# Ipratropium (Atrovent) question



## Shishkabob (Jun 28, 2009)

So, going through my Brady drug guide, studying for a quiz on Wednesday and looking at Atrovent.  Contraindications are pretty simple, but had a question.

One of the only 2 contraindications is 
"It should not be used as the *primary treatment* for acute episodes of bronchospasm"



Why?  Yes, I know albuterol tends to be the go-to, and Duoneb when needed.  Vent, or anyone, wanna regale me on the specifics?  Did I miss something obvious?


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## Sasha (Jun 28, 2009)

Atrovent is to be used with albuterol. It wont treat bronchospasm by itself, to my knowledge.


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## rmellish (Jun 28, 2009)

Sasha said:


> Atrovent is to be used with albuterol. It wont treat bronchospasm by itself, to my knowledge.



I figure ipratropium would act as a muscarinic antagonist, but I'm not sure how quickly this effect occurs, or the degree of effect it would have.


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## daedalus (Jun 28, 2009)

Probably because Albuterol is a adrenergic agonist that directly causes bronchodilation while Atrovent is an anticholinergic that will only prevent further parasympathetic activity.


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## MSDeltaFlt (Jun 28, 2009)

Linuss said:


> So, going through my Brady drug guide, studying for a quiz on Wednesday and looking at Atrovent. Contraindications are pretty simple, but had a question.
> 
> One of the only 2 contraindications is
> "It should not be used as the *primary treatment* for acute episodes of bronchospasm"
> ...


 
Albuterol kicks in faster than Atrovent.  Atrovent lasts longer, but doesn't kick in as fast.  You may use Duoneb when needed because it still has albuterol in it.  Make sense?


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## lafmedic1 (Jun 29, 2009)

On a side note is ipatropium still peanut oil based ? I know we had peanut allergy listed as a contrindication .


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## VentMedic (Jun 29, 2009)

lafmedic1 said:


> On a side note is ipatropium still peanut oil based ? I know we had peanut allergy listed as a contrindication .


 
This has never been an issue for the liquid and that includes Duoneb or any of the Albuterol/Atrovent liquid combos by various manufacturers. There will also be a Xopenex/Atrovent combo in the future.

The Atrovent MDI when it was using a CFC proellant used a Lecithin base.

The HFA Atrovent MDI does not so the soy allergy is not an issue.

However, Combivent MDI has not be able to reformulate to HFA and are still CFC. The FDA has granted them a few more months to achieve this or risk being taken off the market completely.

Atrovent should not be used with patients who have narrow angle glaucoma. Some of the disorders and disease processes get overlooked in an H&P because they are considered to be unimportant. However, the meds used to treat something else can have serious effects or exacerbate something else.

Atrovent is primarily used for COPD such at that with emphysema. Since it has a different mechanism of action, asthmatics do not always need it unless they have a similar obstructive component as found in other forms of COPD. Thus, you may not find many asthmatics on Spiriva unless they are using GP as a physician who is just tossing samples of meds at them at random without any plan of care in mind. Also, if the patient is using Spiriva correctly, the Atrovent will have little effect.

Atrovent will be used by itself to treat some with COPD and if they are not bronchospastic. It may give them relief but not always immediately. They will usually take it as a scheduled med or PRN at the first signs of decompensation. However, they will usually also have a Albuterol inhaler nearby. For some, they become sensitive to the Albuterol as they develop more cardiac problems from advanced COPD.

Still, for rescue, the use of Albuterol or Xopenex is still recommended regardless of what other med is added or to follow.


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## PapaBear434 (Jun 29, 2009)

daedalus said:


> Probably because Albuterol is a adrenergic agonist that directly causes bronchodilation while Atrovent is an anticholinergic that will only prevent further parasympathetic activity.



Pretty much what I came in to say, as I just had that quiz myself.


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## VentMedic (Jun 29, 2009)

Here is the clinical pharmacology of Albuterol and Atrovent taken form their websites. They are two different meds with different actions. 

Again, Atrovent is primarily indicated for those with COPD such as emphysema and chronic bronchitis.

