Here's a list of all medicines currently used to treat lung diseases, or medicines we RTs should be familiar with, including off label use. For old respiratory medicines visit my Respiratory Medicine Archive (coming soon).
(Not familiar with hospital abbreviations? click here)
Fast Acting Bronchodilators (Rescue Medicine):
1. Generic name: Albuterol, Salbutamol
Brand name: Proventil, Ventolin
- SVN: o.5cc or 2.5 mg and usually comes in an amp with 0.3cc normal saline
- MDI: (90 mcg/puff)
- DPI: (200 mcg/cap)
- SVN: 0.5cc every 4-6 hours
- MDI: 2 puffs every 4-6 hours (3-5 puffs are equivelent with SVN)
- DPI: 1 puffs every 4-6 hours
Diagnosis: Used for asthma, COPD,
Comments: Very mild side effects, may cause shakes or nervousness, rarely increases heart rate in patients with healthy heart, safe for all patients of all ages. Can be mixed with Atrovent and Pulmicort (although if you're taking the NBRC exam this is not true). Also safe for children and neonates at the adult dose, especially if given via blowby. Most commonly used beta adrenergic medicine. Low cost per dose. Studies show an MDI use properly with a spacer is equally as effective an an SVN. Studies also show (as you can read here) that Albuterol does increase mucociliary clearance, but studies also show this has no clinical effectiveness. This may also explain why doctors like to use Albuterol to increase sputum and pneumonia. The aerosolized particles are the right size to reach the larger airways (bronchioles) and to some extent the smaller airways, but too large to reach the 0.1 to 0.2 micron alveolar sacs. Despite contrary belief, this medicine does not treat inflammation in the airway nor in the alveolar sacs. It is specifically designed to connect with beta adrenergic receptors in on bronchiole muscles and cause them to relax, and in this way it can make it easier to patients to breathe rather quickly.
Comment #2: Can also be used to lower potassium, yet studies show a minimum dose of 5-20mg Albuterol run continuously over 20 minutes generates the most effect. For more on this, and for links to studies and AARC Guidelines, click here. If a doctor orders one treatment of 5cc Albuterol, you can either keep your mouth shut just to get done, or you can make him aware of the AARC guidelines for lowring Potassium with Albuterol
- To learn about proper technique for using MDI, click here.
- To learn inhaler with spacer and mask for kids, click here.
- Is SVN or MDI with spacer better: to learn more click here.
- When should Albuterol MDI be primed: click here.
Brand name: Xopenex
- SVN: 0.31, 0.63 and 1.25 mg with 3cc normal saline in one amp
- MDI: 650 mcg/puff
- SVN: 1.25 mg every 6-8 hours or three times a day (0.63 for less cardiac effect*)
- MDI: 2 puffs every 4-6 hours
Comments: Minimal side effects. Studies are inconclusive, yet some theorize *that this medicine has fewer side effects than Albuterol. Some also say it works better than Albuterol. Most experts now deny both these claims. However, it generally works as well as Albuterol in treating bronchospasm. It is safe for all populations at all doses. May actually some day be used in place of Albuterol, but at the present time it has a high cost per dose. The S isomer in Albuterol is believed to cause bronchospasm if used long term, and therefore lebalbuterol only contains the R isomer.
- When should Xopenex HFA MDI be primed? Click here.
- For proper inhaler technique click here.
- For proper technique with spacer (ideal), click here.
- For proper technique with spacer and mask (ideal for peds), click here.
Brand name: Vaponepherine, Micronepherine
Delivery Device: SVN 2.25%
Adlt dose and frequency: 0.25 to 0.5 cc to 2.5 cc mixed with normal saline to be given as needed, although the most common dose is 0.5cc and is safe for adults and children.
Action: Onset is 3-5 minutes; Peaks in 5-20 minutes; Duration 0.5 to 2 hours (short)
Comments: Moderate risk of side effects that include shakiness, increased heart rate, palpitations, etc. Although the risk of side effects is much less than epinepherine. Generally used to relax throat muscles or to treat upper airway inflammation in diseases such as croup or post extubation. However it also is used to relieve bronchospasm. It can be used for asthmatics when Albuterol and Xopenex aren't working. Has been known to cause rebound edema. This medicine has an alpha effect that causes vasoconstriction and reduces blood flow and mucosal edema. Studies show it also reduces bronchial and tracheal secretions. Generally shows results in 30 minutes for croup and lasts up to 2 hours. Patients given racemic epinepherine may not be discharged to home unless they show no respiratory distress and no adverse side effects for three hours after therapy. May use in conjunction with dexamethasone (oral) or budesonide (aerosol) for best results.
4. Generic name: Epinepherine*
Brand name: Adrenaline
Delivery Device: SVN: 1% (1:100) 0.25 - 0.5cc prn mixed with 3cc normal saline
Adult dose and frequency: 0.25 to 0.5cc prn as needed to relieve bronchospasm; duration 1-3 hour. Considered a low dose to obtain beta effect.
Comments: Strong side effects. It's actually a vasopressor but I'm listing it here as a bronchodilator because in low doses it's often used as a bronchodilator. Generally not used in the hospital setting anymore for its bronchodilating effects unless all other options fail. Studies show that Albuterol used continuously is safer and works just as well or even better than epinepherine, and therefore epinipherine (epi) is generally only used as a last report to treat respiratory failure before intubation and ventilation. It used to be a front line medicine to treat asthma in the 1970s, and also had a longer lasting version called Susphrine. (Susphrine is no longer produced in the U.S.) It's also used to treat arrythmias such as ventricular tachycardia, ventricular fibrillation, asystole, and bradycardia (see epi under vasopressors below). It's also used in low doses to treat anaphylaxis.
Anticholinergic Bronchodilators: These are back door bronchodilators, knows to block the cholinergic effect and cause bronchdilation that way. These drugs work against the bronchoconstriction caused by the parasympathetic nervous system (decrease cyclic GMP). They block the cholinergic parasympathetic receptors.
1. Generic name: Ipatropium Bromide
Brand name: Atrovent
- SVN: 0.2%
- MDI: 18 mcg/puff
- SVN: 2.5 cc (unit dose) mixed with 3cc normal saline TID or QID.
