Ventolin or Advair. Which comes first?

[mlimoges]

Alright, let me start with some background. I've got a homecare client on Advair BID and was just prescribed Ventolin BID to supplement. She is not asthmatic but does have a Hx of pneumonias.

We have a debate going between our nursing team as to which inhaler should be given first. Two of us were taught one way and the other two the opposite. Just looking for some clarification and insight from all of you.

Team 1) Advair first, then Ventolin - this side is arguing that since Advair is long-acting it should be given first and that Ventolin is a "rescue inhaler" and shouldn't technically have been prescribed at all

Team 2) Ventolin first, then Advair - This side argues that while Ventolin is short-acting its the bronchodilating properties that are more important. Giving the Ventolin first allows the brochioles to dialate (obviously) which in turn allows the Advair deeper into the lungs and making it more effective.

[JustBeachyNurse, LPN]

Team 2. Don't refer to ventolin as a "rescue inhaler" refer to it as a rapid onset or short acting bronchodilator. (SABA) with an onset of 60min, both which need the bronchioles open to work effectively. While the duration of action for Ventolin is 4-6hrs. The drugs in Advair have a duration of action of 12hrs. Taking them first has no physiological benefit if the airways aren't first opened by the SABA.

[SHGR, MSN, RN, CNS]

To clarify, albuterol/ Ventolin is not always a "rescue" inhaler. It may be given prior to planned exercise for exercise-induced asthma, for example.

[greenerpastures]

Team 2. Open the airways first, then give the long acting that is meant to "settle" to do its work.

[thevez]

Bronchodilators before steroid meds.

You want to open up lungs with Ventolin to maximize inhalation absorption of Advair.

Cheers!

[GrannyRRT]

Advair, if used in the DPI (dry particle inhaler form) diskus, can be irritating to some

creating a response which makes delivery ineffective. Pre medicating with albuterol makes it better tolerated. You see this done for patients getting 3% or 7% saline or with nebulized antibiotics during bronchiolitis, CF, PNA, or bronchiectasis protocols. There might be some bronchodilation for better deposition , but usually it is to prepare the airways for inhaled substances which could stimulate them negatively.

Some may have to switch to the Advair HFA_ which might be better tolerated by the patient...but not by the hospital formulary or insurance.

This is where it is vital that those giving MDI medications in the hospital recommend if the patient might benefit from a bronchodilator prior to a DPI or any other inhaler by an on going assessment before, during and after delivery.

[mlimoges]

Team 2. Don't refer to ventolin as a "rescue inhaler" refer to it as a rapid onset or short acting bronchodilator.

Thank you, only referred to it as such because Team 1 had been but i do appreciate the detailed explanation. Ive tried to push this point (the short acting opening the airways first) before but i'm not sure if the one who is causing the most resistance is just annoyed that we dared to challenge her on this (since shes studying to be a physician and believes she knows best), or if she's wholeheartedly team 1. By her notes, i'd say shes just annoyed because she just continues to reiterate the same information but worded differently and increasingly more obnoxious.

Her main rebuttal is that Advair is also a bronchodilator, which makes the Ventolin useless and the fact the Advair is long acting makes it even better. She doesn't seem to see that the client has been on Advair for some time and it is no longer effective alone. I just keep shaking my head in frustration.

[mlimoges]

Advair, if used in the DPI (dry particle inhaler form) diskus, can be irritating to some creating a response which makes delivery ineffective. Pre medicating with albuterol makes it better tolerated. You see this done for patients getting 3% or 7% saline or with nebulized antibiotics during bronchiolitis, CF, PNA, or bronchiectasis protocols. There might be some bronchodilation for better deposition , but usually it is to prepare the airways for inhaled substances which could stimulate them negatively.

Some may have to switch to the Advair HFA_ which might be better tolerated by the patient...but not by the hospital formulary or insurance.

This is where it is vital that those giving MDI medications in the hospital recommend if the patient might benefit from a bronchodilator prior to a DPI or any other inhaler by an on going assessment before, during and after delivery.

She is already on the HFA_ as she uses a spacer. But i agree with you about the ongoing assessment. She has been on this medication for about a week and a half now and i can honestly tell you which nights she received the Ventolin first, she sleeps better and with minimal to zero coughing. Those nights when she was only on Advair or receives the Advair first, shes up coughing quite a few times during the night. I can't comment on during the days but i can definitely notice a different on night shift

[GrannyRRT]

Since you are dealing with a physician wannabe, it is time to up the game for a more detailed explanation. Actually, since nurses are giving the inhaled meds and are responsible for teaching the CLD patients in many places, this knowledge should be required.

