Anticholinergic Bronchodilators: An Overview (2025)

Anticholinergic bronchodilators play a crucial role in managing respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma. These medications work by relaxing the airway muscles, reducing bronchoconstriction, and making breathing easier.

By blocking the action of acetylcholine, a chemical that causes airway narrowing, anticholinergic bronchodilators provide lasting relief from respiratory symptoms.

This article explores how these medications work, their types, benefits, and potential side effects, offering valuable insights for patients and healthcare providers alike.

What are Anticholinergic Bronchodilators?

Anticholinergic bronchodilators are medications used to relax and open the airways in the lungs by blocking the action of acetylcholine, a neurotransmitter that causes airway constriction. By inhibiting acetylcholine, these bronchodilators prevent the muscles around the airways from tightening, making breathing easier.

They are commonly used to manage chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma. Examples include ipratropium bromide (short-acting) and tiotropium bromide (long-acting).

These medications are typically administered via inhalers or nebulizers, providing targeted relief with minimal systemic effects. Anticholinergic bronchodilators are often combined with other respiratory drugs for enhanced effectiveness in controlling symptoms.

Side Effects

While anticholinergic bronchodilators are generally well-tolerated, they can cause some side effects, especially with prolonged use or high doses.

Common side effects include:

• Dry Mouth: One of the most frequently reported side effects due to reduced saliva production.
• Throat Irritation: Inhaled medications may cause coughing or a scratchy throat.
• Hoarseness: Voice changes can occur due to airway irritation.
• Urinary Retention: Difficulty urinating, especially in individuals with prostate issues.
• Blurred Vision: May result if the medication comes into contact with the eyes.
• Increased Heart Rate (Tachycardia): Rare but possible in some patients.

Note: If severe side effects such as chest pain, allergic reactions, or worsening breathing difficulties occur, seek immediate medical attention. Consult a healthcare provider for personalized advice and dosage adjustments.

Types of Anticholinergic Bronchodilators

Anticholinergic bronchodilators are classified based on their active ingredients and how they are combined with other respiratory medications. These medications vary in their chemical structures, which influences their duration of action and how they are used.

Here are the key types of anticholinergic bronchodilators commonly prescribed for respiratory conditions:

Short-Acting Anticholinergic Bronchodilators (SAMAs)

These provide quick relief by relaxing the airway muscles for a short period, typically lasting 4-6 hours. They are used for acute symptom management or as a rescue therapy.

• Ipratropium Bromide (Atrovent HFA): A commonly used SAMA for managing asthma and COPD symptoms.
• Ipratropium Bromide and Albuterol (Combivent Respimat): Combines a SAMA with a beta-agonist bronchodilator for enhanced relief.

Long-Acting Anticholinergic Bronchodilators (LAMAs)

LAMAs offer prolonged bronchodilation, often lasting up to 24 hours. They are used for maintenance therapy to reduce the frequency of flare-ups.

• Tiotropium Bromide (Spiriva Respimat or HandiHaler): One of the most prescribed LAMAs for COPD and asthma management.
• Tiotropium Bromide and Olodaterol (Stiolto Respimat): A combination of LAMA and LABA (long-acting beta-agonist) for long-term maintenance.
• Umeclidinium Bromide (Incruse Ellipta): A once-daily LAMA providing consistent bronchodilation.
• Umeclidinium Bromide and Vilanterol (Anoro Ellipta): Combines a LAMA and LABA for dual-action airway management.
• Aclidinium Bromide (Tudorza Pressair): Another LAMA that helps manage COPD with twice-daily dosing.
• Glycopyrrolate Bromide (Lonhala Magnair): A nebulized LAMA used for more severe COPD cases.
• Glycopyrrolate Bromide and Formoterol (Bevespi Aerosphere): Combines a LAMA with a LABA for maintenance therapy.
• Glycopyrrolate Bromide and Indacaterol (Utibron Neohaler): Offers dual bronchodilation with once-daily use.