Atrovent is an anticholinergic (parasympatholytic) agent. It appears to inhibit vagally-mediated reflexes by antagonizing the action of acetylcholine, the transmitter agent released at the neuromuscular junctions in the lung. *Anticholinergics prevent the increases in intracellular concentration of cyclic guanosine monophosphate (cyclic GMP)* *which are caused by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle*

Albuterol has a preferential effect on beta2-adrenergic receptors. Beta2-adrenergic receptors are the predominant receptors in bronchial smooth muscle, *Activation of beta2-adrenergic receptors on airway smooth muscle leads to the activation of adenylcyclase and to an increase in the intracellular concentration of cyclic-3′,5′-adenosine monophosphate (cyclic AMP). This increase of cyclic AMP leads to the activation of protein kinase A, which inhibits the phosphorylation of myosin and *l*owers intracellular ionic calcium concentrations, resulting in relaxation.* Albuterol relaxes the smooth muscles of all airways, from the trachea to the terminal bronchioles. Albuterol acts as a functional antagonist to relax the airway irrespective of the spasmogen involved, thus protecting against all bronchoconstrictor challenges. *Increased cyclic AMP concentrations are also associated with the inhibition of release of mediators from mast cells in the airway. *


We also have another drug, *Intal, (Cromolyn sodium)* which acts by inhibiting the release of mediators from mast cells. 

Also, get familar with the new MDIs. Since they have reformulated to the HFA propellant, the names have changed and you may not see regular "Albuterol" inhaler. You will be seeing ProAir, Ventolin and Proventil.

There are also new names for the solutions with AccuNeb being one for Albuterol sulfate and it comes in different dosages.

Vospire ER is the albuterol sulfate tablets.

There names are for the U.S. as Canada and Mexico as well as the European countries have their own trade names and newer meds that are not available in the U.S. at this time as well as other approved routes in their country such as IV. 




.


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## ResTech (Jun 30, 2009)

The main reason for Atrovent is for the synergistic effect when administered together with Albuterol. Both albuterol and atrovent work by different mechanisms or pathways so when administered together you get a greater efficacy then if each med was administered alone. 

Atrovent is a parasympatholytic which as you know works by blocking acetylcholine at the muscarinic receptors in the lungs to reduce bronchoconstriction. Atrovent has a greater onset of action time and its maximum effect is less than albuterol which is why I understand it not to be recommend for administration solely by itself. And factoring the synergistic effect with albuterol, it makes sense to administer atrovent together.

Its 1:30am and is all I can recall from class at the moment. zzzzzz zzzzz


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## Shishkabob (Jun 30, 2009)

See, that's what I've come to understand, but wondered why they had it as a contraindication instead of "Pre-hospital considerations" or something.

Guess it's just an editorial thing.


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## ResTech (Jun 30, 2009)

I guess maybe they listed it as a contraindication as a sole medication because it has a likelihood of failing and not reversing the bronchoconstriction if given alone and so you always go for the albuterol or albuterol/ipratropium... just a guess.


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## austinmedic2004 (Jul 2, 2009)

So, let's clarify exactly why you use Atrovent, a parasympatholytic much like atropine...I haven't seen anyone mention the specific reason, so here it is. I am sure everyone is familiar with why you would use Atropine for an organophosphate poisonoing...it will dry the secretions caused by the hyper-parasympathetic state induced by the acetocholinesterase inhibition. So, to take this mechanism of action to, specifically, the asthmatic patient we need to look at what is happening. We are getting a histamine response leading to secretions in addition to a narrowing of the bronchioles caused again by an inflammatory response. Depending on the severity of the reactive airway disease process, the beta-2 properties of albuterol may be enough to relieve the reaction...however, if the inflammatory response is severe enough you will need the assistance of Atrovent to in effect dry up the secretions released as a result.


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## VentMedic (Jul 2, 2009)

austinmedic2004 said:


> So, let's clarify exactly why you use Atrovent, a parasympatholytic much like atropine...I haven't seen anyone mention the specific reason, so here it is. I am sure everyone is familiar with why you would use Atropine for an organophosphate poisonoing...it will dry the secretions caused by the hyper-parasympathetic state induced by the acetocholinesterase inhibition. So, to take this mechanism of action to, specifically, the asthmatic patient we need to look at what is happening. We are getting a histamine response leading to secretions in addition to a narrowing of the bronchioles caused again by an inflammatory response. Depending on the severity of the reactive airway disease process, the beta-2 properties of albuterol may be enough to relieve the reaction...however, if the inflammatory response is severe enough you will need the assistance of Atrovent to in effect dry up the secretions released as a result.


