repeat every 4– Children 0–5 years: nebuliser solution
6 hours 250 mcg nebule

IV magnesium sulfate Second-line bronchodilator in IV infusion over Adults: 10 mmol Avoid magnesium
severe or life-threatening 20 minutes Children 2 years and sulfate in children
acute asthma, or when poor over: 0.1– younger than 2 years
response to repeated maximal 0.2 mmol/kg Dilute in compatible
doses of other bronchodilators (maximum 10 mmol) solution
Agent Recommended use in acute Administration and dosage Notes

IV salbutamol Third-line bronchodilator in Follow hospital/organisation’s protocol  Use only in critical
(only in ICU) life-threatening acute asthma   care units (e.g.
that has not responded to emergency
continuous nebulised department, intensive
salbutamol after considering care unit/high-
other add-on treatment dependency unit)
options Monitor blood
electrolytes, heart
rate and acid/base
balance (blood

Reduce initial dose
for older adults.
Consider dose
reduction for those
with impaired renal
function. Impaired
liver function may
result in
accumulation of

Non-invasive positive Consider if starting to tire or   Do not sedate patient
pressure ventilation  signs of respiratory failure If no improvement,
intubate and start

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