Albuterol Sulfate (Ventolin, ProAir, Proventil, AccuNeb, Salbutamol)

Preoperative Preparation for Peds - demonstrated to reduce perioperative respiratory adverse events by ~43% in children undergoing tonsillectomy. This benefit is most pronounced in children with moderate-to-severe OSA, asthma, recent upper respiratory tract infection, or other known risk factors for airway reactivity.

Asthma Management - Albuterol is recommended preoperatively for all asthmatic patients; Where feasible, a 5-day course of albuterol combined with systemic corticosteroids before high-risk surgery markedly decreases post-intubation bronchospasm.

Secretion-sparing - Unlike ketamine, albuterol does not increase secretion production which makes this a favorable alternative in airway surgery where secretion burden is a concern.

Timing - Preoperatively, administer at least 20 minutes before induction to ensure maximal bronchodilation at time of airway manipulation. If surgery is delayed >60 minutes after initial dose (half-life ~2.5 hours), consider re-dosing ~20 minutes before the new surgical start time.

Non-asthmatic patient benefits - Albuterol acutely inhibits mast cell release of inflammatory mediators; may also suppress cough receptors and airway reflexes.

Tremor - fine skeletal muscle tremor from beta-2 receptor activation; This is typically mild and transient at standard doses.

Tachycardia - beta-1 spillover may cause dose-dependent heart rate increase; monitor in patients with baseline arrhythmia or coronary artery disease

Blood pressure - mild decrease in systemic vascular resistance possible at higher doses due to peripheral beta-2 vasodilation; generally clinically insignificant at standard inhaled doses.

Electrolytes - can cause hypokalemia and hypomagnesemia via beta-2–mediated intracellular shift; relevant in patients on digoxin or those with baseline electrolyte disturbances. The risk of these electrolyte disturbances goes up with repeat dosing.

Hyperglycemia - beta-2–mediated glycogenolysis and gluconeogenesis; monitor BG's in diabetic patients or those on insulin infusions.

Paradoxical bronchospasm - rare; if wheezing worsens after administration, discontinue and switch to alternative bronchodilator class.

Drug Interactions:

Non-selective beta-blockers (propranolol, labetalol, and carvedilol) antagonize bronchodilatory effect; If beta-blockade is required, use cardioselective agents (esmolol, metoprolol) instead.

MAO inhibitors / tricyclic antidepressants - potentiate cardiovascular effects of albuterol; use with caution and monitor hemodynamics.

Volatile anesthetics - halogenated agents (sevoflurane, isoflurane) sensitize the myocardium to catecholamines; risk of arrhythmia increased with concurrent albuterol at high doses — generally not clinically significant at standard inhaled doses.

Digoxin - albuterol-induced hypokalemia may increase digoxin toxicity; monitor potassium levels.

Relative - Uncontrolled tachyarrhythmia, hypertrophic obstructive cardiomyopathy, thyrotoxicosis.

Use with caution - Coronary artery disease, heart failure, diabetes mellitus, hypokalemia, hypomagnesemia, concurrent use of non-selective beta-blockers, monoamine oxidase inhibitor (MAOI) therapy, pheochromocytoma

Not FDA-approved in US; used internationally.
250 mcg slow IV bolus; infusion 5–20 mcg/min; titrate to effect

Beta-2 adrenergic receptors (primary); minor beta-1 activity at high doses

Selective beta-2 agonist → activates adenylyl cyclase → increases cAMP → activates protein kinase A → phosphorylates myosin light-chain kinase → relaxes bronchial smooth muscle

Hepatic; also gut wall (swallowed fraction). Hepatic impairment has minimal clinical impact at standard inhaled doses due to low systemic bioavailability

No clinically significant active metabolites

Renal (primary, ~72% as metabolites); fecal (minor)
Elimination Half-Life: ~2.5–5 hours (inhaled/IV); ~5–6 hours (oral)
Monitor for accumulation with repeated high-dose nebulization in severe renal failure.

None. Cardioselective beta-blockers (metoprolol, esmolol) may be used cautiously to counter cardiovascular effects (tachycardia, arrhythmia) if clinically necessary — however, risk of bronchospasm exists.

Dosing

Inhaled MDI — Preoperative premedication (adults) - 2–4 puffs (180–360 mcg) via spacer, 20–30 min before induction

Inhaled MDI — Preoperative premedication (children ≤8 yr) - 2 puffs (200 mcg) via spacer, at least 20 min before induction (REACT protocol)

Inhaled MDI — Intraoperative bronchospasm - 2–8 puffs via MDI adaptor in breathing circuit; may repeat every 20 min as needed

Nebulized (adults) — Acute bronchospasm - 2.5 mg in 3 mL NS over 5–15 min; may repeat every 20 min × 3, then every 1–4 hr

Nebulized (peds) — Acute bronchospasm - 0.15 mg/kg (min 2.5 mg) in 3 mL NS every 20 min × 3 doses; then 0.15–0.3 mg/kg/hr continuous nebulization if needed

Continuous nebulization — Severe bronchospasm - 10–15 mg/hr (adults) or 0.5 mg/kg/hr (children, max 20 mg/hr)