Indications Use in patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator.

 Contraindications History of hypersensitivity to soya lecithin or related food (eg, soybean, peanuts) or to atropine.

 Route/Dosage

Combivent

Adults: Inhalation 2 inhalations qid (max, 12 inhalations/24 hr).

DuoNeb

Adults: Inhalation One 3 mL vial qid via nebulization with up to 2 additional 3 mL doses daily, if needed.

 Interactions

Anticholinergic Agents: Possible additive anticholinergic effects. Beta-adrenergic Agonists: Risk of adverse cardiovascular effects may be increased. Beta-Receptor Blocking Agents: These agents and albuterol may inhibit the effect of each other. Digoxin: Albuterol component may decrease serum digoxin concentrations and therapeutic effects. Diuretics: Albuterol component may exaggerate ECG or hypokalemia from non-potassium-sparing diuretics. MAO Inhibitors, Tricyclic Antidepressants: Concomitant use of these agents or use within 2 weeks of stopping such agents may potentiate the cardiovascular effects of albuterol.

 Lab Test Interferences None well documented.

 Adverse Reactions

CARDIOVASCULAR: Hypertension; hypotension; arrhythmia; palpitation; tachycardia; angina. CNS: Headache; fatigue; weakness; dizziness; nervousness; tremor; insomnia; drowsiness; stimulation; coordination difficulty; paresthesia. DERMATOLOGIC: Skin rash; itching; flushing; alopecia. EENT: Precipitation or worsening of narrow-angle glaucoma; acute eye pain; blurred vision; nasal congestion; drying of secretions; mucosal ulcers; sinusitis; rhinitis; pharyngitis; irritation from aerosol; dysphonia. GI: Nausea; vomiting; dry mouth; dyspepsia; taste perversion; indigestion; diarrhea; constipation; GI distress; heartburn. GU: UTI; dysuria; urinary difficulties. RESPIRATORY: Dyspnea; bronchitis; coughing; respiratory disorders; pneumonia; upper respiratory tract infection; paradoxical bronchospasm; wheezing; exacerbation of COPD symptoms; increased sputum. OTHER: Pain; flu-like symptoms; chest pain; edema; arthralgia; allergic reactions (eg, skin rash; angioedema of tongue, lips, and face; urticaria; laryngospasm; anaphylaxis).

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction. Cardiovascular Effects: Toxic symptoms may occur in patients with cardiovascular disorders. Use with caution in patients with coronary insufficiency, arrhythmias, or hypertension. CNS Effects: CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism. Diabetes: Dosage adjustment of insulin may be required. Excessive Use: Death may occur with excessive use of inhaled sympathomimetic drugs in patients with asthma. Hypersensitivity: Immediate hypersensitivity reactions may occur. Hypokalemia: Transient decreases in potassium levels may occur. Paradoxical bronchospasm: Life-threatening bronchospasms can occur, usually with the first use of a new container.

 Administration/Storage

• Available as metered dose inhaler (MDI) for inhalation administration only.
• Store canister at room temperature (59° to 86°F). Avoid excessive humidity. For best results, canister should be at room temperature before use.
• Shake canister well before using.
• Test spray 3 times before using the first time when the aerosol has not been used for more than 24 hr.
• Use of a spacing device (eg, Aerochamber) will enhance interpulmonary deposition of medication.
• Allow 5 min between inhalations.
• Discard canister after labeled number of actuations have been used. Inaccurate dosage may occur if used after a total of 200 actuations.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Check pulse, BP, respirations, and lung sounds before and after administration.
• If exacerbations of symptoms occur, notify health care provider.
• Monitor for cardiovascular (eg, hypertension, tachycardia, dysarrhythmia) and anticholinergic side effects (eg, dry mouth, urinary difficulties), and notify health care provider if noted.

