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 don’t 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:
As a side note, we were recently approved to use CPAP in asthma and COPD. I haven’t used it yet for these indications.
Class: Anticholinergic Bronchodilator
Action: Relaxes bronchial smooth muscle
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: ß2 Agonist
Action: Stimulates ß2 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.