In an adult or adolescent with acute hyperkalaemia (serum potassium ≥ 6.0 mmol/L or ECG changes), what is the recommended dose and administration protocol for nebulised salbutamol?

Nebulized Salbutamol for Acute Hyperkalemia

For adults or adolescents with acute hyperkalemia (serum potassium ≥ 6.0 mmol/L or ECG changes), administer 10–20 mg nebulized salbutamol in 4 mL over 10–15 minutes as part of a multi-agent regimen to shift potassium intracellularly. 1

Dosing Protocol

Standard dose: 10–20 mg salbutamol nebulized over 10–15 minutes 2, 1

• The 10 mg dose produces maximal potassium reduction at 120 minutes (mean decrease 1.29 mmol/L) 3
• The 20 mg dose achieves peak effect at 90 minutes (mean decrease 1.18 mmol/L) 3
• Onset of action: 30 minutes, with potassium reduction of approximately 0.5–1.0 mEq/L 1, 4
• Duration of effect: 2–4 hours, requiring concurrent definitive potassium removal strategies 1, 4
• May be repeated every 2 hours if needed, provided cardiac and respiratory monitoring continues 4

Clinical Evidence

Nebulized salbutamol is highly effective for acute hyperkalemia management:

• In hemodialysis patients with severe hyperkalemia (mean 6.5 mmol/L), 15 mg nebulized salbutamol reduced potassium to 5.6 mmol/L within 30 minutes, maintained for 3 hours 5
• A 20 mg dose in chronic dialysis patients produced maximal reduction of 1.12 mEq/L at 90 minutes, persisting for at least 3 hours 6
• Salbutamol via nebulizer or metered-dose inhaler produces comparable efficacy to intravenous salbutamol 3

Integration into Treatment Algorithm

Step 1: Cardiac membrane stabilization (if ECG changes present)

• Administer calcium gluconate 10% (15–30 mL) or calcium chloride 10% (5–10 mL) IV over 2–5 minutes 2, 1
• Onset 1–3 minutes, duration 30–60 minutes; does NOT lower potassium 1, 4

Step 2: Shift potassium intracellularly (administer ALL simultaneously)

• Insulin-glucose: 10 units regular insulin IV with 25 g dextrose (50 mL D50W) over 15–30 minutes 2, 1
• Nebulized salbutamol: 10–20 mg in 4 mL over 10–15 minutes 2, 1
• Sodium bicarbonate: 50 mEq IV over 5 minutes ONLY if metabolic acidosis present (pH <7.35, bicarbonate <22 mEq/L) 2, 1, 4

The combined insulin-glucose plus nebulized salbutamol regimen is more effective than either agent alone 4, 3

Step 3: Definitive potassium removal

• Loop diuretics (furosemide 40–80 mg IV) if adequate renal function (eGFR >30 mL/min) 1, 4
• Hemodialysis for severe cases, oliguria, ESRD, or refractory hyperkalemia 2, 1, 4
• Potassium binders (patiromer or sodium zirconium cyclosilicate) for subacute management 1, 4

Comparative Efficacy

• Salbutamol vs placebo: Significantly more effective at all time points 3
• Salbutamol vs insulin-dextrose: Comparable efficacy 3
• Salbutamol vs bicarbonate: Salbutamol more effective at 60 minutes (mean difference 0.46 mmol/L) 3
• Combined salbutamol + bicarbonate: Greater potassium reduction (-0.96 mEq/L) than either agent alone in patients with metabolic acidosis 7

Side Effects and Monitoring

Common side effects (generally well-tolerated):

• Sinus tachycardia (modest increase in heart rate) 2, 5, 6
• Fine tremor 6
• Mild anxiety 6
• Transient decrease in blood pressure (systolic 134→119 mmHg, diastolic 74→64 mmHg at 60–80 minutes) 6
• Slight increase in blood glucose 5

Monitoring requirements:

• Continuous cardiac monitoring during and after administration 4
• Recheck potassium 1–2 hours after treatment 4
• Continue potassium checks every 2–4 hours until stable 4

Critical Clinical Considerations

Salbutamol is a temporizing measure only—it does NOT remove potassium from the body 1, 4

• Rebound hyperkalemia commonly occurs after 2–4 hours as the effect wanes 1
• Must be combined with definitive potassium removal strategies (diuretics, dialysis, or potassium binders) 1, 4
• In patients who do not respond to salbutamol alone, the combined regimen with bicarbonate (if acidotic) produces substantially greater potassium reduction 7

Salbutamol can be used as monotherapy when insulin is contraindicated (e.g., severe hypoglycemia risk), though its effect is less reliable than the combined regimen 4

Common Pitfalls to Avoid

• Do not use salbutamol as sole therapy without arranging definitive potassium removal—the effect is temporary 1, 4
• Do not delay calcium administration while nebulizing salbutamol if ECG changes are present—calcium provides immediate cardiac protection 1, 4
• Do not add sodium bicarbonate unless metabolic acidosis is documented—it is ineffective without acidosis 1, 4
• Do not assume all patients will respond—approximately 10–20% may have minimal response to beta-agonists 3, 7