Welcome to UH EMS-I’s Pharmacy Phriday. In this installment, we’ll review a common medication administered in cases of respiratory distress: albuterol and ipratropium aerosol.
It is no surprise that the albuterol and ipratropium aerosol is one of the medications most often administered in EMS. It is a treatment indicated for many of the respiratory complaints listed in the UH protocols.
The albuterol and ipratropium aerosol is a 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, reducing bronchospasm through two distinctly different mechanisms.
The first component of the combined 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, such as the cardiovascular system, so care should be used with elderly patients and those with a cardiac history, cardiac arrhythmias, and hypertension. The other component of the combination is ipratropium, a parasympatholytic agent. Ipratropium blocks the parasympathetic effect of bronchoconstriction, as well as decreasing bronchiole secretions.
The albuterol and ipratropium aerosol treatment is the preferred aerosol in cases such as asthma, COPD, CHF, and respiratory distress for adult patients, as well as pediatric patients in moderate to severe distress. It is the second-line treatment for pediatric patients in mild distress if repeat treatments are needed (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 combination of albuterol and ipratropium aerosol treatment IS NOT indicated for use in cases of hyperkalemia. A single-dose unit of albuterol is provided in the UH drug boxes for this indication, in addition to cases of the pediatric patient with mild respiratory distress as noted above.
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, including having to do with the patient, 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 from 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 of a flow of oxygen can create a mist with particles too large to reach the respiratory tract; too high of a flow can create a mist with smaller particles, and the length of the treatment is reduced with less medication delivery. Thus, 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 improve the FiO2 even greater, the delivery device may need to be adapted to that of a mask or possibly a CPAP device.
Many of the side effects of an albuterol and ipratropium aerosol are related to the sympathetic activation. Be sure complete vital signs and lung sounds are obtained and documented before and after each treatment.
Remember: With the changes to the OHIO EMS Scope of Practice in 2024, Basic EMT providers can administer aerosols in certain circumstances based on protocols or offline medical direction. The UH EMS Protocols now have a warning or caution (stop sign) associated with the albuterol/ipratropium aerosol order that explains further: “EMT may administer only with proper training or online Medical Control.” The administration of an aerosol in cases of hyperkalemia is not included in the scope of the Basic EMT, as such treatments require the interpretation of an ECG.
Till our next edition, stay safe!