- MDI: 2-3 PUFFS TID or QID
- When should Atrovent HFA be primed? Click here.
2. Generic name: Tiotropium Bromide
Generic name: Spiriva
Delivery Device: DPI 18 mcg/puff
Adult dose: 1 puff per day
Action: Onset 30 minutes; peak 3 hours, duration 24 hours
Comments: Can cause dryness and paradoxical bronchospasm; has been shown to improve lung function in COPD, and is proven safer than Atrovent; Generally not used for asthma, although it can be used if other medicines don't work. This is the long acting version of anticholinergic bronchodilator.
3. Generic name: Aclidinium Bromide
Brand name: unknown at present, possibly Genuair
Delivery device: Genuair inhaler. The inhaler has a built in feedback system to inform the patient if the medicine was used correctly. It also has an anti double dosing mechanism and a dose counter.
Adult dose: 1 puff twice a day
Comments: It's a long acting anti cholinergic agent It is a medicine that has been sent for approval by the FDA, so it's currently not available on the shelves. Early studies show it improves exercise tolerence and lung function in COPD patients. It appears to be similar to tiatropium bromice (Spiriva) except that it must be taken twice daily. No studies have yet been conducted to compare tiatropium bromide with acclidinium bromide
4. Generic name: Oxitropium bromide
Brand name: Oxivent
Delivery device: MDI 100 mcg/ puff
Adult dose: 2 puffs every 8-12 hours
Action: similar to Atrovent
Comments: Not available in the U.S.
5. Generic name: Atropine
Brand name: none
Delivery device: SVN aerosol
Adult dose: 0.05 mg/kg in 3 cc normal saline every 6-8 hours.
Action: Similar to Atrovent
Comments: No longer used considering Atrovent and Spiriva have fewer side effects, yet it is still available in hospitals as an option and that's why I list it here. It's also used to treat the cardiac arrythmia of bradycardia.
Long Acting Bronchodilators:
1. Generic name: Formeterol
Generic name: Foradil
Delivery device: DPI 25 mcg/ puff
Adult dose: 1 puff BID
Comments: Use only if inhaled steroids do not control COPD or asthma; the FDA recommends if you need Foradil for your asthma you should also be getting an inhaled corticosteroid with it, so generally Symbicort is a better option for asthmatics and COPD patients. Sometimes Foradil alone can be useful for COPD. Studies link Foradil with increased asthma deaths, although some experts contend this is not so much the medicine itself but that fact that some asthmatics rely to much on the medicine (perhaps even abuse it) as opposed to seeking help. So patients should be instructed to use this medicine as prescribed only, and not to over use it.
2. Generic name: Salmeterol
Brand name: Serevent
- MDI: 25 mcg/ puff (phased out)
- DPI: 50 mcg/puff
- MDI: 2 puffs BID
- DPI: 1 puff BID
Technique: To learn how to use Serevent Discus, click here.
Comments: Use only if inhaled steroids do not control asthma; patients should seek treatment if symptoms worsen instead of over relying on this medicine. The FDA recommends if an asthmatic needs this medicine it should be used in conjunction with an inhaled corticosteroid (either with Flovent or Advair should be used) to treat both bronchospasm and chronic underlying inflammation that is generally present with asthma lungs.
1. Generic name: Ipatropium Bromide + Albuterol
Brand name: Duoneb SVN (Combivent MDI)
- SVN: 2.5 mg albuterol plus 0.5 mg ipatropium bromide with 3cc normal saline
- MDI: 90 mcg albuterol plus 18 mcg ipatropium bromide
- SVN: Treatments TID or QID or as needed to relieve bronchospasm
- MDI: 2 puffs TID or QID or as needed to relieve bronchospasm
Comments: See Albuterol and Ipatropium bromide
2. Generic name: Fluticasone + Salmeterol
Brand name: Advair
Adult dose: Fluticanasone = 100, 250, or 500; Salmeterol = 50 mcg; Comes with 60 capsules to last one month.
Action: See Salmeterol above and Fluticasone below
Comments: See Salmeterol above and Fluticasone below. Advair should be used when the benefits outweight the disadvantages. Generally, it has proven safe and very effective as a top line asthma treatment recommended by the asthma guidelines. Studies show it is safe to use as a top line asthma treatment, and is safe to use as I write in this post.
Technique: To learn how to use Advair Discus, click here.
3. Generic name: Budesonide + Formeterol
Brand name: Symbicort
Delivery device: Turbohaler
Action: See Formeterol above and Budesonide below
Comments: In Europe the SMART program is available, which allows asthmatics to use up to 8 puffs of this medicine as needed through the day. The FDA has yet to legalize this in the U.S. For other notes, see Formeterol above and Budesonide Below. The medicine should not be used more often than prescribed by a doctor. Symbicort is also proven safe to use and is highly recommended as a top line treatment for asthma as I write about in this post.
Technique: To learn how to use the Turbohaler, click here.
3. Generic name: Mometasone furoate and formoterol fumarate dihydrate
Brand name: Dulura
Comments: A combination of Mometasone Furoate (the main ingredient of the inhaled steroid Asmanex available since 2005) and Formoterol Fumarate (main ingredient of the LABA, Foradil available since 2001 and also in Symbicort). Dulera is indicated for the treatment of asthma in ages 12 and above. It is an aerosol inhaler that has a digital dose counter and comes in two strengths. It is a controller inhaler that should be taken as two puffs twice daily. It should never be used to relieve symptoms.. Short acting reliever inhalers should also be on hand for use as needed. Dulera is another alternative for treating asthma that fails to respond to medium or high dose inhaled steroids.
Corticosteroid inhalers: Used to reduce bronchial inflammation to control asthma, COPD; usually take 1-2 weeks to take full effect.
1. Generic name: Beclomethosone
Brand name: Qvar (Vanceril and Beclovent have been phased out)
Delivery device: MDI: 40 mcg/puff and 80 mcg puff
Adult dose: 2 puffs BID
Technique: To learn proper use of Qvar with spacer, click here.
Comments: Have patient rinse mouth with water post treatment to prevent pharyngitis, oral candiditis (thrush). Studies show that Qvar might be better at reaching the smaller airways as compared to other inhaled corticosteroids, and it may be used in conjunction with another inhaled steroid in severe cases of asthma. I write about Qvar in this post.
