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Does Your Albuterol Contain a Hidden Bronchoconstrictor?

May 14, 2020

Written by Clay Smith

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Children with severe asthma who needed continuous nebulizer therapy were on the treatment 3 hours longer when the albuterol solution contained the preservative benzalkonium than those who received preservative-free albuterol.

Why does this matter?
Benzalkonium chloride is a preservative in the larger containers of albuterol often used in continuous nebulizer treatments. It is known to induce bronchospasm. If there is an agent that causes bronchospasm in the medicine we are trying to use as a bronchodilator in ill patients, it seems we need to fix this.

A bronchoconstrictor in the bronchodilator – who thought that was a good idea?
This was a retrospective review of patients under age 18 who received albuterol with benalkonium (n=236) and those who did not (n=241). For the primary outcome of time on continuous nebs, those with benzalkonium were on treatment for 9 hours vs 6 hours in the control group who did not have benzalkonium (adjusted hazard ratio 1.79 (95%CI 1.45 to 2.22). It did not impact overall hospital length of stay. This retrospective study cannot account for all potential confounders, but this finding held up with statistical adjustment for known confounders and with propensity score matching. The adult and peds pharmacists confirmed albuterol has benzalkonium at my facility. It would require special compounding to have a preservative-free quantity large enough for continuous nebs. MDIs and single-dose ampules are preservative-free alternatives. In the meantime, when continuous nebs are needed, this preservative is likely to have a negative impact on ED length of stay and crowding.

Continuous Albuterol With Benzalkonium in Children Hospitalized With Severe Asthma. Pediatrics. 2020 Apr;145(4). pii: e20190107. doi: 10.1542/peds.2019-0107. Epub 2020 Mar 12.

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