Untitled Document

The above link is from the late, great Dr. Tom Petty whose informational books and resources are world renowned for patients with chronic lung diseases and those requiring oxygen. I like this article since it mentions the interstitial lungs diseases associated with pneumonias (BOOP, DIP etc) or Interstitial Lung Diseases (ILD). Strep and kleb pneumonias are particularly noted in long term maintenance.

For anyone who gives respiratory meds or works with patients with CLD, it is essential that you understand their disease stage classification to understand the way inhalers are prescribed. This is also very beneficial to School Nurses who deal with asthma and other forms of CLD associated with prematurity or congenital abnormalities.

Each disease will have its own specific diagnosis of severity and medication recommendation for each stage but the concept is still basically the same.

Next time someone wants to argue, ask if he or she saw the spirometry or knows what the severity classification is. Did they note the FEV1 response pre and post bronchodilator? As the severity classification increases the SABA may also be prescribed as routine rather than just rescue along with the LABA and/or anticholinergic.

This is the ATS EPR 3 staging and scoring for Asthma.

http://www.med.umich.edu/1info/FHP/practiceguides/asthma/EPR-3_pocket_guide.pdf

This is the GOLD for COPD.

http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_May2512.pdf

Some of the pneumonias will fall more into the COPD treatment plan due to chronic changes and a few will go with more of the asthma guideline depending on origin and RAD processes. There are some patients who only take a controller or maintenance inhaler and no SABA with it or anywhere in their treatment plan. Again, spirometry testing will have determine a treatment plan.

There is a difference in the way SABA (albuterol) medications are recommended. in GOLD, they are recommended as routine. They are also taught as rescue and pre treatment for exercise in Pulmonary Rehab classes or just daily activities to maintain mobility.

This post might seem a little overwhelming but if you look through the staging and the meds your patients are on, it will start to make sense. We (RTs, Pulmonologists, Asthma and COPD educators) want more nurses to be informed about disease severity and treatment recommendations to properly educated patients. CMS is all over this and the high readmission rates for patients with CLD. If the caregivers don't know, neither will the patients. Spirometry testing is now done at bedside by RTs for many of their CLD patients especially if a 496 diagnosis billing code is used.

[JustBeachyNurse, LPN]

Since you are dealing with a physician wannabe, it is time to up the game for a more detailed explanation. Actually, since nurses are giving the inhaled meds and are responsible for teaching the CLD patients in many places, this knowledge should be required.

Untitled Document

The above link is from the late, great Dr. Tom Petty whose informational books and resources are world renowned for patients with chronic lung diseases and those requiring oxygen. I like this article since it mentions the interstitial lungs diseases associated with pneumonias (BOOP, DIP etc) or Interstitial Lung Diseases (ILD). Strep and kleb pneumonias are particularly noted in long term maintenance.

For anyone who gives respiratory meds or works with patients with CLD, it is essential that you understand their disease stage classification to understand the way inhalers are prescribed. This is also very beneficial to School Nurses who deal with asthma and other forms of CLD associated with prematurity or congenital abnormalities.

Each disease will have its own specific diagnosis of severity and medication recommendation for each stage but the concept is still basically the same.

Next time someone wants to argue, ask if he or she saw the spirometry or knows what the severity classification is. Did they note the FEV1 response pre and post bronchodilator? As the severity classification increases the SABA may also be prescribed as routine rather than just rescue along with the LABA and/or anticholinergic.

This is the ATS EPR 3 staging and scoring for Asthma.

http://www.med.umich.edu/1info/FHP/practiceguides/asthma/EPR-3_pocket_guide.pdf

This is the GOLD for COPD.

http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_May2512.pdf

Some of the pneumonias will fall more into the COPD treatment plan due to chronic changes and a few will go with more of the asthma guideline depending on origin and RAD processes. There are some patients who only take a controller or maintenance inhaler and no SABA with it or anywhere in their treatment plan. Again, spirometry testing will have determine a treatment plan.

There is a difference in the way SABA (albuterol) medications are recommended. in GOLD, they are recommended as routine. They are also taught as rescue and pre treatment for exercise in Pulmonary Rehab classes or just daily activities to maintain mobility.

This post might seem a little overwhelming but if you look through the staging and the meds your patients are on, it will start to make sense. We (RTs, Pulmonologists, Asthma and COPD educators) want more nurses to be informed about disease severity and treatment recommendations to properly educated patients. CMS is all over this and the high readmission rates for patients with CLD. If the caregivers don't know, neither will the patients. Spirometry testing is now done at bedside by RTs for many of their CLD patients especially if a 496 diagnosis billing code is used.