 
Atrovent is not an anti-inflammatory. Many asthmatics already have thick tenacious secretions that need mobilizing. The EPR-3 also no longer promotes Atrovent for those that have asthma unless they have another COPD component.

Atrovent IS NOT a rescue medication and should not be promoted as one.  It has its purposes and can be used with albuterol.


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## ResTech (Jul 2, 2009)

Atrovent does have a drying effect due to being an anticholinergic and will be effective in drying some secretions. It is my understanding though that Atrovent is administered pre-hospital for it's ability to aid in bronchodilation which is additive to the bronchodilation effect brought about by the beta-2 stimulation from Albuterol. In other words, atrovent is not indicated for its drying effect as you said but instead for its ability to bronchodilate through an additional pathway (blocking acetylcholine) in addition to a beta-2 agonist. 

If the inflammatory response is severe enough, wouldn't Solu-Medrol or a similar steroid be indicated and not atrovent to reduce the inflammation which should also reduce the secretions from the inflammatory response?


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## terrible one (Jul 2, 2009)

Not to hijack this thread but Im curious as do any of your protocols include Mag Sulfate for the treatment of Asthma/COPD refractory to an Albuterol treatment for a patient that will not benefit from Epi?


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## Melbourne MICA (Jul 2, 2009)

*Thunder gone*

Stole my thunder Venty and others. Atrovent increases vagal tone (parasympathetic via muscarinic receptors) and attacks bronchospasm that way as opposed to say Salbutamol which you know is a beta 2 agonist (sympathetics). This is why bronchospasm management is a multipronged attack via the neb route.

Another beta agonist you will be familiar with is adrenaline though I'm still not sure why its affects are counterproductive in asthma (except when the pt is pegging out). (Venty this is where you come in -again).

So I guess it figures you wouldn't give it to someone who is already brady lest 40 beats per minute becomes 10 beats per minute.

Ahh - The wonders of pharmacology.

MM


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## VentMedic (Jul 2, 2009)

ResTech said:


> Atrovent does have a drying effect due to being an anticholinergic and will be effective in drying some secretions. It is my understanding though that Atrovent is administered pre-hospital for it's ability to aid in bronchodilation which is additive to the bronchodilation effect brought about by the beta-2 stimulation from Albuterol. In other words, atrovent is not indicated for its drying effect as you said but instead for its ability to bronchodilate through an additional pathway (blocking acetylcholine) in addition to a beta-2 agonist.
> 
> *If the inflammatory response is severe enough, wouldn't Solu-Medrol or a similar steroid be indicated and not atrovent to reduce the inflammation* which should also reduce the secretions from the inflammatory response?


 
Again, Atrovent is NOT an anti-inflammatory. We do have other MDIs and liquid nebulizers that are anti-inflammatories as well as Solu-medrol. But, before administering, it is always good to first see how much the patient is already taking. 

We do not use it just for drying secretions but to reduce the contractility of smooth muscle. However, Atrovent is available in a nasal spray that is use to treat rhinorrhea. 

Dry muscus in the lungs is not always a good thing. Mucus plugs can create massive atelectasis, require intubation and even bronchoscopy. 

One Atrovent is probably not going to do harm to a patient but one has to understand the whole disease process and the goals. 



> *quote terrible one*
> Not to hijack this thread but Im curious as do any of your protocols include Mag Sulfate for the treatment of Asthma/COPD refractory to an Albuterol treatment for a patient that will not benefit from Epi?


 
How do you know the patient is refractory to Albuterol? Some patients may require over 12 hours of a 20 mg/hour Albuterol treatement given continuously with a special neb. We also give a concentrated 5 mg Albuterol treatment with a breath activated nebulizer to ensure more than 20% reaches the patient. This is for inhospital and on CCT/Specialty transport. As well, we may also need to give the treatment with heliox.

Mag Sulfate has its place in Asthma but in COPD patients it is still controversial. Due to age, many other medical conditions and medications they are taken it is given with caution or after lab values are confirmed.

