Ventolin (Albuterol)

Brand name : Ventolin

Generic Name : Albuterol

Manufacturer : Glaxo Wellcome

Description

Each 5 mL of expectorant syrup contains salbutamol sulfate equivalent to salbutamol BP 1 mg and guaifenesin BPC 50 mg.

Each pressurized metered-dose inhaler delivers salbutamol (as sulfate) 100 mcg/actuation, into the mouthpiece of a specially designed actuator.

Each 2.5 mL nebule contains 2.5 mg salbutamol sulfate solution in normal saline. The concentration of salbutamol is 0.1% (salbutamol as the sulfate 1 mg/mL).

Each mL of ampoule contains salbutamol sulfate equivalent to salbutamol 0.5 mg (500 mcg/mL) in a sterile isotonic solution adjusted to pH 3.5.

The respirator solution is adjusted with acid to pH 3.5.

The evohaler also contains CFC-free propellant HFA134A.

Precautions

The management of asthma should normally follow a stepwise programme, and response should be monitored clinically and by lung function tests.

Increasing use of short-acting inhaled ß2-agonists to control symptoms indicates deterioration of asthma control. Under these conditions, the patient’s therapy plan should be reassessed.

Sudden and progressive deterioration in asthma control is potentially life-threatening and consideration should be given to starting or increasing corticosteroid therapy.

If dose fails to give usual relief, medical advice should be sought.

Use with caution in patients with thyrotoxicosis.

In common with other ß-adrenoceptor agonists, Ventolin can induce reversible metabolic changes, eg reversible hypokalaemia and increased blood sugar levels. Concurrent administration of corticosteroids can exaggerate this effect.

Potentially serious hypokalaemia may result from ß2-agonist therapy mainly from parenteral and nebulised administration. Particular caution is advised in acute severe asthma as this effect may be potentiated by concomitant treatment with xanthine derivatives, steroids, diuretics and by hypoxia. It is recommended that serum potassium levels are monitored in such situations.

Expectorant Syrup: Long-term treatment with Ventolin expectorant (sugar-containing preparation) increases the risk of dental caries. It is important that adequate dental hygiene is maintained.

Respirator Solution/Nebules: Caution in patients who have received large doses of other sympathomimetic drugs.

Acute angle-closure glaucoma with a combination of nebulised salbutamol and ipratropium bromide. A combination of nebulised salbutamol with nebulised anticholinergics should therefore be used cautiously. Patients should be warned not to let the solution or mist enter the eye.
Patients receiving treatment at home with Ventolin respirator solution must be warned that if either the usual relief is diminished or the usual duration of action reduced, they should not increase the dose or its frequency of administration, but should seek medical advice.

Respirator Solution: Reversible metabolic changes, eg increased blood glucose.

Evohaler: In patients considered at risk, daily peak flow monitoring may be instituted.

In the event of a previously effective dose of inhaled salbutamol failing to give relief for at least 3 hrs, seek medical advice.

Patients’ inhaler technique should be checked to make sure that aerosol actuation is synchronised with inspiration of breath for optimum delivery of the drug to the lungs.

Nebules: In domiciliary use, if dose fails to give usual relief, medical advice should be sought.

Injection: The use of Ventolin parenteral preparations in the treatment of severe bronchospasm or status asthmaticus does not obviate the requirement for glucocorticoid steroid therapy as appropriate. When practicable, administration of oxygen concurrently with parenteral Ventolin is recommended, particularly when it is given by IV infusion in hypoxic patients.

Diabetic patients and those currently receiving corticosteroids should be monitored frequently during IV infusion of Ventolin. For these patients, Ventolin injection should be diluted with sodium chloride injection BP, rather than sodium chloride and dextrose injection BP.

In the treatment of premature labour by IV infusion of salbutamol increases in maternal heart rate of the order of 20-50 beats/min usually accompany the infusion. The maternal pulse rate should be monitored and not normally allowed to exceed a steady rate of 140 beats/min. Maternal blood pressure may fall slightly during the infusion; the effect being greater on diastolic than on systolic pressure. Falls in diastolic pressure are usually within the range of 10-20 mm Hg. The effect of infusion on foetal heart rate is less marked but increases of up to 20 beats/min may occur. In the treatment of premature labour, before Ventolin parenteral preparations are given to any patient with known heart disease, an adequate assessment of the patient’s cardiovascular status should be made by a physician experienced in cardiology.

