Albuterol


Article Author:
Donavon Johnson


Article Editor:
Connor Bounds


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
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William Gossman
Hassam Zulfiqar
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Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
10/9/2019 7:48:15 PM

Indications

Albuterol has an indication for the treatment and prevention of bronchospasm (acute or severe) in patients with reversible obstructive airway disease. It is also indicated for the prevention of exercise-induced bronchospasm.[1][2][3]

Mechanism of Action

Albuterol acts on beta2-receptors to relax the bronchial smooth muscle. It also inhibits the release of immediate hypersensitivity mediators from cells, especially mast cells. Although albuterol affects beta1-receptors, this is minimal and has little effect on the heart rate.[4][5]

Administration

Albuterol comes in a variety of dosing forms and strengths. An aerosol metered-dose inhaler gives 90 mcg (base)/actuation, which is equivalent to 108 mcg of albuterol sulfate. The powder metered-dose inhaler form gives the same values as the aerosol metered-dose inhaler. Albuterol also is offered in 2 mg and 4 mg tablets. Extended-release tablets are available in 4 mg and 6 mg versions. As a nebulized solution, albuterol is offered in 0.083%, 0.5%, 0.63 mg/3mL, and 1.25 mg/3 mL forms. There is also an available syrup offered in a 2 mg/5 mL solution.[6]

Several forms of accepted treatment for bronchospasm. A nebulized solution of 2.5 mg two or three times a day as needed is acceptable for quick relief of symptoms. Dosing of 1.25 to 5 mg every four to eight hours as needed of the nebulized solution is also effective for quick relief of symptoms. For the powdered and aerosol metered-dose inhaler, it is advised to use one or two puffs of 90 mcg every four to six hours depending on the patient, but it is advised not to exceed 12 puffs within 24 hours. For tablet and syrup formulations, 2 to 4 mg every 6 to 8 hours is recommended with the advisory not to exceed 32 mg in one day. The extended-release tablets are taken in either 4 mg or 8 mg doses (depending on the patient’s need) every 12 hours with the limit of 32 mg per day.[7]

For the treatment of acute or severe bronchospasm, it is advised to use a nebulizer solution with a concentration of 2.5 to 5 mg every 20 minutes for three cycles, followed by repeat nebulizer treatments of 2.5 to 10 mg every 1 to 4 hours as needed. Treatment can be maintained with continuous nebulizer treatments every 10-15 minutes. If treating with a metered-dose inhaler, 4 to 8 puffs of 90 mcg every 20 minutes for up to 4 hours is a standard practice followed by 4 to 8 puffs every 1 to 4 hours as needed.

For exercise-induced bronchospasm, it is advised to treat with aerosol or powder metered-dose inhaler before exercise. Two puffs of 90 mcg (for a total of 180 mcg) taken 15 to 20 minutes prior to exercise may help prevent symptoms.

For the treatment of pediatric patients, age becomes a significant factor in our course of treatment. For children under two years old, nebulizer solution with dosing by weight of 0.2-0.6 mg/kg/day divided into either a 4 or 6-hour cycle. For children two years old and older, a nebulizer solution dosing of the 2.5mg/0.5mL solution is given every 6 to 8 hours with a maximum of 10 mg given in any 24 hours.

The use of aerosol metered-dose inhalers in the pediatric population under the age of 4 years old has not had research conducted. The dosing recommendation for four years and older is 90 to 180 mcg (1 to 2 puffs) every 4 to 6 hours.

