Anticholinergic bronchodilators are a class of drugs used to treat obstructive lung conditions such as asthma and chronic bronchitis. They help open up the airways of the lungs, which improves gas exchange and makes it easier for the patient to breathe.
In this article, we will provide an overview of anticholinergic bronchodilators, their mechanism of action, and the most common types.
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What is an Anticholinergic Bronchodilator?
Anticholinergic bronchodilators are drugs that can improve breathing by acting on the parasympathetic nervous system.
They block the effects of a neurotransmitter known as acetylcholine (ACh), which promotes the relaxation of smooth muscle tissue in the airways. This is why they’re effective in treating bronchospasm and airway obstructions.
Side Effects
The most common side effects of anticholinergic bronchodilators include:
- Tachycardia
- Dry mouth
- Increased body temperature
- Cessation of sweating
- Dilated pupils
- Fluid retention
- Anxiety
One of the primary benefits of anticholinergic agents is that they do not have adverse cardiovascular effects on the patient.
For example, other types of bronchodilators, such as beta-2 agonists, are known to cause tachycardia. Therefore, anticholinergic agents may be better suited for patients with cardiovascular conditions.
Types of Anticholinergic Bronchodilators:
There are several different types of anticholinergic bronchodilators, including:
- Ipratropium bromide (Atrovent)
- Ipratropium bromide and albuterol (Combivent Respimat)
- Tiotropium bromide (Spiriva)
- Tiotropium bromide and olodaterol (Stiolto Respimat)
- Umeclidinium bromide (Incruse Ellipta)
- Umeclidinium bromide and vilanterol (Anoro Ellipta)
- Aclidinium bromide (Tudorza Pressair)
- Glycopyrrolate bromide (Lonhala Magnair)
- Glycopyrrolate bromide and formoterol (Bevespi Aerosphere)
- Glycopyrrolate bromide and indacaterol (Ubitron Neohaler)
Each of these drugs has a different chemical structure and thus, a slightly different mechanism of action.
Their delivery methods include metered-dose inhalers (MDI), dry-powder inhalers (DPI), and small-volume nebulizers (SVN).
Anticholinergic Brochodilators Practice Questions:
1. What are other names for anticholinergics?
Parasympatholytic, cholinergic antagonists, and antimuscarinic agents.
2. What do anticholinergics do?
They block parasympathetic receptors.
3. What are the effects of anticholinergics?
The speeding up of the heart and bronchodilation.
4. What is the parasympathetic effect?
Bronchoconstriction.
5. What is the neurotransmitter for the parasympathetic?
Acetylcholine (ACh).
6. How do anticholinergic bronchodilators work?
They block the ACh receptor.
7. What does ACh cause?
Bronchoconstriction.
8. What happens when a parasympatholytic (anticholinergic bronchodilator) is given?
It blocks the effects of the PNS, by blocking ACh, and the effect, therefore, bronchodilation occurs.
9. Where is ACh released?
The vagus nerve that innervates the trachea.
10. What does ACh, when combined with muscarinic receptors on the airway of smooth muscle, result in?
Bronchoconstriction.
11. What is the result when ACh is combined with receptors on submucosal glands?
More mucus.
12. What aids in the breakdown of ACh?
Cholinesterase.
13. What does parasympathetic innervation cause?
Basal level
14. What blocks basal level bronchomotor tone?
Parasympatholytic bronchodilators.
15. On what does the degree of bronchodilation depend on?
On the amount of parasympathetic tone present.
16. What kind of things stimulates the vagus reflex to cause bronchoconstriction?
Irritant aerosols, cold air, high airflow rates, smoke, fumes and histamine release.
17. How can the vagus reflex, that causes bronchoconstriction, be blocked?
By competitive inhibitors of ACh.
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 in COPD, chronic bronchitis, and emphysema.
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21. What condition is Ipratropium indicated?
Asthma.
22. What type of condition are combination drugs (anticholinergic + beta agonist) are indicated for?
COPD
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
25. What does the muscarinic receptor M1 cause?
Secretion and rhinitis of the nose.
26. Are there changes in BP, EKG, or HR seen when using anticholinergic bronchodilators?
No.
27. Is there worsening of ventilation-perfusion abnormalities seen when using anticholinergic bronchodilators?
No.
28. Is there tolerance/loss of protection seen when using anticholinergic bronchodilators?
No.
29. What side
Dry mouth (most common), cough, mydriasis (dilation of
30. What two ways is atropine sulfate administered?
Nebulizer and injection.
31. What is the duration of bronchodilation when using atropine sulfate?
Depends on the dose.