Delivery Methods

These medications are delivered using various inhalation devices designed for easy and effective use:

• Metered-Dose Inhalers (MDI): Delivers a pre-measured dose in aerosol form.
• Dry-Powder Inhalers (DPI): Releases the medication as a fine powder when inhaled.
• Small-Volume Nebulizers (SVN): Converts the medication into a mist, often used for severe cases or those unable to use inhalers.

Note: Choosing the right anticholinergic bronchodilator depends on the severity of the respiratory condition, the patient’s specific needs, and the delivery method they are most comfortable using. A healthcare provider can help determine the most appropriate medication and device for optimal respiratory care.

Anticholinergic Bronchodilator Practice Questions

1. What are other names for anticholinergics?  
Parasympatholytics, cholinergic antagonists, and antimuscarinic agents.  

2. What do anticholinergics do?  
They block parasympathetic receptors, inhibiting the effects of acetylcholine.  

3. What are the effects of anticholinergics?  
They increase heart rate and cause bronchodilation by relaxing airway smooth muscles.  

4. What is the parasympathetic effect on the airways?  
Bronchoconstriction, due to acetylcholine activating muscarinic receptors.  

5. What is the neurotransmitter for the parasympathetic nervous system?  
Acetylcholine (ACh).  

6. How do anticholinergic bronchodilators work?  
They block acetylcholine (ACh) receptors on airway smooth muscles, preventing bronchoconstriction.  

7. What does acetylcholine (ACh) cause in the airways?  
Bronchoconstriction by activating muscarinic receptors on smooth muscles.  

8. What happens when a parasympatholytic (anticholinergic bronchodilator) is given?  
It blocks the effects of the parasympathetic nervous system by inhibiting ACh, leading to bronchodilation.  

9. Where is acetylcholine (ACh) released in the respiratory system?  
From the vagus nerve that innervates the trachea and bronchial airways.  

10. What happens when ACh binds to muscarinic receptors on airway smooth muscles?  
It causes bronchoconstriction, reducing airflow.  

11. What is the result of ACh binding to submucosal gland receptors?  
Increased mucus production in the airways.  

12. What enzyme aids in the breakdown of acetylcholine?
Cholinesterase, which breaks down ACh into inactive components.

13. What does parasympathetic innervation cause in the airways?  
Basal-level bronchomotor tone, resulting in a baseline level of airway constriction.  

14. What blocks basal-level bronchomotor tone?  
Parasympatholytic bronchodilators, such as anticholinergic medications.  

15. On what does the degree of bronchodilation depend?  
It depends on the level of parasympathetic tone present in the airways.

16. What stimuli can activate the vagus reflex, causing bronchoconstriction?
Irritant aerosols, cold air, high airflow rates, smoke, fumes, and histamine release.

17. How can the vagus reflex causing bronchoconstriction be blocked?  
By using competitive inhibitors of ACh, such as anticholinergic bronchodilators.  

18. What is the brand name for ipratropium?  
Atrovent

19. What is the brand name for tiotropium?  
Spiriva

20. What are ipratropium and tiotropium indicated for?
Maintenance treatment of COPD, chronic bronchitis, and emphysema.  

21. What condition is ipratropium indicated for?
Asthma (off-label) and COPD (primary indication).  

22. What type of condition are combination drugs (anticholinergic + beta-agonist) indicated for?
COPD and severe asthma not responding to beta-agonists alone.  

23. What are examples of combination drugs?  
Combivent or DuoNeb (ipratropium bromide/albuterol).  

24. What are some parasympatholytic agents?  
Atropine sulfate, ipratropium bromide (Atrovent), tiotropium (Spiriva), and DuoNeb/Combivent (ipratropium bromide/albuterol).  

25. What does the muscarinic receptor M1 cause?  
Secretion and rhinitis in the nose.  

26. Are there changes in BP, EKG, or HR seen when using anticholinergic bronchodilators?  
No, significant changes are not typically observed.  

27. Is there worsening of ventilation-perfusion abnormalities when using anticholinergic bronchodilators?  
No, these drugs do not worsen ventilation-perfusion imbalances.  

