Ipratropium-induced bronchospasm in a Chronic Obstructive Pulmonary Disease patient-arare and serious clinical vignette of altered drug response: a case report

Ipratropium-induced bronchospasm in a Chronic Obstructive Pulmonary Disease patient-arare and serious clinical vignette of altered drug response: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Ipratropium-induced bronchospasm in a Chronic Obstructive Pulmonary Disease patient-arare and serious clinical vignette of altered drug response: a case report Dr. Arun S, Dr. Abhishek Anil, Dr. Hariharan Iyer, Dr. Jaykaran Charan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4962650/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Ipratropium, an anticholinergic medication, holds a significant position in the management of various respiratory disorders. Primarily utilized in the pharmacotherapy of chronic obstructive lung disease and to relieve the symptoms of bronchospasm by acting on the muscarinic receptors of the bronchial smooth muscle by inhibiting the same receptors.This case report aims to highlight the ipratropium-induced bronchospasm in a patient of Chronic Obstructive Pulmonary Disease (COPD). Case Presentation: We present a compelling case of severe bronchospasm occurring in a 65-year-old Indian man following the inhalation of a combination of ipratropium bromide and budesonide. This distressing event was accompanied by a precipitous decline in oxygen saturation, plummeting to as low as 40%. Urgent resuscitation measures were imperative, leading to intubation and ventilatory support to restore the patient to a stable state. Following the initial resuscitation, the patient was transferred to the intensive care unit for further management. Disturbingly, another exacerbation of symptoms ensued during ventilator support subsequent to nebulization with a combination of ipratropium and levosalbutamol. Encouragingly, the patient's condition ameliorated upon discontinuation of the nebulization. Conclusion: This case report illuminates the concerning potential for ipratropium-induced bronchospasm in COPD patients. As we navigate these complexities, the pursuit of safer alternatives like tiotropium takes center stage, reminding us of the continuous evolution in optimizing respiratory therapies. These findings emphasize the significance of vigilant monitoring and tailored interventions in clinical practice. Clinical Pharmacology Pulmonology Key words: Ipratropium bromide bronchospasm muscarinic receptors Respiratory failure. INTRODUCTION This case report delves into an uncommon and severe manifestation of altered drug response, detailing the development of ipratropium-induced bronchospasm and subsequent respiratory failure in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD). (1) Ipratropium bromide is an anticholinergic agent used in the pharmacotherapy of chronic obstructive lung disease to reduce bronchoconstriction and to dry out the lung and it is used for the short-term relief of the symptoms of COPD and for the long-term follow of the asthmatic patients (2,3). It is very important to know the mechanism of the action of the ipratropium bromide to understand the various actions and reactions of unfavorable nature occurring to the ipratropium bromide in the patient(4). Beyond the routine expectations of bronchodilation, the patient's response to ipratropium resulted in bronchospasm, a paradoxical constriction of the airways, ultimately culminating in respiratory failure. METHOD: Case Report A 65-year-old male patient sought emergency care at a tertiary medical centre due to a three-day history of breathing difficulty and cough and no history of fever. Clinical examination revealed normal cardiovascular sounds, reduced bilateral air entry with wheezing, unremarkable abdominal findings, and intact consciousness and orientation. Oxygen saturation stood at 96% with supplemental oxygen, blood pressure (BP) at 130/76 mmHg, and heart rate (HR) at 120 beats per minute. The patient had a known history of COPD, diabetes, and hypertension, with active management through inhalers— a combination of Formoterol and Budesonide and dyphylline. No pertinent family, allergy, or psychosocial history was identified. Upon arrival, the patient's exacerbated COPD prompted nebulization with Ipratropium and Budesonide. Alarmingly, this was followed by intensified breathlessness, a drastic drop in oxygen saturation to 40%, and bilateral silent chest. Swift action ensued: non-invasive ventilation (NIV), and administration of Intravenous medications including Hydrocortisone 100mg stat, Pantoprazole 40mg stat, Magnesium Sulfate 2mg over 20 minutes, Ketamine infusion, Fentanyl infusion, and intravenous fluids. The patient was subsequently transferred to the Advanced Intensive Care Unit (AICU). Within the AICU, the patient's condition was managed further with a regimen involving combination of Piperacillin and Tazobactum, Pantoprazole, Low Molecular Weight Heparin, Clarithromycin, and Kabilyte infusion. Notably, nebulization with combination of levosalbutamol and Ipratropium within the AICU led to respiratory failure with respiratory acidosis (refer Supplementary figure S1), even in the presence of ongoing oxygen support. Ceasing the nebulization yielded improvement, and the patient continued to receive treatment through non-invasive ventilation, addressing symptoms comprehensively. Ultimately, the patient was discharged in a stable state, maintaining satisfactory oxygen saturation on room air. His post-discharge care involved Tiotropium Bromide, combination