While Asthma is listed in the COPD category, it is treated differently as are those with emphysema, Cystic Fibrosis, bronchitis and bronchiectasis.


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## terrible one (Jul 2, 2009)

VentMedic said:


> How do you know the patient is refractory to Albuterol? Some patients may require over 12 hours of a 20 mg/hour Albuterol treatement given continuously with a special neb. We also give a concentrated 5 mg Albuterol treatment with a breath activated nebulizer to ensure more than 20% reaches the patient. This is for inhospital and on CCT/Specialty transport. As well, we may also need to give the treatment with heliox.
> 
> Mag Sulfate has its place in Asthma but in COPD patients it is still controversial. Due to age, many other medical conditions and medications they are taken it is given with caution or after lab values are confirmed.
> 
> While Asthma is listed in the COPD category, it is treated differently as are those with emphysema, Cystic Fibrosis, bronchitis and bronchiectasis.



Maybe refractory was the wrong the word, but a patient in moderate to severe distress not benefiting from Albuterol Tx. (Pre-hospital Setting) What is the mechanism of action of Mag for a respiratory patient?


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## VentMedic (Jul 2, 2009)

terrible one said:


> What is the mechanism of action of Mag for a respiratory patient?


 
Magnesium sulfate inhibits smooth muscle contraction, decreases histamine release from mast cells, and inhibits acetylcholine release.


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## VentMedic (Jul 2, 2009)

There is one more little point about Atrovent that should be noted. It does not have FDA approval for the treatment of asthma although it is used off label in emergency situations in combination with albuterol. But then I have already made reference to the EPR-3 guidelines and that probably has been already noted by some. 

There is FDA approval for COPD.

This article also appeared last year. But, some COPD patients have many meds and many medical problems so it is truly difficult to single out one cause.

*Risk For Cardiac Events, Cardiac Death Increased By Popular COPD Treatment*
http://www.medicalnewstoday.com/articles/122842.php



austinmedic2004 said:


> So, let's clarify exactly why you use Atrovent, a parasympatholytic much like atropine...I haven't seen anyone mention the specific reason, so here it is. I am sure everyone is familiar with why you would use Atropine for an organophosphate poisonoing...it will dry the secretions caused by the hyper-parasympathetic state induced by the acetocholinesterase inhibition. So, to take this mechanism of action to, specifically, the asthmatic patient we need to look at what is happening.


 
Nebulized Atropine has not been used for at least 15 years due to its side effects and one of which was the drying of secretions which is not always a good thing. While atropine and Atrovent are in the same family, they have different chemical structures.


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## ResTech (Jul 2, 2009)

For primarily the other students on here... something I realized today to also keep in mind when treating COPD with inhaled medications.... a lot of COPD patients also have a cardiac hx or HTN and may be on a beta blocker. 

The beta blocker that the patient is taking may blunt the effect of the beta-2 agonist rendering it not as effective. So when COPD is treated with a combination therapy of a beta-2 agonist and an anticholinergic, the anticholinergic can work to induce bronchodialtion through a completely different pathway that is not effected by the beta blocker. The atrovent can get around the beta blocker. 

Just wanted to throw that out there as food for thought and to reinforce another reason why combination therapy is advocated as a good idea.... I devoted some study time today to COPD and its treatment and read some good studies and information.


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## austinmedic2004 (Jul 2, 2009)

VentMedic said:


> There is one more little point about Atrovent that should be noted. It does not have FDA approval for the treatment of asthma although it is used off label in emergency situations in combination with albuterol. But then I have already made reference to the EPR-3 guidelines and that probably has been already noted by some.
> 
> There is FDA approval for COPD.
> 
> ...



Atrovent is recommended by EPR-3 in the prehospital management of asthma in Section 5 page 374:

For the treatment of exacerbations, the current update:
— Adds levalbuterol as a SABA treatment for asthma exacerbations.
— For home management of exacerbations, no longer recommends doubling the dose of
ICSs.
— For prehospital management (e.g., emergency transport), encourages standing orders
for albuterol and—for prolonged transport—repeated treatments and protocols to allow
consideration of ipratropium and oral corticosteroids.
— For ED management, reduces dose and frequency of administration of oral
corticosteroids in severe exacerbations, adds consideration of magnesium sulfate or
heliox for severe exacerbations, and adds consideration of initiating an ICS upon
discharge.
— For hospital management, no longer recommends ipratropium bromide.

