Question about proventil and Duoneb breathing treatment for nebulizer?

**canoehead, BSN, RN** · Mar 4, 2020

TALK TO YOUR OWN PHYSICIAN ABOUT YOUR CARE.

We cant give advice.

CritterLover, BSN, RN · Mar 4, 2020

On 3/1/2020 at 6:42 PM, mzsuccess said:
Can a patient use both of these at the same time as they both contain albuterol?
My pt pulmonologist sent both one to use prn QID and one to use TID. I looked up interactions it only mention both can lead to possible rare albuterol OD.

I called the Dr for clarification. The MAR says Duoneb. I know this may sound extremely dumb.
The lead nurse said the pt can use both but I just wanted to hear from others. Thanks!

It's pretty common to see duoneb scheduled and then just plain albuterol prn. You generally wouldn't give them at the same time, but would be reasonable to give the duoneb as scheduled and then follow it up with plain albuterol if the duoneb wasn't enough.

Canoehead -- it says "My pt pulmonologist" so I don't think the poster is asking about a personal med. Easy to miss that "pt" though.

KatieMI, BSN, MSN, RN · Mar 4, 2020

Patient can use both

Duoneb in a combo med as it contains ipratropium and is considered "safer" for prolonged use in terms of b-2 overstimulation and side effects. There are no conclusive studies but Duoneb is commonly prefered for scheduled use while pure albuterol is used as "resque" med. Levalbuterol (Xopenex) is slightly less prone to b-2 overstimulation side effects but there are no studies showing any particular benefits over albuterol, and the latter one is much cheaper.

Patients on both meds should be educated and re-educated about overdose and resistance. Total b-2 "overload" is one of the worst case scenarios in clinical medicine, and albuterol is easy, quick and cheap to use. Too many patients believe that it is OK to sit on'porch with their buddies smoking all the way around if they just can give themselves a puff or two (or three, or four) every so often. They have no idea that they can get heart attack or have their lungs ripped through by hopelessly increasing PEEP.

mzsuccess · Mar 4, 2020

1 hour ago, CritterLover said:
It's pretty common to see duoneb scheduled and then just plain albuterol prn. You generally wouldn't give them at the same time, but would be reasonable to give the duoneb as scheduled and then follow it up with plain albuterol if the duoneb wasn't enough.
Canoehead -- it says "My pt pulmonologist" so I don't think the poster is asking about a personal med. Easy to miss that "pt" though.

Hello,

thanks so much.

what if both are PRN? That isn’t common right?

1 hour ago, KatieMI said:
Patient can use both
Duoneb in a combo med as it contains ipratropium and is considered "safer" for prolonged use in terms of b-2 overstimulation and side effects. There are no conclusive studies but Duoneb is commonly prefered for scheduled use while pure albuterol is used as "resque" med. Levalbuterol (Xopenex) is slightly less prone to b-2 overstimulation side effects but there are no studies showing any particular benefits over albuterol, and the latter one is much cheaper.
Patients on both meds should be educated and re-educated about overdose and resistance. Total b-2 "overload" is one of the worst case scenarios in clinical medicine, and albuterol is easy, quick and cheap to use. Too many patients believe that it is OK to sit on'porch with their buddies smoking all the way around if they just can give themselves a puff or two (or three, or four) every so often. They have no idea that they can get heart attack or have their lungs ripped through by hopelessly increasing PEEP.

Amazing! Thanks

KatieMI, BSN, MSN, RN · Mar 4, 2020

They should not be ordered both PRN simultaneously, although it happens. Sometimes one is used through nebulizer and another patient can carry around in inhaler. Or patient can jump from one to another due to insurance quirks. Sometimes asthmatics with long "stage" (like myself) know which one is better to use at which time and keep both to use accordingly.

The main point is to be sure they do not substitute either for more expensive baseline control meds and do not "cover up" excessively. I preferred to teach them how to self-dose plain steroids instead of letting them overuse b-2 agonists as they pleased.

caliotter3 · Mar 4, 2020

Sometimes med orders that are not quite clear and making sense in context with other orders are that way because the orders were written at different times by different providers. Provider 2 may not know that provider 1 has written order 1 which overlaps, duplicates, or contradicts order 2. This situation more likely to happen when there is no electronic tracking of med orders. When a caregiver comes across such a situation they contact the primary care physician for discussion and clarification. One of the orders may be discontinued altogether in favor of a treatment program that makes better sense.

Silverdragon102, BSN · Mar 4, 2020

My suggest is to speak to your pharmacist

MunoRN, RN · Mar 4, 2020

The order could be worded better, but it's not unusual for patients requiring prn albuterol to also be prescribed ipratropium, partly for it's direct benefits in treating symptoms, but also partly because it helps counteract the adverse effects of the non-therapeutic byproduct contained in albuterol.

Basically, if a patient is requiring additional albuterol before an additional dose of ipratropium is needed, then they should use just the albuterol, not the albuterol / ipratropium combo (duoneb). But at the same time, whenever the patient is using the albuterol, they should have some ipratropium on board as well, ideally all the way through the duration of the albuterol doses since the non-beneficial, and potentially harmful, component of albuterol has a duration that is slightly longer than the beneficial component, and the ipratropium helps treat the effects of that non-beneficial component which otherwise can cause a recurrence of symptoms that necessitate another albuterol dose.

amoLucia · Mar 5, 2020

Through all the above explanations I know one thing - too much duoneb, even alone, but too soon repeated, caused me BIG distress.

Will never take my nebs that close together again,

So I'd be VERY CAREFUL about taking those two too close again, whether singularly or overlapping.