 Patient/Family Education

• Instruct patient on proper use of inhaler. Explain value of using spacing device.
• Teach patient how to determine when canister is empty (200 actuations) and needs to be replaced.
• Instruct patient not to use the actuator with other inhaled medications and not to use other medication actuators with Combivent canister.
• Instruct patient to wait 5 min after Combivent before using inhaler with glucocorticoids.
• Warn patient not to exceed 12 doses within a 24-hr period.
• Instruct patient to notify health care provider if condition worsens; Combivent becomes less effective for symptomatic relief; there is a need to use Combivent more frequently than usual; or dizziness, nausea, headache, palpitations, or cough occur.
• Advise patient to avoid spraying medication in eyes; temporary blurred vision or irritation may result.
• For relief of dry mouth, suggest using saliva substitute, practicing good oral hygiene, and rinsing mouth after inhalation. Instruct patient to take frequent sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum.
• Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness.

Indications for Drugs ::

 Action Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation.

 Indications Use in patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator.

 Contraindications History of hypersensitivity to soya lecithin or related food (eg, soybean, peanuts) or to atropine.

 Route/Dosage

Combivent

Adults: Inhalation 2 inhalations qid (max, 12 inhalations/24 hr).

DuoNeb

Adults: Inhalation One 3 mL vial qid via nebulization with up to 2 additional 3 mL doses daily, if needed.

 Interactions

Anticholinergic Agents: Possible additive anticholinergic effects. Beta-adrenergic Agonists: Risk of adverse cardiovascular effects may be increased. Beta-Receptor Blocking Agents: These agents and albuterol may inhibit the effect of each other. Digoxin: Albuterol component may decrease serum digoxin concentrations and therapeutic effects. Diuretics: Albuterol component may exaggerate ECG or hypokalemia from non-potassium-sparing diuretics. MAO Inhibitors, Tricyclic Antidepressants: Concomitant use of these agents or use within 2 weeks of stopping such agents may potentiate the cardiovascular effects of albuterol.

 Lab Test Interferences None well documented.

 Adverse Reactions

CARDIOVASCULAR: Hypertension; hypotension; arrhythmia; palpitation; tachycardia; angina. CNS: Headache; fatigue; weakness; dizziness; nervousness; tremor; insomnia; drowsiness; stimulation; coordination difficulty; paresthesia. DERMATOLOGIC: Skin rash; itching; flushing; alopecia. EENT: Precipitation or worsening of narrow-angle glaucoma; acute eye pain; blurred vision; nasal congestion; drying of secretions; mucosal ulcers; sinusitis; rhinitis; pharyngitis; irritation from aerosol; dysphonia. GI: Nausea; vomiting; dry mouth; dyspepsia; taste perversion; indigestion; diarrhea; constipation; GI distress; heartburn. GU: UTI; dysuria; urinary difficulties. RESPIRATORY: Dyspnea; bronchitis; coughing; respiratory disorders; pneumonia; upper respiratory tract infection; paradoxical bronchospasm; wheezing; exacerbation of COPD symptoms; increased sputum. OTHER: Pain; flu-like symptoms; chest pain; edema; arthralgia; allergic reactions (eg, skin rash; angioedema of tongue, lips, and face; urticaria; laryngospasm; anaphylaxis).

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction. Cardiovascular Effects: Toxic symptoms may occur in patients with cardiovascular disorders. Use with caution in patients with coronary insufficiency, arrhythmias, or hypertension. CNS Effects: CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism. Diabetes: Dosage adjustment of insulin may be required. Excessive Use: Death may occur with excessive use of inhaled sympathomimetic drugs in patients with asthma. Hypersensitivity: Immediate hypersensitivity reactions may occur. Hypokalemia: Transient decreases in potassium levels may occur. Paradoxical bronchospasm: Life-threatening bronchospasms can occur, usually with the first use of a new container.

 Administration/Storage

• Available as metered dose inhaler (MDI) for inhalation administration only.
• Store canister at room temperature (59° to 86°F). Avoid excessive humidity. For best results, canister should be at room temperature before use.
• Shake canister well before using.
• Test spray 3 times before using the first time when the aerosol has not been used for more than 24 hr.
• Use of a spacing device (eg, Aerochamber) will enhance interpulmonary deposition of medication.
• Allow 5 min between inhalations.
• Discard canister after labeled number of actuations have been used. Inaccurate dosage may occur if used after a total of 200 actuations.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Check pulse, BP, respirations, and lung sounds before and after administration.
• If exacerbations of symptoms occur, notify health care provider.
• Monitor for cardiovascular (eg, hypertension, tachycardia, dysarrhythmia) and anticholinergic side effects (eg, dry mouth, urinary difficulties), and notify health care provider if noted.

