Which inhaler needs to be given first?

[solanim]

Hi.

Last week I had a chance to give medications to one patient who was metal disorder i kni knwith COPD.

At same time, he was on seretide, ventolin, and spiriva . I just had a brief idea of these inhalers that helps breathing by expanding lung capacity and relives COPD symptoms.

I gave him spiriva first then pt used it. Then he asked me " do you really know what you are doing? I mean what meds you are giving to me?"

So i told him that I know these medication helps your breathing by expanding your lung capacity..

The patient said. " no I don't think you know what you are doing. You are supposed to give me ventolin first which opens my airway and expand my lung capacity and then the one you gave me helps remaining expansion. Then you need to give me other.

OMG. I was so embarrassed and shamed myself. But I was wondering why he took spiriva first then pt said " because you gave it first!"

OMG...although he was with mental condition, he has been on these inhalers for many years so I think he is probably right. When I finished my work, I tried to find more info through internet regarding this issue , but I couldn't find good resources. Can anyone teach me about this?

I

[AmyRN303, BSN, RN]

Also Ventolin HFA is not given routinely. It is suppose to be ordered or given prn. If the patient is using that MDI more than twice a week then they need intervention. That means that their asthma or symptoms are not under control.

For asthma, yes, but this patient had COPD, so his ventolin could be a scheduled med instead of PRN.

[reddgirl]

There are guidelines for COPD management. You can use a SABA prn for mild cases, for moderate you can do a combination inhaler such as Combivent, and for end-stage or severe we use the SABA routinely. If the order was followed as written then it really doesn't matter what the patient says but the SABA should be given first to open up the airways to allow the the steroids to work. Psych patients can be manipulative so be careful. I get them every day in the clinic asking to me to alter their meds. Go to goldcopd.org if you wanna know the management of said condition. ?

[JustBeachyNurse, LPN]

My grandmother has COPD after 65 years of smoking. Her pulmonologist explained that many times daily SABA is indicated. Some insurance doesn't cover combivent. But they cover Ventolin plus spiriva (spiriva is anticholinergenic similar to Atrovent. Atrovent plus Ventolin = combivent). Spiriva much more effective 5 minutes post Ventolin

Seretide is like advair (Flovent (steroid) plus serevent (laba).

In my experience it should be Ventolin, wait, spiriva wait then seretide/advair to have optimal effects

[Meriwhen, ASN, BSN, MSN, RN]

Ventolin first. Spiriva won't do the patient any good if it has a hard time getting there.

You would be surprised how well psychiatric patients, even geriatric ones, know their medications. Do not fall into the trap of thinking otherwise.

As for delusions...well, if they give you some hare-brained story about how they take Haldol intranasally for their hemorrhoids, or whatever other idea that you know for a fact is false or doesn't sound right, then don't listen to it. If they want medication changes, remind them that you need to defer to their MD/prescriber.

Otherwise, consider what feedback the patient has to say...because it's likely that the patient knows what he or she is talking about.

[TheGooch]

I'm not sure what the patient having a "mental disorder" has to do with anything. Do you think a patient with depression or anxiety or bipolar disorder is clueless about his or her own medical conditions/history? That is laughably untrue and a borderline offensive suggestion. The bronchodilator should be given first, the patient is correct.

That's because patients with mental conditions are CRAZEEEEEEEEEEE and don't have a clue as to what is going on around them!

At least that's the impression I get from some medical professionals.

[KelRN215, BSN, RN]

That's because patients with mental conditions are CRAZEEEEEEEEEEE and don't have a clue as to what is going on around them!

At least that's the impression I get from some medical professionals.

Yes that has been my experience too. I've told this story here before but it's something that I will not forget for the entirety of my career. I was working in the hospital, come onto a night shift, assigned to take care of a post-op teenager. This teenager happened to have a history of cutting. We did written report and in the day nurse's report, she had written "hx of cutting but so nice you would never know." This was probably 5 years ago and I remain horrified and dumbfounded at this comment. What on earth does being nice have to do with the inner turmoil that causes one to self-injure? People with mental illness can be nice, mean, black, white, knowledgeable about their medical conditions or not, employed, unemployed, your mother, your sister, your brother, your next door neighbor, you.

[GrannyRRT]

, for moderate you can do a combination inhaler such as Combivent, and for end-stage or severe we use the SABA routinely. If the order was followed as written then it really doesn't matter what the patient says but2;

We have to remind the doctors of the order of the meds also especially during the month of July.