Technique: When should QVAR HFA be primed? Click here.
2. Generic name: Budesonide
Brand name: Pulmicort
- DPI: 200cg/puff pulmicort turbohaler
- SVN: 80 mcg/puff
- DPI: 1-3 puffs BID
- SVN: 2 cc (unit dose with 3cc normal saline)
Comments: Pulmicort SVN advertised for children, especially those who have trouble with DPIs. The only reason adults should be prescribed Pulmicort SVN is if they have trouble with DPIs. DPI and MDI may be prescribed as preferred by physician and patient. Have patient rinse mouth after using to prevent thrush and other side effects. Studies show that nebulized budesonide is equally effective as dexamethosone in treating croup, allows for shorter hospital stays, and less use of epinepherine.
3. Generic name: Fluticasone propronate
Brand name: Flovent, Flovent Rotadisk
- MDI: 44, 110 and 220 mcg/ puff (phased out)
- DPI: 50, 100, and 250 mcg/ puff
4. Generic name: Mometasone furoate
Brand name: Asmanex
Delivery device: DPI: Turbohaler (powder) 110 mcg delivers 100 mcg of the medicine; 22 mcg delivers 200 mcg of the medicine; the 110 and 220 mcg doses come with 30 capsuls to last one month; there is also a 440 mcg dose as well.
Adult dose: Once daily in the evening, usually the 120 dos
Comments: The 110 dose can be used for children ages 4-11; the 440 dose can be used for those with severe asthma or severe COPD who require higher doses of inhaled corticosteroids to control pulmonary inflammation. Those using the 440 dose may take it up to twice a day if recommended by a physician. Patients must be encouraged to rinse their mouth out after therapy to prevent thrush and other side effects.
Systemic Corticosteroids: Used to reduce bronchial inflammation. They are anti-inflammatory, immunosuppresive agents (decrease sputum eosinophils) with direct bronchodilating effect. Because it's given systemically, the medicine works better for exacerbations of COPD and asthma or other pulmonary conditions. Patients will have to slowly be weaned off this medicine. Used for acute exacerbations only. Side effects may be severe. Can cause glucose to rise so glucose will need to be monitored, especially in patients with diabetes or the elderly. Can lead to adrenal suppression, cushing's syndrome (if used for long periods of time), osteoporosis, hypertension, oral candidiasis (thrush), and may effect the immune response and healing post operative. They must be used judiciously.
1. Generic name: Methylprednisolone
Brand name: Solu-Medrol
Comments: Given intravenously by IV or injection in hospital to patients who are in respiratory distress, and the underlying reason for the distress is believed to be inflammation of the air passages of the lungs (bronchospasm) or alveoli (pneumonia). Generally takes an hour or two to take effect. A patient generally cannot go home from the ER until this medicine takes effect and the patient is no longer in respiratory distress. If given for pneumonias caused by bacteria, it should be given in conjuntion with an antibiotic. Should also be given in conjunction with a bronchodilator is bronchospasm is also present (COPD, Cystic Fibrosis, Asthma, etc.)
2. Generic name: Prednisone
Brand name: Metricorten, Sterapred, Sterapred DS
Comments: orally and can be taken at home. Oral prednisone is equally effective as nebulized dexamethasone when terating croup. In the hospital setting a patient is usually given IV solumedrol, which is titrated down, and then the patient goes home with prednisone pills. Prednisone packs allow the patient to slowly wean off the medicine.
3. Generic name: Dexamethasone
Brand name: Dexamethasone Intensol, Dexpac JR, Taperpak, Dexpak Taperpak
Comments: Can be aerosolized 5-10 cc and used to treat inflammation in the upper airways. Studies are inconclusive, yet some show it is more effective than recemic epi in reducing upper airway inflammation for croup and post extubation inflammation. In fact, this study from pubmed.gov showed that croupy kids given dexamethasone orally demonstrated more rapid resolution of symptoms as compared to those given the aerosolized version or placebo. New studies such as this show that aerosolized dexamethasone is inferior to intravascular dexamethasone and therefore the medicine should always be given via the IV. The study also showed that nebulized steroids are more expensive. Should be used for croup only when the patient is in respiratory distress. Studies also show shorter hospital stays in patients croupy kids given this medicine. It also allows for less use of epinepherine. Studies like this show it is equally as effective as oral prednisone when treating croup.
Mucolytics: Used for patients with thick, tenacious or inspissated secretions that cannot be easily removed (usually COPD or CF patients).
Generic name: Acetylcysteine
Generic name: Mucomyst
Delivery device: 10% and 20% (4, 10 and 30cc vials) via SVN
Adult dose: 3-4 cc or 6-10 cc of the 10% dose TID or QID (dilute 20% for equivilancy) We usually just give 1 cc dose
Action: Decreases sputum viscosisity on contact
Comments: Can cause bronchospasm and should be given with a bronchodilator, usually Albuterol or Xopenex. The medicine disolves disulfide bonds and is used to liquify thick tenacious secretions and for acetaminophen overdose. Side effects include nausea and vomiting, bronchospasm, bronchorrhea, airway obstruction, incompatibility with antibiotics and are rare.
2. Generic name: Sodium bicarbonate
Brand name: none
Delivery device: 2% solution svn
Adult dose: 2-5cc prn
Action: Decreases sputum viscosity on contact
Comments: Can cause bronchospasm so should be given with a bronchodilator. Increases mucus pH thereby decreasing its viscosity.
3. Generic name: Dornase Alpha (recombinantDNAse)
Brand name: Pulmozyme
Delivery device: SVN: 2.5cc single-use ampules (1.0 mg/cc)
Adult dose: 1 ampule per day or BID
Action: Decreases sputum viscosity on contact
Comments: Can cause bronchospasm, so should be given with bronchodilator; specifically indicated for CF patients. Decreases the frequency of respiratory infection in cystic fibrosis patients requiring parenteral antibiotics, and for treating viscious secretions seen in patients with cystic fibrosis. Side effects include: Voice alteration, pharyngitis, larygitis, rash, chest pain, conjunctivitis.
Wetting Agents: Water: Given orally or IV fluids are the best mucolytic. It's also used to treat dehydration caused by increased work of breathing that results from asthma or COPD exacerbations. (Note that sterile distilled water aerosol is very irritating to the airway and may cause bronchospasm.
