Asthma Management Handbook
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Table. Add-on treatment options for acute asthma


Recommended use in acute asthma

Administration and dosage


Inhaled ipratropium bromide

Second-line bronchodilator if inadequate response to salbutamol

Via pMDI 21 mcg/actuation every 20 minutes for first hour

Repeat every 4–6 hours for 24 hours



Adults and children 6 years and over:
8 puffs

Children 0–5 years:
4 puffs

Use spacer (plus mask, if patient cannot use mouthpiece)

Via nebuliser every 20 minutes for first hour

Repeat every 4–6 hours

Adults and children 6 years and over:
500 mcg nebule

Children 0–5 years:
250 mcg nebule

If salbutamol is delivered by nebuliser, add to nebuliser solution

IV magnesium sulfate

Second-line bronchodilator in severe or life-threatening acute asthma, or when poor response to repeated maximal doses of other bronchodilators

IV infusion over 20 minutes

Adults: 10 mmol

Children 2 years and over: 0.1–0.2 mmol/kg (maximum 10 mmol)

Avoid magnesium sulfate in children younger than 2 years

Dilute in compatible solution

IV salbutamol

(only in ICU)

Third-line bronchodilator in life-threatening acute asthma that has not responded to continuous nebulised salbutamol after considering other add-on treatment options

Follow hospital/organisation’s protocol 



Use only in critical care units (e.g. emergency department, intensive care unit/high-dependency unit)

Monitor blood electrolytes, heart rate and acid/base balance (blood lactate)

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

Non-invasive positive pressure ventilation 

Consider if starting to tire or signs of respiratory failure


Do not sedate patient

If no improvement, intubate and start mechanical ventilation

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