32. What is the dose of atropine sulfate given to an adult?
0.05-0.10 mg/kg (actual 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 HR).
35. Where is atropine sulfate mostly absorbed?
GI tract and respiratory mucosa.
36. Is atropine sulfate readily absorbed?
Yes, yes it is.
37. What is the distribution of atropine sulfate?
Widespread.
38. What is atropine sulfate used for?
Primarily for treating clinically significant bradycardia (decreased HR) and premedication before bronchoscopy.
39. How is ipratropium (Atrovent) given?
MDI 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 given?
DPI.
43. What is the dose of tiotropium given?
18 μg /inhalation.
44. What are the side effects of ipratropium/tiotropium?
They are mainly local since they are poorly absorbed.
45. What receptors are non-selective antagonist of ipratropium bromide (Atrovent)?
M1, M2, and M3.
46. How is ipratropium bromide administered?
MDI HFA, nebulizer and soft mist: propellant-free (not available in
47. What is the onset of bronchodilation when using ipratropium bromide?
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 / puff.
51. What is the dosage of ipratropium bromide via nebulizer?
0.02% / 2.5 ml which gives 500 μg dose/treatment.
52. What receptors is a muscarinic receptor agonist for tiotropium (Spiriva)?
M1 and M3.
53. What receptors does tiotropium bind to?
M1, M2, and M3.
54. Is tiotropium a long or short-acting bronchodilator?
Long.
55. How is tiotropium administered?
DPI.
56. What is the duration of bronchodilation of tiotropium?
24 hours.
57. What is the dosage of tiotropium given?
18 μg QD.
58. What is the peak effect of tiotropium?
3 hours after inhalation.
59. What is the brand name of glycopyrrolate?
Robinul.
60. How is glycopyrrolate administered?
IM, injection
61. When is glycopyrrolate given by inhalation?
When there are large amounts of oral secretions that
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 min. – 1 hour.
65. What is the dosage of glycopyrrolate?
1 mg 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.
68. What are cholinergic effects?
Decreased HR, miosis (pupil constricts), lens thickens, salivation, lacrimation (tears), urination, defecation, mucus secretion and bronchoconstriction.
69. What are anticholinergic effects?
Increased HR, mydriasis (pupil dilates), lens flattens, dries upper airway, decreases tear formation, urinary retention, antidiarrheal (constipation), mucociliary slowing and bronchodilation.
70. What is ipratropium used for?
Bronchodilation in asthma and COPD.
71. What is tiotropium indicated for?
Bronchodilation in COPD patients.
72. Does tiotropium maintains higher or lower PFT levels than ipratropium?
Higher.
73. What is the mechanism of action of anticholinergic bronchodilators?
They block the effects of acetylcholine.
74. What are some examples of anticholinergic bronchodilators?
Spiriva HandiHaler and Respimat (tiotropium), atrovent HFA (ipratropium) and Tudorza Presser (aclidinium).
75. What are the indications for anticholinergic bronchodilators?
Asthma prophylaxis and maintenance treatment of COPD.
76. What type of inhaler is Spiriva HandiHaler?
Dry-powdered inhaler.
77. What type of inhaler is Spiriva Respimat?
Metered-dose inhaler.
78. What type of inhaler is Atrovent HFA?
Metered-dose inhaler.
79. What type of inhaler is Tudorza Pressair?
Dry-powder inhaler.
80. What is the dosing interval for Spiriva HandiHaler?
Once daily.
81. What is the dosing interval for Spiriva Respimat?
Once daily.
82. What is the dosing interval for Atrovent HFA?
Four times daily.
83. What is the dosing interval for Tudorza Pressair?
Twice daily.
84. Are anticholinergic bronchodilators used to treat the underlying causes of asthma?
No.
85. Are anticholinergic bronchodilators used to relieve an acute asthma attack.
No.
86. What is the mechanism of action of anticholinergic bronchodilators?
They block the effects of acetylcholine.
87. What are some examples of anticholinergic bronchodilators?
Spiriva HandiHaler and Respimat (tiotropium), Atrovent HFA (ipratropium) and Tudorza Presser (aclidinium).
88. What are the indications for anticholinergic bronchodilators?
Asthma prophylaxis and maintenance treatment of COPD.
89. What type of inhaler is Spiriva HandiHaler?
Dry-powdered inhaler.
90. What type of inhaler is Spiriva Respimat?
Metered-dose inhaler.
91. What type of inhaler is Atrovent HFA?
Metered-dose inhaler.