Tablet/Injection: As maternal pulmonary oedema has been reported during or following treatment of premature labour with ß2-agonists, careful attention should be given to fluid balance and cardiorespiratory function monitored.

Use in pregnancy & lactation: As with any medicine, administration of drugs during pregnancy should only be considered if the expected benefit to the mother is greater than any possible risk to the foetus.

During worldwide marketing experience, rare cases of various congenital anomalies, including cleft palate and limb defects have been reported in the offspring of patients being treated with salbutamol. Some of the mothers were taking multiple medications during their pregnancies.
Because no consistent pattern of defects can be discerned, and baseline rate for congenital anomalies is 2-3%, a relationship with salbutamol use cannot be established.

As salbutamol is probably secreted in breast milk, its use in nursing mothers is not recommended unless the expected benefits outweigh any potential risk. It is not known whether salbutamol in breast milk has a harmful effect on the neonate.

Indications

Tablet: For the relief of bronchospasm in bronchial asthma of all types, chronic bronchitis and emphysema. Management of uncomplicated premature labour during the 3rd trimester of pregnancy following the control of uterine contractions with parenteral salbutamol.

Syrup: Management and prevention of attack in asthma. For the relief of bronchospasm in bronchial asthma of all types, chronic bronchitis and emphysema. It is a suitable oral therapy for children or those adults who prefer liquid medicines.

Expectorant Syrup: For respiratory disorders where bronchospasm and excessive secretion of tenacious mucus are complicating factors, eg bronchial asthma, chronic bronchitis and emphysema.
Respirator Solution/Nebules: Management and prevention of attack in asthma. Routine management of chronic bronchospasm unresponsive to conventional therapy. Treatment of acute severe asthma (status asthmaticus).

Evohaler: Management and prevention of attack in mild asthma and for the treatment of acute exacerbations in moderate and severe asthma.

Injection: Management of an asthmatic attack, and for uncomplicated premature labor, under the direction of a physician. Relief of severe bronchospasm associated with asthma or bronchitis and for the treatment of status asthmaticus. For the management of uncomplicated premature labour in the last trimester of pregnancy.

Actions

Pharmacology: Salbutamol is a selective ß2-adrenoceptor agonist. At therapeutic doses, it acts on the ß2-adrenoceptors of bronchial muscle, with little or no action on the ß1-adrenoceptors of the heart. With its fast onset of action, it is particularly suitable for the management and prevention of attack in asthma.

Bronchodilators should not be the only or main treatment in patients with severe or unstable asthma. Severe asthma requires regular medical assessment as death may occur. Patients with severe asthma have constant symptoms and frequent exacerbations, with limited physical capacity, and Peak Expiratory Flow (PEF) values <60% predicted at baseline with >30% variability, usually not returning entirely to normal after a bronchodilator. These patients will require high dose inhaled (eg, >1 mg/day beclomethasone dipropionate) or oral corticosteroid therapy. Sudden worsening of symptoms may require increased corticosteroid dosage which should be administered under urgent medical supervision.

With this primary background corticosteroid treatment, Ventolin provides essential rescue medication for a severe asthmatic in treating acute exacerbations. Failure to respond promptly or fully to such rescue medication signals a need for urgent medical advice and treatment.
Salbutamol provides short-acting (4 hrs) bronchodilation with fast onset (within 5 min) in reversible airways obstruction due to asthma, chronic bronchitis and emphysema. It is suitable for long-term use in the relief and prevention of asthmatic symptoms.

Ventolin should be used to relieve symptoms when they occur and to prevent them in those circumstances recognised by the patient to precipitate an asthmatic attack (eg, before exercise or unavoidable allergen exposure).

Ventolin is particularly valuable as rescue medication in mild, moderate or severe asthma provided that reliance on it does not delay the introduction and use of regular inhaled corticosteroid therapy.
Expectorant Syrup: The combination of salbutamol with guaifenesin is designed to relieve respiratory obstruction.

Pharmacokinetics: Salbutamol administered IV has a half-life of 4-6 hrs (tablet/syrup/evohaler/nebules) and 2.4-4.2 hrs (expectorant syrup/respirator solution/injection), and orally 2.7-5.5 hrs (expectorant syrup), and is cleared partly renally and partly by metabolism to the inactive 4’-O-sulfate (phenolic sulfate) which is also excreted primarily in the urine. The faeces is a minor route of excretion. The majority of a dose of salbutamol given IV, orally or by inhalation is excreted within 72 hrs. Salbutamol is bound to plasma proteins to the extent of 10%.