Saline solutions include:
1. 0.45% saline: hypotonic saline
Comments: Used to liquify secretions and humidify the airway; may be irritating and cause swelling of dried retained secretins or bronchospasm. Not used often anymore, but still available some places
2. 0.9% saline: Isotonic or normal saline
Comments: Sometimes used to liquify secretions and to humidify the airway, although studies question it's effecatiousness in this area and it's not used so much any more. It is commonly used as a diluent for medication, as you'll see it listed many times in this post for aerosolized medication. Most medicines that come in an amp are pre mixed with 2-3cc of normal saline.
3. 1.8-15% saline: hypertonic saline
Comments: Occasionally used to induce sputum specimins, and can irritate the airway and cause bronchospasm or secretion obstruction. Study results are inconclusive that it does any good and therefore it's rarely used.
1.Generic name: Colisimethate
Brand name: Colistin, Coly,Mycin
Delivery device: 150 mg vials (powder); add 2 cc sterile water
Adult dose: 37.5-150 mg every 8-12 hours
Action: Anti-pseudomonal agent
Comment: Requires valved nebulizer to prevent the RT or others from inhaling the medicine
2. Generic name: Tobramycin
Brand name: Tobi
Delivery device: 300 mg in 5 cc saline ampule
Adult dose: 300 mg every 12 hours for 28 days; followed by 28 days off
Action: Anti pseudomonal agent
Comments: Many side effects; do not mix with other drugs; give bronchodilator first; requires valved nebulizer
3. Generic name: Nanimivir
Brand name: Relenza
Delivery device: DPI 5 mg/ blister
Adult dose: 10 mg (2 blisters) BID for 5 days
Action: Stops viral replication (influenza A and B)
Comments: Not for use in asthma or COPD patients; if bronchospasm develops, stop therapy and treat immediately
Generic name: Pentamidine
Brand name: Nebupent, Pentam 300
Comments: According to drugs.com, it's used to prevent and treat serious infections such as pneumocystis pneumonia. Generally, it's used on patients who have a diminished immune system, such as AIDS and certain cancers. It may effect blood sugar levels, cause headache, chills, anxiety, loss of appetite, increase urine output, and cause drowsiness. Must be given with a filtered nebulizer to prevent therapist from inhaling medicine.
Generic name: Magnesium sulfate
Comments: According to medscapes.com, it is a smooth muscle relaxant by interfering with calcium uptake. It also has counteracting effects against bronchoconstrictors like histamine, methacholine, and metabisulfite. Intravenous magnesium sulfate is generally considered a mild bronchodilator and studies show that use of this for exacerbations of asthma may be of some benefit. It has been used more and more in hospitals, especially for difficult to manage asthma patients. As this study notes, magnesium sulfate does have significant bronchodilating effect, but results were not significantly different from an Albuterol nebulizer treatment. It is an option for use in hospitals for the treatment of asthma. May be nebulized at 95mg to 385 mg mixed with 2-3cc normal saline, up to four doses with 20 minutes between doses. Adverse effects are minimal. Studies show that nebulized magnesium and Albuterol together showed even greater bronchodilating effects lasting up to 20 minutes. Improvement in some patients was significant. Exact mechanism of action is yet unknown.
Loop Diuretics: Used to decrease preload to the heart by causing patinet to urinate. Used for right heart failure, left heart failure, valvular diseases and kidney failure.
1. Generic name: Furosimide
Generic name: Lasix
Comments: Commonly known as the water pill. According to emedtv, it's a loop diuretic because it effects the loop of henle, a part of the kidney. "It works by increasing the amount of saltand water that the kidneys remove from the blood. This extra salt and water is then passed out through the urine. By increasing the amount of water removed from the blood, furosemide causes a decrease in blood volume. Because of this effect, the drug can lower blood pressure and help with water retention." Aside from that, studies also show that aerosolized lasix (as I wrote about here) it has been proven to reduce dyspnea in COPD patients.
2. Generic name: Bumetanide
Brand name: Bumex
Comments: Used in patients when high doses of Furosemide are inefective. According to Wikipedia it is 40 times more potent than Furosemide.
1. Generic name: Chlorothiazide
Comments: Used as a diuretic to treat pulmonary or other edema throughout the body. Also used to treat edema caused by corticosteroid therapy, hepatic cirrhosis, and estrogen therapy. It's also used as an antihypertensive. should not be used during pregnancy. May use in pregnancy if pedal edema is due to cardiac abnormalities, but not for normal pedal edema caused by the mechanical process of pregnancy (source RXlist.com)
2. Generic name: Hydrochlorothiazide
Brand name: Hydrodiuril
Comments: A water pill used to treat accumulation of fluid in the body (edema) and hypertension. It blocks salt and fluid reabsorption by kidneys and therefore increases urine output. Can be used for edema caused by heart failure, cirrhosis, chronic kidney failure, and systemic corticosteroids. (source Medicinenet.com)
3. Generic name: Mannitol
Brand name: Osmitrol
Comments: Osmotic diuretic. Uses are cerebral edema, drug toxicity and overdose. Adverse effects include increased cardiac workload due to increased plasma volumes. According to Wikepedia it's an osmotic diuretic and weak vasodilator to lower blood pressure. It was originally isolated from flowering plants called manna, hence the name.
