Abstract Rationale Continuous nebulized albuterol is frequently used to treat children with status asthmaticus in the pediatric emergency department (ED) but can have cardiovascular side effects. Data describing beta-agonist toxicity in the pediatric ED setting are limited. We aimed to characterize the clinical and pharmacologic features of cardiovascular beta-agonist toxicity in children receiving ED treatment for moderate to severe asthma exacerbations. Methods This was a secondary analysis of data collected for a prospective, randomized controlled trial evaluating children 5-17 years treated in a tertiary pediatric ED for moderate-to-severe asthma exacerbations (NCT05848115). Children with a Pediatric Respiratory Assessment Measure (PRAM) of 4 or greater after standard first-line asthma therapies who required continuous albuterol therapy were eligible. Dosing and duration of continuous albuterol were not affected by the study protocol. Medications administered and cardiovascular adverse events (diastolic hypotension and tachycardia for age) were recorded during the 4-hour study period. Results Between June 2023-May 2025, 67 study participants were enrolled with median age 10.28 (IQR 6.82, 13.09); 32 (48%) were female, 19 (28%) identified as Black/African-American, and 30 (45%) identified as Hispanic/Latinx. The average dose and duration of continuous nebulized albuterol was 10.68 mg/hr and 2.82 hours, respectively. A total 42 (63%) participants experienced at least one cardiovascular adverse event during the study period; 23 (52%) had diastolic hypotension and 19 (43%) had tachycardia for age, including 4 (9%) participants with both. Of those with adverse events, the average dose of continuous nebulized albuterol was 0.25 mg/kg/hr and average duration was 2.96 hours. For those without adverse events, the average dose was 0.23 mg/kg/hr and average duration was 2.44 hours. The average hourly dose of continuous nebulized albuterol for participants with and without adverse events is displayed in the Figure. Fluid boluses were administered for 25 (60%) participants with adverse events. No participants received vasopressors. Conclusions Even within a relatively short, 4-hour time-frame, diastolic hypotension and/or tachycardia for age were noted in over half of children receiving continuous nebulized albuterol. These findings suggest beta-agonist toxicity in children treated for status asthmaticus in the ED is more common than widely assumed. The dose threshold for toxicity appears to be narrow, and IV fluids were administered to a majority of patients with signs of acute albuterol toxicity. Future studies are needed to further evaluate the efficacy and toxicity of pediatric continuous albuterol to establish a dose threshold that minimizes toxicity while ensuring adequate clinical response. This abstract is funded by: R33HL158814, Children’s Hospital Colorado Research Scholar Award
Tanverdi et al. (Fri,) studied this question.