The use of powder metered-dose inhalers in the pediatric population under the age of 4 years old has not been studied. Dosing recommendation for four years and older to take 180 mcg (2 puffs) every 4 to 6 hours not to exceed 12 puffs within 24 hours.[2]

The dosing of albuterol tablets in pediatric patients under six years old is 0.3 to 0.6 mg/kg/day divided into three treatments given every 8 hours throughout the day. It is advised not to exceed 12 mg/day. For those ages 6 to 12, 2 mg every 6 to 8 hours is the recommended dosage with a daily maximum of 24 mg per day. For pediatric patients over the age of 12, 2 to 4 mg given every 6 to 8 hours with a daily maximum of 32 mg.[8]

Extended-release albuterol tablets are not recommended for those under the age of 6. For pediatric patients between 6 and 12 years of age, the recommendation is for a dose of 4 mg every 12 hours is given, not to exceed 24 mg in 24 hours. For pediatric patients over the age of 12, 8 mg taken every 12 hours is the recommended dose.

The syrup formulation has not been studied in children under the age of 2. For patients between the ages of 2 and 6, the dose is 0.1 mg/kg every 8 hours. This dosing can increase if needed, to 0.2 mg/kg every 8 hours. For those 6 to 14 years of age, 2 mg taken every 6 to 8 hours should suffice. For pediatric patients over the age of 14, 2 to 4 mg taken every 6 to 8 hours is the recommended dose with a daily maximum of 32 mg/day.

Adverse Effects

The primary adverse effects of albuterol therapy are tremors and nervousness, mostly seen in children who are 2 to 6 years of age. These side effects occur in approximately one in every five patients. Other side effects include insomnia and nausea, which occur in approximately 1 in every ten patients. Less common adverse effects may include fever, bronchospasm, vomiting, headache, dizziness, cough, allergic reactions, otitis media, epistaxis, increased appetite, urinary tract infections, dry mouth, gas, hyperhidrosis, pain, dyspepsia, hyperactivity, chills, lymphadenopathy, ocular pruritus, sweating, conjunctivitis, and dysphonia. Albuterol also has been shown to increase blood pressure and may cause hypokalemia. Increased blood glucose level and prolonged QT interval and ST-segment depression have occurred, although rarely.[9][10]

Contraindications

Hypersensitivity is a contraindication for albuterol. Also, if a patient is severely hypersensitive to milk protein, it is advised to avoid the use of albuterol.

Monitoring

Monitoring parameters for albuterol include forced expiratory volume, peak flow, blood pressure, heart rate, Central nervous system stimulation, serum potassium, serum glucose, and asthma symptoms. Since paradoxical bronchospasm may occur, it is important to advise patients to discontinue use and seek medical attention if symptomology worsens with use. If more doses are necessary over time, the clinician may need to make alterations to the patient’s current treatment regimen, as the patient's condition may have deteriorated.[11]

Toxicity

A dose of 1 mg/kg is potentially toxic in the pediatric population under the age of six.

Enhancing Healthcare Team Outcomes

All healthcare workers, including nurse practitioners who prescribe inhalers, should educate the patients on how to use these medications. It is essential to use a face mask in children under the age of 4. Caution is necessary when treating patients with cardiovascular disease, such as heart disease, as albuterol may exacerbate heart failure with reduced ejection fraction. It is also essential to monitor patients closely with diabetes, hyperthyroidism, hypokalemia, glaucoma, or history.[12]

While the clinician will initiate albuterol therapy, the nurse and pharmacist will play significant roles in contributing to the interprofessional team management of treatment. Nursing can provide education on administration and dosing, and monitor therapy at subsequent visits while also assessing patient compliance. The pharmacist can assist in this area, demonstrating proper inhaler use, how to use a spacer, and how to operate and load the nebulizer. Both nurses and pharmacists need an open line of communication with the prescribing clinician to report any concerns. Albuterol management with an interprofessional team will best drive positive patient results. [Level V]


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Albuterol - Questions

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A patient with severe allergies and asthma is currently on a regimen including omalizumab, budesonide, montelukast, and has albuterol available for quick relief of acute symptoms. During a recent exacerbation, she becomes concerned about tremors. Which of the following medications is most likely responsible for her tremors?



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By what mechanism does albuterol cause bronchodilation?



