logo

Pulmonary

Pulmonary Medications

Anticholinergics  | Beta-2 agonists | Combination products | Corticosteroids | Leukotriene Inhibitors  |  Mast cell stabilizers  |  Other
Anticholinergics       [TOP]

ipratropium 
Atrovent ®

Blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation.
Adult (usual): Nebulization: 500 mcg (one vial) 3-4 times/day with doses 6-8 hours apart.  Metered dose inhaler: 2 puffs 4 times/day -  up to 12 puffs /24 hours.

Supplied:  Nebulization (soln): 0.02% (2.5 ml).  MDI: 18 mcg/actuation. 

tiotropium 
Spiriva ®

Anticholinergic agent (bronchodilator).
Adult (usual): COPD: Oral inhalation: Contents of 1 capsule (18 mcg) inhaled once daily using HandiHaler® device.
Beta-2 agonists  (short acting)        [TOP]

albuterol 
Proventil ®

Beta-2 Agonist.   Adult (usual): Asthma: 1-2 puffs every 4-6 hours as needed. Maximum: 12 inhalations/day. Prophylaxis of exercise-induced bronchospasm:  MDI: 2 puffs 5-30 minutes prior to exercise.
Nebulized 2.5 mg 3-4 times daily.  Tablets: 2-4 mg orally 3-4 times daily.  Sustained release tablets:  4-8 mg q12h (Maximum dose: 32 mg/day).

Acute treatment of bronchospasm:  MDI (90 mcg/puff): 4-8 puffs every 20 minutes for up to 4 hours, then every 1-4 hours as needed.  Nebulization: 2.5 mg (3ml)   3-4 times/day over 5-15 minutes.

Bronchospasm in ICU patients (acute):  Nebulization: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed, or 10-15 mg/hour continuously.

bitolterol 
Tornalate ®

(Beta-2 agonist):   Adult (usual): Bronchospasm, acute: MDI  2 puffs separated by 1-3 minutes, follow with third as needed.   Bronchospasm, prevention: MDI,  2 puffs q8h,  Maximum of 3 puffs q6h or 2 puffs q4h.  
Bronchospasm, prevention: (intermittent flow nebulizer) 0.5-1 ml (1-2 mg) 3-4 times per day (Maximum of 8 mg/day).   Bronchospasm, prevention: (continuous flow nebulizer) 1.25 ml (2.5 mg) 3-4 times/day. (Maximum of 14 mg/day).   

Supplied [0.8% aerosol.   0.2% (2 mg/ml) inhalation Soln].

levalbuterol 
Xopenex ®
Beta-2 agonist.  Adult (usual): Bronchospasm:  MDI: Aerosol: 1-2 puffs every 4-6 hours.   Nebulization: 0.63 mg 3 times/day at intervals of 6-8 hours. Dosage may be increased to 1.25 mg 3 times/day with close monitoring for adverse effects. Most patients gain optimal benefit from regular use.
Levalbuterol (R-enantiomer of albuterol) has approximately 2-fold greater binding affinity compared to racemic albuterol, and approximately 100-fold greater binding affinity than S-albuterol. (Bronchodilatory effects of racemic albuterol are due to R-albuterol).
pirbuterol 
Maxair ®
Adult (usual): Asthma: 1-2 puffs every 4-6 hours (up to 12 puffs/day).

metaproterenol 
Alupent ®

Adult (usual):  Asthma, bronchospasm:   20 mg orally 3-4 times/day.  Oral aerosol inhalation:  2-3 puffs q3-4 hours  (Max of 12 puffs/day).   Nebulizer:  0.3 ml (5%) in 2.5 ml NS q4-6 hours prn.  
Beta-2 agonists  (Long acting)       [TOP]
formoterol 
Foradil ®
(Long-acting Beta-2 agonist):  
Adult (usual): 
Asthma
(maintenance therapy): Oral inhalation - 12 mcg (1 capsule) q12h via aerolizer inhaler. (Maximum of 24 mcg/day).   
COPD: Oral inhalation 12 mcg (1 capsule) q12h via aerolizer inhaler.   
Exercise-induced bronchospasm (EIB)
: 12 mcg (1 capsule) at least 15 min before exercise as needed.     

Supplied: [12 mcg capsule]

salmeterol 
Serevent ®
MDI: Inhale 2 puffs twice a day. (Do not exceed).