It is not recommended in the hospital management of asthma as noted in the last point. The use in COPD as well as asthma on a chronic basis would not be recommended due to the cardiac effects and long term cardiac issues, but we are talking about exaserbation of the condition, not maintenance. The risk benefit in the emergent reactive airway indicates the use of Albuterol, Atrovent (for the more serious reaction), corticosteriods, and finally magnesium sulfate IV.


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## VentMedic (Jul 2, 2009)

That's what I stated but it is still off label which is why these are *GUIDELINES* and not specific recipes or protocols.  Please do not confuse these when interpreting them.  Your medical director may have his/her own interpretation based on whatever literature he/she has read or where they did they practice medicine.

I am sorry I do not give out recipes nor do most of the associations that collect the research for *guidelines*.  If you look at Canada's *guidelines* you may find some variations as they have access to different medications and are conducting their own research.  The U.S. usually works with the European Society for their information but even that can differ.

And remember the EPR-3 is directed at Asthma.  If you look on the ATS website you will find the *guidelines* for COPD.


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## VentMedic (Jul 2, 2009)

ResTech said:


> For primarily the other students on here... something I realized today to also keep in mind when treating COPD with inhaled medications.... a lot of COPD patients also have a cardiac hx or HTN and may be on a beta blocker.


 
That is why we were excited when Spiriva became available. Although for difficult cases the doctors may have to get creative with the HTN meds in order to allow for maximum dilation with LABAs and SABAs. 

Also pay close attention to the MDIs the patients are using. They have been noted for easy and sometime accidental OD of the LABA. Symbicort (LABA formotoerol with budesonide) looks very much like ProAir (SABA albuterol). The patient may think they are taking their SABA or rescue albuterol inhaler and are taking the LABA which can present with serious problems including death if too much is taken.


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## MSDeltaFlt (Jul 2, 2009)

I believe I just lost my hearing from all of the explosions because Vent is the bomb!


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## daedalus (Jul 2, 2009)

Melbourne MICA said:


> Stole my thunder Venty and others. Atrovent increases vagal tone (parasympathetic via muscarinic receptors) and attacks bronchospasm that way as opposed to say Salbutamol which you know is a beta 2 agonist (sympathetics). This is why bronchospasm management is a multipronged attack via the neb route.
> 
> Another beta agonist you will be familiar with is adrenaline though I'm still not sure why its affects are counterproductive in asthma (except when the pt is pegging out). (Venty this is where you come in -again).
> 
> ...


Um, no.

Atrovent is not a parasympathomimetic. It is just the opposite. Why would increasing parasympathetic nervous activity help bronchospasm? Where did you get this information?


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## VentMedic (Jul 2, 2009)

MSDeltaFlt said:


> I believe I just lost my hearing from all of the explosions because Vent is the bomb!


 
Now you know why RT was a perfect compliment to my Paramedic cert/degree.   I was able to understand why I could not magically "fix" every patient in the field even back when we had all the cool skills and drugs.  

Seeing just the advancements in the RT field has just been amazing.  Although, there are times I wish I had been a Canadian RT since they were also ahead of the game in some parts of that country.  

Now you combine that with all the other amazing accomplishments in technology, meds and education levels of the healthcare providers, medicine is truly an exciting profession to be a part of.


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## MSDeltaFlt (Jul 2, 2009)

VentMedic said:


> *Now you know why RT was a perfect compliment to my Paramedic cert/degree*. I was able to understand why I could not magically "fix" every patient in the field even back when we had all the cool skills and drugs.
> 
> Seeing just the advancements in the RT field has just been amazing. Although, there are times I wish I had been a Canadian RT since they were also ahead of the game in some parts of that country.
> 
> *Now you combine that with all the other amazing accomplishments* in technology, meds and education levels of the healthcare providers, *medicine is truly an exciting profession to be a part of*.


 
Yes ma'am I do, and yes ma'am it is.


