Which of the following adverse effects should a nurse monitor for when administering albuterol to a client with asthma?

Albuterol comes as a solution (liquid) to inhale by mouth using a special jet nebulizer (machine that turns medication into a mist that can be inhaled) and as an aerosol or powder to inhale by mouth using an inhaler. When the inhalation aerosol or powder for oral inhalation is used to treat or prevent symptoms of lung disease, it is usually used every 4 to 6 hours as needed. When the inhalation aerosol or powder for oral inhalation is used to prevent breathing difficulty during exercise, it is usually used 15 to 30 minutes before exercise. The nebulizer solution is usually used three or four times a day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use albuterol exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor.

Call your doctor if your symptoms worsen or if you feel that albuterol inhalation no longer controls your symptoms. If you were told to use albuterol as needed to treat your symptoms and you find that you need to use the medication more often than usual, call your doctor.

Albuterol controls symptoms of asthma and other lung diseases but does not cure them. Do not stop using albuterol without talking to your doctor.

Each albuterol aerosol inhaler is designed to provide 60 or 200 inhalations, depending on its size. Each albuterol powder inhaler is designed to provide 200 inhalations. After the labeled number of inhalations has been used, later inhalations may not contain the correct amount of medication. Dispose of the aerosol inhaler after you have used the labeled number of inhalations, even if it still contains some liquid and continues to release a spray when it is pressed. Dispose of the powder inhaler 13 months after you open the foil wrapper, after the expiration date on the package, or after you have used the labeled number of inhalation, whichever comes first.

Your inhaler may come with an attached counter that keeps track of the number of inhalations you have used. The counter also tells you when to call your doctor or pharmacist to refill your prescription and when there are no inhalations left in the inhaler. Read the manufacturer's instructions to learn how to use the counter. If you have this type of inhaler, you should not try to change the numbers or remove the counter from the inhaler.

If your inhaler does not come with an attached counter, you will need to keep track of the number of inhalations you have used. You can divide the number of inhalations in your inhaler by the number of inhalations you use each day to find out how many days your inhaler will last. Do not float the canister in water to see if it still contains medication.

The inhaler that comes with albuterol aerosol is designed for use only with a canister of albuterol. Never use it to inhale any other medication, and do not use any other inhaler to inhale albuterol.

Be careful not to get albuterol inhalation into your eyes.

Do not use your albuterol inhaler when you are near a flame or source of heat. The inhaler may explode if it is exposed to very high temperatures.

Before you use albuterol inhaler or jet nebulizer for the first time, read the written instructions that come with the inhaler or nebulizer. Ask your doctor, pharmacist, or respiratory therapist to show you how to use it. Practice using the inhaler or nebulizer while he or she watches.

If your child will be using the inhaler, be sure that he or she knows how to use it. Watch your child each time he or she uses the inhaler to be sure that he or she is using it correctly.

To inhale the aerosol using an inhaler, follow these steps:

1. Remove the protective dust cap from the end of the mouthpiece. If the dust cap was not placed on the mouthpiece, check the mouthpiece for dirt or other objects. Be sure that the canister is fully and firmly inserted in the mouthpiece.
2. If you are using the inhaler for the first time or if you have not used the inhaler in more than 14 days, you will need to prime it. You may also need to prime the inhaler if it has been dropped. Ask your pharmacist or check the manufacturer's information if this happens. To prime the inhaler, shake it well and then press down on the canister 4 times to release 4 sprays into the air, away from your face. Be careful not to get albuterol in your eyes.
3. Shake the inhaler well.
4. Breathe out as completely as possible through your mouth.
5. Hold the canister with the mouthpiece on the bottom, facing you and the canister pointing upward. Place the open end of the mouthpiece into your mouth. Close your lips tightly around the mouthpiece.
6. Breathe in slowly and deeply through the mouthpiece.At the same time, press down once on the container to spray the medication into your mouth.
7. Try to hold your breath for 10 seconds. remove the inhaler, and breathe out slowly.
8. If you were told to use 2 puffs, wait 1 minute and then repeat steps 3-7.
9. Replace the protective cap on the inhaler.
10. Clean your inhaler regularly. Follow the manufacturer's directions carefully and ask your doctor or pharmacist if you have any questions about cleaning your inhaler.

To inhale the powder using the inhaler, follow these steps. Do not use the Respiclick inhaler with a spacer:

1. If you will be using a new inhaler for the first time, remove it from the foil wrapper. Look at the dose counter at the back of the inhaler and check that you see the number 200 in the window.
2. Holding the inhaler upright, with the cap on the bottom and the inhaler pointing upwards, load the dose by opening the protective dust cap at the end of the mouthpiece until it clicks. Do not open the cap unless you are ready to use the inhaler. Every time the protective cap is opened, a dose is ready to inhale. You will see the number in the dose counter go down. Do not waste doses by opening the inhaler unless you are inhaling a dose.
3. Breathe out as completely as possible through your mouth. Do not blow or exhale into the inhaler.
4. Place the mouthpiece between your lips well into your mouth. Close your lips tightly around the mouthpiece. Inhale slowly and deeply through your mouth. Do not breath in through your nose. Make sure that your fingers or lips do not block the vent above the mouthpiece.
5. Remove the inhaler from your mouth and hold your breath for 10 seconds or as long as you comfortably can. Do not blow or exhale through the inhaler.
6. Close the cap firmly over the mouthpiece.
7. If you are to inhale 2 puffs, repeat steps 2-6.
8. Keep the inhaler clean and dry at all times. To clean your inhaler, use a clean, dry tissue or cloth. Do not wash or put any part of your inhaler in water.