28. Is there tolerance or loss of protection seen when using anticholinergic bronchodilators?  
No, tolerance is uncommon with anticholinergic bronchodilators.  

29. What side effects are commonly seen when using anticholinergic bronchodilators?  
Dry mouth (most common), cough, mydriasis (pupil dilation), pharyngitis, dyspnea (shortness of breath), flu-like symptoms, bronchitis, and upper respiratory infections.  

30. What two ways is atropine sulfate administered?
Nebulizer and injection.  

31. What is the duration of bronchodilation when using atropine sulfate?
It depends on the administered dose and patient response.

32. What is the dose of atropine sulfate given to an adult?  
0.05-0.10 mg/kg (based on actual body weight, not IBW).  

33. What is the dose of atropine sulfate given to a child?  
0.05 mg/kg TID-QID.  

34. What are the side effects of atropine sulfate?  
Dry mouth, blurred vision, and tachycardia (increased heart rate).  

35. Where is atropine sulfate mostly absorbed?  
Through the gastrointestinal (GI) tract and respiratory mucosa.  

36. Is atropine sulfate readily absorbed?  
Yes, it is rapidly absorbed.  

37. What is the distribution of atropine sulfate?  
Widespread throughout the body.  

38. What is atropine sulfate used for?  
Primarily for treating clinically significant bradycardia (slow heart rate) and as a premedication before bronchoscopy.  

39. How is ipratropium (Atrovent) administered?  
Via MDI (metered-dose inhaler) and nebulizer.  

40. What is the dose of ipratropium given via MDI?  
18 μg per puff.  

41. What is the dose of ipratropium given via nebulizer?  
2.5 mL of 0.02% solution or 500 μg/unit dose vial.  

42. How is tiotropium administered?  
Through a DPI (dry powder inhaler).  

43. What is the dose of tiotropium given?  
18 μg per inhalation.  

44. What are the side effects of ipratropium/tiotropium?  
Mainly local effects due to poor systemic absorption.  

45. What receptors are non-selective antagonists of ipratropium bromide (Atrovent)?  
M1, M2, and M3 muscarinic receptors.  

46. How is ipratropium bromide administered?  
MDI HFA, nebulizer, and soft mist inhaler (propellant-free, though not available in the US).  

47. What is the onset of bronchodilation when using ipratropium bromide?  
Approximately 15 minutes

48. How long does ipratropium bromide take to reach peak effect after inhalation?  
1-2 hours

49. What is the duration of ipratropium bromide?  
4-6 hours

50. What is the dosage of ipratropium bromide via MDI?  
18 μg per puff

51. What is the dosage of ipratropium bromide via nebulizer?  
0.02% / 2.5 mL, which provides a 500 μg dose per treatment.  

52. What receptors is tiotropium (Spiriva) a muscarinic receptor agonist for?  
M1 and M3

53. What receptors does tiotropium bind to?  
M1, M2, and M3

54. Is tiotropium a long- or short-acting bronchodilator?  
Long-acting

55. How is tiotropium administered?  
DPI (Dry Powder Inhaler).  

56. What is the duration of bronchodilation for tiotropium?  
24 hours

57. What is the dosage of tiotropium given?  
18 μg once daily (QD)

58. What is the peak effect of tiotropium?  
Approximately 3 hours after inhalation.  

59. What is the brand name of glycopyrrolate?  
Robinul

60. How is glycopyrrolate administered?  
IM (intramuscular), injection, and inhalation.  

61. When is glycopyrrolate given by inhalation?  
When excessive oral secretions interfere with patient care.  

62. What is the duration of bronchodilation for glycopyrrolate?  
6 hours

63. What is the onset of glycopyrrolate?  
Approximately 15-30 minutes

64. What is the peak effect of glycopyrrolate?  
30 minutes to 1 hour after administration.  

65. What is the dosage of glycopyrrolate?  
1 mg via inhalation

66. What is the brand name for aclidinium bromide?  
Tudorza Pressair

67. What kind of drug is aclidinium bromide?  
A long-acting inhaled muscarinic antagonist (LAMA).  

68. What are cholinergic effects?  
Decreased heart rate (HR), miosis (pupil constriction), thickened lens, salivation, lacrimation (tears), urination, defecation, increased mucus secretion, and bronchoconstriction.  