Serevent Diskus:  
     Asthma
: usual dosage for adults and children 4 years of age and older is 1 inhalation (50 mcg) twice daily (morning and evening, approximately 12 hours apart).  If symptoms arise in the period between doses, an inhaled, short-acting beta 2 -agonist should be taken for immediate relief.       
    COPD:  usual dosage for adults is 1 inhalation (50 mcg) twice daily (morning and evening, approximately 12 hours apart).    
     Prevention of Exercise-Induced Bronchospasm (EIB):
One inhalation at least 30 minutes before exercise.  Additional doses should not be used for 12 hours after the administration of this drug. If regular, twice-daily dosing is not effective in preventing EIB, other appropriate therapy for EIB should be considered. 
Combination (Beta2 agonist + Anticholinergic)       [TOP]
Combivent ®
albuterol + ipratropium
Adult (usual):  COPD: (MDI):  2 inhalations 4 times daily (Max of 12 puffs/day).    Inhalation solution: one 3 ml vial via nebulization 4 times daily (Max of 6 doses/day).  
Combination (Beta2 agonist + Corticosteroid)       [TOP]
Advair ®
fluticasone + salmeterol
Adult (usual): Asthma: 1 puff twice daily (morning and evening) approximately 12 hours apart.  More frequent administration (more than twice daily) or a higher number of inhalations (more than 1 puff twice daily) is not recommended.   
[Supplied: Advair Diskus: 100/50, 250/50 ,500/50 ]
Symbicort ®
budesonide + formoterol
Adult (usual):  1-2 inhalations once or twice daily (Maximum daily maintenance dose: 4 inhalations).   Maximum dose during worsening asthma: 4 inhalations twice daily.  [Supplied:  100/6 and 200/6]

Inhaled Corticosteroids       [TOP]

beclomethasone Vanceril ® Beclovent ®Inhale 2 puffs 3 to 4 times daily or  4 puffs twice a day.

budesonide 
Pulmicort ®

Adult (usual): Asthma:  1-4 puffs twice daily (Max of 4 puffs bid).  Note: patients with mild symptoms may be converted to once daily administration (1-2 puffs qd).   [Supplied: MDI 200 mcg/inhalation]
flunisolide 
Aerobid ®
inhale 2-4 puffs twice a day.
fluticasone 
Flovent ®
Inhale 2-4 puffs twice a day.   Supplied: [44,110,220 mcg]
mometasone
furoate

Asmanex ®
In-vitro studies show that mometasone is similar in potency to fluticasone and more potent than budesonide, beclomethasone, and triamcinolone.

Adult (usual): Asthma: 
Previous Therapy  Recommended Starting Dose Highest Recommended Daily Dose
Bronchodilators alone 220 mcg QD PM*  440 mcg**
Inhaled corticosteroids 220 mcg QD PM*  440 mcg**
Oral corticosteroids† 440 mcg BID  880 mcg
When administered once daily ASMANEX should only be taken in the PM.   The 440 mcg daily dose may be administered in divided doses of 220 mcg twice daily or as 440 mcg once daily. NOTE: In all patients, it is desirable to titrate to the lowest effective dose once asthma stability is achieved.

For Patients Currently Receiving Chronic Oral Corticosteroid Therapy:  Prednisone should be reduced no faster than 2.5 mg/day on a weekly basis, beginning after at least 1 week of ASMANEX TWISTHALER therapy. Patients should be carefully monitored for signs of asthma instability, including serial objective measures of airflow, and for signs of adrenal insufficiency. Once prednisone reduction is complete, the dosage of mometasone furoate should be reduced to the lowest effective dosage

