Ipratropium nebulised

The patient was discharged from hospital three weeks ago with antibiotics. There was some improvement, but he is still very short of breath at rest. Five days ago, with worsening shortness of breath over the previous week, the patient took clarithromycin 500 mg b.d. Four days ago he took prednisolone 30 mg daily but has now stopped, with no improvement. He is using nebulisers 7 times daily (salbutamol + ipratropium). Because he was no better today, his daughter called an ambulance. 

Patient s COPD seems to be controlled on combination of inhalers and nebuliser solution. He would use salbutamol and ipratropium solution 2-3 times a day, but when his COPD got worse, he would increase to 4-6 times daily. 

A small number of cases of acute angle-closure glaucoma have been reported in patients treated with a combination of nebulised salbutamol and ipratropium bromide, caused possibly by local absorption of mist containing both products. A combination of nebulised salbutamol with nebulised anticholinergics should therefore be used cautiously. Patients should receive adequate instruction in correct administration and be warned not to let the solution or mist enter the eyes. Use of a mouthpiece rather than a mask for administration would reduce the risk associated with this. 

Add ipratropium 0.5 mg to nebuliser and repeat 6-hourly until patient is improving. 

Beasley CRW, Rafferty P, Holgate ST. Bronchoconstrictor properties of preservatives in ipratropium bromide (Atrovent) nebuliser solution. BrMed 1987 294 1197-1198. 

Rafferty P, Beasley R, Holgate S T 1998 Comparison of the efficacy of preservative free ipratropium bromide and Atrovent nebuliser solution. Thorax 43 446-450 Robinson N, Derksen F, Berney C et al 1993 The ainway response of horses with recurrent airway obstruction (heaves) to aerosol administration of ipratropium bromide. Equine Veterinary Journal 25 299-303 Robinson N, Derksen F, Olszewski M 1996 The... 

Acute angle-closure glaucoma developed rapidly in eight patients given nebulised ipratropium and salbutamol. Increased intra-ocular pressure has been reported in others, including one patient using an ipratropium metered-dose inhaler with nebulised salbutamol. 

ShahP,DhurjonL, Metcalfe T, Gibson JM. Acute angle closure glaucoma associated with nebulised ipratropium bromide and salbutamol. BMJ (1992) 304, 40-1. 

Packe GE, Cayton RM, Mashoudi N. Nebulised ipratropium bromide and salbutamol causing closed-angle glaucoma. Lancet 9%A) ii, 691. 

Nervous System A case of anisocoria has been affribufed to iprafropium [46 ]. A 7-year-old child with severe refractory asthma was admitted in the pediatric intensive care xmit. The patient was started on noninvasive ventilation (NIV) and received nebulised salbutamol and ipratropium. Eighteen hours after the admission anisocoria was noted, which gradually subsided once ipratropium was stopped. Nebulised ipratropium leaking from the NIV may be transferred to the conjunctiva, causing the anticholinergic side effects. 

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