I rank duonebs (albuterol/atrovent) 5th out of the 33 drugs we carry.

We use these drugs together in a nebulizer for wheezing related to asthma , COPD or anaphylaxis. Last year I used these drugs together 11 times and Albuterol alone 10 times. When I worked full-time in the city, during the three years I reviewed (1995-1997), I used Albuterol 36, 42, and 37 times. We did not have Atrovent back then. There is a lot more asthma in the inner-city than there is in the town I work in, although there is more COPD out here. One small difference that may attribute to a lower number this past year is I am more careful about giving a breathing treatment to patients with cardiac asthma — wheezes likely caused by fluid in the lungs. There is considerable debate about the merit of giving breathing treatments to people in CHF. I have heard much pro and con. I have a few anecdotal calls where I gave a breathing treatment to someone with CHF who then flashed on me, but there are doctors who I respect who say a breathing treatment is okay for CHF. While I await a definitive study, I will continue to use nebs with caution in these patients.

I was initially surprised when I first conceived this list that I ultimately rated duonebs (combivents) as high as I did. I think I sometimes take for granted what breathing treatments do. Someone is having a hard time breathing, lots of wheezes, you give them a treatment, they start breathing better. Pretty routine.

Consider for a moment where the patients might end up if you didn’t have the treatments for them. They don’t get better, they donít stay the same, they get worse. Breathing treatments can keep moderate dsypneas from becoming respiratory failures.

My least favorite calls are severe dsypneas where I can see the panic in the patient’s eyes (and I hope they can’t see mine) as they struggle to get air. The very worse are asthmas, particularly in young people. Anything that can stave off their respiratory arrest is gold in my book.

On a curious note, the OPALS trials (large and well-respected clinical trials in Canada) which showed that the introduction of ALS (to areas that previously were only BLS) made no difference in mortality for cardiac arrest or trauma, but did make a difference in respiratory emergencies, suggested that the difference in respiratory mortality was not subject to advanced life-support techniques, but to the introduction of nitro and nebulized breathing treatments.

The most substantial change in therapeutic intervention was the marked increase in the use of medications for symptom relief; this intervention is not a component of advanced life support, and it was implemented as part of a separate program. Thus, the benefit of the intervention in this trial may have been primarily due not to the availability of advanced-life-support techniques but to the use of nebulized salbutamol and sublingual nitroglycerin.

Check out the Article here:

Advanced Life Support for Out-of-Hospital Respiratory Distress

As a side note, we were recently approved to use CPAP in asthma and COPD. I havenít used it yet for these indications.


Ipratropium (Atrovent)

Class: Anticholinergic Bronchodilator

Action: Relaxes bronchial smooth muscle

Effect: Bronchodilation

Indication: For use in severe COPD and Asthma cases after Albuterol

Contraindication: Hypersensitivity to ipratropium

Dose: 0.5 mg (2.5ml)

Route: Nebulized updraft

Side effects: Tachycardia, palpitations, headache

Albuterol (Ventolin, Proventil)

Class: Ŗ2 Agonist
Synthetic sympathomimetic

Action: Stimulates Ŗ2 receptors in the smooth muscle of the bronchial tree.

Indication: Relief of bronchospasm.

Contraindication: None for field use.

Precaution: Patient with tachycardia.

Side effect: Tachycardia

Dose: 2.5mg (0.5ml of the 0.5% solution diluted to 3ml NS) for nebulized updraft.
May repeat in 10-20 minutes.

Route: Inhaled as a mist via nebulizer.

Pediatric Dose: 2.5mg nebulized updraft. May repeat in 10-20 minutes.


  • ICU Nurse says:

    How does CPAP help in severe asthma? Isn’t the patient creating their own PEEP a significant problem in a severe asthma attack, without you adding to it?

    In my hospital, we usually go with early intubation for these patients and ventilate them with very little (if any) PEEP.

  • totwtytr says:

    CPAP is supposed to reduce the Work of Breathing in Asthma patients, but it’s efficacy is less than for CHF or COPD. In fact, BiPAP is recommended for Asthma more than CPAP.

    Intubating Asthmatics isn’t particular good care since Asthmatics and COPD patients are notoriously hard to wean from ventilators. We try to avoid intubating Asthma patients if at all possible.

    As to the OPALS study, our experience is much the same. We started BLS use of Albuterol back in the late 1990s and it’s been a tremendous success. Not only does it get care to the patient sooner (we’re a tiered system), it often releases ALS units since the BLS crews can safely transport mildly ill Asthmatics.

    Having BLS crews give NTG to patients who have never taken it before has the huge downside of possibly giving it to patients with Inferior AMI. That’s less likely to happen to someone who has taken NTG regularly.

  • KCurry says:

    I would not use CPAP in an asthmatic condition. A year ago, I had a pt who was unresponsive, asthmatic with a silent chest. I have pulled the valve off a BVM, squirted the albuterol into the BVM bag, valve back on – shook it up; then ventilated the pt.Called the ED for RSI on arrival. Rapid transport initiated. Pt survived to good to favorable outcome.

  • ICU Nurse says:

    Hi – COPD patients can be difficult to wean, and a trial of CPAP (or more often BIPAP) is often better than jumping straight to intubation. However, asthmatics on the whole wean very well from invasive ventilation, once the underlying bronchospasm has been resolved. BIPAP can be an option for asthmastics but,as I said, we tend to intubate them pretty early here as they have a tendency to stop breathing, and BIPAP is not really designed for formal ventilation.

  • medicscribe says:

    Thanks for the comments, interesting discussion.

    Our CPAP indications are broken down into pulmonary edema and then other severe respiratory distress. When it it believed to be pulmonary edema we start at 7.5-10 cm H2O. With other respiratory distress such as possible COPD or asthma, we Apply CPAP at 2.5-5 cm H2O. We then adjust FiO2 to maintain Oxygen Saturation >90%. Our rule is if it is working, keep it on. If it isn’t working, take it off. We don’t have Bi-pap or RSI. For asthma, we also have magnesium and epi as other options after nebs.

    Thanks again for the great comments,


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  • Comments
    Thanks for the advice, love your books by the way!
    2015-09-27 04:04:59
    Keep your eyes open and your mouth shut unless you have something to say. Be nice to everyone, especially your patients. Keep showing up.
    2015-09-27 00:55:46
    The 6 Rs – The Right Drug
    You are right. I wrote the post so long ago, it is hard to remember. Perhaps I meant to write salicylates. Who knows. Good catch.
    2015-09-27 00:54:32
    The 6 Rs – The Right Drug
    ASA is not an NSAID.
    2015-09-24 12:50:52
    Hey PC, do you have any solid advice for someone new to EMS?
    2015-09-18 23:27:32

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