To inhale the solution using a nebulizer, follow these steps;

1. Remove one vial of albuterol solution from the foil pouch. Leave the rest of the vials in the pouch until you are ready to use them.
2. Look at the liquid in the vial. It should be clear and colorless. Do not use the vial if the liquid is cloudy or discolored.
3. Twist off the top of the vial and squeeze all of the liquid into the nebulizer reservoir. If you are using your nebulizer to inhale other medications, ask your doctor or pharmacist if you can place the other medications in the reservoir along with albuterol.
4. Connect the nebulizer reservoir to the mouthpiece or face mask.
5. Connect the nebulizer to the compressor.
6. Place the mouthpiece in your mouth or put on the face mask. Sit in an upright, comfortable position and turn on the compressor.
7. Breathe in calmly, deeply, and evenly for about 5-15 minutes until mist stops forming in the nebulizer chamber.
8. Clean your nebulizer regularly. Follow the manufacturer's directions carefully and ask your doctor or pharmacist if you have any questions about cleaning your nebulizer.

Albuterol is used for the treatment and prevention of bronchospasm (acute or severe) in patients with reversible obstructive airway disease. It also has an indication for the prevention of exercise-induced bronchospasm. This activity reviews the indications, contraindications, mechanism of action, adverse events, and other key elements of albuterol use and highlights the role of the interprofessional team in managing the care of patients receiving therapy with albuterol.

Objectives:

• Identify the mechanism of action of albuterol, and explain how it works in the treatment of obstructive airway disease.

• Describe the approved indications for albuterol.

• Summarize the most common adverse events associated with albuterol.

• Outline the importance of collaboration and coordination among the interprofessional team leading to improved patient care when using albuterol.

Albuterol, also known as salbutamol, has an indication for the treatment and prevention of bronchospasm (acute or severe) in patients with reversible obstructive airway disease, including exercise-induced bronchospasm.[1][2][3] Without the bronchodilatory effects of albuterol, the individual may suffer catastrophic asphyxiation, making this drug highly desirable to keep on hand for individuals who suffer from recurring obstructive airway symptoms such as asthma.

Albuterol has an off-label indication for adjuvant treatment of hyperkalemia. [4] [5] Albuterol should not be used as monotherapy and should only be used after successfully attempting treatment first with intravenous calcium to stabilize the cardiac tissue, the rhythm of which is highly dependent on potassium concentrations, followed by administration of insulin and glucose to facilitate intracellular transport of the potassium. [6] Albuterol should not be used as monotherapy because its potassium-lowering effect can be weakened in patients with end-stage renal disease.

Currie G. et al. conducted a study on Canadian pediatric emergency department physician treatment choices for wheezing preschool patients. Most physicians treated pediatric patients with albuterol in the emergency department and at discharge. The additional treatment with oral glucocorticoids varied from 12 to 81% and factors that determined treatment were age, atopy history, and the type of wheezing, e.g., continuous. Currie G. et al. found that the physicians were willing to enroll their patients in a randomized clinical trial to help with guidance on when to add an oral glucocorticoid for treatment.[7]

Albuterol acts on beta-2 adrenergic receptors to relax the bronchial smooth muscle. It also inhibits the release of immediate hypersensitivity mediators from cells, especially mast cells. Although albuterol also affects beta-1 adrenergic receptors, this is minimal and has little effect on the heart rate.[8][9] In at least one specific study that used immunoliposomes to deliver albuterol to oxytocin receptors, the albuterol was shown to abate uterine contractions. [10] Albuterol, however, is not approved as a tocolytic.

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 strengths. As a nebulized solution, albuterol is available in 0.083%, 0.5%, 0.63 mg/3mL, and 1.25 mg/3 mL dosage forms. There is also an available oral syrup in a 2 mg/5 mL concentration.[11]

Several forms of albuterol are accepted for the treatment of 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, the advice is 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 a limit of 32 mg per day.[12]

For the treatment of acute or severe bronchospasm, it is advisable 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 to 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, the recommendation is to treat with an 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 the 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 2.5 mg/0.5 mL 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 is given every 6 to 8 hours with a daily maximum of 32 mg.[13]

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.

