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Three Part Question

In [patients with hyperkalemia] is [IV Salbutamol more beneficial than nebulized Salbutamol] in [reducing potassium blood levels]?

Clinical Scenario

67yo female with past a medical history of chronic kidney failure presents with chest pain and fatigue. EKG shows wide QRS complex and peaked T waves. iStat shows potassium of 8.3mEq/L. While starting hyperkalemia treatment with Calcium Gluconate, Insulin + Dextrose, nebulized Salbutamol, and Kayexalate, you question whether nebulization or intravenous administration of Salbutamol is more effective in decreasing plasma potassium levels.

Search Strategy

PubMed Search (Nov 2015)
"albuterol"[MeSH Terms] AND "hyperkalemia"[MeSH Terms] AND ("therapy"[Subheading] OR "therapy"[All Fields] OR "treatment"[All Fields] OR "therapeutics"[MeSH Terms] OR "therapeutics"[All Fields]) AND intravenous[All Fields]

Search Outcome

25 papers were found of which four were helpful, which are listed in Table 1 below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Liou HH, et al May 1994 China	34 patients. 12 received IV and 12 received nebulization Salbutamol	Randomized Controlled Trial	IV reduced by 0.95mEq +/- 0.14 mEq/L after 30min	First 90 minutes, the decrease of potassium in IV group was faster and greater than in nebulizer group	Small sample size, only patients with chronic renal failure
			Nebulizer reduced 0.88 +/- 0.13 mEq/L after 90min	Effects of both treatments sustained for at least 3 hours
				Heart rate elevated in both groups, less in nebulizer group
Murdoch, IA, et al April 1991 USA	11 children received IV and nebulized Salbutamol on separate dates	Randomized Controlled Trial	Serum potassium at 30min	IV reduced 0.87 mmol/L & Nebulized reduced 0.61 mmol/L	Small sample size, only children with end stage chronic renal failure
			Serum potassium at 120min before 2nd dose	IV reduced 0.43 mmol/L & Nebulized reduced 0.67 mmol/L
			Serum potassium 30min after 2nd dose (150min)	IV reduced 1.16 mmol/L & Nebulized reduced 1.14 mmol/L
			Serum potassium 120min after 2nd dose (240min)	IV reduced 0.81 mmol/L & Nebulized reduced 1.14 mmol/L
			Serum potassium 300min after initial dose	IV reduced 0.70 mmol/L & Nebulized reduced 1.19 mmol/L
Liou HH, et al Feb 1994 USA	10 patients	Comparative Study	IV reduced 0.92 +/- 0.10 mEq/L after 30 minutes	Both treatments significantly decreased plasma potassium in 10 patients and the decrease was sustained for at least 3 hours	Small sample size, only patients with chronic renal failure
			Nebulizer reduced 0.85 +/- 0.13 mEq/L after 90 minutes
Balanzario, J, et al Aug 2003 Mexico	68 patients. 34 received IV and 34 received nebulization Salbutamol	Randomized Controlled Trial	Serum potassium at 60min	-IV reduced 0.76 mEq/L & Nebulized reduced 0.69 mEq/L	Only patients with chronic renal failure
			Serum potassium at 120min	-IV reduced 0.70 mEq/L & Nebulized reduced 0.71 mEq/L

Comment(s)

Administration of Salbutamol intravenously or through nebulization resulted in a significant decrease of plasma potassium concentration. Both routes are considered simple, effective and safe ways of treating hyperkalemia. IV administration was reported as quicker action but produced bigger side effects. Multiple papers recommended IV therapy for patients requiring rapid lowering of plasma potassium levels while patients with coronary artery disease should be treated with nebulization.

Clinical Bottom Line

Administration of Salbutamol via intravenous or nebulization is equally effective in the treatment in patients with hyperkalemia.

References

1. Liou HH, Chiang SS, Wu SC, et al Intravenous infusion or nebulization of salbutamol for treatment of hyperkalemia in patients with chronic renal failure Chinese Medical Journal 1994 May; 53(5):276-281
2. McClure R, Prasad V, Brocklebank J Treatment of hyperkalaemia using intravenous and nebulized salbutamol Archives of Disease in Childhood 1994 Feb; 70(2): 126-128
3. Liou HH, Chiang SS, Wu SC, et al. Hypokalemic effects of intravenous infusion or nebulization of salbutamol in patients with chronic renal failure: comparative study American Journal of Kidney Disease Feb 1994; 23 (2):266–271
4. Balanzario J, Lozano Nuevo JJ, Hernandez Gaeta D, et al Efecto del salbutamol intravenoso vs salbutamol en micronebulizador en la hipercaliemia por insuficiencia renal cronica Medicine Interna de Mexico 2003 Aug; 19(4):202-205