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Case Report
Extreme elevation of lactate with nebulized albuterol in a complex patient with respiratory failure
1 MD, Emergency Medicine, UT Southwestern, Dallas, TX, USA
2 MD, Department of Medicine, UCSF Health/St. Mary’s Medical Center, San Francisco, CA, USA
3 MD, MS, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
Address correspondence to:
Morgan K Kemerling
5323 Harry Hines Boulevard E4.300, Dallas, TX 75390-8579,
USA
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Article ID: 101510Z01MK2025
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Kemerling MK, Wen Z, Nuckton TJ. Extreme elevation of lactate with nebulized albuterol in a complex patient with respiratory failure. Int J Case Rep Images 2025;16(1):116–120.ABSTRACT
A 67-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and multiple medical problems presented to the emergency department (ED) with worsening shortness of breath for one to two days. He was initially treated with bilevel positive airway pressure (BIPAP) but required intubation approximately 4 hours after presentation. Multiple doses of nebulized albuterol (total of 21 mg) were given both before and after intubation. The patient’s initial lactate level was 2.3 mmol/L, with rapid elevation to a maximum of 11.3 mmol/L. In combination with the markedly elevated lactate, the patient had abdominal distention and nonspecific abdominal pain in the setting of chronic CO2 retention and acute hypercapnic respiratory failure, transient hypotension, an elevated peripheral white blood cell (WBC) count with neutrophil predominance, and an increased anion gap. The clinical presentation, elevated lactate level, and other laboratory abnormalities prompted a concern for severe sepsis and possible bowel ischemia. The patient was treated with intravenous fluids and broad-spectrum antibiotics, but at the same time, albuterol was held. Lactate decreased rapidly after albuterol was discontinued. A computed tomography (CT) scan of the abdomen did not show signs of ischemia, and abdominal distention improved with an orogastric tube. With mechanical ventilation and steroids, the patient’s respiratory status improved, and he was extubated on hospital day six. Final blood cultures were negative, and in retrospect, the patient did not have severe sepsis. The timeline of lactate increase and decrease suggests that the markedly elevated lactate levels in this patient were due to a Type B lactic acidosis related to albuterol.
Keywords: Albuterol, Lactate, Lactic acidosis, Metabolism, Sepsis
SUPPORTING INFORMATION
Author Contributions
Morgan K Kemerling - Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Zhaoyang Wen - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Thomas J Nuckton - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2025 Morgan K Kemerling et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
