All Aboard for Albuterol

Albuterol is a very common medication that you’ll see a lot in the clinical setting and on your exams. Using the Straight A Nursing pharmacology framework (DRRUGS), let’s go through the main things you need to know to understand albuterol administration so you can rock your exams and feel confident in clinical. 

D: Drug class: Beta 2 agonist (therapeutic class: bronchodilator). 

Albuterol belongs to the drug class of beta-2 agonists, more specifically it’s a beta-2 bronchodilator. Beta-2 bronchodilators act on the smooth muscle of the bronchioles by stimulating beta-2 adrenergic receptors in the lung which leads to an increase in cAMP (cyclic adenosine monophosphate) production. It is this increase in cAMP concentrations that relaxes smooth muscle while inhibiting the release of mediators associated with hypersensitivity. Do you need to know this much detail? Maybe not, but at the very least you need to know that albuterol relaxes the smooth muscle of the bronchioles.

You also need to be aware that albuterol is considered a selective beta-2 agonist, though it does have some minor beta-1 effects. Remember that beta-2 receptors are mainly in the lung, though there are some in the heart and skeletal muscle. This will come into play when we discuss albuterol’s side effects later on.

R: Routes

Albuterol is most often administered as an inhalation medication given either through a nebulizer or inhaler. It can also be given IV, as a tablet or an oral elixir. For the purposes of your nursing school exams and clinical practice, we’ll focus on the most common route, which is inhalation.

R: Regular dose range

For nebulized albuterol, the typical dose for adults and children over 12 years is 2.5 mg three or four times a day. If your patient is using an inhaler, the typical dose for adults and children over 4 years is 2 puffs every four to six hours, not to exceed 12 puffs in a 25-hour period. And, in case you were wondering, each “puff” contains 90 mcg of medication. 

Remember this is the “regular” dose range and there are always exceptions. The idea with this is for you to be on high alert if you see a test question or MD order that calls for something that is vastly different. Though it may not be incorrect, it should probably be investigated. Unfortunately, mistakes do happen and it’s often up to the nurse to catch them.

U: Uses

Albuterol is used most commonly to reverse bronchospasm in people with restrictive airway disease such as asthma and COPD. However, it can also be used for patients with bronchitis and to reverse or prevent exercise-induced bronchospasm.

G: Guidelines

Inhaled albuterol can be administered as a nebulized solution, an aerosol, or as a powder.

• For a nebulized solution, you’ll place the albuterol in the reservoir and connect the nebulizer to a face mask or a mouthpiece. The patient then uses the nebulizer to breathe in the albuterol until the reservoir is empty. If your patient is using this system at home, they should be instructed to clean the nebulizer system after each use.*
• The aerosol formulation (ProAir HFA and Proventil HFA) is administered via an inhaler. Teach patients that the medication should be at room temperature prior to use. Before using it for the first time, the patient needs to shake it well and test it by spraying it 3-4 times away from their face (same if it hasn’t been used in more than two weeks). To use this medication, instruct the patient to shake the container, breathe out completely, place the mouthpiece just in front of their open mouth (or use a spacer) and breathe in slowly while pressing down on the canister. They then need to hold their breath for 10 seconds, then exhale slowly. If using more than one puff, they need to wait one full minute before proceeding. Once finished with the full dose, the patient should rinse his mouth with water.*
• To use the inhalation powder (ProAir Digihaler and ProAir Respicklick), the patient should be instructed to breathe out fully, place the mouthpiece into the mouth and close their lips around it. Next, they breathe in a full breath, hold for 10 seconds and exhale slowly. While the patient may use a spacer with the ProAir Respicklick, they should not use a spacer with the ProAir Digihaler.*

S: Side effects:

Because of albuterol’s effect on the beta receptors, side effects include:

• Tachycardia occurs for two reasons. For starters, though the beta receptors in the heart are mostly beta-1 receptors, there are some beta-2 which are stimulated by albuterol. In addition, the beta-2 effect on vascular smooth muscle causes vasodilation, which leads to a drop in blood pressure, which leads to a compensatory increase in heart rate.
• Tremors can occur due to albuterol’s effect on the beta-2 receptors of skeletal muscle.
• Other common side effects include anxiety, insomnia, hypokalemia, and cough.

Critical thinking exercise:

Your patient is fluid overloaded, has a history of asthma and just started on 40mg furosemide BID yesterday morning. She begins to complain of chest tightness and when you listen to her lungs, you hear expiratory wheezes. Her O2 saturation has dropped from 97% on RA to 91%.  What information do you want before administering this patient her prn albuterol? 

Before you answer this, think about this. In addition to reversing bronchospasm, albuterol also causes a shift of potassium from the extracellular to intracellular space.  In fact, it is often used to treat hyperkalemia, which you can learn about here. Loop diuretics, such as furosemide, cause hypokalemia through the increased excretion of potassium.

So, before giving your patient their albuterol, you’d want to know what their potassium level is, especially if they’ve been receiving a powerful loop diuretic such as furosemide. And why do we care so much about hypokalemia? Because of its effect on cardiac function, which can deteriorate to the point of cardiac arrest. In this case, you’d want to alert the MD as other treatment options may need to be explored.

So there you have it…all the details you need to know about albuterol. I hope this helps you breathe a little easier when you take your next nursing school exam (okay, I couldn’t resist!)

*Always follow manufacturer instructions

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References

D’Alonzo, G. E. (2004). Levalbuterol in the Treatment of Patients With Asthma and Chronic Obstructive Lung Disease. The Journal of the American Osteopathic Association, 104(7), 288–293. https://doi.org/10.7556/jaoa.2004.104.7.288

Deglin, J. H., & Vallerand, A. H. (2007). Davis’s drug guide for nurses (11th ed.). F. A. Davis Company.

Drugs.com. (n.d.). Beta blockers. https://www.drugs.com/mca/beta-blockers

Mayo Clinic. (n.d.-a). Albuterol proper use. https://www.mayoclinic.org/drugs-supplements/albuterol-inhalation-route/proper-use/drg-20073536

Mayo Clinic. (n.d.-b). What you should know about beta blockers. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/beta-blockers/art-20044522

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (Eighth). Elsevier.

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (Fourth Edition). F. A. Davis Company.