Should I administer albuterol (salbutamol) to a patient who has just vomited?

Should You Administer Albuterol to a Patient Who Just Vomited?

Yes, you should administer albuterol to a patient who has just vomited, as albuterol is delivered via inhalation (nebulizer or MDI) and does not depend on gastrointestinal absorption. The presence of recent vomiting does not contraindicate inhaled bronchodilator therapy and should not delay treatment of bronchospasm or asthma exacerbation.

Key Clinical Reasoning

Route of Administration is Critical

• Albuterol is administered via inhalation (nebulizer or metered-dose inhaler), not orally, which means it bypasses the gastrointestinal tract entirely and is absorbed directly through the respiratory mucosa 1.
• Unlike oral medications where vomiting would compromise absorption, inhaled albuterol delivers the drug directly to the target organ (lungs) regardless of gastrointestinal status 2.
• The National Asthma Education and Prevention Program guidelines specify nebulizer solutions and MDI formulations as the standard delivery methods for acute bronchospasm, with no contraindications related to recent vomiting 1.

Timing Considerations for Acute Bronchospasm

• For acute asthma exacerbations, albuterol should be administered every 20 minutes for 3 doses initially, then every 1-4 hours as needed 1.
• In severe exacerbations, delays in bronchodilator therapy can worsen respiratory status and increase morbidity 1.
• The rapid onset of action (within minutes) and direct pulmonary delivery make albuterol administration urgent regardless of recent vomiting 2.

Practical Administration Guidelines

Nebulizer Administration

• Adults: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1.
• Children: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg up to 10 mg every 1-4 hours 1.
• Dilute aerosols to minimum of 3 mL at gas flow of 6-8 L/min for optimal delivery 1.

MDI Administration

• Adults: 4-8 puffs every 20 minutes up to 4 hours, then every 1-4 hours as needed 1.
• Children: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 1.
• Use with valved holding chamber (VHC) and face mask for children under 4 years 1.

Important Caveats and Monitoring

When Vomiting May Be Relevant

• If vomiting is a symptom of anaphylaxis (along with bronchospasm, hypotension, or angioedema), albuterol should still be given but epinephrine becomes the primary treatment 1.
• If the patient is actively vomiting during nebulizer treatment, temporarily pause the nebulization to prevent aspiration, then resume once vomiting subsides 1.
• Consider adding ipratropium bromide 0.5 mg to albuterol for moderate-to-severe exacerbations, as this combination can be mixed in the same nebulizer 1.

Side Effects to Monitor

• Tachycardia and tremor are common dose-related effects but are much less prominent with aerosol administration compared to systemic routes 2.
• Hypokalemia can occur with high-dose or repeated albuterol administration, particularly in children, though this is transient and rarely requires supplementation 3.
• One pediatric study documented vomiting as an adverse effect in 1.6% of patients receiving pentobarbital (with one patient responding to albuterol for wheezing), but this was unrelated to albuterol administration itself 1.

Systemic Corticosteroids and Vomiting

• If systemic corticosteroids are indicated (prednisone, methylprednisolone, or prednisolone), there is no advantage to intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1.
• If the patient continues to vomit and cannot tolerate oral corticosteroids, switch to intravenous methylprednisolone at equivalent doses 1.
• For outpatient management, use 40-60 mg prednisone in single or 2 divided doses for 5-10 days in adults (children: 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days) 1.

Common Pitfalls to Avoid

• Do not delay albuterol administration while waiting to assess whether the patient will vomit again—bronchospasm treatment is time-sensitive 1.
• Do not confuse oral albuterol formulations (which would be affected by vomiting) with inhaled formulations (which are not)—inhaled forms are standard of care 1, 2.
• Do not assume vomiting contraindicates all medications—only oral medications requiring GI absorption are affected 1.
• Ensure proper inhaler technique, as poor technique is a more significant barrier to drug delivery than recent vomiting 4.