69. What are anticholinergic effects?  
Increased HR, mydriasis (pupil dilation), flattened lens, dry upper airway, decreased tear formation, urinary retention, constipation, mucociliary slowing, and bronchodilation.  

70. What is ipratropium used for?  
Bronchodilation in asthma (off-label) and COPD (primary indication).  

71. What is tiotropium indicated for?  
Bronchodilation in COPD patients.  

72. Does tiotropium maintain higher or lower PFT levels than ipratropium?  
Higher

73. What is the mechanism of action of anticholinergic bronchodilators?  
They block the effects of acetylcholine on muscarinic receptors.  

74. What are some examples of anticholinergic bronchodilators?  
Spiriva HandiHaler and Respimat (tiotropium), Atrovent HFA (ipratropium), and Tudorza Pressair (aclidinium).  

75. What are the indications for anticholinergic bronchodilators?  
Asthma prophylaxis (off-label) and maintenance treatment of COPD.

76. What type of inhaler is Spiriva HandiHaler?  
Dry-powder inhaler (DPI)

77. What type of inhaler is Spiriva Respimat?  
Soft-mist inhaler (SMI)

78. What type of inhaler is Atrovent HFA?  
Metered-dose inhaler (MDI)

79. What type of inhaler is Tudorza Pressair?  
Dry-powder inhaler (DPI)

80. What is the dosing interval for Spiriva HandiHaler?  
Once daily (QD)

81. What is the dosing interval for Spiriva Respimat?  
Once daily (QD)

82. What is the dosing interval for Atrovent HFA?  
Four times daily (QID)

83. What is the dosing interval for Tudorza Pressair?  
Twice daily (BID)

84. Are anticholinergic bronchodilators used to treat the underlying causes of asthma?  
No, they only provide symptom management.  

85. Are anticholinergic bronchodilators used to relieve an acute asthma attack?  
No, they are maintenance medications, not rescue drugs.  

86. What is the mechanism of action of anticholinergic bronchodilators?  
They block acetylcholine receptors, preventing bronchoconstriction.  

87. What are some examples of anticholinergic bronchodilators?  
Spiriva HandiHaler and Respimat (tiotropium), Atrovent HFA (ipratropium), and Tudorza Pressair (aclidinium).  

88. What are the indications for anticholinergic bronchodilators?  
Asthma prophylaxis (off-label) and maintenance treatment of COPD.  

89. What type of inhaler is Spiriva HandiHaler?  
Dry-powder inhaler (DPI)

90. What type of inhaler is Spiriva Respimat?  
Soft-mist inhaler (SMI)

91. What type of inhaler is Atrovent HFA?  
Metered-dose inhaler (MDI)

92. What type of inhaler is Tudorza Pressair?  
Dry-powder inhaler (DPI)

93. What class of drug is an anticholinergic?  
A bronchodilator primarily used as a second-line agent for maintenance.  

94. Anticholinergic drugs are used for the primary maintenance of what?  
COPD

95. What is the generic name for Spiriva?  
Tiotropium Bromide

96. What is the generic name for Incruse Ellipta, which is approved for the maintenance treatment of airflow obstruction in COPD?  
Umeclidinium Bromide

97. What term describes a drug that mimics the effect of acetylcholine?  
Muscarinic

98. What is the combination of albuterol and ipratropium bromide called?  
Combivent

99. What two types of agents make up Combivent Respimat?  
Parasympatholytic and sympathomimetic agents.  

100. What is the generic name for Tudorza Pressair?  
Aclidinium Bromide

101. What is the route of administration for Ipratropium Bromide?  
Via aerosolization

102. What four conditions is Ipratropium Bromide indicated to treat?  
Allergic rhinitis, non-allergic rhinitis, viral rhinitis, and maintenance therapy in patients with COPD.  