After oral administration, salbutamol is absorbed from the gastrointestinal tract and undergoes considerable first-pass metabolism to the phenolic sulfate. Both unchanged drug and conjugate are excreted primarily in the urine. The bioavailability of orally administered salbutamol is about 50%.
After administration by the inhaled route between 10% and 20% of the dose reaches the lower airways. The remainder is retained in the delivery system or is deposited in the oropharynx from where it is swallowed. The fraction deposited in the airways is absorbed into the pulmonary tissues and circulation but is not metabolized by the lung. On reaching the systemic circulation, it becomes accessible to hepatic metabolism and is excreted, primarily in the urine, as unchanged drug and as the phenolic sulfate.

The swallowed portion of an inhaled dose is absorbed from the gastrointestinal tract and undergoes considerable first-pass metabolism to the phenolic sulfate. Both unchanged drug and conjugate are excreted primarily in the urine.

Toxicology: Preclinical Safety Data: In common with other potent selective ß2-receptor agonists, salbutamol has been shown to be teratogenic in mice when given SC. In a reproductive study, 9.3% of foetuses were found to have a cleft palate, at 2.5 mg/kg, 4 times the maximum human oral dose. In rats, treatment at the levels of 0.5, 2.32, 10.75 and 50 mg/kg/day orally throughout pregnancy resulted in no significant foetal abnormalities. The only toxic effect was an increase in neonatal mortality at the highest dose level as the result of lack of maternal care. A reproductive study in rabbits revealed cranial malformations in 37% of foetuses at 50 mg/kg/day, 78 times the maximum human oral dose.

HFA134a has been shown to be nontoxic at very high vapour concentrations, far in excess of those likely to be experienced by patients, in a wide range of animal species exposed daily for periods of 2 years.

Dosage

Salbutamol has a duration of action of 4-6 hrs in most patients.

Increasing use of ß2-agonists may be a sign of worsening asthma. Under these conditions, a reassessment of the patient’s therapy plan may be required and concomitant glucocorticosteroid therapy should be considered.

As there may be adverse effects associated with excessive dosing, the dosage or frequency of administration should only be increased on medical advice.

Tablet: Adults: The usual effective dose is 2 tabs (4 mg) 3 or 4 times per day.
If adequate bronchodilation is not obtained, each single dose may be gradually increased to as much as 4 tabs (8 mg).

Some patients obtain adequate relief with 1 tab (2 mg) 3 or 4 times daily.
In the management of premature labour, after uterine contractions have been controlled by IV infusion of Ventolin and the infusion has been withdrawn, maintenance therapy can be continued with oral Ventolin. The usual dosage is 2 tabs (4 mg), 3 or 4 times daily.

In elderly patients or in those known to be unusually sensitive to ß-adrenergic stimulant drugs, it is advisable to initiate treatment with Ventolin 1 tab (2 mg) 3 or 4 times per day.
Children >12 years: 1-2 tabs (2-4 mg); 6-12 years: 1 tab (2 mg); 2-6 years: ½-1 tab (1-2 mg). All doses to be given 3 or 4 times daily.

Syrup: Adults: The usual effective dose is 2 tsp (10 mL) 3 or 4 times per day. If adequate bronchodilation is not obtained, each single dose may be gradually increased to as much as 4 tsp (20 mL).

Some patients obtain adequate relief with 1 tsp (5 mL) 3 of 4 times daily.
In elderly patients or in those known to be unusually sensitive to ß-adrenergic stimulant drugs, it is advisable to initiate treatment with 1 tsp (5 mL) 3 or 4 times per day.

Children >12 years: 1-2 tsp (5-10 mL); 6-12 years: 1 tsp (5 mL); 2-6 years: ½-1 tsp (2.5-5 mL). All doses to be given 3 or 4 times daily.

Dilution: Ventolin syrup may be diluted with purified water BP. The resulting mixture should be protected from light and used within 28 days.

A 50% v/v dilution of Ventolin syrup has been shown to be adequately preserved against microbial contamination. However, to avoid the possibility of introducing excessive microbial contamination, the purified water used for dilution should be recently prepared or alternatively, it should be boiled and cooled immediately before use.