4. Generic name: Acetazolamide
Brand name: Diamox
Comments: Used for cerebral edema and peripheral edema; adverse effects include metabolic acidosis; drug is contraindicated in renal failure or respiratory failure because it causes excretion of bicarbonate ions. Opiates, in small doses, have also been proven to reduce the feeling of air hunger (dyspnea). The reason is generally unknown, although (according to Medscapes.com), it's believed to be due to vasodilation, decreased vascular resistance (decreased blood pressure). Plus, "
Analgesics (opoids): Used to reduce patient's sensation of pain. Opiates (narcotics) are the most commonly used in the hospital setting for treatment of disease processes or post operative. According to medscapes.com "they also decrease brainstem responsiveness to carbon dioxide (the primary mechanism of opioid induced respiratory depression) and lessen the reflex vasoconstriction caused by increased blood PCO2 levels so that the perception of dyspnea is reduced." They also reduce dyspnea by vasodilation and decreased peripheral vascular resistance (blood pressure). May cause hypotension and increased hystamine release. It also may decrease gastrointestinal motility (another thing to watch out for). When nebulized, medical professionals must wear appropriate masks to prevent inhalation of opoids. Can be given as needed or continuous infusion. As needed is probably better because it allows you to prevent over sedation
1. Generic name: Morphine
Brand name: none
Comments: Morphine is an opoid and also a mild bronchodilator, and it has also been proven to help with anxiety and the feeling of dyspnea or air hunger in patients with severe or end stage COPD and with severe forms of asthma and end stage lung cancer. It can be provided orally, under the tongue (sublingually), injection and even inhalation via a nebulizer. Here's a scientific article about Morphine for dyspnea, and here's a post from asthmatic Breathin Stephen who uses Morphine for his dyspnea. Nebulized morphine may be an easy method to provide the patient with dyspnea relief and to provide psychological comfort. The therapeutic dose of nebulized morphine is 5 mg of the 0.1% solution every 4 hours as needed. Studies have shown (click here) that opiates (nebulized or other) decrease shortness of breath, allow for a greater feeling of relaxation, and increase exercise tolerance. No significant difference was reported with doses higher than 5 mg. However, since morphine can cause bronchoconstriction, promote histamine release, and depress respirations, it should be used with caution. It also can cause hypotension, so it's ideal for anxious patients in respiratory disterss with high blood pressure.
2. Brand name: Hydromorphone
Generic name: Dilaudid
Comments: A narcotic. 4mg every four hours can be mixed with normal saline and given via nebulizer in patients who are allergic or intollerent to Morphine sulfate to treat dyspnea. Some patients have benefited from 1 mg nebulized dilaudid every four hours, and some required as much as 20mg to receive benefits. Symptom relief was generally felt within 15 minutes and most patients suffered no adverse effects.
Nebulized Dilaudid: Nebulized to treat severe dyspnea. It sometimes works better for those suffering from dyspnea due to fewer side effects than the pill form of opiates. One common side effect is headaches.
3. Generic name: Fenatanyl
Brand name: Dublimaze
Comments: A narcotic. Can also be nebulized and given for dyspnea relief. 25 micrograms in 2cc normal saline is the usual dose. 81% of patients in one study noted relief within 5 minutes, and relief lasted up to an hour. Oxygen saturations and respiratory rate also improved. So it can be used as an alternate for those patients allergic to or intollerent to morphine sulfate. Optimum dose and duration of benefits are unknown at this time. Unlike Morphine, it does not have the side effect of histamine release. It is expensive however.
4. Generic name: Codeine
Brand name: none
Comments: A narcotic. 15 mg nebulized codeine can be given to patients for dyspnea relief is they have an allergy or intollerence to morphine sulphate (source medscapes.com).
5. Generic name: Hydrocodone
Brand name: none
Comments: A narcotic
6. Generic name: Ocycodone
Brand name: Oxycontin
Comments: A narcotic
7. Generic name: Meperedine
Brand name: Demerol
Comments: A narcotic. Not a very good analgesic. It's highly addictive, may cause hallucinations, and buildup can lead to ceizures.
8. Generic name: Anileridine
Brand name: Leritine
Comments: New analgesic no longer available in the United States. Is available in Europe. Similar to Demerol but chemicals are altered slightly to give it a stronger analgesic effect. It's available as a tablet or injection, yet 25mg can be aerosolized in a nebulizer for treating dyspnea.
Analgesics (non opoids)
1. Generic name: Ketorolac
Brand name: Toradol
Comments: Does not cause respiratory depression, however it causes incerased side effects in critically ill. It may cause renal failure and gastritis.
2. Generic name: Tramadol
Brand name: Ultram
Comments: Is a narcotic-like pain reliever. Can be taken while you are working. Use to treat moderate to severe pain when over-the-counter medicines to not help. Time released capsules are available for those who need pain relief around the clock. This medicine should only be used as prescribed, because it can become addictive. The addictive effect of this medicine can be enhanced if used with alcohol. Should not be taken with anti-depressants, muscle relaxers, or medicine for nausea or vomiting. Overdose can have same effect as opiates: slow and shallow respiratory rate, and possible cessation of breathing. Side effects can be severe, so precaution should be used.
2. Generic name: Asprin:
Brand name: none
Comments: Pain reliever and also a blood thinner. Used as a regular treatment for mycardial infarctions to thin the blood and often patients use this daily.
3 Generic name: Acetaminophen
Brand name: Tylenol
Comments: According to pubmed, Tylenol is a pain reliever and fever reducer. Recent studies have linked Tylenol with asthma.
4. Generic name: Ibuprophen
Brand name: Motrin,
Comments: Pain reliever and fever reducer. It's a nonsteroidal anti-inflammatory.
Neuromuscular blockers (paralytics): Indicated for patients receiving mechanical ventilation in order to reduce spontaneous breathing, and prevent movement that can dislodge airways, catheters and chest tubes. Can also be used to prevent increased intracraneal pressure. Can also be used to reduce oxygen consumption in patients with poor cardiopulmonary status, and to improve patient synchrony with the ventilator. They increase risk of DVT, pressuer ulcers, and nerve compression syndromes. Any paralytic may cause prolonged muscle weakness if used for greater than 48 hour. This effect is increased when corticosteroids are used with the paralytic. Therefore paralytics should not be used with any patient on corticosteroids. I've seen this, and it's not good.
1. In. Generic name: Succinylcholine
Brand name: Anectine
Comments: This is a depolarizing neuromuscular blocking agent used to cause total muscle contraction (twitching, fasciculation) followed by complete muscle paralysis. It has a rapid onset (1-1.5 minutes), and it is short acting (7-12 minutes) so there is no need for a reversal. It is primarily used for endotracheal intubations. Side effect is increased potassium and incrased intracraneal pressure.
