Ipratropium
Atrovent · Combivent (with albuterol)
Inhaled quaternary anticholinergic / muscarinic antagonist
Inhaled quaternary ammonium muscarinic antagonist — minimal systemic absorption. Blocks parasympathetic vagal tone in airways → bronchodilation. Synergistic with β2 agonists.
Indications
- •COPD exacerbation (more effective than in asthma)
- •Acute asthma exacerbation (combined with albuterol)
- •Anesthesia-induced bronchospasm in COPD patients
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| Nebulizer | 0.5 mg q4–6 h (or with albuterol q20 min × 3 in acute exacerbation) | 0.25 mg |
| MDI | 2 puffs (17 mcg each) q4–6 h | — |
| Combivent (albuterol + ipratropium) | 1 vial (3 mL) neb q4–6 h | — |
Pharmacokinetics
Onset 15 min (slower than albuterol). Peak 1–2 h. Duration 4–6 h. Minimal systemic absorption.
Hemodynamic effects
Minimal — quaternary structure prevents systemic anticholinergic effects.
Respiratory effects
Bronchodilation; thickens secretions slightly.
Side effects
- !Dry mouth, metallic taste
- !Cough
- !Acute angle-closure glaucoma (if mist contacts eye — use mouthpiece, not face mask, in glaucoma patients)
- !Urinary retention (rare with inhaled)
Contraindications
- ×Hypersensitivity to atropine derivatives
- ×Soy lecithin allergy (some MDI formulations)
Clinical pearls
- ★COPD > ASTHMA: ipratropium is more useful in COPD (vagal-driven bronchospasm) than asthma (inflammatory). Combivent works for both.
- ★MOUTHPIECE NOT MASK in glaucoma — eye exposure can precipitate acute angle closure.
- ★ONSET LAG: 15-min onset means it's not a rescue inhaler. Pair with albuterol for acute relief.
- ★TIOTROPIUM (LAMA): once-daily long-acting cousin used for COPD maintenance — different drug, same mechanism.
Other drugs in Aerosols / Inhalers
- Albuterol
Selective β2 agonist → activates Gs → ↑cAMP → bronchial smooth-muscle relaxation. Some β1 cross-reactivity at high doses (tachycardia).
- Racemic Epinephrine (nebulized)
Topical airway α-agonism → mucosal vasoconstriction → reduced edema. β2 effect contributes to bronchodilation. Used to treat upper-airway edema rather than lower-airway bronchospasm.
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Suggested reading
- •Stoelting & Hines, Pharmacology & Physiology in Anesthetic Practice, 6e
- •Miller's Anesthesia, 9e
- •FDA package insert
