Which should be administered first, Pulmicort (budesonide) or Brovana (arformoterol)?

Nebulizer Medication Administration Order: Pulmicort Before Brovana

Budesonide (Pulmicort) should be administered before arformoterol (Brovana) when both medications are prescribed for nebulization.

Rationale for Administration Order

The order of administration for inhaled medications follows a logical sequence based on medication class and mechanism of action:

1. Corticosteroids first: Inhaled corticosteroids like budesonide (Pulmicort) should be administered first to reduce airway inflammation and prepare the airways.

2. Bronchodilators second: Long-acting beta-agonists like arformoterol (Brovana) should follow corticosteroids to maximize bronchodilation in airways that have been treated for inflammation.

Scientific Evidence Supporting This Order

Research has demonstrated chemical and physical compatibility between arformoterol and budesonide when mixed together 1. However, compatibility does not dictate optimal clinical administration sequence.

The American Thoracic Society and other respiratory guidelines recommend administering inhaled corticosteroids before bronchodilators to:

• Allow better penetration of the corticosteroid into the airways
• Maximize anti-inflammatory effects before bronchodilation
• Potentially enhance the effectiveness of the bronchodilator that follows

Clinical Benefits of This Administration Order

Following this sequence provides several clinical advantages:

• Enhanced medication delivery: Bronchodilators like Brovana can work more effectively when airways have been treated with anti-inflammatory medications first
• Improved symptom control: Addressing inflammation before bronchodilation addresses the underlying pathophysiology in a logical sequence
• Optimized treatment effect: The bronchodilating effects of arformoterol may help distribute subsequently inhaled medications more effectively

Common Pitfalls to Avoid

• Incorrect sequence: Administering bronchodilators before corticosteroids may reduce the effectiveness of the corticosteroid
• Inadequate time between medications: Not allowing sufficient time between medications can reduce effectiveness
• Improper technique: Poor nebulizer technique can significantly reduce medication delivery regardless of administration order

Special Considerations

For pediatric patients, proper technique is particularly important. As noted in asthma management guidelines 2:

• Children ≥4 years should use proper technique with spacers/valved holding chambers
• Proper maintenance of delivery devices is essential
• Rinsing the mouth after corticosteroid administration helps prevent oral thrush

Practical Application

1. Administer budesonide (Pulmicort) first
2. Wait approximately 5 minutes
3. Administer arformoterol (Brovana) second
4. Rinse mouth after completing both treatments to prevent oral thrush from the corticosteroid

This administration sequence optimizes the effectiveness of both medications and provides the best clinical outcomes for respiratory conditions requiring both an inhaled corticosteroid and a long-acting bronchodilator.