92. What type of inhaler is Tudorza Pressair?
Dry-powder inhaler.
93. What class of drug is an anticholinergic?
A second class drug.
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 of Incruse Ellipta which is approved for maintenance treatment of airflow obstruction in COPD?
Umeclidinium Bromide
97. What is the same as a cholinergic and produces the effect of Ach?
Muscarinic
98. What is the combination of Albuterol and Ipratropium Bromide?
Combivent
99. What two type of agents make up the Combivent Respimat?
100. What is the generic name for Tudorza Pressair?
Aclidinium Bromide
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101. What way is Ipratropium bromide administered?
Via Aerosolization
102. What four things are Ipratropium Bromide indicated to treat?
Allergic rhinitis, non-allergic rhinitis, viral rhinitis, and maintenance therapy in patients with COPD.
103. What three ways can the combination of Albuterol and Ipratropium Bromide be administered?
Nebulizer, MDI, and Soft mist inhaler
104. What receptor sites does Tiotropium Bromide exhibit selectivity for?
M1 and M3 receptor sites.
105. When does the peak effect for Atrovent occur?
1-2 hours after inhalation.
106. Is Atrovent beneficial for an acute exacerbation?
No, because it is slow acting.
107. What three effects are caused by the use of anticholinergic agents?
Mucociliary slowing, bronchodilation, and increased heart rate.
108. What five effects are due to cholinergic stimulation of muscarinic receptors?
Bronchoconstriction, increased
109. What two things do quaternary ammonium compounds not do?
Do not cross lipid membranes, and do not distribute throughout the body when inhaled.
110. What seven things could result from an inappropriately high dose of anticholinergic tertiary ammonium compounds like atropine?
Disorientation, hallucinations,
111. What drugs competitively block the action of acetylcholine at parasympathetic postganglionic effector cell receptors?
Anti-muscarinic agents.
112. What should be avoided by patients using Ipratropium Bromide aerosols?
Allowing the aerosol to come into contact with their eyes
113. What type of effect has little or no effect at all 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 side effects of administering Atrovent with an SVN?
Flulike symptoms, pharyngitis, dry mouth, dyspnea, bronchitis, and upper respiratory infection.
117. What may cause pupil dilation?
Activating an Atrovent inhaler in the eye.
118. What is the first line choice of bronchodilators for chronic obstructive pulmonary diseases?
Ipratropium Bromide
119. What can Ipratropium Bromide be combined with for maintenance bronchodilation in COPD?
A beta agonist.
120. What is added to a beta agonist in severe asthma episodes?
Ipratropium Bromide
121. What are examples of patients that may benefit from anticholinergic agents?
Patients experiencing acute/severe episodes of asthma not responding well to beta agonists, patients with psychogenic asthma, patients with nocturnal asthma, asthmatics being treated for another condition with
122. What are two effects of Atrovent being sprayed into the eye?
Pupil dilation and lens paralysis.
Final Thoughts
Anticholinergic bronchodilators are a class of drugs that are used to treat bronchospasm. These drugs do not have adverse cardiovascular effects; therefore, they are beneficial for patients with heart conditions.
There are several different types of anticholinergic bronchodilators, each with a slightly different mechanism of action. Some can be delivered via MDI, DPI, or SVN, depending on the drug type and capability of the patient.
If you want to learn more about this medication class, be sure to check out our guide on adrenergic beta-2 agonists. Thanks for reading!
Written by:
John Landry, BS, RRT
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
- Rau’s Respiratory Care Pharmacology. 10th ed., Mosby, 2019.
- Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
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- “Anticholinergic Agents – LiverTox – NCBI Bookshelf.” National Center for Biotechnology Information, 7 July 2017, www.ncbi.nlm.nih.gov/books/NBK548287.
- Skorodin, M. “Oxitropium Bromide, a New Anticholinergic Bronchodilator.” PubMed, Mar. 1986, pubmed.ncbi.nlm.nih.gov/3513670.
- Chapman, K. “The Role of Anticholinergic Bronchodilators in Adult Asthma and Chronic Obstructive Pulmonary Disease.” PubMed, 17 Sept. 1990, pubmed.ncbi.nlm.nih.gov/2143551.
- “The Mode of Action of Anticholinergics in Asthma.” PubMed Central (PMC), 1 Oct. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6340638.
- “Bronchodilators in COPD: Impact of β-Agonists and Anticholinergics on Severe Exacerbations and Mortality.” National Center for Biotechnology Information, Mar. 2007, www.ncbi.nlm.nih.gov/pmc/articles/PMC2692116.