Mixing Nebulized Asthma Medications

Inhalation is the preferred route for many asthma medications used today. The nebulizer is one option available for asthma treatment if the patient has difficulty manipulating the MDI and spacer, coordinating inhalation with actuation, inhaling deeply or holding her/his breath for the prescribed amount of time.

As new medications have become available in a nebulized form the question of which medications can be mixed and given together often arises.

The following information about nebulized asthma medications was originally developed for a healthcare professional audience and was published in Allergy, Rheumatology, Immunology and Asthma (ARIA), a journal produced by National Jewish Health and The Children's Hospital of Denver.

What asthma medications are available in the nebulized form?
Can nebulized medications be mixed?
What asthma medications need to be nebulized alone?
Is there an ideal amount of medication for nebulization?
What diluent can medications be mixed with?

 

What asthma medications are available in the nebulized form?

A variety of medications are now available in a nebulized form to treat asthma. They include:

Long Term Control Medications

  • Corticosteroids
    Pulmicort Respules™ (budesonide)
  • Cromolyn sodium
    Intal® (cromolyn sodium)

Quick Relief Medications

  • Short-acting Beta2 Agonists
    Airet™, Proventil®, Ventolin®, (albuterol)
    Xopenex® (levalbuterol)
  • Anticholinergics
    Atrovent® (ipratropium)
  • Combination
    DuoNeb® (albuterol and ipratropium)

Can nebulized medications be mixed?

In many situations the drug compatibility, efficacy, and safety of mixing medications has not been studied. The following guidelines are based on information from the Physician's Desk Reference and clinical practice.

 

What asthma medications can be mixed together?

  • Ipratropium can be mixed with albuterol if used within one hour of mixing.
  • Mixing cromolyn with other medications has not been studied, although there is a long clinical history of mixing cromolyn and albuterol. When these medications are mixed, undiluted albuterol is added to cromolyn because using premixed albuterol results in too large a volume of liquid.
  •  

What asthma medications need to be nebulized alone?

  • Budesonide can not be mixed with other nebulized medications and should be administered separately. Although this is the current recommendation in the United States, in Canada and Europe, where nebulized budesonide has been available for some time, the two medications are often mixed and given together. Studies to evaluate giving these two medications together are apparently underway.
  • Levalbuterol cannot be mixed with other nebulized medications.

Is there an ideal amount of medication for nebulization?

The amount of solution to be nebulized must be enough to nebulize the medication, yet not so much the nebulized treatment takes longer than 15 minutes. Two to three ccs of solution is a reasonable amount of medication to meet both needs.

 

What diluent can medications be mixed with?

Many nebulized medications come in a premixed solution. If the medication is not premixed, normal saline is usually recommended to dilute the medication. Broncho Saline® is a convenient, cost effective normal saline solution in a multi-dose push button pressurized container. When the button is pushed and released 1cc of normal saline is dispensed.

 

This information has been reviewed and approved by David Tinkelman, MD (August 2012)

 

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