2. Generic name: Pancuronium
Brand name: Pavulon
Comments: It's a nondepolarizing neuromuscular blocking agent. It binds to receptor sites to prevent stimulation of muscles, resulting in complete paralysis. It has a rapid onset of action (3-5 minutes), and has a long duration of action (35-120 minutes). It can be reversed if desired. Recommended when paralysis is indicated for longer periods of time. This medicine does not affect pain perception or level of consciousness, so patient should also receive sedation and analgesia (pain control). It's inexpensive and lasts long. Side effects: tachycardia
3. Generic name: Vecuronium
Brand name: Norcuron
Comments: See comments for Pavulon above.Onset 1.5 minutes and lasts 30 minutes. Less cerebral vascular effect as other paralytics. Side effect: bradycardia.
4. Generic name: Atracurium
Brand name: Tracrium
Comments: See comments for Pavulon above. Onset 2 minutes and last 30 minutes. May cause rash or histamine release.
5. Generic name: Cisatracurium
Brand name: Nimbex
Comments: See comments for Pavulon above.
6. Generic name: Rocuronium
Brand name: Zemeron
Comments: Onset 1 minutes and lasts 30-60 minutes. Used to relax muscles. According to drugs.com, Usually given before general anesthesia to prepare you for surgery. It also relaxed your throat so it's easier to insert an ETT. No hemodynamic effects, but it is expensive.
7. Generic name: Tubocurare
Comments: Used during surgery as muscle relaxant and anesthetic. Onset 6 minutes and duration is 80 minutes.
1. Generic name: Nalaxone hydrochloride
Brand name: Narcan
Comments: Reverses the effects of opiates such as Morphine. It's a white powder that's soluble in water, and is injected into the IV. Reverses respiratory depression caused by opoids. Can work really fast to wake patients up. According to RXlist, it reverses methadone, propoxyphene, nalbuphine, pentazocine, butorphanol, cyclazocine.
Leukotriene antagonists: Also referred to as leukotriene modifiers. They are non steroid drugs that have been approved for use in cases of mild to moderate persistent asthma. They are known to block leukotrienes that cause bronchospasm and inflammation of the lungs during an allergic/ asthma attack. Can also be used as a premedication for exercise induced asthma. They act to improve lung function, reduce symptoms and the need for beta agonist drugs. Sometimes these alone can prevent asthma. If these alone don't work, then inhaled corticosteroids can be tried, or combination medicines like Advair and Symbicort. They are generally used as a means of controlling asthma long term, should be taken once a day, and should be taken every day to control asthma because it takes 1-2 weeks to obtain a therapeutic level in your system. They are also used to treat rhinitis and hay fever, and may be used in conjunction with an antihistamine if needed. These should not be used to treat an acute exacerbation of asthma.
1. Generic name: Zafirlukast
Brand name: Accolate
Comments: This medicine is usually taken by mouth twice daily. For more information click here.
2. Generic name: Zileuton
Brand name: Zyflo
Comments: It's generally take 4 times daily. As you can see here, this medicine has been discontinued.
3. Brand name: Montelukast
Generic name: Singulair
Comments: The FDA has ordered a black box warning to be added to this medicine because some patients taking it have noted suicidal thoughts. However, the FDA also notes no studies have confirmed this. This medicine should be used when the advantages outweight the disadvantages. The medicine is generally safe. For more information click here.
Xanthines: These are inhibitor drugs that indirectly increase the amount of cAMP within smooth muscle. The inceased amount of cAMP then causes bronchodilation. Other xanthines include caffeine (coffee). Side effects include tachycardia, palpitations, jitters, irritability and diuresis.
1. Generic name: Theophylline
Brand name: Theo-dur, Theolair
Delivery device: oral by tablet, extended release, regular release, syrum and elixer
Adult dose: depends on patient, and should be titrated to maintain a therapeutic level; Remind patient to take doses at the same time every day to maintain therapeutic levels in their system.
Comments: Safe therapeutic blood level of theophylline is 10-20 mg/ml to optimize bronchodilation. blood levels are important to monitor in patients receiving methylxanthine drugs. Used to be a front line therapy for asthma, yet now is a secondary medicine to be used only for difficult to manage asthma cases. If the level exceeds 20, signs of toxicity may occur, including: tremors, nausea and vomiting, nervousness, seizures, tachycardia and other arrythmias that can lead to cardiac arrest. So it's important not to overdose and to have theophylline level checked at least once a year. I wrote about why theophylline is no longer a top line asthma therapy here.
2. Generic name: Aminophyline
Brand name: none
Delivery device: itravenous injection usually through IV
Adult dose: varies
Action: same as theophylline
Comments: Used in hospitals only. Same as theophylline except used in hospitals only and given by IV. For more information see theophylline.
Generic name: Oxytriphylline
Brand name: Choledyl
Delivery method: Regular release, extended release, syrum and elixer are available.
Comments: Similar to theophylline and should be taken at the same time every day to maintain therapeutic level.
1. Generic name: Omalizumab
Generic name: Xolair
Comments: The first IgE blocker developed to treat allergic asthma. Delivered by subcutaneous injection every 2-3 weeks. The dose is determined by the patient's IgE level and body weight. This is not a rescue medicine and should not be used to treat an asthma attack. The medication is for patients 12 years and older who have moderate to severe asthma that is triggered by eyar round allergens and who continue to have symptoms despite inhaled steroid therapy. This medicine is very expensive. Some studies I've seen show mixed results. All asthma patients I've seen who have used this medicine have said it didn't do any good. So, we'll have to wait for further study results to see if this medicine should be used in the future.
Anti- arrhythmic agents:
1. Generic name: Lidocaine
Brand name: Xylocaine
Comments: Can be injected directly under the skin prior to inserting IVs or doing blood gases to numb the area. Also a 5cc of 2%, Lidocaine solution or 100-200mg or 4cc of 4% solution can be aerosolized to numb the airway prior to bronchoscopies or for post extubation laryngospasm. Studies like this show it has been efficatious in reducing laryngospasm. Also can be used to treat laryngospasm caused by anaphlaxis. Also used to control PVCs, pulseless Ventricular Tachycardia, or ventricular fibrilation. Some reports, as this medscapes article notes, shows that aerosolized lidocaine can aleviate bronchoconstriction and cough. While this did work for many patients, it actually worsened bronchoconstricion short term in some patients and treatment had to be stopped before the patients were ultimately stabilized. Lidocain toxicity is a concern with higher doses, such as lightheadedness, hallucinations, tremors, and even cardiac arrest. So since studies are mixed, and side effects are a concern, care givers must "carefully" weight the potential risks with the benefits.