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## fma08 (Dec 28, 2009)

ResTech said:


> For primarily the other students on here... something I realized today to also keep in mind when treating COPD with inhaled medications.... a lot of COPD patients also have a cardiac hx or HTN and may be on a beta blocker.
> 
> The beta blocker that the patient is taking may blunt the effect of the beta-2 agonist rendering it not as effective. So when COPD is treated with a combination therapy of a beta-2 agonist and an anticholinergic, the anticholinergic can work to induce bronchodialtion through a completely different pathway that is not effected by the beta blocker. The atrovent can get around the beta blocker.
> 
> Just wanted to throw that out there as food for thought and to reinforce another reason why combination therapy is advocated as a good idea.... I devoted some study time today to COPD and its treatment and read some good studies and information.



I know this is old but it had been referenced in another thread and I was curious about this post.

It had been my understanding that beta 1 and beta 2 receptors were completely different doing completely different things. beta-1 affecting the heart and beta-2 affecting the lungs. So how would someone being on a beta blocker (eg. metoprolol) for controlling heart rate have problems with a beta-2 agonist?


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## Shishkabob (Dec 28, 2009)

Selective vs non-selective Beta blockers.

Some can be Beta-1 antagonist, some Beta-2, some both.


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## DV_EMT (Dec 28, 2009)

my understanding... vent correct me if i'm wrong... but based upon the contraindacations of Atrovent... you're generally supposed to give Xopenex or Proair as a substitution?


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## fma08 (Dec 28, 2009)

Linuss said:


> Selective vs non-selective Beta blockers.
> 
> Some can be Beta-1 antagonist, some Beta-2, some both.



Gotcha, thanks.


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## fma08 (Dec 28, 2009)

DV_EMT said:


> my understanding... *vent correct me if i'm wrong*... but based upon the contraindacations of Atrovent... you're generally supposed to give Xopenex or Proair as a substitution?



As I understand it, she can't at the moment unless you catch her over at EMT City.

And as it has sounded, you shouldn't be giving Atrovent alone in the pre hospital setting. Also, the liquid or nebulizer form given in the pre-hospital setting, the contraindication of peanut allergy is void because it has to do with the... Solvent? I think in the MDI form. The only contraindication is narrow angle glaucoma I believe and I don't remember why off the top of my head. I'm having a very brain-fart sort of day today.


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## Lifeguards For Life (Dec 28, 2009)

fma08 said:


> As I understand it, she can't at the moment unless you catch her over at EMT City.
> 
> And as it has sounded, you shouldn't be giving Atrovent alone in the pre hospital setting. Also, the liquid or nebulizer form given in the pre-hospital setting, the contraindication of peanut allergy is void because it has to do with the... Solvent? I think in the MDI form. The only contraindication is narrow angle glaucoma I believe and I don't remember why off the top of my head. I'm having a very brain-fart sort of day today.



As an anticholinergic, Ipratropium Bromide is contraindicated in narrow angle glaucoma because  anticholinergics block acetylcholine receptors, resulting in the inhibition of parasympathetic nerve impulses. This action would make stronger the sympathetic nervous system, an action that could dilate the pupil and relax the iris sphincter. Dilation of the pupil could make smaller the passage between the iris and cornea, complicating the exit of the aqueous humor.

The peanut allergy comes into effect because Atrovent utliizes soya lechitin, as an additive in the propellant in the MDI. Soya Lechtin is the phosphatidylcholine, phosphatidylethanolamine, and phosphotidylinositol accumutively extracted from soy beans.


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## Lifeguards For Life (Dec 28, 2009)

Lifeguards For Life said:


> As an anticholinergic, Ipratropium Bromide is contraindicated in narrow angle glaucoma because  anticholinergics block acetylcholine receptors, resulting in the inhibition of parasympathetic nerve impulses. This action would make stronger the sympathetic nervous system, an action that could dilate the pupil and relax the iris sphincter. Dilation of the pupil could make smaller the passage between the iris and cornea, complicating the exit of the aqueous humor.
> 
> The peanut allergy comes into effect because Atrovent utliizes soya lechitin, as an additive in the propellant in the MDI. Soya Lechtin is the phosphatidylcholine, phosphatidylethanolamine, and phosphotidylinositol accumutively extracted from soy beans.



After a talk with Ventmedic, I have just been informed that Atrovent has not contained soy lecithin for at least 2 years when the propellant was converted to HFC. 