HOW TO USE - Remove the ASMANEX TWISTHALER from its foil pouch and write the date on the cap label. It’s important to throw away the inhaler 45 days after this date or when the dose counter reads “00,” whichever comes first.
Step 1. Open inhaler - Hold the inhaler straight up with the pink portion (the base) on the bottom. It is important that you remove the cap of the TWISTHALER® while it is in this upright position to make sure that you get the right amount of medicine with each dose. Holding the pink base, twist the cap in a counterclockwise direction to remove it. As you lift off the
cap, the dose counter on the base will count down by one. (If you began with the dose counter reading “30,” this action will cause it to now read “29.”) This action loads the device with the medicine that you are now ready to inhale. IT IS IMPORTANT TO NOTE that the indented arrow (located on the white portion of the TWISTHALER®, directly above the pink base) is pointing to the dose counter.
Step 2. Inhale dose - Exhale fully. Then bring the TWISTHALER®up to your mouth with the mouthpiece facing toward you. Place it in your mouth, holding it in a horizontal position as illustrated. Firmly closing your lips around the mouthpiece, take in a fast, deep breath. Since the medication is a very fine powder, you may not be able to feel or taste it after inhalation.
Remove the TWISTHALER from your mouth and hold your breath for about 10 seconds, or as long as you comfortably can. IMPORTANT: DO NOT BREATHE OUT THROUGH THE INHALER. After you take your medicine, it is important that you wipe the mouthpiece dry, if necessary, and immediately replace the cap firmly closing the TWISTHALER.
This is the only way to be sure that your next dose is properly loaded. Be sure that the arrow is in line with the dose-counter window. The cap needs to be put back on and turned in a clockwise direction, as you gently press down. You’ll hear a distinctive “click” to let you know that the cap is fully closed.

Supplied:  Powder for oral inhalation:  Asmanex® Twisthaler®: 220 mcg (14 units, 30 units, 60 units, 120 units)

triamcinolone Azmacort ®inhale: 2 puffs 3 to 4 times a day  or 4 puffs twice a day. Maximum: 16 puffs/day.

Leukotriene inhibitors       [TOP]

montelukast Singulair ®Leukotriene Receptor Antagonist.   Adult (usual): Asthma or allergic seasonal rhinitis: 10 mg orally once daily in the evening.

Supplied:  10 mg tablet.   4mg, 5mg chewable tablet.

zafirlukast 
Accolate ®
20 mg orally twice daily between meals.
zileuton 
Zyflo ®
600 mg orally 4 times a day.

Mast Cell stabilizers       [TOP]

cromolyn sodium Intal ®Inhale 2 puffs 4 times a day.
nedocromil 
Tilade ®
Inhale 2 puffs 4 times a day.

Other       [TOP]

acetylcysteine
Mucomyst ®
Acetadote ®

Mucolytic agent. 
Adult
(usual):
 
Acetaminophen poisoning
:   140 mg/kg orally, followed by 17 doses of 70 mg/kg every 4 hours. Repeat dose if emesis occurs within 1 hour of administration. Therapy should continue until all doses are administered even though the acetaminophen plasma level has dropped below the toxic range.  Alternatively: Give Acetadote ®: Loading dose: 150 mg/kg IV over 60 minutes. Maintenance dose: 50 mg/kg infused over 4 hours followed by 100 mg /kg infused over 16 hours. Note: To avoid fluid overload in patients <40 kg and those requiring fluid restriction, decrease volume of D5W proportionally.

Adjuvant therapy in respiratory conditions:  Note: Patients should receive bronchodilator 15 minutes prior to dose.  Inhalation, nebulization: 10% and 20% solution. Dilute 20% solution with sodium chloride or sterile water for inhalation. 10% solution may be used undiluted: 3-5 ml of 20% solution or 6-10 ml of 10% solution until nebulized - given 3-4 times/day. Dosing range: 1-10 ml of 20% solution or 2-20 ml of 10% solution every 2-6 hours.  Into tracheostomy: 1-2 ml of 10% to 20% solution every 1-4 hours.

Decrease risk of contrast-induced nephropathy: (4 doses total): 600 mg (3ml) po BID on the day before the contrast injection, then 600 mg (3ml) in a.m. on the day of the contrast injection (immediately before) and 600 mg (3ml) in the evening. In all cases the patient should be well hydrated. This is particularly important in patients with underlying renal dx or diabetes mellitus. Hydrate patient with saline concurrently.

