Ipratropium is a bronchodilator medication that works to dilate the airways of the lungs. The FDA approved indications are bronchospasms associated with chronic obstructive lung disease (COPD), which include emphysema and chronic bronchitis. Non-FDA indications include asthma exacerbations as well as clearance of secretions, especially in intubated patients in the ICU.[1]

Ipratropium is an acetylcholine antagonist via blockade of muscarinic cholinergic receptors. Blocking cholinergic receptors decreases the production of cyclic guanosine monophosphate (cGMP). This decrease in the lung airways will lead to decreased contraction of the smooth muscles. The actions of intranasal ipratropium mimic the action of atropine by inhibiting salivary and mucous glands secretions as well as dilating bronchial smooth muscle.

Compared to atropine, orally inhaled ipratropium is a more potent antimuscarinic and bronchial dilator of smooth muscle.

Intranasal ipratropium produces a local parasympathetic response, leading to decreased water secretions of mucosal glands of the nasal system alleviating symptoms of rhinorrhea (allergic or non-allergic).[1]

Studies showed that the mean peak percent increases in FEV1 over baseline were 24 to 25 percent for oral inhaled ipratropium in COPD patients. This research noted similar changes in forced vital capacity curves. However, the combination of ipratropium and albuterol, when given via metered-dose inhaler to patients with COPD, proved more effective than either of the two agents alone.[2]

The administration of ipratropium is via inhalation, either orally or intranasally.

Oral Inhalation:

The oral formulation can be aerosol inhalation or a solution for nebulization.

Aerosol inhalation:

If there is a difficulty of inhalation with actuation, a valved holding chamber (VHC) or a spacer can be given to the patient. A patient can choose between a mouthpiece or a face mask along with the VHC or spacer based on patient convenience. Usually, it is more convenient for patients under the age of 4 to use a tight face mask, and VHC or spacer get the most from treatment. When using a face mask, the patient should be instructed to inhale 3 to 5 times per actuation. After administration patient to be instructed to rinse the mouth with water to decrease the side effect of mouth dryness. Patients should be instructed not to use other persons' inhalers to prevent the transfer of any possible infections.[3]

Dosage:

Adults: 

• 17 mcg per spray
• COPD: 2 sprays every 6 hours
• Asthma exacerbation, moderate to severe: 8 sprays every 20 mins as needed for up to 3 hours
• No renal impairment adjustment is necessary.

Pediatrics: 

• NEB (0.02%): 0.25 MG every 20 mins up to 3 doses for moderate to severe asthma exacerbation: if less than 6 years old.
• NEB (0.02%): 0.25-0.5 MG every 20 mins as needed up to 3 hours for moderate to severe asthma exacerbation: if age from 6 to 12 years old.
• NEB (0.02%): 0.5 MG every 20 mins as needed up to 3 hours for moderate to severe asthma exacerbation: if age 13 years old or above.

Solution for nebulization:

Ipratropium can be mixed with albuterol formations in the same nebulizer within one hour of use. On the other hand, ipratropium should not be mixed with cromolyn solutions as both are incompatible.

Intranasal Inhalation:

Nasal spray solution:

• Prime the unit before using it for the first time.
• Point the sprayer away from patients or other persons/animals.
• Push the activator 6 to 7 pushes until a wide and fine spray is observed.
• After that, if the unit remains unused for over 24 hours, then prime the unit again by pushing the pump at least twice before use. If the unit remains unused for more than 7 days, then prime the unit again by pushing the pump seven times all over again.
• Patients should be instructed not to use other peoples' inhalers to prevent the transfer of any possible infections.[2]

Dosage:

• 0.03% solution: 21 mcg/spray
• 0.06% solution: 42 mcg/spray
• Rhinorrhea (allergic or nonallergic rhinitis): 2 sprays of 0.03% solution per nostril every 6 hours. Seasonal allergic rhinitis: 2 sprays of 0.06% per nostril every 6 hours or every 8 hours.
• Common cold: 2 sprays of 0.06% per nostril every 6 hours or every 8 hours
• No renal impairment adjustment is necessary.

Ipratropium Inhaled:

Most common adverse reactions:

• Bronchitis
• Nausea
• Mouth dryness
• Skin flushing
• Dyspnea
• Symptoms of a common cold
• Dizziness
• Sinusitis
• Dyspepsia
• Back pain
• UTI
• Tachycardia
• Arrhythmias
• Severe adverse reactions:
• Hypersensitivity reaction
• Paradoxical bronchospasms
• Anaphylaxis
• Closed-angle glaucoma

Ipratropium Intranasal:

Most common adverse reactions:

• Upper respiratory infections
• Epistaxis
• Pharyngitis
• Headache
• Xerostomia
• Change of taste
• Nausea
• Nasal irritation
• Arrhythmias

Severe adverse reactions[4]:

• Hypersensitivity reaction
• Anaphylaxis

Contraindications to ipratropium inhaler use include patients that are hypersensitive to atropine; this is secondary to the similarity in structure to atropine.

Ipratropium aerosols can cause bronchospasms (paradoxical), which usually happens upon the initial use of this medication. Patients should understand this possibility. If this adverse reaction occurs, then this medication should be immediately discontinued.

Previous severe allergic reaction symptoms upon the use of ipratropium or atropine and its other derivatives, such as angioedema, urticaria, severe shortness of breath, oropharyngeal edema, and ultimately anaphylaxis is a contraindication to ipratropium use.

Caution is necessary for the use of intranasal/inhaled ipratropium in patients with hypertrophic prostate.

Exercise caution with the use of intranasal/inhaled ipratropium in patients with obstruction of the bladder neck.[1]

Caution is recommended in the use of intranasal/inhaled ipratropium in patients with closed-angle glaucoma.[1]

Ipratropium is labeled as category B regarding pregnancy since there are no reports of teratogenesis in animals or humans with ipratropium use (aerosols or nasal spray), but studies in humans are limited. Ipratropium should only be used during pregnancy if the mother's benefits outweigh possible fetus risks.[1]