 Patient/Family Education

• Instruct patient on proper use of inhaler. Explain value of using spacing device.
• Teach patient how to determine when canister is empty (200 actuations) and needs to be replaced.
• Instruct patient not to use the actuator with other inhaled medications and not to use other medication actuators with Combivent canister.
• Instruct patient to wait 5 min after Combivent before using inhaler with glucocorticoids.
• Warn patient not to exceed 12 doses within a 24-hr period.
• Instruct patient to notify health care provider if condition worsens; Combivent becomes less effective for symptomatic relief; there is a need to use Combivent more frequently than usual; or dizziness, nausea, headache, palpitations, or cough occur.
• Advise patient to avoid spraying medication in eyes; temporary blurred vision or irritation may result.
• For relief of dry mouth, suggest using saliva substitute, practicing good oral hygiene, and rinsing mouth after inhalation. Instruct patient to take frequent sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum.
• Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness.

Drug Dose ::

 Action Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation.

 Indications Use in patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator.

 Contraindications History of hypersensitivity to soya lecithin or related food (eg, soybean, peanuts) or to atropine.

 Route/Dosage

Combivent

Adults: Inhalation 2 inhalations qid (max, 12 inhalations/24 hr).

DuoNeb

Adults: Inhalation One 3 mL vial qid via nebulization with up to 2 additional 3 mL doses daily, if needed.

 Interactions

Anticholinergic Agents: Possible additive anticholinergic effects. Beta-adrenergic Agonists: Risk of adverse cardiovascular effects may be increased. Beta-Receptor Blocking Agents: These agents and albuterol may inhibit the effect of each other. Digoxin: Albuterol component may decrease serum digoxin concentrations and therapeutic effects. Diuretics: Albuterol component may exaggerate ECG or hypokalemia from non-potassium-sparing diuretics. MAO Inhibitors, Tricyclic Antidepressants: Concomitant use of these agents or use within 2 weeks of stopping such agents may potentiate the cardiovascular effects of albuterol.

 Lab Test Interferences None well documented.

 Adverse Reactions

CARDIOVASCULAR: Hypertension; hypotension; arrhythmia; palpitation; tachycardia; angina. CNS: Headache; fatigue; weakness; dizziness; nervousness; tremor; insomnia; drowsiness; stimulation; coordination difficulty; paresthesia. DERMATOLOGIC: Skin rash; itching; flushing; alopecia. EENT: Precipitation or worsening of narrow-angle glaucoma; acute eye pain; blurred vision; nasal congestion; drying of secretions; mucosal ulcers; sinusitis; rhinitis; pharyngitis; irritation from aerosol; dysphonia. GI: Nausea; vomiting; dry mouth; dyspepsia; taste perversion; indigestion; diarrhea; constipation; GI distress; heartburn. GU: UTI; dysuria; urinary difficulties. RESPIRATORY: Dyspnea; bronchitis; coughing; respiratory disorders; pneumonia; upper respiratory tract infection; paradoxical bronchospasm; wheezing; exacerbation of COPD symptoms; increased sputum. OTHER: Pain; flu-like symptoms; chest pain; edema; arthralgia; allergic reactions (eg, skin rash; angioedema of tongue, lips, and face; urticaria; laryngospasm; anaphylaxis).

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction. Cardiovascular Effects: Toxic symptoms may occur in patients with cardiovascular disorders. Use with caution in patients with coronary insufficiency, arrhythmias, or hypertension. CNS Effects: CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism. Diabetes: Dosage adjustment of insulin may be required. Excessive Use: Death may occur with excessive use of inhaled sympathomimetic drugs in patients with asthma. Hypersensitivity: Immediate hypersensitivity reactions may occur. Hypokalemia: Transient decreases in potassium levels may occur. Paradoxical bronchospasm: Life-threatening bronchospasms can occur, usually with the first use of a new container.

