Eur J Pediatr (2006) 165: 323325

DOI 10.1007/s00431-005-0049-0

ORIGINA L PA PER

Jeremy R. Parr . Amanda Salama . Peter Sebire

A survey of consultant practice: intravenous salbutamol

or aminophylline for acute severe childhood asthma
and awareness of potential hypokalaemia
Received: 9 October 2005 / Accepted: 9 November 2005 / Published online: 19 January 2006
# Springer-Verlag 2006

Abstract British Thoracic Society guidelines recommend

intravenous salbutamol or aminophylline for acute severe
asthma in children. In the survey reported here, 133
consultant paediatricians completed a questionnaire aimed
at evaluating their choice of intravenous bronchodilator for
acute severe asthma and their awareness of subsequent
hypokalaemia. Of the non-Paediatric Intensive Care Unit
(PICU) consultants who responded, 82%, including respiratory paediatricians, reported using aminophylline; in
contrast, PICU consultants were significantly more likely
to use salbutamol (p=<0.001). There was a lack of
awareness that hypokalaemia occurs with aminophylline:
50% of the consultants suggested that hypokalaemia was
rare or did not occur. Consultants using intravenous
aminophylline were significantly less likely to recheck
serum potassium levels than those using intravenous
salbutamol (p=0.03). Based on the completed questionnaires, salbutamol infusions are rarely used outside the
PICU, and the awareness of potential hypokalaemia
following intravenous bronchodilator treatment is variable.
It would appear, therefore, that standardised clinical
practice is required in order to recognise and treat potential
hypokalaemia.
Keywords Asthma . British Thoracic Society (BTS)
Guidelines . Salbutamol . Aminophylline . Hypokalaemia

Introduction and methods

Aminophylline has been the intravenous drug of choice in
United Kingdom paediatric practice following the failure
of nebulised therapy in acute severe asthma, and has been

J. R. Parr (*) . A. Salama . P. Sebire

Department of Paediatrics, Wexham Park Hospital,
Slough, SL2 4HL, UK
e-mail: jeremyparr@doctors.org.uk

confirmed to be more effective than nebulised therapy

alone [5]. National evidence-based guidelines [1] now
suggest the use of intravenous salbutamol or aminophylline. A recent study showed that in children with acute
severe asthma, intravenous salbutamol was no more
effective than aminophylline as an intravenous bronchodilator, and was associated with a longer hospital stay [4].
Children suffering from acute severe asthma are at risk
of hypokalaemia due to treatment with frequent doses of
inhaled and nebulised salbutamol and ipratropium bromide
in addition to oral or intravenous steroids. The risk of
hypokalaemia may be further increased by hypoxia and
variable oral intake. Recent studies have reported hypokalaemia associated with intravenous salbutamol (45% of
cases) [2] and theophylline (65% of cases) [3], although
Habashy et al. [2] did not find the hypokalaemia to be of
clinical significance. Roberts et al. [4] reported no significant difference between the side effect profiles of these
medications.
Following the publication of the British Thoracic
Society (BTS)/Scottish Intercollegiate Guidelines Network
(SIGN) guidelines in 2003 [1], we surveyed 169 consultant
paediatricians to evaluate both clinical practice in the use of
either intravenous salbutamol or aminophylline and the
prevailing opinions regarding the potential side effect of
hypokalaemia. During May and June 2004, a postal
questionnaire (see Fig. 1) was sent to all consultant
paediatricians working in District General Hospitals
(DGHs), Tertiary centres and Paediatric Intensive Care
Units (PICUs) in the Oxford, Mersey and South Thames
regions. Names and addresses of DGH paediatricians were
obtained from the Directory of Critical Care 2004 (C.M.A.
medical data), which lists all acute paediatricians at each
DGH. The names of consultants on the acute on-call rota in
Tertiary centres and PICUs were gathered from the relevant
paediatric departments by telephone. The completed
questionnaires were analysed using SPSS ver. 11.5
(SPSS, Chicago, Ill.), and statistically significant differences were computed using chi-square tests.

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Fig. 1 Study questions as written in the questionnaire

1.

In patients with acute severe asthma who are not responding to hourly
salbutamol nebulisers, do you usually use:
a. An IV aminophylline infusion? Yes / No
OR
b. An IV salbutamol infusion? Yes / No
Now please complete the following questions with regard to your use of either
IV salbutamol OR aminophylline

2.