Dilution of Ventolin syrup with syrup BP or sorbitol solution is not recommended as this may result in precipitation of the cellulose thickening agent.
Admixture of Ventolin syrup with other liquid preparations is not recommended.

Expectorant Syrup: Adults: 2-4 tsp (10-20 mL) 3 or 4 times daily.
Children >12 years: 2-4 tsp (10-20 mL) 3 or 4 times daily; 6-12 years: 2 tsp (10 mL) 3 or 4 times daily; 2-6 years: 1-2 tsp (5-10 mL) 2 or 3 times daily.

The volumes quoted are based on a formulation strength of salbutamol 1 mg per 5 mL of syrup.
Salbutamol has a duration of action of 4-6 hrs in most patients.
As there may be adverse effects associated with excessive dosing, the dosage or frequency of administration should only be increased on medical advice.

Increasing use of ß2-agonists may be a sign of worsening asthma. Under these conditions, a reassessment of the patient’s therapy plan may be required and concomitant glucocorticosteroid therapy should be considered.

Respirator Solution: Ventolin respirator solution is to be used with a respirator or nebuliser, only under the direction of a physician. The solution must not be injected.
Delivery of the aerosol may be by face mask, ‘T’ piece or via an endotracheal tube. Intermittent positive pressure ventilation may be used but is rarely necessary. When there is a risk of anoxia through hypoventilation, oxygen should be added to the inspired air.
As many nebulisers operate on a continuous flow basis, it is likely that the nebulised drug will be released in the local environment. Ventolin respirator solution should therefore be administered in a well ventilated room, particularly in hospitals when several patients may be using nebulisers at the same time.

By Intermittent Administration: Intermittent treatment may be repeated 4 times daily.
Adults: 0.5-1 mL (2.5-5 mg of salbutamol) should be diluted to a final volume of 2 or 2.5 mL using normal saline for injection as a diluent. The resulting solution is inhaled from a suitably driven nebuliser until aerosol generation ceases. Using a correctly matched nebuliser and driving source, this should take about 10 min.
Ventolin respirator solution may be used undiluted for intermittent administration. For this, 2 mL of Ventolin respirator solution (10 mg salbutamol) is placed in the nebuliser and the patient allowed to inhale the nebulised solution until bronchodilatation is achieved. This usually takes 3-5 min.
Some adult patients may require higher doses of salbutamol, up to 10 mg, in which case, nebulisation of the undiluted solution may continue until aerosol generation ceases.

Children: The same mode of administration for intermittent administration is also applicable to children.
The usual dosage for children <12 years is 0.5 ml (2.5 mg salbutamol) diluted to 2 or 2.5 mL using normal saline for injection as diluent. Some children may however require higher doses of salbutamol up to 5 mg.
Clinical efficacy of nebulised salbutamol in infants <18 months is uncertain. As transient hypoxaemia may occur, supplemental oxygen therapy should be considered.

By Continuous Administration: Ventolin respirator solution is diluted with normal saline for injection to contain 50- 100 mcg of salbutamol per mL, (1-2 mL solution made up to 100 ml with diluent). The diluted solution is administered as an aerosol by a suitably driven nebuliser. The usual rate of administration is 1-2 mg/hr.

Dilution: Ventolin respirator solution may be diluted with sodium chloride injection BP (normal saline). Any unused solution in the chamber of the nebuliser must be discarded.
Evohaler: Ventolin evohaler is administered by the oral inhaled route only. In patients who find coordination of a pressurised metered-dose inhaler difficult, a Volumatic spacer may be used with Ventolin evohaler.
Babies and young children may benefit from use of the Babyhaler spacer device with Ventolin evohaler.

Relief of Acute Bronchospasm: Adults: 100 or 200 mcg.

Children: 100 mcg, the dose may be increased to 200 mcg as prescribed by the physician.
Prevention of Allergen or Exercise-Induced Bronchospasm: Adults: 200 mcg before challenge.

Children: 100 mcg before challenge, the dose may be increased to 200 mcg as prescribed by the physician.

Chronic Therapy: Adults: Up to 200 mcg 4 times daily.

Children: Up to 200 mcg 4 times daily.
On demand use of Ventolin should not exceed 4 times daily. Reliance on such supplementary use or a sudden increase in dose indicates deteriorating asthma (see Precautions).

