Albuterol and Ipratropium (Duoneb)

DuoNeb

Bronchodilator

March 31, 2023

Dear colleagues:

 

Welcome to another of our Pharmacy Phriday CE offerings.  This week we will review the DuoNeb aerosol treatment, the last of the top five medications administered in 2022 by UH squads.  It seems hard to believe we are over a week into spring already, but here we are at the end of March.  The pollen season is starting, and the allergy and asthma calls will likely start increasing. And the DuoNeb can be an important part of our treatment for these types of calls.

 

It is no surprise that the DuoNeb was one of the most frequently administered medications in 2022.  It is a treatment indicated for many respiratory complaints listed in the UH protocols, including asthma, COPD, pulmonary edema with wheezing, moderate to severe allergic reactions, and anaphylaxis.  DuoNebs can also be administered by the EMT with online medical direction, increasing their use.


DuoNeb is an aerosol medication provided in UH drug boxes that includes both Albuterol (2.5 mg) and Ipratropium (0.5 mg) in a single unit dose.  The combination is often referred to as a one-two punch or premixed cocktail treatment for many patients in respiratory distress that reduces bronchospasm through two distinctly different mechanisms: the sympathomimetic, or that producing effects characteristic of the sympathetic nervous system (albuterol sulfate) and the parasympatholytic, or that which reduces the activity of the parasympathetic nervous system (ipratropium bromide). 


The first component of a DuoNeb treatment is Albuterol, a selective Beta 2 adrenergic agonist that initiates a sympathetic response in the body, causing a rapid onset of bronchodilation.  Though Albuterol is “selective,” it can still have some effect on Beta 1 receptors, i.e., the cardiovascular system, so care should be used with elderly patients, those with a cardiac history, cardiac arrhythmias, and hypertension.  The other component of a DuoNeb treatment is Ipratropium, a parasympatholytic agent.  Ipratropium blocks the parasympathetic effect of bronchoconstriction, as well as decreasing bronchiole secretions. 


The DuoNeb treatment is the preferred aerosol in cases mentioned above for adult patients, pediatric patients in moderate to severe distress, and as a second-line treatment for pediatric patients in mild distress if repeat treatments are required (the first line treatment being Albuterol alone).  Treatments may be repeated as needed.  Note that for the pediatric patient, the maximum dose is limited to three treatments in the field.


A DuoNeb treatment IS NOT indicated for use in cases of hyperkalemia.  Single-dose unit Albuterol is provided in the UH drug Boxes for this indication as well as in the case of the pediatric patient with only mild respiratory distress, as noted above. (This topic will be covered in a later installment of Pharmacy Phriday).   


Remember that the effectiveness of a nebulized treatment is only as effective as the administration!  The amount of medication delivered to the lungs will depend on many factors.  Some of those factors include patient factors such as the ability to move adequate air (if they can’t move air, they can’t move medication), the ability to hold their breath for a period of time, and even their ability to hold the nebulizer.  These factors may require coaching by the provider! 


Other factors can include the effectiveness of the nebulizer setup.  To generate the optimal mist of medication, the flow of oxygen should be at least 6 lpm.  Too low a flow of oxygen can create a mist with particles too large to reach the respiratory tract.  Too high a flow can create a mist with particles smaller, and the length of the treatment is reduced with less medication delivery. Therefore, the recommended flow of air or oxygen is 6-8 lpm.   


With the use of the nebulizer and oxygen, the fraction of inspired oxygen (FiO2) may increase from 21% to 30% to 40%. To increase the FiO2 even greater, the delivery device may need to be adapted to that of a mask or possibly a CPAP device. 


Remember that an additional consideration of a nebulized treatment relates to use with patients exhibiting COVID or other viral symptoms.  Caution should be taken in providing such aerosol treatments in other than a closed space area such as the back of a squad if possible.

 

Many of the side effects of a DuoNeb are related to the sympathetic activation. Ensure complete vital signs, including continuous ECG monitoring, lung sounds, and pulse oximetry are obtained and documented before and after each treatment. 


Recent headlines, as well as a memo from Dr. Cunningham of the Ohio Department of EMS, have highlighted a shortage of Albuterol, one of the components of the DuoNeb. In fact, Albuterol has been on the FDA’s shortage list since October 2022.  With the Increase in respiratory patients over the fall and winter and the approaching allergy season, concern does exist regarding supplies.  It is reported that current stocks in UH hospital pharmacies have been adequate to meet demands even as supplies have been unavailable or difficult to obtain from wholesalers.  Options are being considered if the shortages become more of a problem.  Expect just-in-time training from your Medical Director and EMS Coordinators in the case of changes or alternative medications.