 Administration/Storage

• Available as metered dose inhaler (MDI) for inhalation administration only.
• Store canister at room temperature (59° to 86°F). Avoid excessive humidity. For best results, canister should be at room temperature before use.
• Shake canister well before using.
• Test spray 3 times before using the first time when the aerosol has not been used for more than 24 hr.
• Use of a spacing device (eg, Aerochamber) will enhance interpulmonary deposition of medication.
• Allow 5 min between inhalations.
• Discard canister after labeled number of actuations have been used. Inaccurate dosage may occur if used after a total of 200 actuations.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Check pulse, BP, respirations, and lung sounds before and after administration.
• If exacerbations of symptoms occur, notify health care provider.
• Monitor for cardiovascular (eg, hypertension, tachycardia, dysarrhythmia) and anticholinergic side effects (eg, dry mouth, urinary difficulties), and notify health care provider if noted.

 Patient/Family Education

• Instruct patient on proper use of inhaler. Explain value of using spacing device.
• Teach patient how to determine when canister is empty (200 actuations) and needs to be replaced.
• Instruct patient not to use the actuator with other inhaled medications and not to use other medication actuators with Combivent canister.
• Instruct patient to wait 5 min after Combivent before using inhaler with glucocorticoids.
• Warn patient not to exceed 12 doses within a 24-hr period.
• Instruct patient to notify health care provider if condition worsens; Combivent becomes less effective for symptomatic relief; there is a need to use Combivent more frequently than usual; or dizziness, nausea, headache, palpitations, or cough occur.
• Advise patient to avoid spraying medication in eyes; temporary blurred vision or irritation may result.
• For relief of dry mouth, suggest using saliva substitute, practicing good oral hygiene, and rinsing mouth after inhalation. Instruct patient to take frequent sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum.
• Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness.

Contraindication ::

 Action Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation.

 Indications Use in patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator.

 Contraindications History of hypersensitivity to soya lecithin or related food (eg, soybean, peanuts) or to atropine.

 Route/Dosage

Combivent

Adults: Inhalation 2 inhalations qid (max, 12 inhalations/24 hr).

DuoNeb

Adults: Inhalation One 3 mL vial qid via nebulization with up to 2 additional 3 mL doses daily, if needed.

 Interactions

Anticholinergic Agents: Possible additive anticholinergic effects. Beta-adrenergic Agonists: Risk of adverse cardiovascular effects may be increased. Beta-Receptor Blocking Agents: These agents and albuterol may inhibit the effect of each other. Digoxin: Albuterol component may decrease serum digoxin concentrations and therapeutic effects. Diuretics: Albuterol component may exaggerate ECG or hypokalemia from non-potassium-sparing diuretics. MAO Inhibitors, Tricyclic Antidepressants: Concomitant use of these agents or use within 2 weeks of stopping such agents may potentiate the cardiovascular effects of albuterol.

 Lab Test Interferences None well documented.

 Adverse Reactions

CARDIOVASCULAR: Hypertension; hypotension; arrhythmia; palpitation; tachycardia; angina. CNS: Headache; fatigue; weakness; dizziness; nervousness; tremor; insomnia; drowsiness; stimulation; coordination difficulty; paresthesia. DERMATOLOGIC: Skin rash; itching; flushing; alopecia. EENT: Precipitation or worsening of narrow-angle glaucoma; acute eye pain; blurred vision; nasal congestion; drying of secretions; mucosal ulcers; sinusitis; rhinitis; pharyngitis; irritation from aerosol; dysphonia. GI: Nausea; vomiting; dry mouth; dyspepsia; taste perversion; indigestion; diarrhea; constipation; GI distress; heartburn. GU: UTI; dysuria; urinary difficulties. RESPIRATORY: Dyspnea; bronchitis; coughing; respiratory disorders; pneumonia; upper respiratory tract infection; paradoxical bronchospasm; wheezing; exacerbation of COPD symptoms; increased sputum. OTHER: Pain; flu-like symptoms; chest pain; edema; arthralgia; allergic reactions (eg, skin rash; angioedema of tongue, lips, and face; urticaria; laryngospasm; anaphylaxis).