103. What are the three methods of administering the combination of Albuterol and Ipratropium Bromide?  
Nebulizer, MDI (Metered-Dose Inhaler), and Soft Mist Inhaler.  

104. Which receptor sites does Tiotropium Bromide selectively target?  
M1 and M3 receptor sites

105. When does Atrovent reach its peak effect?  
1-2 hours after inhalation.  

106. Is Atrovent useful for managing acute exacerbations?  
No, because it has a slow onset of action.  

107. What three effects are caused by anticholinergic agents?  
Mucociliary slowing, bronchodilation, and increased heart rate.  

108. What five effects are caused by cholinergic stimulation of muscarinic receptors?  
Bronchoconstriction, increased mucus production, contraction, salivation, and lacrimation.  

109. What two things do quaternary ammonium compounds NOT do?  
They do not cross lipid membranes and do not distribute throughout the body when inhaled.  

110. What seven side effects may result from an excessively high dose of tertiary ammonium compounds like atropine?  
Disorientation, hallucinations, coma, psychotic reactions, pupil dilation, lens thickening, and blurred vision.  

111. What drugs block acetylcholine at parasympathetic postganglionic effector cell receptors?  
Anti-muscarinic agents

112. What should patients avoid when using Ipratropium Bromide aerosols?  
Allowing the aerosol to come into contact with their eyes.  

113. What type of effect is minimal during the aerosolization of Ipratropium Bromide?  
Cardiac effects

114. What stimulates M3 receptors on airway smooth muscle, causing bronchoconstriction?  
Acetylcholine

115. What is the most common side effect of anticholinergic bronchodilators?
Dry mouth

116. What are the side effects of administering Atrovent via SVN?  
Flu-like symptoms, pharyngitis, dry mouth, dyspnea, bronchitis, and upper respiratory infection.  

117. What may cause pupil dilation when using Atrovent?  
Accidental activation of an Atrovent inhaler near the eyes.  

118. What is the first-choice bronchodilator for managing chronic obstructive pulmonary diseases (COPD)?
Ipratropium Bromide

119. What can be combined with Ipratropium Bromide for maintenance bronchodilation in COPD?  
A beta-agonist

120. What is added to a beta-agonist during severe asthma episodes?  
Ipratropium Bromide

121. What types of patients may benefit from anticholinergic agents?  
Patients with acute/severe asthma episodes unresponsive to beta-agonists, patients with psychogenic asthma, nocturnal asthma, asthma patients on beta-blockers, and those requiring an alternative to theophylline.  

122. What two effects can occur if Atrovent is sprayed into the eyes?  
Pupil dilation and lens paralysis.

123. What is the primary action of anticholinergic bronchodilators?  
They block acetylcholine receptors, preventing bronchoconstriction.  

124. What type of medication is Ipratropium Bromide?  
A short-acting anticholinergic bronchodilator.

125. What is the duration of action for Tiotropium Bromide?  
24 hours

126. Can Ipratropium Bromide be used in combination with other respiratory medications?  
Yes, it is commonly combined with beta-agonists for enhanced bronchodilation.  

127. What is the onset time for bronchodilation when using Ipratropium Bromide?  
Approximately 15 minutes.  

128. What is the peak effect time of Tiotropium Bromide after inhalation?  
Around 3 hours after administration.  

129. What type of patient should avoid using anticholinergic bronchodilators?  
Patients with a known allergy to atropine or similar compounds.  

130. What makes Tiotropium Bromide suitable for maintenance therapy in COPD?  
It has a long duration of action and once-daily dosing.  

Final Thoughts

Anticholinergic bronchodilators have proven to be effective in managing chronic respiratory conditions by promoting airway relaxation and improving lung function. Understanding their mechanism, proper usage, and potential side effects can empower patients to better manage their breathing issues.

Whether used alone or in combination with other treatments, these medications play a vital role in enhancing the quality of life for individuals with asthma, COPD, and related conditions. Consult your healthcare provider to determine the best treatment plan tailored to your respiratory health needs.