When evaluating children who have been treated with hourly salbutamol
inhalers and an aminophylline/salbutamol infusion, do you suggest that
potassium levels are rechecked?
Yes / No

3.

Is it your clinical experience that children are

subsequently hypokalaemic (serum potassium <3.2)?
Frequently / Occasionally / Rarely / Never

4.

Which type of unit do you work in?

PICU / District General Hospital / Regional Centre

5.

Is Respiratory Paediatrics your special interest?

Yes / No

Do you have any further comments about the study or these questions?

Results

Awareness of hypokalaemia

A total of 137 questionnaires (81%) were returned. Four

respondents answered yes to both Questions 1a and 1b
and were subsequently excluded from analysis. Of the 133
remaining respondents, 97 were DGH consultants, 15 were
consultants from Tertiary centres (non-PICU) and 21 were
PICU consultants.

Hypokalaemia following any intravenous bronchodilator

was considered a frequent side effect by 14% of
consultants, and 44% thought it occurred occasionally.
Opinions on the likelihood of hypokalaemia were more
varied with regard to the use of aminophylline than
salbutamol; 50% of consultants suggested that hypokalaemia was rare, or never occurred following aminophylline
treatment, whilst 50% thought that hypokalaemia was
occasional or frequent (Table 1). Consultants using intravenous salbutamol were significantly more likely to report

Choice of intravenous bronchodilator

The majority of consultants working in DGHs and Tertiary
centres (82%) were using intravenous aminophylline rather
than intravenous salbutamol; in contrast PICU consultants
were significantly more likely to use intravenous salbutamol (90%, p=<0.001). When PICU consultants were
excluded, consultants with a special interest in respiratory
paediatrics did not use intravenous salbutamol more
frequently than colleagues without a respiratory special
interest (20 vs. 17%); only one of the four Tertiary centre
consultants with a special interest in respiratory paediatrics
used intravenous salbutamol.

Table 1 All responses to question 3: is it your clinical experience

that children are subsequently hypokalaemic (serum potassium <3.2)
Likelihood of hypokalaemia
Never Rarely Occasionally Frequently
Aminophylline (n=94)
Salbutamol (n=39)

8
3

39
5

43
16

4
15

325

hypokalaemia frequently or occasionally than with aminophylline (31/39 vs. 47/94, p=0.002).
Regardless of the medication used, rechecking serum
potassium levels was suggested by all 15 Tertiary and 21
PICU consultants; DGH consultants were less likely to do
so (71/97, 73%). When PICU consultants were excluded,
Tertiary consultants were significantly more likely to
recheck serum potassium than colleagues in DGHs
(p=0.02). Overall, consultants using intravenous aminophylline were significantly less likely recheck serum potassium levels than those using intravenous salbutamol (71/94
vs. 36/39, p=0.03).

Discussion and conclusions

These data indicate that aminophylline is preferred to
salbutamol as first-line intravenous therapy in acute severe
asthma outside a PICU setting. Treatment protocols are
likely to include aminophylline; however, a number of
respondents replied that despite publication of the BTS/
SIGN guidelines, their unit protocol did not allow the use
of intravenous salbutamol outside the PICU setting. PICU
consultants use intravenous salbutamol in the majority of
cases; the previous failure of aminophylline as first-line
treatment at the referring hospital is likely to be the reason
for this.
With respect to hypokalaemia, there is recognition
amongst those using intravenous salbutamol that this is a
possible side effect; however, these results are skewed by
its predominant use in the PICU setting. A significant
minority of consultants do not suggest that serum potassium levels are rechecked when a child is treated with
intravenous aminophylline. This practice may reflect a lack

of awareness of potential hypokalaemia or indicate that in

their clinical experience, symptomatic hypokalaemia is
rare. It is unclear why DGH consultants were significantly
less likely to recheck potassium levels than non-PICU
colleagues in Tertiary centres, as both groups would treat
patients with a similar severity of asthma attacks.
Despite BTS/SIGN guidelines suggesting the use of
intravenous salbutamol or aminophylline, salbutamol
infusions are rarely used outside the PICU setting. The
awareness of potential hypokalaemia is variable, particularly in those using intravenous aminophylline. It would
appear that standardised clinical practice is required in
order to recognise and treat potential hypokalaemia.

References
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