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction. Cardiovascular Effects: Toxic symptoms may occur in patients with cardiovascular disorders. Use with caution in patients with coronary insufficiency, arrhythmias, or hypertension. CNS Effects: CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism. Diabetes: Dosage adjustment of insulin may be required. Excessive Use: Death may occur with excessive use of inhaled sympathomimetic drugs in patients with asthma. Hypersensitivity: Immediate hypersensitivity reactions may occur. Hypokalemia: Transient decreases in potassium levels may occur. Paradoxical bronchospasm: Life-threatening bronchospasms can occur, usually with the first use of a new container.

 Administration/Storage

• Available as metered dose inhaler (MDI) for inhalation administration only.
• Store canister at room temperature (59° to 86°F). Avoid excessive humidity. For best results, canister should be at room temperature before use.
• Shake canister well before using.
• Test spray 3 times before using the first time when the aerosol has not been used for more than 24 hr.
• Use of a spacing device (eg, Aerochamber) will enhance interpulmonary deposition of medication.
• Allow 5 min between inhalations.
• Discard canister after labeled number of actuations have been used. Inaccurate dosage may occur if used after a total of 200 actuations.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Check pulse, BP, respirations, and lung sounds before and after administration.
• If exacerbations of symptoms occur, notify health care provider.
• Monitor for cardiovascular (eg, hypertension, tachycardia, dysarrhythmia) and anticholinergic side effects (eg, dry mouth, urinary difficulties), and notify health care provider if noted.

 Patient/Family Education

• Instruct patient on proper use of inhaler. Explain value of using spacing device.
• Teach patient how to determine when canister is empty (200 actuations) and needs to be replaced.
• Instruct patient not to use the actuator with other inhaled medications and not to use other medication actuators with Combivent canister.
• Instruct patient to wait 5 min after Combivent before using inhaler with glucocorticoids.
• Warn patient not to exceed 12 doses within a 24-hr period.
• Instruct patient to notify health care provider if condition worsens; Combivent becomes less effective for symptomatic relief; there is a need to use Combivent more frequently than usual; or dizziness, nausea, headache, palpitations, or cough occur.
• Advise patient to avoid spraying medication in eyes; temporary blurred vision or irritation may result.
• For relief of dry mouth, suggest using saliva substitute, practicing good oral hygiene, and rinsing mouth after inhalation. Instruct patient to take frequent sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum.
• Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness.

Drug Precautions ::

 Action Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation.

 Indications Use in patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator.

 Contraindications History of hypersensitivity to soya lecithin or related food (eg, soybean, peanuts) or to atropine.

 Route/Dosage

Combivent

Adults: Inhalation 2 inhalations qid (max, 12 inhalations/24 hr).

DuoNeb

Adults: Inhalation One 3 mL vial qid via nebulization with up to 2 additional 3 mL doses daily, if needed.

 Interactions

Anticholinergic Agents: Possible additive anticholinergic effects. Beta-adrenergic Agonists: Risk of adverse cardiovascular effects may be increased. Beta-Receptor Blocking Agents: These agents and albuterol may inhibit the effect of each other. Digoxin: Albuterol component may decrease serum digoxin concentrations and therapeutic effects. Diuretics: Albuterol component may exaggerate ECG or hypokalemia from non-potassium-sparing diuretics. MAO Inhibitors, Tricyclic Antidepressants: Concomitant use of these agents or use within 2 weeks of stopping such agents may potentiate the cardiovascular effects of albuterol.

 Lab Test Interferences None well documented.