Teper A. et al. conducted a double-blinded randomized study in asthmatic children (N = 50) to compare the bronchodilating effects of nebulized albuterol in normal saline solution or 3% hypertonic saline solution. The mean age was 12 +/- 3 years and there were 29 boys and 21 girls. The children had mild to moderate asthma with a predicted FEV1 of 40 to 79%. The bronchodilating effects of albuterol were determined 30 minutes after administration of the two dosage forms. The bronchodilating effects of FEV1 were 41.2% and 17.3% for 3% hypertonic saline and normal saline solutions, respectively. The maximum mid-expiratory flow was 130% and 69.8% for 3% hypertonic saline and normal saline solutions, respectively. Teper A. et al. concluded that the 3% hypertonic saline dosage form of albuterol produced a greater bronchodilating effect.[14]

The primary adverse effects of albuterol therapy are tremors and nervousness, mostly seen in children who are 2 to 6 years of age, though can be seen at any age. Tremors are the result of activation of the beta-2 receptors found on the motor nerve terminals which increases intracellular cAMP. 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 concentrations and prolonged QTc interval and ST-segment depression have occurred, although rarely.[15][16]

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 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.[17]

A dose of 1 mg/kg is potentially toxic in the pediatric population under the age of six. Similar to other beta-2 adrenergic receptor agonists, albuterol has been shown to cause an increase in liver aminotransferase concentrations on very rare occasions. This particular toxicity reaction is much more common in other beta-2 adrenergic receptor agonists, such as terbutaline, that are administered in much greater quantities such as in the case of abating uterine contractions.

All healthcare workers, including physicians, physician assistants, and 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 diseases, such as heart disease, as albuterol may exacerbate heart failure with reduced ejection fraction. It is also essential to monitor patients closely with diabetes mellitus, hyperthyroidism, hypokalemia, or glaucoma.[18]

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 adherence. 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 outcomes.

Review Questions

1.

Gardiner MA, Wilkinson MH. Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma. J Pediatr. 2019 Jan;204:245-249.e2. [PubMed: 30392872]

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. Am J Health Syst Pharm. 2018 Nov 15;75(22):1791-1797. [PubMed: 30282664]

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. J Asthma. 2019 Oct;56(10):1079-1086. [PubMed: 30207821]

Evans KJ, Greenberg A. Hyperkalemia: a review. J Intensive Care Med. 2005 Sep-Oct;20(5):272-90. [PubMed: 16145218]

Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008 Dec;36(12):3246-51. [PubMed: 18936701]

Viera AJ, Wouk N. Potassium Disorders: Hypokalemia and Hyperkalemia. Am Fam Physician. 2015 Sep 15;92(6):487-95. [PubMed: 26371733]

Currie G, Crotts J, Nettel-Aguirre A, Johnson D, Stang A. Management of Wheezy Preschoolers in the Emergency Department: A Discrete Choice Experiment. Pediatr Emerg Care. 2021 Dec 01;37(12):e922-e929. [PubMed: 30281552]

Almadhoun K, Sharma S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 21, 2021. Bronchodilators. [PubMed: 30085570]

Condella A, Mansbach JM, Hasegawa K, Dayan PS, Sullivan AF, Espinola JA, Camargo CA. Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis. West J Emerg Med. 2018 May;19(3):475-483. [PMC free article: PMC5942012] [PubMed: 29760843]

Paul JW, Hua S, Ilicic M, Tolosa JM, Butler T, Robertson S, Smith R. Drug delivery to the human and mouse uterus using immunoliposomes targeted to the oxytocin receptor. Am J Obstet Gynecol. 2017 Mar;216(3):283.e1-283.e14. [PubMed: 27567564]

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. Beta2 -adrenoceptor agonist salbutamol increases protein turnover rates and alters signalling in skeletal muscle after resistance exercise in young men. J Physiol. 2018 Sep;596(17):4121-4139. [PMC free article: PMC6117560] [PubMed: 29968301]

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. J Pediatr Pharmacol Ther. 2019 Jan-Feb;24(1):53-57. [PMC free article: PMC6397012] [PubMed: 30837815]

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. Pediatr Emerg Care. 2021 Nov 01;37(11):560-569. [PMC free article: PMC6693989] [PubMed: 30829849]

Teper A, Kofman C, Alchundia Moreira J, Köhler T, García Bournissen F. Bronchodilator response to albuterol nebulized with hypertonic saline in asthmatic children. Pediatr Pulmonol. 2021 Dec;56(12):3714-3719. [PubMed: 34499820]

Berlinski A. Pediatric Aerosol Therapy. Respir Care. 2017 Jun;62(6):662-677. [PubMed: 28546371]

Ng G, da Silva O, Ohlsson A. Bronchodilators for the prevention and treatment of chronic lung disease in preterm infants. Cochrane Database Syst Rev. 2016 Dec 14;12:CD003214. [PMC free article: PMC6463958] [PubMed: 27960245]

Yuknis ML, Weinstein E, Maxey H, Price L, Vaughn SX, Arkins T, Benneyworth BD. Frequency of Pediatric Emergencies in Ambulatory Practices. Pediatrics. 2018 Aug;142(2) [PubMed: 30030368]

Kola M, Hacıoğlu D, Erdöl H, Türk A. Bilateral acute angle closure developing due to use of ipratropium bromide and salbutamol. Int Ophthalmol. 2018 Feb;38(1):385-388. [PubMed: 28168569]