Supplied: (Mucomyst ® soln): 10% [100 mg/ml] - 4 ml, 10 ml, 30 ml.  20% [200 mg/ml] - 4 ml, 10 ml, 30 ml.  (Acetadote ® injection): 20% [200 mg/ml] (30 ml)

aminophylline /theophylline:Maximum rate: 25 mg/min. IV loading: 5 mg/kg TBW based on theophylline or 6 mg/kg based on aminophylline. 
Previous therapy: [Loading dose= 0.5 L/kg TBW x (desired level - current level)] IV maintenance dose based on IBW and theophylline. For aminophylline dosing divide result by 0.8. 
Adult non-smoker
: 0.4 mg/kg/hr 
Adult (smoker): 0.7 mg/kg/hr 
Elderly (smoker): 0.5 mg/kg/hr 
Elderly (non-smoker)/ CHF/ Liver disease: 0.2 mg/kg/hr. 

Obtain level 24-48 hours after initiation of therapy. Average half-life: 3 to 12 hrs. Vd: 0.5 L/kg. Therapeutic range: 5-20 mcg/ml. IVPB is the least desirable route of admin. It is less effective than a continuous infusion. IVPB-cyclic improvement is seen at the peak with a rapid decline towards the trough.



Comparable Daily Doses for Inhaled Corticosteroids 
 

A D U L T S

Drug

Low Dose

Medium Dose

High Dose

Beclomethasone dipropionate

168 – 504 mcg

504 – 840 mcg

>840 mcg

42 mcg/puff (4-12 puffs – 42 mcg) (12-20 puffs – 42 mcg) (>20 puffs – 42 mcg)
84 mcg/puff (2-6 puffs – 84 mcg) (6-10 puffs – 84 mcg) (>10 puffs – 84 mcg)
 

Budesonide
DPI:
  200 mcg/dose

200 – 400 mcg
(1-2 inhalations)

400 – 600 mcg
(2-3 inhalations)

>600 mcg
(>3 inhalations)

 

Flunisolide
250 mcg/puff

500 – 1000 mcg
(2-4 puffs)

1000 – 2000 mcg
(4-8 puffs)

>2000 mcg
(>8 puffs)

 

Fluticasone

88 – 264 mcg

264 – 660 mcg

>660 mcg

MDI:  44, 110, 220 mcg/puff

(2-6 puffs – 44 mcg  OR 2 puffs – 110 mcg)

(2-6 puffs – 110 mcg)

(>6 puffs – 110 mcg OR >3 puffs – 220 mcg)

DPI:  50, 100, 250 mcg/dose (2-6 inhalations – 50 mcg) (3-6 inhalations – 100 mcg)

(>6 inhalations – 100 mcg   OR  >2 inhalations – 250 mcg)

 

Triamcinolone acetonide
100 mcg/puff

400 – 1000 mcg
(4-10 puffs)

1000 – 2000 mcg
(10-20 puffs)

>2000 mcg
(>20 puffs)

 

 

 

 

CHILDREN

Drug

Low Dose

Medium Dose

High Dose

Beclomethasone dipropionate

84 – 336 mcg

336 – 672 mcg

>672 mcg

42 mcg/puff (2-8 puffs – 42 mcg) (8-16 puffs – 42 mcg) (>16 puffs – 42 mcg)
84 mcg/puff (1-4 puffs – 84 mcg) (4-8 puffs – 84 mcg) (>8 puffs – 84 mcg)
 

Budesonide
DPI:  200 mcg/dose

100 – 200 mcg

200 – 400 mcg
(1-2 inhalations)

>400 mcg
(>2 inhalations)

 

Flunisolide
250 mcg/puff

500 – 750 mcg
(2-3 puffs)

1000 – 1250 mcg
(4-5 puffs)

>1250 mcg
(>5 puffs)

 

Fluticasone

88 – 176 mcg

176 – 440 mcg

>440 mcg

MDI:  44, 110, 220 mcg/puff (2-4 puffs – 44 mcg)

(4-10 puffs – 110 mcg  OR 2-4 puffs – 110 mcg)

(>4 puffs – 110 mcg, OR >2 puffs – 220 mcg)

DPI:  50, 100, 250 mcg/dose (2-4 inhalations – 50 mcg) (2-4 inhalations – 100 mcg)

(>4 inhalations – 100 mcg OR >2 inhalations – 250 mcg)

 

Triamcinolone acetonide
100 mcg/puff

400 – 800 mcg
(4-8 puffs)

800 – 1200 mcg
(8-12 puffs)

>1200 mcg
(>12 puffs)


DPI = dry powder inhaler                   MDI = metered dose inhaler
more Career Center image description
Medical Calculators - A thru Z
Lab Values - A thru Z