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Clinical Investigations: BRONCHODILATORS |

Salbutamol Metered-Dose Inhaler With Spacer for Hyperkalemia*: How Fast? How Safe?

Avigdor Mandelberg, MD; Zipora Krupnik, MD; Sion Houri, MD; Shmuel Smetana, MD; Ely Gilad, MD; Zipora Matas, PhD; Israel E. Priel, MD, FCCP
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*From the Department of Pulmonary Medicine (Drs. Mandelberg and Priel), the Pediatric Critical Care Unit (Drs. Krupnik, Houri, and Gilad), the Nephrology Unit (Dr. Smetana), and the Biochemistry Laboratory (Dr. Matas), The Edith Wolfson Medical Center, Hulon, Israel.



Chest. 1999;115(3):617-622. doi:10.1378/chest.115.3.617
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Objective: To determine the efficacy of inhaled salbutamol (rapidly delivered, using a metered-dose inhaler with a spacer device [MDI-S]) in lowering the serum potassium levels in patients with hyperkalemia.

Design: A randomized, double-blind, placebo-controlled trial.

Patients: Seventeen chronic renal failure patients referred to the Nephrology Unit between October 1, 1997 and March 31, 1998 for hemodialysis were randomized.

Intervention and results: Group 1 received salbutamol followed by a placebo. Group 2 received a placebo followed by salbutamol. Each patient inhaled 1,200 μg salbutamol or a placebo through an MDI-S within 2 min. Blood samples were obtained repeatedly before inhalation and after 1, 3, 5, 10, and 60 min. The pulse rate and blood pressure were repeatedly measured. Insulin levels were examined in a subset of patients (n = 10) before, and 1 and 5 min following inhalation. Salbutamol’s known side effects, palpitation, tachycardia tremor, and headache, were recorded. Potassium levels rose after 1 min following the completion of treatment and then decreased steadily thereafter. A rise of ≥ 0.1 mEq/L was seen in 10 of 17 patients (59%) during the treatment period and there was no change (0%) seen during the placebo period (p < 0.0001). Within 3 min after inhalation of salbutamol, potassium levels declined as a function of time. Potassium levels in those patients taking the placebo did not change as a function of time (p < 0.001). The difference between the placebo and the salbutamol-treated periods reached significance after 5 min (p < 0.05). The serum glucose levels rose following inhalation of salbutamol, with a significant rise after 3 min. The heart rate rose significantly within the first 5 min following inhalation. Serum insulin levels remained unchanged 1 min after inhalation; however, after 5 min, a significant elevation was detected.

Conclusion: Salbutamol inhalation of 1,200μ g, using an MDI-S, has a relatively rapid onset of action that induces a consistent reduction in serum potassium levels, starting 3 to 5 min following delivery. Unexpectedly, a paradoxical elevation was detected in serum potassium levels in the first minutes following inhalation. This effect, although minor (0.15 mEq/L above baseline), may cast some doubt on the role of salbutamol inhalation as the first treatment for excessive hyperkalemia.

Abbreviations: MDI-S = metered-dose inhaler with spacer device

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