Thank you! As a recently qualified trach/vent nurse with many opportunities to teach patients and parents this is an awesome resource. My classroom & hands on training was conducted by both a RRT & former critical care nurse. Most of my kiddos were ex-preemies with various respiratory sequelae and more knowledge and comprehension is always beneficial!

Many of my patients are too young, developmentally delayed or physically impaired to complete PFTs. Not able to coordinate well enough for even peak flows. What else can be used to assess effectiveness & appropriateness r/t SABA aside from observation (breath sounds, pulse ox (if ordered, most insurance only cover home pulse ox if continuous or high risk to require supplemental O2), work of breathing, breath sounds, etc)?

[GrannyRRT]

Great question!

If the child is in Pressure Control or even Pressure Support, the tidal volume is great indicator.

For volume the inhaled (set) vs exhaled helps along with PIP.

Several small vents now have some graphic capability which is a big plus.

Monitoring ET CO2 is another good vital sign especially if you have a waveform.

We (RTs) have equipment to measure or download data from vents or to measure at a trach. If on CPAP or BIPAP via trach or mask, most of these machines re order and even adjust settings. This helps with collecting data to determine nocturnal breathing data.

In the ICU, our vents can collect ongoing data for resistance and compliance. This is why we switch over even for simple procedures. It gives us a chance to measure various factors which might benefit from med adjustment. Even the delivery method is a huge factor. The appropriate trach is of course considered.

[mlimoges]

Since you are dealing with a physician wannabe, it is time to up the game for a more detailed explanation. Actually, since nurses are giving the inhaled meds and are responsible for teaching the CLD patients in many places, this knowledge should be required.

Untitled Document

The above link is from the late, great Dr. Tom Petty whose informational books and resources are world renowned for patients with chronic lung diseases and those requiring oxygen. I like this article since it mentions the interstitial lungs diseases associated with pneumonias (BOOP, DIP etc) or Interstitial Lung Diseases (ILD). Strep and kleb pneumonias are particularly noted in long term maintenance.

For anyone who gives respiratory meds or works with patients with CLD, it is essential that you understand their disease stage classification to understand the way inhalers are prescribed. This is also very beneficial to School Nurses who deal with asthma and other forms of CLD associated with prematurity or congenital abnormalities.

Each disease will have its own specific diagnosis of severity and medication recommendation for each stage but the concept is still basically the same.

Next time someone wants to argue, ask if he or she saw the spirometry or knows what the severity classification is. Did they note the FEV1 response pre and post bronchodilator? As the severity classification increases the SABA may also be prescribed as routine rather than just rescue along with the LABA and/or anticholinergic.

This is the ATS EPR 3 staging and scoring for Asthma.

http://www.med.umich.edu/1info/FHP/practiceguides/asthma/EPR-3_pocket_guide.pdf

This is the GOLD for COPD.

http://www.goldcopd.org/uploads/users/files/GOLD_Pocket_May2512.pdf

Some of the pneumonias will fall more into the COPD treatment plan due to chronic changes and a few will go with more of the asthma guideline depending on origin and RAD processes. There are some patients who only take a controller or maintenance inhaler and no SABA with it or anywhere in their treatment plan. Again, spirometry testing will have determine a treatment plan.

There is a difference in the way SABA (albuterol) medications are recommended. in GOLD, they are recommended as routine. They are also taught as rescue and pre treatment for exercise in Pulmonary Rehab classes or just daily activities to maintain mobility.

This post might seem a little overwhelming but if you look through the staging and the meds your patients are on, it will start to make sense. We (RTs, Pulmonologists, Asthma and COPD educators) want more nurses to be informed about disease severity and treatment recommendations to properly educated patients. CMS is all over this and the high readmission rates for patients with CLD. If the caregivers don't know, neither will the patients. Spirometry testing is now done at bedside by RTs for many of their CLD patients especially if a 496 diagnosis billing code is used.

Thank you for all the info, while some of this info is taught, other bits are not. Its a great resource and i will gladly share with my colleagues.

That being said, THIS is what nursing and healthcare in general needs to get to. TEAMWORK! Where someones knowledge may be lacking, there is always someone who can fill in those gaps. People need to toss their egos aside and look at the bigger picture. enhanced knowledge = enhanced patient care. It shouldn't matter who in the healthcare team the information is coming from as long as our patients benefit. I'm not ashamed to say that i didn't know some of the information you presented and I'm grateful that you happened to pass by this thread and share your knowledge on the subject. Thank you again.