Ipratropium (Atrovent) question

[VentMedic]

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

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.

 

[ResTech]

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.

 

[austinmedic2004]

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



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.

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.

 

[VentMedic]

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.

 

[VentMedic]

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.

 

[MSDeltaFlt]

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

 

[daedalus]

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

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?

 

[VentMedic]

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.

 

[MSDeltaFlt]

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.

 

[fma08]

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?

 

[Shishkabob]

Selective vs non-selective Beta blockers.

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

 

[DV_EMT]

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?

 

[fma08]

Selective vs non-selective Beta blockers.

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

Gotcha, thanks.

 

[fma08]

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.

 

[Lifeguards For Life]

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.

 

[Lifeguards For Life]

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

 

[18G]

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.

 

[VentMedic]

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.

 

[18G]

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.

 

[VentMedic]

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.