 

Till our next edition, stay safe!




Sincerely,



The UH EMS-I Team

University Hospitals

July 4, 2022

Dear Colleagues,


Welcome! Following our previous discussion of the use of Benadryl for allergic reactions and anaphylaxis, this week we will focus on the aerosol medication DuoNeb, a common treatment also used for allergies, anaphylaxis, and other causes of respiratory distress.


The term “one-two punch” is often used in the boxing and MMA setting.  Searching “one-two punch” on the internet reveals the terms recently used in referring to the housing market’s effect on homebuyers citing disastrous weather and storm patterns and even alcoholic drinks and recipes.  In EMS, it is often used when relating to a DuoNeb aerosol treatment in respiratory emergencies.


The Merriam-Webster definition of a one-two punch is (1) a left jab followed at once by a hard blow with the right hand (not really what we think of with an aerosol!) or (2) two forces combining to produce a marked effect. This applies as we consider how and why a DuoNeb aerosol treatment is indicated in cases of respiratory distress, asthma, COPD, CHF, anaphylaxis, or other medical emergencies presenting with wheezing and bronchoconstriction.


DuoNeb is an aerosol medication provided in UH drug boxes that includes both Albuterol (2.5 mg) and Ipratropium (0.5 mg) in a single unit dose.  The combination one-two punch of a DuoNeb treatment is expected to maximize the response to treatment in patients by reducing bronchospasm through two distinctly different mechanisms: sympathomimetic (albuterol sulfate) and anticholinergic/parasympatholytic (ipratropium bromide).  It is the preferred aerosol treatment in cases mentioned above for adult patients, pediatric patients in moderate to severe distress, and as a second-line treatment for pediatric patients in mild distress if repeat treatments are required (the first-line treatment being Albuterol alone).  The medication can be administered by EMT level providers with approval by online medical control.  


One component of a DuoNeb treatment is the Albuterol, a selective beta 2 adrenergic agonist that initiates a sympathetic response in the body causing a rapid onset of bronchodilation.  Though Albuterol is “selective”, it can still have some effect on Beta 1 receptors, i.e., the cardiovascular system, so care should be used with elderly patients, those with a cardiac history, cardiac arrhythmias, and hypertension.  Patients should have cardiac monitoring and IV established.


Another interesting fact regarding Albuterol is its ability to promote the uptake of potassium in hyperkalemia, which is why the provider will find it listed as a treatment under the “dialysis/renal patient” algorithm in cases of missed dialysis with ECG changes. As you may recall, this aspect was discussed in last month’s cardiac case CE presentation.  (This use of Albuterol is only permitted for AEMT and paramedic providers).  A DuoNeb treatment IS NOT indicated for this use.  Single-dose unit Albuterol is provided in the UH drug boxes for this indication, as well as in the case of the pediatric patient with only mild respiratory distress as noted above. 


The other component of a DuoNeb treatment is Ipratropium, an anticholinergic (parasympatholytic) agent.  Ipratropium blocks the parasympathetic effect of bronchoconstriction as well as decreasing bronchiole secretions.  This aspect of the treatment is the other flank of the attack on the respiratory emergency and is thought to have a slightly extended duration.  


Remember that the effectiveness of a nebulized treatment is only as effective as the administration!  Like all other nebulized treatments, the amount delivered to the lungs will depend on many factors.  Some of those factors include patient factors such as the ability to move adequate air (if they can’t move air, they can’t move medication), the ability to hold their breath for a period of time, and even their ability to hold the nebulizer.  These factors may require coaching by the provider!  Other factors can include the effectiveness of the nebulizer (is there adequate oxygen, usually 6-8 lpm, to create a mist of medication) or the need to change the delivery device from a patient held nebulizer to that of a mask.  An additional consideration of a nebulized treatment is related to such use in cases of COVID patients.  Caution should be taken in providing aerosol treatments in places other than a closed space area such as the back of a squad if possible.


Many of the side effects of a DuoNeb are related to the sympathetic activation. Be sure complete vital signs, including continuous ECG monitoring, lung sounds, waveform capnography, and pulse oximetry are obtained and documented before and after each treatment.  Note that protocol does allow for repeat treatments as needed in the adult patient, with a limit of 3 treatments in the pediatric patient (the first being Albuterol alone, and the final 2 being a DuoNeb treatment) unless serious adverse reactions or side effects occur, in which case, treatments should be suspended.

 

Thank you for checking out this installment of Pharmacy Phriday and for all you do in maintaining quality patient care!  Till next time, stay safe!!!




Sincerely,


The UH EMS-I Team

University Hospitals