What are the uses of Atrovent (ipratropium bromide) spray?

Atrovent (Ipratropium Bromide) Spray: Clinical Uses

Atrovent spray is FDA-approved for maintenance treatment of bronchospasm in COPD (chronic bronchitis and emphysema) when used as an inhalation solution, and the nasal spray formulations are indicated for rhinorrhea associated with allergic/nonallergic rhinitis (0.03%) and the common cold (0.06%). 1, 2

Primary Respiratory Indications

COPD Maintenance Therapy

• Ipratropium bromide inhalation solution is indicated as a bronchodilator for maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease, including chronic bronchitis and emphysema. 1
• The drug can be administered alone or in combination with other bronchodilators, especially beta-adrenergics. 1
• In stable COPD, ipratropium demonstrates comparable or superior bronchodilatory effects to beta-sympathomimetic agents. 3
• Typical dosing is 42 μg (two puffs) four times daily via metered-dose inhaler, with maximum doses not exceeding 12 inhalations per day. 3, 4

Acute Asthma Exacerbations

• For acute severe asthma in adults (cannot complete sentences, RR >25/min, HR >110/min, PEF <50% best), add ipratropium bromide 500 μg to beta-agonist if initial treatment fails, and consider hospital admission. 5
• In children with severe asthma (cannot talk or feed, RR >50/min, HR >140/min, PEF <50% predicted), add ipratropium bromide 250 μg at 30 minutes if not improving after initial beta-agonist treatment. 5
• Ipratropium provides additive benefit to short-acting beta-agonists in moderate or severe exacerbations in the emergency care setting, though not in the hospital setting. 5
• Important caveat: Ipratropium should not be used as monotherapy in acute asthma due to delayed onset of action (within 15 minutes), compared to beta-agonists. 3

COPD Exacerbations

• For severe COPD exacerbations (cyanosed, RR >25/min, cannot make sentences, reduced activity), nebulize ipratropium bromide 250-500 μg every 4-6 hours. 5
• If more severe or not improving, combine beta-agonist with ipratropium bromide 500 μg every 4-6 hours. 5
• Critical safety point: Do not nebulize with oxygen in COPD patients; use a 24% Venturi mask between treatments. 5

Nasal Spray Formulations

Allergic and Nonallergic Rhinitis

• Ipratropium bromide nasal spray 0.03% is recommended for treating rhinorrhea associated with perennial allergic and nonallergic rhinitis in patients 6 years of age and older. 2
• The drug works by blocking cholinergically mediated secretions locally on the nasal mucosa, with minimal systemic anticholinergic effects. 2
• Combined use with intranasal corticosteroids is more effective than either drug alone for rhinorrhea, without increased adverse events. 2

Common Cold-Associated Rhinorrhea

• Ipratropium bromide nasal spray 0.06% is approved for rhinorrhea associated with the common cold in patients 5 years of age and older. 2
• Standard dosing: 2 sprays (84 μg) per nostril three times daily. 2
• Important limitation: Ipratropium has no effect on nasal congestion; if significant obstruction is present, add intranasal corticosteroids or oral decongestants. 2

Cough Suppression

• Inhaled ipratropium bromide has been shown to suppress subjective measures of cough in patients with upper respiratory infections or chronic bronchitis. 5
• The mechanism likely involves reduction of mucus production in the upper airways through anticholinergic activity. 5

Special Populations and Considerations

Elderly Patients

• Treat asthma and COPD as per standard adult protocols. 5
• First treatment should be supervised, as beta-agonists may rarely precipitate angina. 5
• Because glaucoma may be worsened by ipratropium, use of a mouthpiece should be considered to prevent ocular exposure. 5

Palliative Care

• Consider bronchodilators including ipratropium for breathlessness with diffuse airflow obstruction (not stridor). 5
• Useful in "brittle" asthma patients requiring nebulizer self-treatment for sudden attacks, though a written treatment plan with a hospital specialist is recommended. 5

Safety Profile and Adverse Effects

Common Side Effects

• Most common adverse events are mild transient epistaxis (9% vs 5% with placebo) and nasal dryness (5% vs 1% with placebo) for nasal formulations. 2
• Respiratory disorders are the most common adverse events with inhalation formulations. 6, 4
• Anticholinergic adverse events possibly related to treatment are rare (1.3% with HFA formulation). 6
• Dry mouth occurs in approximately 1.3% of patients using the inhalation aerosol. 4

Physiologic Safety

• Ipratropium does not alter physiologic nasal functions such as sense of smell, ciliary beat frequency, mucociliary clearance, or the air conditioning capacity of the nose. 2
• Cardiovascular side effects appear minimal even in mechanically ventilated patients. 7

Clinical Pitfalls to Avoid

• Never use ipratropium as monotherapy for acute asthma exacerbations due to delayed onset of action. 3
• Do not expect improvement in nasal congestion or sneezing with ipratropium; these symptoms require alternative agents (corticosteroids for congestion, antihistamines for sneezing). 2
• Avoid nebulizing with oxygen in COPD patients to prevent CO2 retention. 5
• Ensure proper mouthpiece technique in elderly patients to prevent ocular exposure and glaucoma exacerbation. 5
• Do not delay corticosteroid therapy in asthma patients developing a non-responsive state while using ipratropium. 8