Flooding risk of Ventolin in ACPE?

It is not true that administering salbutamol to a wheezing CHF patient inherently causes pulmonary “flooding.” Inhaled salbutamol does not generate a significant enough pressure shift to worsen pulmonary edema. The concern that often arises is due to the increase in heart rate and the passage of time without preload reduction, which can lead to worsening symptoms if appropriate ACPE management is delayed. This is not the result of salbutamol worsening the condition but rather a reflection of the underlying pathophysiology progressing without targeted treatment such as nitroglycerin or diuretics. In patients with coexisting CHF and COPD or asthma, it is clinically appropriate to administer both salbutamol and nitroglycerin simultaneously. Inhaled beta-2 agonists have been shown to improve pulmonary function and may even enhance alveolar fluid clearance in acute heart failure. There is no consistent evidence linking inhaled salbutamol to new or worsening pulmonary edema. Caution is still appropriate, particularly in monitoring for tachycardia or hypokalemia, but this should not preclude its use when bronchospasm is suspected.

Summary:

• Inhaled salbutamol does not cause flooding in ACPE patients.
• Worsening symptoms after salbutamol are usually due to delayed preload reduction, not the medication itself.
• Tachycardia may unmask existing cardiac decompensation, but does not create it.
• Concurrent ACPE and COPD/asthma is common, and dual treatment with salbutamol and nitroglycerin is reasonable.
• Inhaled beta-2 agonists may improve pulmonary function and aid fluid clearance.
• Careful monitoring is advised, but inhaled bronchodilators are not contraindicated in ACPE with suspected bronchospasm.

References:

Germano, N., Summerfield, D., & Johnson, B. (2019). A mini review of inhaled beta₂ agonists in acute decompensated heart failure requiring respiratory support. Pulm Crit Care Med, 4(3), 1000161. https://doi.org/10.15761/PCCM.1000161

Licker, M., Tschopp, J. M., Robert, J., Frey, J. G., Diaper, J., & Ellenberger, C. (2008). Aerosolized salbutamol accelerates the resolution of pulmonary edema after lung resection. Chest, 133(4), 845–852. https://doi.org/10.1378/chest.07-1710

Maak, C. A., Tabas, J. A., & McClintock, D. E. (2008). Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure? Journal of Emergency Medicine, 40(2), 135–145. https://doi.org/10.1016/j.jemermed.2007.11.056

Matthay, M. A. (2014). Resolution of pulmonary edema. Thirty years of progress. American Journal of Respiratory and Critical Care Medicine, 189(12), 1053–1060. https://doi.org/10.1164/rccm.201406-1030PP