2. Generic name: Quinidine, Propranolol
Brand name: Inderal
Comments: Used to treat atrial arrythmias.
3. Generic name: Procainamide
Brand name: Pronestyl
Comments: Treatment of ventricular ectopic beats, ventricular tachycardia, and atrial arrythmias.
4. Generic name: Verapamil
Brand name: none
Comments: Used to control ventricular rates in narrow complex supraventricular tachycardia.
5. Generic name: Amioderone
Brand name: none
Comments: Used for the treatment of pulseless ventricular tachycardia and ventricular fibrillation that has not responded to defibrillation.
6. Generic name: Atropine
Comments: see Atropine above
7. Generic name: Epinepherine:
Comments: see above
Anesthetics: These are used to relax airway smooth muscles. According to Fatal Asthma, "Rapid, dramatic improvement is reported, leading to more effective ventilation and in some cases early extubation." For other alternative therapies for asthma or COPD click here.
1. Generic name: Ketamine hydrochloride
Brand name: Ketamine
Comments: This is a smooth muscle relaxant and antihistamine, and is given intravenously. It's a really good bronchodilator. Of course this medicine is a known hallucinogenic, and it is a sedative. Many doctors prefer to wait until a patient is intubated to use it, and follow it up with a paralytic, as you can read here. May cause hypertension, hallucinations, hypertonicity, and nightmares.
2. Generic name: Isoflurane
Brand name: Forane
Comments: This is an anaesthetic and bronchodilator that has been proven to be efficacious in ventilated patients in status asthmaticus. According to this study, " Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management."
3. Generic name: Propofol
Brand name: Diprovan
Comments: Used as a sedative, amneseic and anesthetic. RTs will see it used on ventilator patients, particularly asthma and COPD patients. However, it must be used cautiously because it can cause respiratory and cerebral vascular deperssion. Rapid onset in 1 minute, and peaks at 2 minutes. Duration is 4-8 minutes. Not effected by kidney and liver disease.
1. Generic name: Haloperedol
Brand name: Haldol
Comments: It's an anti-psychotic tranquilizer used for patients that are non-compliant and confused, agitated, delerious, and/ or psychotic. Does not cause respiratory depression.
Sedatives: Anti anxiety medicine. Used to manage fear, anxiety and agitation, reduce pain, increase comfort while receiving mechanical ventilation, reduce oxygen demand, and to induce sleep. Some also create amnesia. Benzodiazepines are the most common and include the following. May be used to prevent sleep deprivation and delerium in ventilator patients, and to help with alcohol and drug withdrawl, depression, etc. RTs must be aware that sedatives may increase length of stay on ventilators and increase costs. Therefore, a good ventilator strategy is to have sedation vacations every day where you can assess patient for weaning criteria. As appropriate, sedation should be stopped no less than 2 hours prior to this assessment. Also, must be used carefully because a patient may develop a dependance.
1. Generic name: Alprazolam
Brand name: Xanax
2. Generic name: Diazepam
Brand name: Valium
Comments: Oset is 1-3 minutes and peaks in 3-4 minutes. Dose is 2-5mg.
3. Generic name: Midazolam
Brand name: Versed
Comments: Fast onset and short duration. Onset 1-3 minutes and peaks in 5-30 minutes. Dose 1-5 mg.
4. Generic name: Iorazepam
Brand name: Ativan
Comments: Slow onset and longest lasting. Metabolism not effected by liver disease. Onset 5-15 minutes and peaks in 15-20 minutes. Dose 1-2 mg.
Generic name: Flumazenil
Brand name: Romazoicon
Comments: Can be administered to reverse the effets of the benzodiazepine sedatives listed above.
Brand names (Generic names): Mevacor (Levostatin), Zocor (simvastatin), Pravachol (Pravastatin), Lipitor (Atorvastatin), Crestor (Rosavastin), and more
Comments: While designed to treat high cholesterol and lower blood pressure, a number of studies showed dramatic reductions in emergency room (ER) visits and hospitalizations for asthma patients taking cholesterol-lowering statins in addition to common asthma treatments, according to this article from HealthCentral.com. Statins are not currently approved to treat asthma.
Cardiac drugs: These are used to treat CHF to increase the strength of contraction. The are referred to as inotropic agents. Side effects are nausea, vomiting, headache, arrythmias.
1. Generic name: Digitalis
Brand name: Crystodigin
2. Generic name: Digoxin
Brand name: Lanoxin
Antianginal: These are used to relieve pain (anginal pectoris and results are almost immediate. Usually used by people with heart disease.
1. Generic name: Nitroglycerin
2. Generic name: Isordil
Sympatholytics: Used to treat high blood pressure to prevent stroke, heart and kidney problems.
1. Generic name: Methyldopa
Brand name: Aldomet
Comments: Blocks sympathetic neurotransmission
2. Generic name: Propranolol
Brand name: Inderal
Comments: Blocks over-reactive sympathetic neurons
3. Generic name: Metoprolol
Brand name: Lopressor
Comments: Beta one blockade that slows down the rate of the heart
1. Generic name: Diazoxide
Brand name: Hyperstat IV
2. Generic name: Sodium Nitroprusside
Brand name: Nipride
Comments: light sensitive. Lowers blood pressure and decreases ventricular preload.
Vasopressors: Will increase blood pressure. Usually will use one of these and a direct vasodilator to try to balance out the blood pressure in critically ill patients. They increase heart contractility and strength by causeing peripheral vasoconstriction (alpha effect). They also cause arteriol vasodilation and bronchodilation (b2 effect).
1. Generic name: Norepinepherine
Brand name: Levophed
Adult dose: 1-12 mcg/ min
Comments: Cardiac and vascular effects; used in cardiogenic shock. Causes vasoconstriction without the cardiac effects. Good medicine to increase systemic vascular resistance (increase blood pressure and cardiac output), especially in shock. Can cause the vagal response (bradycardia).
2. Generic name: Dopamine
Brand name: none
Adult dose: Renal dose 2-4 mcg/kg/min; modest inotropic effect 5-10 mcg/kg/min; vasoconstriction 10-20 mcg/kg/min
Comments: Used to increase blood pressure. Increases mesentric blood flow with renal dose. May cause tachyarythmias.
