Short-acting Beta Agonist

Inhaled Bronchodilators target Beta 2 Adrenergic Receptors on Bronchial Smooth Muscle
1. Increase cAMP messenger levels
2. cAMP relaxes Bronchial Smooth Muscles resulting in bronchodilation
Adverse effects (e.g. Tachycardia) are related to Beta 1 Adrenergic Receptor activity

Albuterol Inhaler (Ventolin, Proventil, ProAir HFA, ProAir RespiClick)
1. See Hydrofluoroalkane Inhaler (HFA Inhaler) for technique
2. Rescue Inhaler: 2 puffs every 4 to 6 hours as needed
3. Exercise Induced Asthma: 2 puffs used 10 to 30 minutes before Exercise
4. Severe COPD or Asthma Exacerbation
  1. Use 6 to 8 puffs every 1-2 hours (max) OR
  2. Use 2 puffs every 20 minutes as needed for up to 3 doses every 1 to 4 hours
Albuterol Nebulizer
1. Dilute Albuterol solution (5 mg/ml) in Normal Saline (NS) as described above
2. Weight <10 kg or age under 12 months (0.15 mg/kg)
  1. Albuterol 1.25 mg (0.25 cc) in 2 cc NS q1-4 hours
3. Weight 10-35 kg or age 12 months to adult (Typical, standard dose)
  1. Albuterol 2.5 mg (0.5 cc) in 2 cc NS q1-4 hours
4. Weight >35 kg or age over 10 years (High Dose)
  1. Albuterol 5.0 mg (1.0 cc) in 2 cc NS q1-4 hours
  2. Standard dose of 2.5 mg is used instead in most cases
5. Continuous Nebulizer
  1. Dose 10 to 15 mg/hour until improvement (typically first hour)
  2. Intensive monitoring including telemetry within emergency department or ICU
Levalbuterol Inhaler (age 4 years and older)
1. See Hydrofluoroalkane Inhaler (HFA Inhaler) for technique
2. Take 2 puffs up to every 4 to 6 hours
3. Generic in 2016
Levalbuterol (Xopenex) Nebulizer
1. Indicated for Age over 12 years
2. Age >=12 years: 0.63 (up to maximum of 1.25 mg) nebulized every 6 to 8 hours as needed
3. Age 6 to 11 years: 0.31 mg nebulized every 8 hours as needed

Terbutaline (Brethaire)
1. Dose: 2 puffs q4-6 hours
2. Not as potently dosed as others
3. Use for patients sensitive to adrenergic effects
Pirbuterol (Maxair)
1. Dose: 2 puffs q4-6 hours
Isoproterenol
1. Dose: 2 puffs q3-4 hours
Isoetharine
1. Dose: 2 puffs q4 hours
Metaproterenol
1. Dose: 2 puffs q4-6 hours
Bitolterol
1. Dose: 2 puffs q4-6 hours

Avoid Scheduled short acting MDI use
1. Loss of indicator for worsening Asthma
2. Delays use of Inhaled Corticosteroid
3. Increases airway hyper-reactivity
4. Greater allergen exposure
  1. Treats only acute phase reaction
5. Regular use associated with increased mortality
  1. Inhaled Terbutaline may be more risk than other preparations
6. Acute Coronary Syndrome risk in those with CAD risk
  1. Au (2002) Chest 121:846-51 [PubMed]
Monitoring Use
1. Most Metered Dose Inhalers supply 100-120 two spray doses
2. Four times daily dosing will last one month
3. In well controlled Asthma, Inhaler will last one year