Can albuterol be used to treat hypotension?

No—Albuterol Should Not Be Used to Treat Hypotension

Albuterol is contraindicated for the treatment of low blood pressure and will likely worsen hypotension through peripheral vasodilation, despite causing reflex tachycardia. The drug's primary mechanism is β2-adrenergic receptor stimulation, which relaxes vascular smooth muscle and decreases systemic vascular resistance (SVR), the opposite of what is needed in hypotension 1, 2.

Why Albuterol Worsens Hypotension

Cardiovascular Effects of β2-Agonism

• Albuterol causes peripheral vasodilation by relaxing vascular smooth muscle, resulting in decreased SVR (from baseline 1661 to 1384 dynes•sec/cm⁵ within 90 minutes) 2.
• Diastolic blood pressure drops significantly with albuterol administration, creating a state of diastolic hypotension that impairs coronary perfusion 3, 4.
• In a controlled study of healthy subjects, nebulized albuterol 2.5 mg caused no significant change in blood pressure overall, but this was only because increased cardiac output compensated for the profound drop in SVR 2.

Documented Hypotensive Events

• Salbutamol (albuterol) overdose produces frank hypotension: A case report documented blood pressure of 80/50 mmHg following ingestion of 300 mg albuterol 4.
• Diastolic hypotension occurred in 56-98% of children receiving high-dose albuterol for asthma, defined as values below the 5th percentile for age 3.
• The combination of diastolic hypotension and tachycardia from albuterol was associated with biochemical myocardial injury (elevated troponin) in children with asthma 3.

Appropriate Vasopressors for Hypotension

First-Line Agents for Hypotension

• For refractory hypotension after volume resuscitation, dopamine 2-20 mcg/kg/min IV should be used, with continuous hemodynamic monitoring 5.
• Norepinephrine is the preferred vasopressor for most causes of shock, as it increases both SVR and blood pressure through α1-adrenergic stimulation 5.
• Phenylephrine is appropriate for hypotension accompanied by tachycardia, as it provides pure α1-agonism without β-effects 5.

When β-Agonists Are Appropriate

• Albuterol is indicated for bronchospasm, not hypotension—it should be used for "bronchospasm resistant to epinephrine" in anaphylaxis at 2.5-5 mg nebulized 5.
• In spinal cord injury with bradycardia, enteral albuterol (mean 7.8 mg/day) reduced bradycardic events in a dose-dependent manner, but this was for heart rate support, not blood pressure 6.

Critical Clinical Pitfalls

Misunderstanding β-Agonist Pharmacology

• Do not confuse the tachycardia from albuterol with effective blood pressure support—the increased heart rate is a compensatory reflex to peripheral vasodilation, not a therapeutic effect 2.
• The increase in cardiac output with albuterol (from 3.6 to 4.4 L/min) occurs through increased stroke volume and heart rate, but this does not overcome the vasodilatory effect on blood pressure 2.

Dangerous Drug Combinations

• Albuterol combined with other vasodilators (nitrates, calcium channel blockers, ACE inhibitors) will produce additive hypotensive effects 5.
• In patients on β-blockers, albuterol's β2-effects may be blunted, leaving unopposed α-effects from endogenous catecholamines, but this does not make it appropriate for hypotension 5.

Metabolic Complications

• Albuterol causes hypokalemia (as low as 2.1 mEq/L), hyperglycemia, and increased plasma norepinephrine, which can precipitate arrhythmias in the setting of hypotension 4, 2.
• Skeletal muscle tremor is a dose-related side effect that occurs with systemic absorption 1.

Correct Management Algorithm for Hypotension

1. Assess volume status with passive leg raise test—if cardiac output increases, give IV fluids 5.
2. If preload is adequate, initiate vasopressor therapy with norepinephrine or dopamine 5.
3. For hypotension with tachycardia, use phenylephrine to avoid further increasing heart rate 5.
4. Never use albuterol as a vasopressor—its β2-agonism will worsen hypotension through peripheral vasodilation 1, 2.