We also are constantly changing the times in the MAR since there is a conflict in timing the order with the BID, 4x_day and q 4 schedules. It really messes up the bronhiectasis, CF and some mixed CLD_ with pulmonary htn if you mix up the meds. It is up to you to know the specific policy or the how to and whys for pulmonary drugs to be effective. DPIs_ such as Spiriva_ are challenging to ensure the pt is able to achieve max inspiratory flow for adequate delivery. Also, for the MDIs_, almost every one had different priming puffs and schedule. As expensive as these meds are, you don't want to waste but delivery needs to be effective.

The hospital times also promotes noncompliance since it wants people to breathe around a computer generated schedule rather than their activity. No wonder people with COPD are in respiratory distress when they have a full set of early morning tests or PT but only can get a QID_ albuterol at 0900. Some COPD pts like their albuterol first thing in the morning with their coffee and cigarette.

Insurance isn't paying for Combivent because it is no longer available as an MDI since HFA_ replaced the CFC_ inhalers. It is now Respimat_, an atomizer type inhaler costing around $350.

*** Combivent is also a name for the liquid combo in Canada and a few other countries which in the US was known as DuoNeb, a brand name.

[reddgirl]

Look, I just gave examples of which meds to use and I'm sure epocrates, the GOLD guidelines, or MPR won't steer us wrong as far as reference goes. I always start the patient off on the cheapest SABA or LABA combination necessary then I refer out. I work for a community health center so believe me I know about cost. The ACA insurance plan barely covers Albuterol let alone the combination inhalers. It's a daily challenge managing chronic conditions but the guidelines will never steer you wrong. I always consult the Pharm-D where I work to keep up with what is affordable and what is covered.

[reddgirl]

Bottom line the answer is: the Albuterol or SABA goes first. That's an NCLEX question I believe in management of patient care and also basic pharmacology. It is also proven in Evidenced Based Practice. ?

[GrannyRRT]

Look, I just gave examples of which meds to use and I'm sure epocrates, the GOLD guidelines, or MPR won't steer us wrong as far as reference goes. I always start the patient off on the cheapest SABA or LABA combination necessary then I refer out. I work for a community health center so believe me I know about cost. The ACA insurance plan barely covers Albuterol let alone the combination inhalers. It's a daily challenge managing chronic conditions but the guidelines will never steer you wrong. I always consult the Pharm-D where I work to keep up with what is affordable and what is covered.

Guidelines are guidelines and not laws.

There are a few basic principles but sometimes you have mixed disease processes. Albuterol (but no generic available at this time), is generally given first. But that is not to say that a patient may want or need a puff during or after a DPI or hypersonic saline treatment. We also advise them to puff a SABA before physical activity. It is a real challenge to have a patient in pulmonary rehab who refuses to take their inhaler because the nurse said only 2x a day at 0900 and 2100.

Each disease process has some type of guideline. ATS_ has asthma guidelines. CF and bronhiectasis guidelines are around also. You might find the national guidelines are modified depending on what coast you are near and the closest research hospital.

The ACA is not to blame for what has happened in the pharmaceutical side of respiratory medications. The Montreal Protocol (1987) initiated a change in the propellant used in inhalers. They went from CFC to HFA. This did not start affecting the US until 2005. Combivent was one of the last to change but was unable to just make a simple modification. It had to become Respimat which is why it is expensive. Same meds but a different delivery and packaging. We had hoped Xopenex_ and atrovent would come up with and inhaler together. Hasn't happened yet but keep hoping.

Albuterol also reformulated to be compliant. At this time there is still no generic "albuterol". ProAir_ is reasonable but it depends on the buying power of you health care system and insurance.

No need to get defensive. Just understand why some things are as they are. American pharmaceuticals are out of control and any mandated change for medications will come with some consequences. It sucks to need $600 - $15, 000 dollars worth of meds just to breathe. Of course that doesn't include the cost of other meds for the complications of chronic lung disease. I am also just quoting the costs for kids and young adults.

[reddgirl]

Ok I will have to sign off this thread because clearly the OP asked which inhaler comes first and certainly I am not blaming the affordable care act if anything. Frankly, all insurances suck when it comes to how much dictation they have over patient care. That's why there is a speciality called pulmonary and I certainly consult them whenever needed. Thanks for the info and good night. ?

[reddgirl]

I see what you are saying. That's why I hate texting/typing because some statements come across or can be perceived differently but I will say that I agree with what you are posting and the prices are horrendous. I don't think anyone should prescribe or dispense meds based on how much a drug costs. That is the most frustrating part of my job. I'm always talking with the IDT to find out how we can effectively manage the patient whether it's MD, DO, ARNP, RRT, RN, etc.