ALBUTEROL VS LEVOALBUTEROL IN INTUBATED PATIENTS

Effects of Nebulized Bronchodilator Therapy on Heart Rate and Arrhythmias in Critically Ill Adult Patients.

1Pulmonary and Critical Care Medicine Department, Genesys Regional Medical Center, Grand Blanc, Michigan.
BACKGROUND:Tachycardia and tachyarrhythmias are associated with increased morbidity and mortality in adult intensive care unit patients. This study examines the effects of nebulized bronchodilator therapy (albuterol and ipratropium) on heart rate and arrhythmias in this population and tests the proposition that levalbuterol is safer than albuterol in that regard.

METHODS:

A randomized, single-blind, cross-over, prospective study with 70 critically ill adult patients treated with nebulized bronchodilators. Patients were randomized to nebulized albuterol alternating with levalbuterol every 4-6 hours. Group A received albuterol 2.5 mg alternating with levalbuterol 0.63 mg. Group B received albuterol 2.5 mg alternating with levalbuterol 1.25 mg. All patients received nebulized ipratropium bromide with each treatment. Heart rate (HR) was recorded before and after each treatment. Cardiac rhythm was continuously monitored using electronic telemetry units.

RESULTS:

In Group A, change in HR post-albuterol 2.5 mg (n=303) was 0.89± 4.5 (mean± SD) beats per minute (bpm), compared with 0.85± 5.3 post-levalbuterol 0.63 mg (n=301) (p=0.89). In Group B (n=114), HR decreased 0.16± 5.1 bpm post-albuterol 2.5 mg compared with an average increase in HR of 1.4± 5.4 bpm post-levalbuterol 1.25 mg (n=118) (p=0.03). Five events of arrhythmias (0.6%) occurred during the course of 836 treatments. Four consisted of occasional premature ventricular contractions. Only one patient stopped treatment due to five beat run of ventricular tachycardia (1 in 70 patients, 1.4%).

CONCLUSIONS:

In critically ill adult patients, nebulized albuterol and ipratropium does not cause significant tachycardia or tachyarrhythmias. Substitution of levalbuterol for albuterol to avoid tachycardia and tachyarrhythmias is unwarranted.

PMID:
21960699
[PubMed - as supplied by publisher]
LUNGLORD COMMENT: Many factors contribute to tachycardia in the ICU including anxiety, alarms, altered sleep patterns, inability to find a position of comfort, IV access, restrains, medications of every sort, as well as weepy and creepy family members.  LUNGLORD was reading this article with skepticism from the outset, thinking that there could be no smoking (had to get that in there) gun of proof without controlling for these data deflecting gorillas also.
In clinical practice LUNGLORD has seen only a small benefit derived from this drug. For routine use, the cost of levoalbuterol, which is approximately 8x albuterol has little benefit to cost ratio unless therapies are spaced so that fewer treatments are needed and staffing is thus right sized.
In the ER setting, levoalbuterol should be reserved for adult patients who present with HR greater than 100 or have a history of SVT or A fib. The best care is not always the most expensive care. This is not a new conclusion unless you are trying to get a 2,500 page health care bill through Congress without reading it first ala N. Pelosi. If the  patient has pre medicated before coming to the ER with many albuterol doses, the beta sites are 50/50 full of R and S isomers of albuterol. If tachycardic, further treatment may be contraindicated since the S side of the molecule has far more negative effects and is slower to metabolize. Repeat dosing proportionately layers up their S isomer load. Therapeutic space in the B2 site may not be available. The third great bronchodilator ( a very old LUNG LAW circa 1980)  Ativan should be employed, along with Atrovent and steroids to manage the patient unless their condition warrants immediate dosing or their ability to give an accurate history is in question. As far as remembering R and S isomers-which is which?  R is the RESPONSIVE side chain. S is the SIDE EFFECT CHAIN. Mnemonics often substitute for intelligence at a certain point in the late adult development process. LUNGLORD requires a mnemonic to recall the spelling of the word itself without consulting the dictionary. Please advise.

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