Combivent does contain lecithin but it may soon be pulled from the market if it can not reformulate.

Some good information is provided in the following thread.
http://www.emtlife.com/showthread.php?t=13454


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## 18G (Jan 1, 2010)

Narrow angle glaucoma is a relative contraindication. In a patient having acute respiratory distress, your not gonna withhold atrovent if you discover the patient has glaucoma... important to keep in mind.


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## VentMedic (Jan 1, 2010)

18G said:


> Narrow angle glaucoma is a relative contraindication. In a patient having acute respiratory distress, your not gonna withhold atrovent if you discover the patient has glaucoma... important to keep in mind.


 
Is Atrovent considered an emergency medication?  No.

It may be used with an emergency bronchodilator such as Albuterol but by itself it is not to be considered an emergency medication.

Many people get only Albuterol especially if it is bronchospasm.


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## 18G (Jan 1, 2010)

Perhaps I was assuming ppl knew I was meaning using atrovent in conjunction with a beta-2 agonist (ie albuterol) and not solely by itself. Our protocols, as do many surrounding jurisdictions, call for albuterol/atrovent for the first treatment and than just albuterol thereafter. 

I was meaning to say even if a patient does have glaucoma that I am aware of, I would not withhold the atrovent given its benefits in the acute respiratory distress patient. Airway and breathing come before eyes.


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## VentMedic (Jan 1, 2010)

18G said:


> I was meaning to say even if a patient does have glaucoma that I am aware of, I would not withhold the atrovent given its benefits in the acute respiratory distress patient. Airway and breathing come before eyes.


 
But why blind someone if you don't have to?

It is a sinking feeling when you do blind someone and you clearly knew better.


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## 18G (Jan 1, 2010)

But why withhold a medication that will help improve someones respiratory status especially when they are a priority patient and in a lot of distress?

As I have said, glaucoma is a relative contraindication. Atrovent is not going to make a patient go blind when used acutely.


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## VentMedic (Jan 1, 2010)

18G said:


> But why withhold a medication that will help improve someones respiratory status especially when they are a priority patient and in a lot of distress?


 
Atrovent is not going to miraculously cure your patient.

Read its website or the package insert and understand its mechanisms.  

If the patient is a known COPD patient, they will know if they can take Atrovent.  

For someone who had never been diagnosed with lung disease and are having wheezing, the etiology may not even call for atrovent but you have it as a blanket order in your protocols because of limited respiratory knowledge. 

If your patients are in that much distress the albuterol probably will be of little benefit either.


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## VentMedic (Jan 1, 2010)

18G said:


> As I have said, glaucoma is a relative contraindication. Atrovent is not going to make a* patient go blind when used acutely*.


 
Says who?

I have seen this first hand.


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## 18G (Jan 1, 2010)

> Atrovent is not going to miraculously cure your patient.
> *Never said that it would. Although does help in many cases and allows attacking the resp distress through two different pathways versus just one.*
> 
> Read its website or the package insert and understand its mechanisms.
> ...


*

Bottom line is always use your clinical judgment and be familiar with your medications.*


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## VentMedic (Jan 1, 2010)

18G said:


> Bottom line is always use your clinical judgment and be familiar with your medications.


 
Which is why I questioned you about why give atrovent if it may not even be indicated for your patient.


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## Dutch-EMT (Jan 2, 2010)

Atrovent / ipratropiumbromide (parasympathicolyticum) takes 5 minutes to work at maximum effect.
The effect holds on forabout 6-8 hours.

Salbutamol (sympathicomimeticum) takes 1-2 minutes to work at maximum effect. It works shorter, about 5 hours. 

We use in my hospital the combinations of both (known as combivent and ipramol or ipratropium/salbutamol).
We use it a lot and the most commonly side-effects are palpations and agitation, dry mouth, dry cough and sometimes headache.


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## VentMedic (Jan 2, 2010)

Dutch-EMT said:


> Atrovent / ipratropiumbromide (parasympathicolyticum) takes 5 minutes to work at maximum effect.
> The effect holds on forabout 6-8 hours.
> 
> Salbutamol (sympathicomimeticum) takes 1-2 minutes to work at maximum effect. It works shorter, about 5 hours.
> ...