 Adverse Reactions

CARDIOVASCULAR: Hypertension; hypotension; arrhythmia; palpitation; tachycardia; angina. CNS: Headache; fatigue; weakness; dizziness; nervousness; tremor; insomnia; drowsiness; stimulation; coordination difficulty; paresthesia. DERMATOLOGIC: Skin rash; itching; flushing; alopecia. EENT: Precipitation or worsening of narrow-angle glaucoma; acute eye pain; blurred vision; nasal congestion; drying of secretions; mucosal ulcers; sinusitis; rhinitis; pharyngitis; irritation from aerosol; dysphonia. GI: Nausea; vomiting; dry mouth; dyspepsia; taste perversion; indigestion; diarrhea; constipation; GI distress; heartburn. GU: UTI; dysuria; urinary difficulties. RESPIRATORY: Dyspnea; bronchitis; coughing; respiratory disorders; pneumonia; upper respiratory tract infection; paradoxical bronchospasm; wheezing; exacerbation of COPD symptoms; increased sputum. OTHER: Pain; flu-like symptoms; chest pain; edema; arthralgia; allergic reactions (eg, skin rash; angioedema of tongue, lips, and face; urticaria; laryngospasm; anaphylaxis).

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction. Cardiovascular Effects: Toxic symptoms may occur in patients with cardiovascular disorders. Use with caution in patients with coronary insufficiency, arrhythmias, or hypertension. CNS Effects: CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism. Diabetes: Dosage adjustment of insulin may be required. Excessive Use: Death may occur with excessive use of inhaled sympathomimetic drugs in patients with asthma. Hypersensitivity: Immediate hypersensitivity reactions may occur. Hypokalemia: Transient decreases in potassium levels may occur. Paradoxical bronchospasm: Life-threatening bronchospasms can occur, usually with the first use of a new container.

 Administration/Storage

• Available as metered dose inhaler (MDI) for inhalation administration only.
• Store canister at room temperature (59° to 86°F). Avoid excessive humidity. For best results, canister should be at room temperature before use.
• Shake canister well before using.
• Test spray 3 times before using the first time when the aerosol has not been used for more than 24 hr.
• Use of a spacing device (eg, Aerochamber) will enhance interpulmonary deposition of medication.
• Allow 5 min between inhalations.
• Discard canister after labeled number of actuations have been used. Inaccurate dosage may occur if used after a total of 200 actuations.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Check pulse, BP, respirations, and lung sounds before and after administration.
• If exacerbations of symptoms occur, notify health care provider.
• Monitor for cardiovascular (eg, hypertension, tachycardia, dysarrhythmia) and anticholinergic side effects (eg, dry mouth, urinary difficulties), and notify health care provider if noted.

 Patient/Family Education

• Instruct patient on proper use of inhaler. Explain value of using spacing device.
• Teach patient how to determine when canister is empty (200 actuations) and needs to be replaced.
• Instruct patient not to use the actuator with other inhaled medications and not to use other medication actuators with Combivent canister.
• Instruct patient to wait 5 min after Combivent before using inhaler with glucocorticoids.
• Warn patient not to exceed 12 doses within a 24-hr period.
• Instruct patient to notify health care provider if condition worsens; Combivent becomes less effective for symptomatic relief; there is a need to use Combivent more frequently than usual; or dizziness, nausea, headache, palpitations, or cough occur.
• Advise patient to avoid spraying medication in eyes; temporary blurred vision or irritation may result.
• For relief of dry mouth, suggest using saliva substitute, practicing good oral hygiene, and rinsing mouth after inhalation. Instruct patient to take frequent sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum.
• Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness.

Drug Side Effects ::

 Action Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation.

 Indications Use in patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator.

 Contraindications History of hypersensitivity to soya lecithin or related food (eg, soybean, peanuts) or to atropine.

 Route/Dosage

Combivent

Adults: Inhalation 2 inhalations qid (max, 12 inhalations/24 hr).

DuoNeb

Adults: Inhalation One 3 mL vial qid via nebulization with up to 2 additional 3 mL doses daily, if needed.