3. Generic name: Dobutamine
Brand name: none
Adult dose: 5-15 mcg/kg/min
Comments: used to increase blood pressure. Depending on dose will increase the stroke volume with decreased filling pressures. May decrease systemic vascular resistance (blood pressure), although blood pressure may not change (depends on disease state). Used for left and right heart failure. May cause tachyarythmias. May be useful in septic shock.
4. Generic name: Epinepherine
Brand name: none
Comments: Used during asystole and pulseless electrical activity (PEA) and bradycardia during adult cardiac life support (ACLS) and pediatric cardiac life support (PALS) and neonatal resuscitation (NRP). It's also used for it's beta adrenergic effects. For more information see beta adrenergics above.
5. Generic name: Phenylephrine
Brand name: Neosynephrine.
Comment: Strong alpha effect. Causes vasoconstriction with minimal increase in heart rate or contractility. Used to increase blood pressure. It's also used as a nasal decongestant (sudafed).
6. Generic name: Vasopressin
Brand name: Pitressin
Adult dose: 0.4 units/ min
Comments: Vasoconstrictor that is particularly useful in shock. According to drugs.com, "it helps reduce loss of water by reducing urine output and helping the kidneys reabsorb water in the body. It also raises blood pressure by constricting (narrowing) blood vessels."
7. Generic name: Nitroglycerine
Brand name: Nitrostat, NitroQuick, Nitro-Dur, Nitro-Bid
Adult dose: Venodilator at low doses (less than 40 mcg/min); Arteriole dilator at high doses (greater than 200 mcg/min). Rapid onset and short duration and highly tolerable. May cause headache. Also used as an antianginal agent. Commonly used in the emergency room and at home. May be available as a spray under the tongue, pill that disolves under tongue, etc. Is a part of the MI protocol according to ACLS.
8. Generic name: Nitroprusside
Brand name: Nitropress
Adult dose: 0.2-10 mcg/kg/min
Comments: Vasodilator. Rapid onset and short elimination time. Very good hypertensive agent (makes blood pressure go up) in emergency situations, CHF and aortic dissections. Ordered quite often when patient in critical care and pressure not under control. Lopressor will be ordered to lower blood pressure when it gets too high, and Nitroprusside used to increase it when it gets low.
PDE inhibitors: Used to increase cardiac contractility to treat cardiac shock
9. Generic name: Amrinone (inamrinone) changed to Amiodarone
Brand name: Inocor, Cordarone, Pacerone, Cordarone
Adult dose: 50 mcg/kg/ bolus and 0.375 to 0.5 mcg/kg/min
Comments: Positive inotropic (increases cardiac contractility) and vasodilator with little effect on heart rate. Used to treat CHF short term only (in the hospital). Blood pressure, pulse, and EKG should be constantly monitored. Given by IV. Lasix should not be inserted into same IV line. It's also an antiarrythmic medicine used during ACLS to help keep the heart beating in people with life threatening cardiac arrythmias. In ACLS it's used to treat ventricular tachycardia and ventricular fibrillation.
10. Generic name: Milrinone
Brand name: Primacore
Adult dose: 50 mcg/kg bolus and 0.375 mcg/kg/min infusion
Comments: It inhibits the relaxation of left ventricle. A positive inotropic (increases contractility of heart) and is a vasodilator. Has little effect on heart rate. Used for CHF only when conventional therapy does not work, including vasodilators and diuretics. It should not be a front line medicine because it may cause fatal arrhythmias.
11. Generic name: Labatolol
Brand name: Normodyne, Trandate
Adult dose: Bolus 20 mg; infusion is 2mg/ min
Comments: A vasodilator. Increases blood flow through the veins to increase blood pressure. Decreases systemic vascular resistance and blood pressure without tachycardia. Used in emergency situations when patient has a very low blood pressure. Useful when patient has had an aortic dissection.
Ace inhibitors: The angiotension converting enzyme (ACE) triggers a reaction that causes the blood vessels to narrow resulting in high blood pressure. ACE inhibitors slow or inhibit the activity of the ACE enzyme, this causes the blood vessels to dilate, and blood pressure is reduced. In essence these are used to terat shock when afterload reduction is needed. Afterload is the force the heart has to pump against. When afterload is high, blood pressure is high.
Generic names (brand names): benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), trandolapril (Mavik).
Medicines no longer prescribed or being phased out:
1. Generic name: Bitolterol
Generic name: Tornalate
Delivery device and dose: Adult dose:
- SVN: 1.25 mL TID/ QID
- MDI: 2 puffs Q6 hours
Comments: Mild CV/CNS side effects; do not mix with other drugs
4. Generic name: Pirbuterol
Generic name: Maxair
Delivery device: MDI: (200 mcg/puff)
Adult dose: 2 puffs q 4-6 hours
Action: Onset in 5 minutes; peaks in 1/2- 1 hour; duration is 3-5 hours (medium)
Comments: Mild CV/CNS side effects. This medicine is currently being phased out
Mast Cell Stabilizers:
1. Generic name: Cromolyn sodium
Brand name: Intal, Aarane
- SVN: 20 mg four times a day
- MDI dosage is 2 inhalations four times a day
2. Generic name: Nedocromil sodium
Brand name: Tilade
Delivery device: Only available as MDI
Dosage: 2 puffs 4 times a day
Comments: Due to 4 puffs 4 times a day compliance became an issue. Also CFC inhalers were phased out and it wasn't cost effective to make any changes or to continue the medicine.
1. Generic name: Isuprel
Comments: Increases heart rate and heart oxygen consumption. May worsen ischemia. No longer used.
2. Generic name: Ephedrine
Brand name: none
Adult dose: 5-25 mg IVP
Comments: Used to relieve congestion due to colds, hay fever, allergies, etc. It's a decongestant and bronchodilator. Releases tissue stores of epinepherine to cause bronchodilation. Longer lasting and less potent than epinepherine. No longer available over the counter but still available to anesthesiologists.
New nebulized medicines I haven't classified yet:
*Not necessarily classified as a beta adrenergic medicine, yet I'm listing it here for simplicity purposes because it has very strong bronchodilating effect.