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Research Snapshot Theater: Pediatric III

Continuous Levalbuterol vs Racemic Albuterol During a National Shortage: A Cohort Study

Sunday, March 22, 2026
12:15 PM - 1:15 PM Central Time
Location: Connections Central - RST 07
  • AT

    Allyson Tank, MD

    Cohen Children's Medical Center

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • LS

    Layne Silver, MD

    Assistant Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
    Cohen Children's Medical Center, New York

    Disclosure information not submitted.

  • AS

    Alice Shanklin, MD

    Cohen Children's Medical Center

    Disclosure information not submitted.

Introduction: Continuous racemic albuterol is a mainstay of treatment for bronchospasm. However, its’ racemic composition may cause tachyphylaxis, paroxysmal bronchoconstriction, and β-mediated adverse effects. Levalbuterol (isolated R-albuterol) was developed to eliminate these effects and is commonly used in pediatric care. This study aimed to determine if levalbuterol is associated with shorter duration of continuous bronchodilator and noninvasive mechanical ventilation (NIV) use compared to racemic albuterol in critically ill children, and if continuous levalbuterol is associated with lower heart rates.


Methods: This single center retrospective cohort study utilized two periods of continuous racemic albuterol shortage, when levalbuterol was used instead. Encounters including ≥12 hours of continuous levalbuterol during these periods (1/1/23-5/17/23 and 12/19/24-4/28/25) were compared to those including ≥12 hours of continuous racemic albuterol in the interim 1.5 years (6/1/23-1/30/24). Encounters that required invasive mechanical ventilation were excluded. Duration of continuous bronchodilator and NIV use were compared between groups. The % change in median heart rate from continuous bronchodilator initiation to each subsequent 6-hour epoch was compared between groups.


Results: 793 encounters met study criteria; 273 in the levalbuterol group and 520 in the racemic albuterol group. 76.5% of the levalbuterol group and 79.2% of the racemic albuterol group required NIV. There was no significant difference in continuous bronchodilator duration (29.3 vs 30.5 hours, p=0.50) or NIV duration (28.5 vs 25.9 hours, p=0.11) between groups. There was no difference in the % change in heart rate between groups in 6-12 hours (-1.2% in the levalbuterol group vs -1.9% in the albuterol group, p=0.37) or 12-18 hours (-2.0% in the levalbuterol group vs -2.8% in the albuterol group, p=0.56) after continuous bronchodilator initiation. Results were similar when encounters that received dexmedetomidine were excluded.


Conclusions: Continuous levalbuterol was not associated with shorter duration of therapy or lower heart rates when compared to continuous racemic albuterol. These findings suggest that levalbuterol is not safer or more effective than racemic albuterol, despite its theoretical benefits.