Question

• What is the evidence that nebulized albuterol decreases potassium (K) levels in children with hyperkalemia?

Clinical Bottom Lines

1. There is only one study that investigates the use of nebulized albuterol in children with hyperkalemia. 30 min after treatment serum potassium levels were shown to have decreased significantly from pretreatment levels. However, it is not known if an initial rise in potassium occurred.
2. Mandelberg, et al., showed an initial rise in potassium levels (mean 0.15mEq/L), 1 min after inhaler treatment, in 59% of their patients. Two of the patients had an increase of >0.4mEq/L.
3. Du Plooy, et al., conducted a study using baboons. In this study, three of the six animals treated with intravenous salbutamol developed left ventricular conduction defects during the hyperkalemic phase. However, these conduction defects may be related to the dose of salbutamol used.

Summary of Key Evidence

1. In this study, 11 children (5-18 years) who had end stage chronic renal failure were treated for hyperkalemia with intravenous salbutamol (4mcg/kg and repeated at 120 min) (pretreatment K 5.6mmol/1), and one week later with nebulized salbutamol (2.5 or 5mg and repeated at 120 min) (pretreatment K 5.9mmol/1). [OR] They were treated with the nebulized salbutamol and one week later with the intravenous salbutamol.
2. Figure 1 shows the change in mean plasma K (mmol/1) with time after treatment with intravenous salbutamol. Within 30 min after treatment there was a significant fall in K by 0.87mmol/1. 120 min after the first dose, the second dose caused K to fall by 1.16mmol/1 from pretreatment level. 120 min after the second dose, K was 0.81mmol/1 below pretreatment concentration.
3. Figure 2 shows the change in mean plasma K (mmol/1) with time after treatment with nebulized salbutamol. Within 30 min after treatment there was a significant fall in K by 0.61mmol/1. 120 min after the first dose, the second dose caused K to fall by 1.14mmol/1 (after 60 min) from pretreatment level. 120 min after the second dose, K was 1.14mmol/1 below pretreatment concentration...
4. At 300 min (end point), the level of reduction in plasma K in the nebulized group was significantly greater than in the group receiving iv salbutamol (1.19 vs. 0.7mmol/1). No significant adverse effects were seen.

Additional Comments

• More studies on the use of nebulized albuterol for hyperkalemia in children are needed before we can feel comfortable about using it.
• More studies should address the issue of using nebulized albuterol in children with higher pretreatment levels of potassium.
• As has been seen in adults, does an initial rise in potassium occur in children treated with salbutamol?

Citation

1. Allon M, et al. Nebulized albuterol for acute hyperkalemia in patients on hemodialysis. Ann Int Med, 1989; 110:426-429.
2. Allon M, et al. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kid Int, 1990; 38:869-872.
3. Du Plooy WJ, et al. The dose-related hyper-and-hypokalemic effects of salbutamol and its arrhythmogenic potential. Bri J Pharmacol, 1994; 111:73-76.
4. Mandelberg A, et al. Salbutamol metered-dose inhaler with spacer for hyperkalemia. How fast? How safe? Chest, 1999; 115:617-622.
5. McClure RJ, et al. Treatment of hyperkalemia using intravenous and nebulised salbutamol. Arch Dis Child, 1994; 70:126-128.
6. Mocan MZ, et al. Inhaler salbutamol for acute hyperkalemia in renal failure. Isr J Med Sci, 1993; 29:39-41.
7. Montoliu J, et al. Treatment of hyperkalemia in renal failure with salbutamol inhalation. J Int Med, 1990; 228:35-37.
8. Semmekrot BA, et al. A warning for the treatment of hyperkalemia with salbutamol. Eur J Ped, 1996; 420.
9. Wang P, et al. Treatment of attacks in hyperkalemic familial periodic paralysis by inhalation of salbutamol. Lancet, 1976; 221-223.
10. Wong S-L, et al. Albuterol for the treatment of hyperkalemia. Ann Pharm, 1999; 33:103-106.

CAT Author: Raymond F. Castro, MD, PhD

CAT Appraisers: John G. Frohna, MD

Date appraised: October 25, 1999