 
But even in the European guidelines Atrovent is not recommended for any and all respiratory diseases.

Combivent is an MDI which I am surprised you are still using? Wasn't your area a little more strict with the CFC and HFA regulation so an extension was not so easy to get?


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## coolidge (Jan 2, 2010)

Ipratropium 
-anticholinergic
-is a bronchodilator
-has a slower onset of action than beta agonists
-competitive inhibitor of muscarinic cholinergic receptors
-anticholinergics are less potent bronchodilators than inhaled beta-2 agonists 
-may provide additive effects to beta-2 agonist 
-not used to block exercise-induced bronchospasm. 
-associated with drying of the mouth and respiratory secretions
-it may increase wheezing


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## Dutch-EMT (Jan 3, 2010)

The latest Dutch Ambulance protocols for Astma Bronchialis/COPD.


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## redcrossemt (Jan 4, 2010)

VentMedic said:


> We also have another drug, *Intal, (Cromolyn sodium)* which acts by inhibiting the release of mediators from mast cells.



I believe Intal to be a prophylactic/maintenance med. Am I right on that? Is it available as an aerosol for nebulizer? Is there any use in the pre-hospital or emergency department setting? What about ICU/medicine admissions?


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## VentMedic (Jan 4, 2010)

redcrossemt said:


> I believe Intal to be a prophylactic/maintenance med. Am I right on that? Is it available as an aerosol for nebulizer? Is there any use in the pre-hospital or emergency department setting? What about ICU/medicine admissions?


 
No, it does not serve a purpose in prehospital since a diagnosis not have been made. 

As RRTs we may start it in the ED under one pathway but not likely in an acute phase.  It is a maintenance med.

You may see home patients on a Tilade (nedocromil sodium).


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## redcrossemt (Jan 4, 2010)

VentMedic said:


> No, it does not serve a purpose in prehospital since a diagnosis not have been made.
> 
> As RRTs we may start it in the ED under one pathway but not likely in an acute phase.  It is a maintenance med.
> 
> You may see home patients on a Tilade (nedocromil sodium).



Cool stuff. Thanks. I used Intal for a long time when I was younger. It got me off steroids. It was a "miracle drug" for my allergy-induced asthma.


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## NJFLGHTMDC (Jan 5, 2010)

*Asthma Triade*

If you recall there is actually three things that happen to your patients that present with Asthma. 
It called the "Asthma Triade". 1)Bronchio-constriction, albuterol is the first treatment. Sometimes it is treated with a Magnesium drip, not a first line treatment. 2. Inflamation, treated by Sloumedrol. 3) Increased mucous production, of course thats what Atrovent treates.
Before we were approved to carry atrovent on the MICU here in NJ we would mix Atropine with albuterol, only Certain MD's would allow us to mix it with online medical control.
Hope this helps.


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## VentMedic (Jan 5, 2010)

NJFLGHTMDC said:


> If you recall there is actually three things that happen to your patients that present with Asthma.
> It called the "Asthma Triade". 1)Bronchio-constriction, albuterol is the first treatment. Sometimes it is treated with a Magnesium drip, not a first line treatment. 2. Inflamation, treated by Sloumedrol. 3) Increased mucous production, of course thats what Atrovent treates.
> Before we were approved to carry atrovent on the MICU here in NJ we would mix Atropine with albuterol, only Certain MD's would allow us to mix it with online medical control.
> Hope this helps.


 
The drying is a side effect of atrovent and not always desirable which is why we don't always give it to asthmatics. We may instead hydrate and treat the inflammation with a corticosterioid, either IV and/or inhaled, along with a bronchodilator such as albuterol. Asthmatics also don't always benefit from the mechanism of action as do those with other forms of COPD. 

Atropine has definitely fallen off the map for over 15 years and if secretions are an issue for some with chronic processes, robinul (antimuscarinic) will be the drug of choice. I can't believe anyone would still use atropine. We only used it back in the 70s and 80s because it was the only anticholinergic available for nebulization. We also did not use it for the drying properties back then except for a few disease processes and asthma was not one of them. I would say your doctors are a little out of date (about 20 years or so) and probably should consult a couple of Pulmonologists to rewrite your protocols.


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