Instructions For Use/Handling:
Testing the Inhaler: Before using for the first time, remove the mouthpiece cover by gently squeezing the sides of the cover, shake the inhaler well, and release 2 puffs into the air to make sure that it works.
If it has not been used for several days, shake it well and release 1 puff into the air to make sure that it works.

Using the Inhaler:
1. Remove the mouthpiece cover by gently squeezing the sides of the cover and check the mouthpiece inside and outside to see that it is clean.
2. Shake the inhaler well.
3. Hold the inhaler upright between fingers and the thumb with the thumb on the base, below the mouthpiece.

4. Breathe out as far as is comfortable and then place the mouthpiece in the mouth between the teeth and close the lips around it but do not bite it.
5. Just after starting to breathe in through the mouth, press down on the top of the inhaler to release salbutamol while still breathing in steadily and deeply.
6. While holding the breath, take the inhaler from the mouth and take the finger from the top of the inhaler. Continue holding the breath for as long as is comfortable.

7. If it is needed to take further puffs, keep the inhaler upright and wait about half a minute before repeating steps 2-6.

The mouthpiece cover is replaced by firmly pushing and snapping the cap into position.

Note: Do not rush steps 4, 5 and 6. It is important to start breathing in as slowly as possible just before operating the inhaler.

Practice in front of a mirror for the first few times. If a ‘mist’ is seen coming from the top of the inhaler or the sides of the mouth, start again from step 2.
If the doctor has given different instructions for using the inhaler, follow them carefully. Tell the doctor if there are any difficulties.

Cleaning: The inhaler should be cleaned at least once a week.

Remove the metal canister from the plastic casing of the inhaler and remove the mouthpiece cover.
Rinse the actuator thoroughly under warm running water.
Dry the actuator thoroughly inside and out.
Replace the canister and mouthpiece cover.
Do not put the metal canister into water.

Nebules: Ventolin nebules are intended to be used undiluted. However, if prolonged delivery time is desirable (>10 min) dilution using normal saline for injection as a diluent may be required.

Ventolin nebules are to be used with a nebuliser, under the direction of a physician. The solution must not be injected.

Delivery of the aerosol may be by face mask, ‘T’ piece or via an endotracheal tube.
Intermittent positive pressure ventilation may be used but is rarely necessary. When there is a risk of anoxia through hypoventilation, oxygen should be added to the inspired air.

As many nebulisers operate on a continuous flow basis, it is likely that nebulised drug will be released in the local environment. Ventolin nebules should therefore be administered in a well ventilated room, particularly in hospitals when several patients may be using nebulisers at the same time.

Adults and Children: A suitable starting dose of salbutamol by wet inhalation is 2.5 mg. This may be increased to 5 mg. Treatment may be repeated 4 times daily. In adults, higher dosing, up to 40 mg/day, can be given under strict medical supervision in hospital for the treatment of severe airways obstruction.

Clinical efficacy of nebulised salbutamol in infants <18 months is uncertain. As transient hypoxaemia may occur, supplemental oxygen therapy should be considered.

Dilution: Ventolin nebules may be diluted with sodium chloride injection BP.
Injection: Ventolin parenteral preparations are to be used under the direction of a physician and should not be administered in the same syringe or infusion as any other medication.

Adults: Severe Bronchospasm and Status Asthmaticus:
SC Route: 500 mcg (8 mcg/kg body weight) and repeated every 4 hrs as required.
IM Route: 500 mcg (8 mcg/kg body weight) and repeated every 4 hrs as required.
IV Route: 250 mcg (4 mcg/kg body weight) injected slowly. If necessary, the dose may be repeated. If used for slow IV injection, Ventolin injection may be diluted with water for injection BP. A suitably dilute preparation is 250 mcg in 5 mL (50 mcg/mL).

Infusion: In status asthmaticus, infusion rates of 3-20 mcg/min are generally adequate but in patients with respiratory failure, higher dosage has been used with success. A starting dose of 5 mcg/min is recommended with appropriate adjustment in dosage according to patient response.
A suitable solution for infusion may be prepared by diluting 1 mL of Ventolin injection in 50 mL of an infusion solution, eg sodium chloride and dextrose injection BP to provide a salbutamol dose of 10 mcg/mL of solution.

