Bronchodilators -Anticholinergics

Name of the Anticholinergics Drugs

1. Ipratropium
2. Tiotropium

Mechanism Of Action

Competitive antagonists of acetylcholine in bronchial smooth muscle

Inhaled antimuscarinics bind to and block muscarinic (M3) receptors, therapy preventing smooth muscle contraction and consequent airway constriction

Indication

• Asthma (ipratropium bromide only)
• COPD

Cautions and contra-indications

Caution in patient susceptible to close –angle glaucoma

Side –Effects

• Dry mouth
• Nausea
• Headache other systemic side effects may occur but are rare

Monitoring

No specific drug monitoring required

Drug interactions

Increased risk of adverse effects if co -administered with another anticholinergic agent

Important points

• Ipratropium bromide Is used predominantly in COPD but can be used in a nebulized form with salbutamol for acute asthma not responsive to standard therapy
• The maximal effect of ipratropium bromide is achieved 30-60 min after administration and the duration of action is 3-6 hrs
• Tiotropium is a long-acting agent that isn’t suitable for the treatment of acute bronchospasm

1.IPRATROPIUM

Nursing Considerations

• Use ipratropium cautiously in patients with angle-closure glaucoma, benign prostatic hyperplasia, or bladder neck obstruction and in patients with hepatic or renal dysfunction.
• As prescribed, mix ipratropium inhalation solution with preservative-free albuterol, and preservative-free ipratropium inhalation solution with cromolyn inhalation solution. Use within 1 hour.
• When using a nebulizer, apply a mouthpiece to prevent drug from leaking out around mask and causing blurred vision or eye pain.

PATIENT TEACHING

• Caution patient not to use ipratropium to treat acute bronchospasm.
• Inform patient that although some people feel relief within 24 hours of drug use, maximum effect may take up to 2 weeks.
• Teach patient to use inhaler or nasal spray Tell him to shake inhaler well at each use.
• Advise patient to keep spray out of his eyes because it may irritate them or blur his vision. If spray comes in contact with eyes, instruct patient to flush them with cool tap water for several minutes and to contact prescriber.
•  Instruct patient to rinse mouth after each nebulizer or inhaler treatment to help minimize throat dryness and irritation.
• If patient is using 0.06% nasal spray for a common cold, advise against use for longer than 4 days.
• Teach patient to track canister contents by counting and recording number of doses.
• Advise patient to report decreased response to ipratropium as well as difficulty voiding, eye pain, nasal dryness, nose bleeds, palpitations, and vision changes.

2. TIOTROPIUM

Patient monitoring

• Closely monitor patient for allergic reaction and paradoxical bronchospasm; if these occur, discontinue drug and consider alternative therapy.
• Closely monitor patients with moderate to severe renal impairment.

Patient teaching

• Give patient information portion of package insert on HandiHaler use.
• Inform patient that drug is once daily maintenance medicine that opens narrowed airways and helps keep them open for 24 hours. Stress that it’s not for immediate (rescue) relief of breathing problems.
• Tell patient that capsules are intended for oral inhalation only and should be used only with Handi Haler device. Emphasize that Handi Haler must not be used to take any other drug.
• Caution patient not to let powder get into eyes.
• Teach patient to take prescribed dose in these steps: Immediately before use, open one sealed blister foil and Handi Haler device, insert capsule, press Handi Haler button once to pierce capsule, and exhale completely before placing mouthpiece into mouth with head upright. Then breathe in slowly and deeply at a rate fast enough to hear capsule vibrate, until lungs are full. Holding breath as long as comfortable, take Handi Haler device out of mouth. Then place device back in mouth and inhale again to get full dose.
• Tell patient not to exhale into Handi Haler mouthpiece at any time.
• Caution patient not to swallow capsules.
• Tell patient not to store capsules in Handi Haler device.
• Instruct patient to clean device as shown in patient information sheet.
• Instruct patient to discard any capsules inadvertently exposed to air while preparing dose.
• Tell patient to contact prescriber immediately if eye pain or discomfort, blurred vision, visual halos, or coloured images occur.
• Instruct patient to immediately stop drug and report signs and symptoms of hypersensitivity reaction (including itching, rash, swelling of the lips, tongue, or throat) or difficulty breathing.
• Tell patient to immediately report signs and symptoms of prostatic hyperplasia or bladder-neck obstruction (such as difficulty passing urine or painful urination).
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the tests mentioned above.

REFERENCES

1. Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
2. McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
3. April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
4. Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
5. Nursebro.com, Search – Nursebro

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