UMEM Educational Pearls

Albuterol, a common bronchodilator used in the treatment of asthma and chronic obstructive pulmonary disease (COPD), can cause a surprising increase of lactate levels. The increase in lactate is usually mild to moderate (typically < 4 mmol/L) and transient. It does not necessarily indicate underlying sepsis, tissue hypoxia, or severe metabolic acidosis.

Mechanism:

Albuterol can cause a transient increase in lactate levels due to its beta-2 agonist effects, which promote glycogenolysis and increase anaerobic metabolism. This can result in elevated lactic acid production, even in the absence of tissue hypoxia or shock. 
 

Timing:  

This effect is typically seen within 30 minutes of albuterol administration and can persist for 1-2 hours after discontinuing treatment. 
 

Monitoring:

If lactate levels are elevated in a patient receiving albuterol, consider the possibility of a pharmacologic cause rather than immediately assuming a more serious etiology like shock or severe metabolic disturbance. 
 

Differentiating Causes of Elevated Lactate:
In a critically ill patient, elevated lactate can indicate hypoperfusion (e.g., septic shock, cardiogenic shock, or hypovolemic shock). However, when elevated lactate is associated with albuterol administration, the rise in lactate is often lower and resolves without intervention. 
 

Management:
If albuterol-induced lactate elevation is suspected, continue with supportive care and monitor lactate trends. No specific treatment is necessary for the elevated lactate unless there are other concerning clinical findings that suggest a different underlying cause. 
 

Conclusion:
In emergency settings, it's important to recognize that albuterol can cause a transient increase in lactate levels. Understanding this phenomenon can help avoid misdiagnosis and prevent unnecessary interventions in patients receiving albuterol therapy. Always correlate lactate levels with the broader clinical picture to guide management decisions.

References

Hockstein M, Diercks D. Significant Lactic Acidosis from Albuterol. Clin Pract Cases Emerg Med. 2018 Mar 14;2(2):128-131. doi: 10.5811/cpcem.2018.1.36024. PMID: 29849230. 

Lewis LM, Ferguson I, House SL, Aubuchon K, Schneider J, Johnson K, Matsuda K. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest. 2014 Jan;145(1):53-59. doi: 10.1378/chest.13-0930. PMID: 23949578. 

Liedtke AG, Lava SAG, Milani GP, Agostoni C, Gilardi V, Bianchetti MG, Treglia G, Faré PB. Selective ß2-Adrenoceptor Agonists and Relevant Hyperlactatemia: Systematic Review and Meta-Analysis. J Clin Med. 2019 Dec 27;9(1):71. doi: 10.3390/jcm9010071. PMID: 31892109. 

Maeda T, Paralkar J, Kuno T, Patrawalla P. Inhaled Albuterol Use and Impaired Lactate Clearance in Patients With Sepsis: A Retrospective Cohort Study. J Intensive Care Med. 2021 Mar;36(3):284-289. doi: 10.1177/0885066619901095. Epub 2020 Jan 22. PMID: 31964210. 

Zitek T, Cleveland N, Rahbar A, Parker J, Lim C, Elsbecker S, Forred W, Slattery DE. Effect of Nebulized Albuterol on Serum Lactate and Potassium in Healthy Subjects. Acad Emerg Med. 2016 Jun;23(6):718-21. doi: 10.1111/acem.12937. Epub 2016 May 11. PMID: 26857949.