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Benzalkonium in Albuterol Preparations Used for Nebulization: Friend or Foe? :

March 12, 2020

You may not know it but liquid albuterol for nebulizer use may contain benzalkonium chloride.

You may not know it but liquid albuterol for nebulizer use may contain benzalkonium chloride (BAC). Why is this a problem? Because BAC has been associated with bronchospasm, something that albuterol itself is trying to treat. Does the addition of BAC to albuterol result in lower therapeutic efficacy for the treatment of an asthma exacerbation? Pertzhorn et al (10.1542/peds.2019-0107) conducted a retrospective cohort study looking at outcomes of children under 18 years of age who received albuterol with and without BAC. Overall, 236 patients had albuterol with BAC and 241 did not. The authors’ hypothesis that BAC would prolong the need for continuous nebulization proved correct (9 hours versus 6 hours, p<.001).  In addition, 15.7% of children with asthma needed continuous albuterol nebulization in the BAC group at 24 hours compared to 5.8% of those who did not get BAC. 

So, what should we do about this? We asked toxicologist Dr. Alan Woolf and pharmacologist Dr. Shannon Manzi from Boston Children’s to weigh in with an accompanying commentary (10.1542/peds.2019-3590). They note the solid methods used in this study but at the same time point out that both groups of patients had similar overall length of stays even if continuous nebulization was shorter in the BAC-free albuterol group. In addition, they note the benefits of continuous nebulization using a multidose vial with BAC versus the number of individual vials without BAC that would be needed to provide a similar continuous dose. Providing that many individual vials is not feasible. Before you throw away your multidose vials of BAC-containing albuterol, you will want to review the findings in this study as well as the accompanying commentary. No matter what you decide, reading both the study and commentary may make you breathe somewhat easier should your hospital be using a multidose vial of albuterol with BAC.

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