Management of Premature Labour: A suitable solution for IV infusion may be prepared by diluting 1 mL of Ventolin injection in 50 mL of an infusion solution, eg sodium chloride and dextrose injection BP to provide a salbutamol dose of 10 mcg/mL of solution. Infusion rates of 10-45 mcg/min are generally adequate to control uterine contractions but greater or lesser infusion rates may be required according to the strength and frequency of contractions. A starting rate of 10 mcg/min is recommended, increasing the rate at 10-min intervals until there is evidence of patient response shown by diminution in strength, frequency or duration of contractions. Thereafter, the infusion rate may be increased slowly until contractions cease. The maternal pulse rate should be monitored and the infusion rate adjusted to avoid excessive maternal heart rates (>140 beats/min). Once uterine contractions have ceased, the infusion rate should be maintained at the same level for 1 hr and then reduced by 50% decrements at 6-hourly intervals. Treatment may be continued orally with Ventolin tablet 4 mg given 3-4 times daily.

As an alternative procedure or to counteract inadvertent overdosage with oxytocic drugs, Ventolin injection may be administered as a single injection by the IV or IM routes. The usual recommended dose is 100-250 mcg of salbutamol. The dose may be repeated according to the response of the patient.

Children: At present, there is insufficient evidence to recommend a dosage regimen for routine use in children.

Dilution: Ventolin parenteral preparations may be diluted with water for injections BP, sodium chloride injection BP, sodium chloride and dextrose injection BP or dextrose injection BP. These are only recommended diluents.

Overdosage

The preferred antidote for overdosage with salbutamol is a cardioselective ß-blocking agent. However, ß-blocking drugs should be used with caution in patients with a history of bronchospasm.
Hypokalaemia may occur following overdosage with salbutamol. Serum potassium levels should be monitored.

Respirator Solution: During continuous administration of Ventolin respirator solution, any signs of overdosage can be usually counteracted by withdrawal of the drug.

Contraindication

Patients with a history of hypersensitivity to any of the components of Ventolin.

Although intravenous salbutamol and occasionally salbutamol tablets are used in the management of premature labour, uncomplicated by conditions, eg placenta praevia, antepartum haemorrhage or toxaemia of pregnancy, salbutamol presentations should not be used for threatened abortion.
Respirator Solution/Nebules: Inhaled salbutamol presentations are not appropriate for managing premature labour.

Drug Interaction

Salbutamol and nonselective ß-blocking drugs, eg propranolol, should not usually be prescribed together.

Salbutamol is not contraindicated in patients under treatment with monoamine oxidase inhibitors (MAOIs).

Cautions For Usage

As with most inhaled medications in aerosol canisters, the therapeutic effect of this medication may decrease when the canister is cold.

The canister should not be broken, punctured or burnt, even when apparently empty.

Storage

Tablet: Store at a temperature not exceeding 30°C. Store in a dry place and replace cap securely.

Syrup: Store at a temperature not exceeding 30°C. Protect from light.

Expectorant Syrup: Store at a temperature not exceeding 25°C. Protect form light. Ventolin expectorant may be diluted with unpreserved syrup BP. The resulting mixture should be protected from light and will keep for 14 days.

Respirator Solution: Store at a temperature below 25°C. Protect form light. Once the bottle has been opened, the contents should be discarded after 1 month.

Evohaler: Store below 30°C. Protect from frost and direct sunlight.

Nebules: Store at a temperature below 30°C. Protect from light. Any unused solution in the chamber of the nebuliser must be discarded.

Injection: Store below 30°C. Protect from light. All unused admixtures of Ventolin parenteral preparations with infusion fluids should be discarded 24 hrs after preparation.

Annual Packing/Presentation

Tab 2 mg x 100 x 10's, 500's.

Syrup 2 mg/5 mL (sugar-free, fruit-flavoured) x 60 mL, 2 x 1 L.

Expectorant liqd (fruit-flavored) 60 mL, 1 L x 2's.

Respirator soln 0.5% w/v (aqueous, colourless) x 20 mL.

Evohaler 100 mcg/inhalation x 200 doses.

Nebules 2.5 mg x 20's. Amp 0.5 mg/mL (colourless or faintly straw-coloured) x 1 mL x 5's.

Buy Ventolin (Albuterol) Online without Prescription.

No prescription Needed. Free worldwide Shipping Fee.