Is Salbutamol (albuterol) indicated for an 84-year-old female with influenza-like illness, presenting with shortness of breath, productive cough, wet lungs, and tachycardia, and a history of Chronic Obstructive Pulmonary Disease (COPD) and/or asthma?

Salbutamol Use in an 84-Year-Old Female with Influenza-Like Illness and COPD/Asthma History

Yes, salbutamol is indicated for this patient, but with critical caveats regarding the tachycardia and need for careful monitoring. The patient's shortness of breath and productive cough in the context of COPD/asthma history warrant bronchodilator therapy, but the existing tachycardia requires cautious administration and close cardiovascular surveillance 1.

Primary Indication and Dosing

Nebulized salbutamol 2.5-5 mg should be administered for acute exacerbation of COPD with shortness of breath and productive cough 1, 2. The British Thoracic Society guidelines specifically recommend this approach for elderly patients with COPD presenting with respiratory distress 1.

• Initial treatment should be given under supervision, particularly in elderly patients where β-agonists may precipitate cardiac complications 1
• Dosing frequency: 4-6 hourly intervals initially, with potential for more frequent administration if required and tolerated 1
• The nebulizer should be driven by compressed air rather than oxygen if hypercapnia is present, with supplemental oxygen delivered via nasal prongs at 1-2 L/min during nebulization 1

Critical Cardiovascular Considerations

The pre-existing tachycardia (>110 bpm) represents a significant concern that requires immediate assessment before salbutamol administration 1.

• β2-agonists can increase heart rate by approximately 9 beats/min and increase the relative risk for adverse cardiovascular events including atrial fibrillation (RR 2.54; 95% CI 1.59-4.05) 1
• In patients with COPD and structural heart disease, salbutamol has been associated with paroxysmal atrial fibrillation and supraventricular tachycardia 1
• The first treatment must be supervised with continuous monitoring of heart rate and rhythm 1
• If tachycardia worsens significantly or new arrhythmias develop, consider adding or switching to ipratropium bromide 0.25-0.5 mg, which lacks β-adrenergic effects 1

Clinical Assessment Algorithm

Before administering salbutamol, obtain:

1. Baseline vital signs including heart rate, respiratory rate (>25/min indicates severity), and oxygen saturation 1
2. Arterial blood gas if the patient appears acidotic, hypercapnic, or has severe respiratory distress 1
3. ECG given the tachycardia to rule out underlying arrhythmia or acute cardiac pathology 1

Treatment Protocol for This Patient

For moderate-to-severe exacerbation with tachycardia:

• Start with nebulized salbutamol 2.5 mg (lower end of dosing range) rather than 5 mg given the cardiovascular concerns 1
• Monitor heart rate and rhythm continuously during the first treatment 1
• If response is inadequate and tachycardia remains stable, increase to 5 mg for subsequent doses 1
• If response to salbutamol alone is poor or tachycardia worsens, add ipratropium bromide 0.25-0.5 mg to the regimen 1, 2

Additional Acute Management

Concurrent therapies that should be initiated:

• Systemic corticosteroids: Prednisolone 30 mg daily for 7-14 days (or hydrocortisone 100 mg IV if oral route compromised) 1
• Antibiotics: Amoxicillin or tetracycline as first-line for the influenza-like illness with productive cough, suggesting bacterial superinfection 1
• Controlled oxygen therapy: Target SpO2 88-92% in COPD patients, using 24% Venturi mask or nasal prongs at 1-2 L/min 1

Common Pitfalls to Avoid

Do not:

• Use oxygen to drive the nebulizer if the patient is hypercapnic or acidotic—this can worsen respiratory acidosis 1
• Assume that lack of FEV1 improvement means treatment failure—volume responses (improved inspiratory capacity) may occur without significant flow responses in severe COPD 1
• Continue salbutamol if new arrhythmias develop or if heart rate exceeds 140 bpm without reassessment 1
• Delay hospital admission if the patient fails to improve after initial nebulization 1

Monitoring Parameters

Reassess within 60 minutes:

• Heart rate and rhythm 1
• Respiratory rate and work of breathing 1
• Oxygen saturation 1
• Arterial blood gases if initially abnormal 1
• Clinical response (ability to speak in sentences, reduced dyspnea) 1

If the patient deteriorates or fails to improve, consider:

• Hospital admission for closer monitoring 1
• Addition of intravenous aminophylline 0.5 mg/kg/hour (though evidence is limited and cardiac effects must be monitored) 1
• Non-invasive positive pressure ventilation if pH <7.26 with rising PaCO2 1