Question About Albuterol Atrovent Neb. Tx

Trauma Columnist · May 27, 2011

When you are giving albuterol 2.5mg per neb the dosing is every 4 hours. You may give every 2 hours if there is an acute exacerbation x4 doses. However, if you have to give every 1 hour, the pt needs to be evaluated in the ER.

hiddencatRN, BSN, RN · May 28, 2011

Well we put serious wheezers who don't respond to triple nebs on continuous albuterol. If they need it for more than 24 hours we check lytes and make sure they're on a high potassium diet during treatment.

MunoRN, RN · May 28, 2011

If the patient is needing it that often, or even just more often than every 4 hours, you consider having it switched to levalbuterol. Albuterol should never be scheduled, only prn.

Regular albuterol contains both levalbuterol as well as it's by product. The byproduct is pro-inflammatory and can cause bronchospasm and bronchoconstriction, this is usually cancelled out by the levalbuterol unless you are taking it frequently, in which case the byproduct levels can build it up beyond that of the levalbuterol since the byproduct has a longer half-life.

GilaRRT · May 28, 2011

Not a by-product. Racemic albuterol contains both the (L) & (S) enantiomer of albuterol. Basically, same components with a different mirror image configuration. Also, light will take a different path around each type of molecule.

Let's be clear about the inflammation and constriction. The literature is in vitro based not in vivo, so take it for what it's worth. Not absolute at this point.

Anna Flaxis, BSN, RN · May 28, 2011

I was told by my former DON that a Pt can receive a breathing tx every hour and it not be harmful. Under what circumstances would this be true?

In acute bronchospasm, albuterol can be given Q20 minutes X3 doses. We do this in the ED quite often.

NYnurseatheart · May 28, 2011

The albuterol treatment via nebulizer is okay every hour (if necessary), however you should not be giving the Atrovent that frequently. If you have to give more than 4 treatments in a row each hour, I would be phoning the physician.

Anna Flaxis, BSN, RN · May 28, 2011

Obviously what you should do is dependent upon the setting. In the ED, we give stacked nebs quite frequently. In an LTC setting, an increased need for nebs would be an indication to seek further evaluation.

However, that was not the original question.

MunoRN, RN · May 28, 2011

Not a by-product. Racemic albuterol contains both the (L) & (S) enantiomer of albuterol. Basically, same components with a different mirror image configuration. Also, light will take a different path around each type of molecule.
Let's be clear about the inflammation and constriction. The literature is in vitro based not in vivo, so take it for what it's worth. Not absolute at this point.

Racemic albuterol was developed with the goal of producing ®-albuterol, or levalbuterol. The closest they could get at the time was to split a larger molecule producing ®-albuterol and it's chiral counterpart (S)-albuterol. The combination of the two was effective and a better option than racemic albuterol, and since they didn't know how to separate the two at the time they just left the (S)-albuterol in the mix and deemed it an inert byproduct. It wasn't until many years later when ® and (S)-albuterol were successfully isolated and could be studied.

There have been both in vitro and in vivo studies on the effects of (S)-albuterol, the abstract of this study from 2004 sums it up: "Pro-constrictory and proinflammatory properties of (S)-albuterol have been widely reported both under in vivo and in vitro conditions. However, underlying mechanisms are unclear." http://www.ncbi.nlm.nih.gov/pubmed/15007354

You really only need look at the well established dosages and administration intervals for levalbuterol and albuterol particularly when given in larger doses and to treat more severe symptoms; given the same amount of ®-albtuerol, levalbuterol requires a smaller dosage for the same effect, the result of containing a component with opposing effects to levalbuterol.

GreyGull · May 28, 2011

You really only need look at the well established dosages and administration intervals for levalbuterol and albuterol particularly when given in larger doses and to treat more severe symptoms; given the same amount of ®-albtuerol, levalbuterol requires a smaller dosage for the same effect, the result of containing a component with opposing effects to levalbuterol.

You can not compare "dosages" when you now have two different chemical configurations.

You can also look at other medications which also have similar differences with the isomers.

L-epinephrine1:1000 and Racemic Epinephrine 2.25% are good examples.

You could also take a look at the albuterol dosage in DuoNeb (or the generic) and the single unit dose.

Duoneb contains 3.0 mg (0.1%) of albuterol sulfate, the equivalent to 2.5 mg (0.083% of albuterol base).

hiddencatRN, BSN, RN · May 28, 2011

In acute bronchospasm, albuterol can be given Q20 minutes X3 doses. We do this in the ED quite often.

Our protocol is three doses each of albuterol and atrovent at once for an hour long neb plus a loading dose of orapred. Patients who "fail" the treatment end up being admitted on Q3/4 or continuous albuterol, but in many of our patients they can go home on orapred and maintenance albuterol for the next few days.

hiddencatRN, BSN, RN · May 28, 2011

Oops double post