albuterol sulfate
(al byoo' ter ole)
AccuNeb, Novo-Salmol (CAN), Proventil, Proventil HFA, Proventil Repetabs, Salbutamol (CAN), Ventodisk (CAN), Ventolin, Ventolin HFA, Volmax

Pregnancy Category C

Drug classes
Sympathomimetic drug
Beta2-selective adrenergic agonist
Bronchodilator
Antiasthmatic drug

Therapeutic actions
In low doses, acts relatively selectively at beta2-adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic cardiac effects.

Indications
· Relief and prevention of bronchospasm in patients with reversible obstructive airway disease
· Treatment of acute attacks of bronchospasm (inhalation)
· Prevention of exercise-induced bronchospasm
· Unlabeled use: adjunct in treating serious hyperkalemia in dialysis patients; seems to lower potassium concentrations when inhaled by patients on hemodialysis

Contraindications and cautions
· Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke; COPD patients with degenerative heart disease.
· Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis); hyperthyroidism; history of seizure disorders; psychoneurotic individuals; labor and delivery (oral use has delayed second stage of labor; parenteral use of beta2-adrenergic agonists can accelerate fetal heart beat and cause hypoglycemia, hypokalemia, pulmonary edema in the mother and hypoglycemia in the neonate); lactation.

Available forms
Tablets--2, 4 mg; SR tablets--4, 8 mg; syrup--2 mg/5 mL; aerosol--90 mcg/actuation; solution for inhalation--0.083%, 0.5%, 1.25 mg/3 mL, 0.63 mg/3 mL; capsules for inhalation--200 mcg

Dosages
ADULTS
Oral
Initially, 2 or 4 mg (1–2 tsp syrup) tid–qid PO; may cautiously increase dosage if necessary to 4 or 8 mg qid, not to exceed 32 mg/day. Extended release tablets: 8 mg q 12 hr (Volmax); 4–8 mg q 12 hr (Proventil)
Inhalation
Each actuation of aerosol dispenser delivers 90 mcg albuterol; 2 inhalations q 4–6 hr; some patients may require only 1 inhalation q 4 hr; more frequent administration or larger number of inhalations not recommended.
· Prevention of exercise-induced bronchospasm: 2 inhalations 15 min prior to exercise.
· Solution for inhalation: 2.5 mg tid to qid by nebulization.
· Inhalation capsules: One 200 mcg capsule q 4–6 hr up to two 200 mcg capsules q 4–6 hr.
· Prevention of exercise-induced asthma: One 200 mcg capsule inhaled 15 min before exercise.
PEDIATRIC PATIENTS
Oral, tablets
· 12 yr or older: Same as adult.
· 6–12 yr: 2 mg tid–qid. Do not exceed 24 mg/day.
Extended release tablets
· 6–12 yr: 4 mg q 12 hr (Volmax).
· 6–11 yr: 4 mg q 12 hr (Proventil).
Oral, syrup
· > 14 yr: Same as adult.
· 6–14 yr: 2 mg (1 tsp) tid–qid; if necessary, cautiously increase dosage. Do not exceed 24 mg/day in divided doses.
· 2–6 yr: Initially, 0.1 mg/kg tid, not to exceed 2 mg (1 tsp) tid; if necessary, cautiously increase stepwise to 0.2 mg/kg tid. Do not exceed 4 mg (2 tsp) tid.
· < 2 yr: Safety and efficacy not established.
Inhalation
· 12 yr or older: Same as adult.
· 2–12 yr: 10–15 kg--1.25 mg; > 15 kg--2.5 mg
Solution for inhalation
· 10–15 kg: 1.25 mg bid–tid by nebulization.
· > 15 kg: 2.5 mg bid–tid by nebulization.
Inhalation capsules
· 4 yr or older: One 200 mcg capsule inhaled q 4–6 hr.
· Prevention of exercise-induced asthma: One 200 mcg capsule inhaled 15 min before exercise.
GERIATRIC PATIENTS AND PATIENTS SENSITIVE TO BETA-ADRENERGIC STIMULATION
Restrict initial dose to 2 mg tid–qid; individualize dosage thereafter. Patients > 60 yr are more likely to develop adverse effects.

Pharmacokinetics
Route
Onset
Peak
Duration
Oral
30 min
2–2.5 hr
4–8 hr
Inhalation
5 min
1.5–2 hr
3–8 hr

Metabolism: Hepatic; T1/2: 2–4 hr
Distribution: Crosses placenta; passes into breast milk
Excretion: Urine

Adverse effects
· CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesia, insomnia, tremor, drowsiness, irritability, weakness, vertigo, headache
· CV: Cardiac arrhythmias, tachycardia, palpitations, PVCs (rare), anginal pain
· Dermatologic: Sweating, pallor, flushing
· GI: Nausea, vomiting, heartburn, unusual or bad taste
· GU: Increased incidence of leiomyomas of uterus when given in higher than human doses in preclinical studies
· Respiratory: Respiratory difficulties, pulmonary edema, coughing, bronchospasm, paradoxical airway resistance with repeated, excessive use of inhalation preparations

Interactions
Drug-drug
· Increased sympathomimetic effects with other sympathomimetic drugs
· Increased risk of toxicity, especially cardiac, when used with theophylline, aminophylline, oxtriphylline
· Decreased bronchodilating effects with beta-adrenergic blockers (eg, propranolol)
· Decreased effectiveness of insulin, oral hypoglycemic drugs
· Decreased serum levels and therapeutic effects of digoxin

Nursing considerations
Assessment
· History: Hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane; unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke; COPD patients who have developed degenerative heart disease; diabetes mellitus; hyperthyroidism; history of seizure disorders; psychoneurotic individuals; lactation
· Physical: Weight; skin color, temperature, turgor; orientation, reflexes, affect; P, BP; R, adventitious sounds; blood and urine glucose, serum electrolytes, thyroid function tests, ECG

Interventions
· Use minimal doses for minimal periods; drug tolerance can occur with prolonged use.
· Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur.
· Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline; deliver over 5–15 min by nebulization.
· Do not exceed recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive.

Teaching points
· Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant.
· These may occur: dizziness, drowsiness, fatigue, headache (use caution if driving or performing tasks that require alertness); nausea, vomiting, change in taste (small, frequent meals may help); rapid heart rate, anxiety, sweating, flushing.
· Report chest pain, dizziness, insomnia, weakness, tremors or irregular heart beat, difficulty breathing, productive cough, failure to respond to usual dosage.

Adverse effects in Italic are most common; those in Bold are life-threatening.