Differentiating COPD Exacerbation From ACPE: Implications for Salbutamol Use

Administering salbutamol to a patient with COPD who presents with shortness of breath, increased work of breathing, coughing, and crackles does not pose a risk of “flooding” the lungs. The misconception comes from cases where patients have acute cardiogenic pulmonary edema (ACPE) rather than pure bronchospasm. In those cases, the underlying heart failure, not the salbutamol, is responsible for fluid accumulation in the lungs. It's not the medication that "floods", but rather worsening of the heart failure.



Salbutamol is a beta-2 agonist that promotes bronchodilation and does not increase hydrostatic pressure or cause pulmonary edema. In fact, some studies suggest beta-agonists may even improve pulmonary function and may even enhance alveolar fluid clearance in acute heart failure.



The concern usually arises when crackles are due to acute cardiogenic pulmonary edema (ACPE) rather than bronchospasm. In such cases, salbutamol will not address the underlying problem and may worsen tachycardia, further straining cardiac function. The wheeze in ACPE is usually from fluid, not bronchoconstriction.



For COPD exacerbations with bronchospasm, salbutamol is appropriate and beneficial even if crackles are present. However, if signs of heart failure are evident—such as pink frothy sputum, severe hypertension, jugular venous distension, or peripheral edema—treatment should prioritize nitroglycerin and CPAP rather than bronchodilators. The main risk is misdiagnosis, not lung flooding, so careful assessment is essential before deciding on therapy. Caution is still appropriate, particularly in monitoring for tachycardia or hypokalemia, but this should not preclude its use when bronchospasm is suspected.



Bottom line: Salbutamol does not flood the lungs. The real risk is misdiagnosis—giving salbutamol when the primary issue is ACPE won’t help and may delay appropriate treatment. If bronchospasm is suspected, administer salbutamol; if ACPE is suspected, treat with nitro and CPAP first.