 Interactions

Anticholinergic Agents: Possible additive anticholinergic effects. Beta-adrenergic Agonists: Risk of adverse cardiovascular effects may be increased. Beta-Receptor Blocking Agents: These agents and albuterol may inhibit the effect of each other. Digoxin: Albuterol component may decrease serum digoxin concentrations and therapeutic effects. Diuretics: Albuterol component may exaggerate ECG or hypokalemia from non-potassium-sparing diuretics. MAO Inhibitors, Tricyclic Antidepressants: Concomitant use of these agents or use within 2 weeks of stopping such agents may potentiate the cardiovascular effects of albuterol.

 Lab Test Interferences None well documented.

 Adverse Reactions

CARDIOVASCULAR: Hypertension; hypotension; arrhythmia; palpitation; tachycardia; angina. CNS: Headache; fatigue; weakness; dizziness; nervousness; tremor; insomnia; drowsiness; stimulation; coordination difficulty; paresthesia. DERMATOLOGIC: Skin rash; itching; flushing; alopecia. EENT: Precipitation or worsening of narrow-angle glaucoma; acute eye pain; blurred vision; nasal congestion; drying of secretions; mucosal ulcers; sinusitis; rhinitis; pharyngitis; irritation from aerosol; dysphonia. GI: Nausea; vomiting; dry mouth; dyspepsia; taste perversion; indigestion; diarrhea; constipation; GI distress; heartburn. GU: UTI; dysuria; urinary difficulties. RESPIRATORY: Dyspnea; bronchitis; coughing; respiratory disorders; pneumonia; upper respiratory tract infection; paradoxical bronchospasm; wheezing; exacerbation of COPD symptoms; increased sputum. OTHER: Pain; flu-like symptoms; chest pain; edema; arthralgia; allergic reactions (eg, skin rash; angioedema of tongue, lips, and face; urticaria; laryngospasm; anaphylaxis).

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder neck obstruction. Cardiovascular Effects: Toxic symptoms may occur in patients with cardiovascular disorders. Use with caution in patients with coronary insufficiency, arrhythmias, or hypertension. CNS Effects: CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism. Diabetes: Dosage adjustment of insulin may be required. Excessive Use: Death may occur with excessive use of inhaled sympathomimetic drugs in patients with asthma. Hypersensitivity: Immediate hypersensitivity reactions may occur. Hypokalemia: Transient decreases in potassium levels may occur. Paradoxical bronchospasm: Life-threatening bronchospasms can occur, usually with the first use of a new container.

 Administration/Storage

• Available as metered dose inhaler (MDI) for inhalation administration only.
• Store canister at room temperature (59° to 86°F). Avoid excessive humidity. For best results, canister should be at room temperature before use.
• Shake canister well before using.
• Test spray 3 times before using the first time when the aerosol has not been used for more than 24 hr.
• Use of a spacing device (eg, Aerochamber) will enhance interpulmonary deposition of medication.
• Allow 5 min between inhalations.
• Discard canister after labeled number of actuations have been used. Inaccurate dosage may occur if used after a total of 200 actuations.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Check pulse, BP, respirations, and lung sounds before and after administration.
• If exacerbations of symptoms occur, notify health care provider.
• Monitor for cardiovascular (eg, hypertension, tachycardia, dysarrhythmia) and anticholinergic side effects (eg, dry mouth, urinary difficulties), and notify health care provider if noted.

 Patient/Family Education

• Instruct patient on proper use of inhaler. Explain value of using spacing device.
• Teach patient how to determine when canister is empty (200 actuations) and needs to be replaced.
• Instruct patient not to use the actuator with other inhaled medications and not to use other medication actuators with Combivent canister.
• Instruct patient to wait 5 min after Combivent before using inhaler with glucocorticoids.
• Warn patient not to exceed 12 doses within a 24-hr period.
• Instruct patient to notify health care provider if condition worsens; Combivent becomes less effective for symptomatic relief; there is a need to use Combivent more frequently than usual; or dizziness, nausea, headache, palpitations, or cough occur.
• Advise patient to avoid spraying medication in eyes; temporary blurred vision or irritation may result.
• For relief of dry mouth, suggest using saliva substitute, practicing good oral hygiene, and rinsing mouth after inhalation. Instruct patient to take frequent sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum.
• Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness.

Drug Mode of Action ::  

 Action Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation.