Increased blood alcohol with albuterol

It is true that some MDI bronchodilators contain alcohol or ethanol. There are reports of breath testing for ethanol being elevated immediately following the use of specific inhalers (1). You did not specify which inhaler was used and the formulations have changed since the publication in 1995. One source stated that the amount of alcohol in 2 puffs of an ethanol containing inhaler is less than 10 mg. A ripe banana has 40 mg of ethanol; thus, there insufficient ethanol to cause measurable blood levels or physiologic effects. Blood alcohol measurements would not be affected by inhalers, but some assays are affected by high lactate levels (2). This does not seem relevant in this case.

There is a rare phenomenon called “auto-brewery syndrome” (3). This has nothing to do with albuterol but is due to endogenous fermentation by fungi or bacteria in the gastrointestinal system, oral cavity or urinary system. Following a high-sugar or high-carbohydrate diet ethanol may be generated internally. This has been associated with Candida and Saccharomyces organisms as well as Klebsiella, Enteococcus and Citrobacter. Auto-brewery syndrome is more prevalent in patients with co-morbidities such as diabetes, obesity, and Crohn disease but can occur in otherwise healthy individuals. The literature has differing opinions as to whether auto-brewery syndrome is potential defense strategy (4,5) “Those who are aware of this condition may falsely rely on it as a method to avoid penalties. On the other hand, genuine patients suffering from this condition may be caught by traffic control and become victims of the condition. For that reason, a meticulous and planned approach should be taken to verify the condition and to ensure that it is not overlooked (4).” “With reliable gas chromatographic methods of analysis, the concentrations of endogenous ethanol in peripheral venous blood of healthy individuals, as well as those suffering from various metabolic disorders (diabetes, hepatitis, cirrhosis) ranged from 0-0.08 mg/dl. These concentrations are far too low to have any forensic or medical significance. The notion that a motorist's state of intoxication was caused by endogenously produced ethanol lacks merit (5).”

In summary, I could not find any description of ethanol in current albuterol MDIs (6,7,8,9), although ethanol has been in inhalers in the past. There is no mention of ethanol side-effects in the product labels discussing overdoses of albuterol. Auto-brewery syndrome is another consideration but is very rare and not likely relevant.

1. Gomez, Hernan F., et al. "Elevation of breath ethanol measurements by metered-dose inhalers." Annals of emergency medicine 25.5 (1995): 608-611.
2. False-Positive Blood Alcohol (weebly.com)
3. Auto-brewery Syndrome - StatPearls - NCBI Bookshelf (nih.gov)
4. Akbaba M. A medicolegal approach to the very rare Auto-Brewery (endogenous alcohol fermentation) syndrome. Traffic Inj Prev. 2020;21(5):295-297. doi: 10.1080/15389588.2020.1740688. Epub 2020 Apr 7. PMID: 32255712
5. Logan BK, Jones AW. Endogenous ethanol 'auto-brewery syndrome' as a drunk-driving defence challenge. Med Sci Law. 2000 Jul;40(3):206-15. doi: 10.1177/002580240004000304. PMID: 10976182.
6. VENTOLIN HFA (fda.gov)
7. PROAIR HFA (albuterol sulfate) Label (fda.gov)
8. label (fda.gov)
9. 021457s001lbl.pdf (fda.gov)

I hope this information is of help to you and your practice.

All my best.
Dennis K. Ledford, MD, FAAAAI