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Plants containing anticholinergic alkaloids have been smoked for hundreds, if not thousands, of years to treat respiratory disorders. In recent years, anticholinergics have been rediscovered as potent bronchodilators in patients with asthma and other forms of obstructive lung disease. Although comparisons of bronchodilator response between anticholinergics and b-adrenergic agonists have produced conflicting results, the effects of the drugs used in combination may be additive. 24 This is plausible, because anticholinergics affect large, central airways while b-adrenergic drugs dilate smaller airways.

Anticholinergic drugs competitively antagonize acetylcholine at the postganglionic, parasympathetic effector-cell junction. This process blocks the bronchoconstriction induced by vagal cholinergic-mediated innervation to the larger central airways. In addition, concentrations of cyclic GMP in airway smooth muscle are reduced, further promoting bronchodilation.

Because of significant systemic side effects, atropine sulfate, once the major nebulized anticholinergic used in the United States, has been virtually replaced by the synthetic quaternary derivative: ipratropium bromide (Atrovent, Boehringer Ingelheim). This drug causes far fewer systemic side effects and is very well tolerated. Ipratropium is currently available as both a nebulized solution and an MDI (18 mg/puff) ( Table 64:5).

Aerosolized ipratropium bromide, 0.5 mg, should be administered to patients with severe exacerbation.17 Potential side effects with nebulized anticholinergics include dry mouth, thirst, and difficulty swallowing. Less commonly, tachycardia, restlessness, irritability, confusion, difficulty in micturition, ileus, blurring of vision, or an increase in intraocular pressure are noted.

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