# ALBUTEROL vs. COMBIVENT



## cactusmedic (Apr 9, 2010)

There has been some discussion out here over the treatment of an ALB SVN and an ALB/IPRATROPIUM (Combivent, Duoneb).

I've been hearing that a lot of ER Docs are suggesting to give an ALB SVN before you give a Duoneb for a difficulty breather, specifically COPD. They suggest giving an ALB SVN first, then following with a Duoneb five minutes after finishing the first breathing treatment. I was always told Ipratropium dries out secretions and helps prolong the effects of Albuterol.

Anyone have any suggestions or input on the efficacy of giving ALB before the Duoneb??


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## usafmedic45 (Apr 9, 2010)

There are some who believe that the "double dose" of albuterol has better efficacy in controlling COPD exacerbations.  It is not the emergency physicians in my experience that buy into this, but primary care docs with their patients admitted to the hospital.  I can't recall seeing any information on the subject to allow me to say one way or the other.  For the sake of disclosure, it is probably because I haven't looked.  The major problem with the practice in COPDers is that a lot of them will have side effects (nausea, tachycardia, anxiety, etc) from a rapid back to back double dose of albuterol with little to no added clinical benefit.  Unless the patient is still wheezing, I am hesitant to double up on bronchodilators.

Given that a significant portion COPDers are not having acute reversible bronchospasm (read as "what albuterol treats") and the problem is much more complicated (a mix of what is called loss of "dynamic coupling" (loss of synchronization of the chest wall and the lung secondary to the loss of elastic recoil of the lung in COPD), secretion buildup (especially in the form of COPD where chronic bronchitis predominates), etc it is probably unnecessary to double dose the patients _as a standard practice_.  That said, albuterol is a safe enough drug (outside of frank cardiac events causing wheezing due to pulmonary edema) that it is something that can, and probably should, be given to any suspected COPD exacerbation. 

BTW, ipratroprium does not "prolong" the effects of the albuterol.  It is simply a longer acting separate medication that has both bronchodilatory effects and helps to reduce the volume of secretions.


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## 18G (Apr 9, 2010)

I have never heard of albuterol only first. We give albuterol/ipratroprium first and than just albuterol if needed after the initial treatment. 

As a side note about ipratroprium ..... (sharing helps me keep things fresh in my mind  

Ipratroprium is a parasympatholytic and as such works on a different pathway than does albuterol in reducing broncoconstriction and secretions. In remembering that the parasympathetic system controls primary bronchomotor tone, its obvious to see how a medication such as ipratroprium will work to block acetylcholine from affecting the muscarinic receptors that are abundant in the lungs and promote bronchodilation.  

Effectively, when administering albuterol/ipratroprium, you are working to open up the lungs along two separate pathways at one time and the ipratroprium is longer acting.

The two drugs together have a synergistic effect and are thought to be more effective when administered together.


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## Shishkabob (Apr 9, 2010)

My internship location, along with most of the Dallas area EMS agencies, do albuterol first, then 2x albuterol/atrovent.


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## reaper (Apr 9, 2010)

I have never seen a system give x2 on atrovent. You sure it is not backs wards?

Most do one ALB/ATROVENT, followed by ALB x2.


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## Shishkabob (Apr 9, 2010)

"Not improving with the first albuterol dose, combine 2nd and 3rd albuterol doses with ipratropium 0.5 mg (ipratropium dose for infant less than 1 year is 0.25 mg)."


I promise


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## usafmedic45 (Apr 9, 2010)

> I have never seen a system give x2 on atrovent. You sure it is not backs wards?



I think you have it backwards.   Re-read what he said. He was talking about doubling up on albuterol.


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## Flight-LP (Apr 10, 2010)

I've seen it go both ways. Our current guidelines allow unlimited use per patient presentation for both medications. There are some agencies out this way that are still unsure about allowing Atrovent into their clinical practice. Personally, I have never understood why. Take the COPD'r for instance. You arrive and you give them Albuterol for their wheezing and "generalized dyspnea". It doesn't help, so you give another one. By the time you are at the ER, you have the same level of dyspnea, an overworked tachycardic heart that has increased metabolic and oxygen demands, your pt. is exhausted, and now will likely buy an ET tube due to fatigue. Chances are that only 1-2 Atrovent treatments would have significantly decreased this pts. dyspnea by providing the much needed anticholenergic effects. It is a rather benign medication that's benefits far outweigh the risks. As such, it is authorized as an EMT-B intervention in my system within established parameters. Now if we can just get ignorant people past the "you can't give nebulized Atrovent with a peanut allergy" myth.....................................


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## reaper (Apr 10, 2010)

usafmedic45 said:


> I think you have it backwards.   Re-read what he said. He was talking about doubling up on albuterol.



From what he wrote, They do one treatment of Albuterol, then second and third treatments are Albuterol/Atrovent. That is what I was asking about!


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## usafmedic45 (Apr 10, 2010)

> They suggest giving an ALB SVN first, then following with a Duoneb five minutes after finishing the first breathing treatment.



That would be two treatments.    Two doses of albuterol and one of Atrovent.


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## reaper (Apr 10, 2010)

Then a third of duoneb. That would be three!

"Not improving with the first albuterol dose, combine 2nd and 3rd albuterol doses with ipratropium 0.5 mg (ipratropium dose for infant less than 1 year is 0.25 mg)."


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## usafmedic45 (Apr 10, 2010)

> Then a third of duoneb. That would be three!



Ah, I see that you were referring to Linus' comment and not the OP's.  That's what I get for posting after being up for way too long I guess.  

Regardless, an additional dose of ipratroprium is not a big deal.  As Linus pointed out, it is done in hospitals all the time (it's called "front loaded dosing" by some), especially in patients who are heavy on secretions.  You are not, in most circumstances going to encounter any major problems with doubling up or even tripling up on ipratroprium.  If anything you would be far more likely see issues from the multiple doses of albuterol including tachycardia, nausea and/or vomiting, paradoxical bronchospasm (the frequency of which increases non-linearly once you get past two to three doses in most adults), anxiety, etc.  The ipratroprium is not a serious concern although you generally max out the utility of it after about two doses within 8 hours of one another and anything beyond that is both wasteful and ineffective. 

The only problem I have seen with the dosing discussed here is the interval between treatments the OP described (five minutes).  It's documented and taught that it is best to wait at least fifteen minutes since albuterol generalyl takes that long to have a significant effect (anything seen before that is likely due to the moisture in a neb treatment and placebo effect; especially in the setting of "immediate" relief) to assess the impact the albuterol is going to have so as to not unnecessarily give "extra" doses of medication.  



> I have never seen a system give x2 on atrovent.



You know what they say about relying on experience alone.  That said , what Linus described is pretty much standard practice for every EMS agency I've ever had anything to do with (either as a clinician or as a quality control person; about nine  and roughly 15 respectively), not to mention every hospital I've been an RT at  (that would be about nine of them, counting temp staffing and part time and counting the military as a single "hospital", for those of you playing along at home)


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