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What is the most appropriate drug to rapidly reverse wheezing?



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Which of the following is a common adverse effect of albuterol?



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Which of the following medications is a direct bronchodilator that acts by stimulating selective receptors on bronchial smooth muscle?



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What is the most commonly used medication for acute asthma in the prehospital setting?



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A patient was prescribed an albuterol inhaler to be used for rescue, 2 puffs every 4 to 6 hours as needed. Which of the following dose-related adverse effects should be highlighted when counseling a patient about this medication?



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A prescriber wants to give a young patient albuterol 0.1mg/kg orally three times a day. What should you advise to the prescriber?



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Which is the best choice in the treatment of an acute asthma attack?



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A female presents with pneumococcal pneumonia. In addition to antibiotics, you decide a bronchodilator is also in order. Which of these is an appropriate choice?



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A 14-year-old boy with asthma develops muscle tremors from one of his asthma medications. What is the likely agent?



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In which drug category is albuterol correctly placed?



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Albuterol most commonly is administered via which of the following routes?



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A 1-year-old male is seen for trouble breathing. A nebulizer is ordered. If the child weights 10 kg, how many milligrams of albuterol should be given via nebulizer within a 24 hour period?



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Which of the following are common adverse effects of albuterol? Select all that apply.



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Which of the following is true regarding albuterol? Select all that apply.



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A 12-year-old female presents to your clinic with complaints of recent episodes of shortness of breath while playing soccer. She states that if she rests she eventually can catch her breath. She is diagnosed with asthma and prescribed an albuterol rescue inhaler. Which of the following is the most likely target for her inhaler?



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Albuterol - References

References

Gardiner MA,Wilkinson MH, Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma. The Journal of pediatrics. 2018 Nov 2     [PubMed]
Orth LE,Kelly BJ,Lagasse CA,Collins SW,Ryan MF, Safety and effectiveness of albuterol solutions with and without benzalkonium chloride when administered by continuous nebulization. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2018 Nov 15     [PubMed]
Abaya R,Delgado EM,Scarfone RJ,Reardon AM,Rodio B,Simpkins D,Mehta V,Hayes K,Zorc JJ, Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler. The Journal of asthma : official journal of the Association for the Care of Asthma. 2018 Sep 12     [PubMed]
Almadhoun K,Sharma S, Bronchodilators null. 2018 Jan     [PubMed]
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Berlinski A, Pediatric Aerosol Therapy. Respiratory care. 2017 Jun     [PubMed]
Ng G,da Silva O,Ohlsson A, Bronchodilators for the prevention and treatment of chronic lung disease in preterm infants. The Cochrane database of systematic reviews. 2016 Dec 14     [PubMed]
Hostrup M,Reitelseder S,Jessen S,Kalsen A,Nyberg M,Egelund J,Kreiberg M,Kristensen CM,Thomassen M,Pilegaard H,Backer V,Jacobson GA,Holm L,Bangsbo J, Beta{sub}2{/sub} -adrenoceptor agonist salbutamol increases protein turnover rates and alters signalling in skeletal muscle after resistance exercise in young men. The Journal of physiology. 2018 Sep;     [PubMed]
Gulley SL,Baltzley SM,Junkins AD,Murray TD,Simms SF,Sullivan JE,Al-Ghananeem AM,O'Hagan AR, Sterility and Stability Testing of Preservative-free Albuterol. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG. 2019 Jan-Feb;     [PubMed]
Fishe JN,Palmer E,Finlay E,Smotherman C,Gautam S,Hendry P,Hendeles L, A Statewide Study of the Epidemiology of Emergency Medical Services' Management of Pediatric Asthma. Pediatric emergency care. 2019 Feb 14;     [PubMed]
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Kola M,Hacıoğlu D,Erdöl H,Türk A, Bilateral acute angle closure developing due to use of ipratropium bromide and salbutamol. International ophthalmology. 2018 Feb;     [PubMed]

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