A patient you are caring for has been ordered the following metered dose inhalers:

Ventolin (Salbutamol), 2 puffs, PO, TID, to be given at 0600, 1400 and, 2200.
Atrovent (Ipratropium Bromide), 2 puffs, PO, TID, to be given at 0600, 1400 and, 2200.
Flovent (Fluticasone), 2 puffs, PO, BID, to be given at 1000 and 2200.
It is 2200 and your client should receive all three puffers. In what order would you administer these meds?

1st 2nd 3rd

Ventolin
(salbutamol)
Bronchodilator
-b2-specific adrenergic agonist
- sympathomimetic
bronchodilators
b-agonists dilate airways by
stimulating the b2 -adrenergic
receptors located throughout the
lungs
Used during acute phase of an
asthmatic attack to quickly reduce
airway constriction and restore
airflow to normal
Atrovent
(ipratropium bromide)
Anticholinergic
-cholinergic refers to acetylcholine
-Ach (acetylcholine) the chemical
that motor neurons of the nervous
system release in order to activate
muscles
block ACh receptors. This action
indirectly causes airway dilation
since Ach causes
bronchoconstriction.
Slow and prolonged, used for
prevention of the bronchospasm
associated with chronic bronchitis
or emphysema and not for the
management of acute
symptoms.
Flovent
(fluticasone)
Corticosteroid
- glucocorticoids
dual effect of both reducing
inflammation and enhancing the
activity of b-agonists
prevent nonspecific inflammatory
processes.
Primary treatment of
bronchospastic disorders to control
the inflammatory responses

Inhaled b2-agonist may be used before the inhaled glucocorticoid to provide bronchodilation before administration
of the anti-inflammatory drug. The bronchodilator inhaled drug is generally taken several minutes before the
glucocorticoid or corticosteroid aerosol.
Reference

Lilley, L. L., Harrington, S., Snyder, J. S., Canadian, Swart, B. and Savoca, D. (2010) Pharmacology for Canadian
health care practice. 2nd edn. Toronto: Elsevier Canada.

Shake inhaler well.

(1) Take a drink of water to moisten the throat; place the inhaler mouthpiece 2 finger-widths away from mouth; tilt
head back slightly. While activating the inhaler, take a slow, deep breath for 3 5 sec; hold the breath for 10 sec;
and breathe out slowly.

(2) Exhale and close lips firmly around mouthpiece. Administer during second half of inhalation, and hold breath for
as long as possible to ensure deep instillation of medication.

(3) Use of spacer. Consult health care professional to determine method desired prior to instruction. Allow 1 2 min
between inhalations. Rinse mouth with
water or mouthwash after each use to minimize dry mouth and hoarseness. Wash inhalation assembly at least daily
in warm running water.

For use of dry powder inhalers, turn head away from inhaler and exhale (do not blow into inhaler). Do not shake.
Close mouth tightly around the mouthpiece of the inhaler and inhale rapidly.Steps for Using Your Inhaler*

Removethecapandholdinhalerupright.

Shaketheinhaler.

Tiltyourheadbackslightlyandbreatheoutslowly.

Positiontheinhalerinoneofthefollowingways(AorBisoptimal,butCisacceptableforthosewho
have difficulty with A or B. C is required for breath-activated inhalers):
Pressdownontheinhalertoreleasemedicationasyoustarttobreatheinslowly.
Breatheinslowly(3to5sec).
Holdyourbreathfor10sectoallowthemedicinetoreachdeeplyintoyourlungs.
Repeatpuffasdirected.Waiting1minutebetweenpuffsmaypermitsecondpufftopenetrateyour lungs better.
Spacers/holdingchambersareusefulforallpatients.Theyareparticularlyrecommendedforyoung children and older
adults and for use with inhaled corticosteroids. Avoid common inhaler mis- takes. Follow these inhaler tips:
Breathe out before pressing your inhaler.
Inhale slowly.
Breathe in through your mouth, not your nose.
Pressdownonyourinhaleratthestartofinhalation(orwithinthefirstsecondofinhalation).
Keep inhaling as you press down on inhaler.
Press your inhaler only once while you are inhaling (one breath for each puff).
Makesureyoubreatheinevenlyanddeeply.
If you are using a short-acting bronchodilator inhaler and a corticosteroid inhaler, use the bronchodilator first,
and allow 5 min to elapse before using the corticosteroid.Other inhalers have become available in addition to the
one illustrated here. Different types of inhalers may require different techniques.

Deglin, J. H., Vallerand, A. H. and Sanoski, C. A. (2010) Daviss drug guide for nurses. 12th edn. Philadelphia: F. A.
Davis Company.

(Deglin, Vallerand, and Sanoski, 2010)