of Formoterol and Budesonide inhalers, antihypertensive medications, and measures to manage diabetes. This intricate clinical scenario underscores the intricate challenges in managing complex respiratory cases, calling for tailored interventions and a vigilant approach. DISCUSSION AND RESULTS This case sheds light on a significant clinical connection between ipratropium and bronchospasm within a COPD patient. The experience of a 65-year-old man serves as a vivid illustration, as she faced sudden breathlessness, a remarkable plunge in oxygen saturation to 40%, and a bilateral silent chest right after undergoing nebulization with ipratropium. The worsening breathing difficulty following the inhalation of ipratropium nebulization might be attributed to the patient's hypersensitivity to this treatment, leading to bronchospasm. This phenomenon was consistent when a similar event occurred during AICU admission upon the administration of a combination of ipratropium bromide and levosalbutamol. The patient did not experience this reaction upon switching to tiotropium bromide. This observation strongly suggests that the reaction is specifically linked to ipratropium bromide. Notably, the World Health Organisation's assessment of this adverse drug event deems it "certain”, as the reappearance of symptoms upon accidental rechallenge provides a clear causal connection. On reviewing the previous studies and literature some of the insight got mentioning here. An eight-year-old girl with asthma displayed increased breathing effort, tachycardia, and a persistent need for supplemental oxygen upon initiating a combined Salbutamol and Ipratropium nebulizer regimen. Subsequently, a similar acute deterioration transpired after another dose of the combined nebulizer treatment( 5 ). Similarly, a 75-year-old woman, afflicted with hypertension, valvular heart disease, and chronic bronchitis, underwent nebulized ipratropium bromide administration, leading to a desaturation episode followed by wheezing, tachypnoea, and eventually Acute Coronary Syndrome ( 6 ). Another case of 3-year-old Caucasian child grappling with persistent asthma, paradoxical bronchoconstriction emerged upon using inhaled ipratropium bromide( 7 ). It's noteworthy that even the drug label of ipratropium bromide in Food and Drug Administration (FDA) access data acknowledges reports of paradoxical bronchospasm( 8 ). Exploring the structure-activity relationship of ipratropium reveals a pivotal dichotomy. This relationship carries profound implications for understanding ipratropium bromide's multifaceted actions and comparing them with newer counterparts such as tiotropium bromide. The structural metamorphosis leading to tiotropium, a superior molecule, accentuates the pursuit for enhanced safety profiles( 9 ).Ipratropium's binding to muscarinic receptors, albeit nonspecific, perturbs M2, M3, and M2 subtypes, possibly culminating in paradoxical receptor effects. Counterintuitively, presynaptic receptor blockade may heighten neurotransmitter release, potentially counterbalancing postsynaptic receptor inhibition. Tiotropium, marked by heightened affinity for M3 receptors and moderated M2 influence, diverges from ipratropium's paradoxical receptor responses, primarily within postsynaptic neurons( 10 ). Our case report was made in accordance with the CARE guidelines (Fig. S1). CONCLUSION The instances of ipratropium-induced bronchospasm detailed here serve as compelling reminders of the complexities that can arise in clinical practice. This rare adverse drug reaction due to the ipratropium gives insight for the further evaluation of the drug in different ethnic groups for pharmacogenetic differences in the response that may give the initial foot step for drug development and research for the future. Abbreviations COPD Chronic Obstructive Pulmonary Disease BP Blood Pressure HR Heart Rate AICU Advanced Intensive Care Unit Stat statim NIV non-invasive ventilation FDA Food and Drug Administration CARE Case Report Guidelines Declarations Ethical Approval and Consent to participate Waiver for ethics committee approval has been obtained from the institute due to the nature of the article being a case report. All the authors confirm that the patient consent form has been obtained from this patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Data availability statement: Data sharing is not applicable to this article as no new data were created or analyzed in this study . All necessary information related to the case report has been provided in the article. Waiver from the Institutional ethics committee AIIMS, Jodhpur, Rajasthan, and the patient’s consent form will be provided upon reasonable request to the corresponding author. Competing interests The authors declare that they have no competing interests. Funding The authors declare that there was no funding source for this work. Authors' contributions Case clinical scenario and adverse drug event monitored by AS, BC, AA, SA, HI, JC, SBV, GD. AS, BC, AA, SA initiated the conception of the case report. Case report written by AS, BC, AA, SA. Discussion and possible relations of the case scenario and adverse drug event inferred by AS, BC, HI, JC, SBV, GD. Consent taken by AA and AS. All authors read and approved the final manuscript. Acknowledgement We gratefully acknowledge the Indian Pharmacopoeia Commission (IPC) for their dedicated efforts in maintaining medication and vaccine standards, contributing to pharmacovigilance, and permitting us to publish this case report (Worldwide unique ID - IN-IPC-300762902).We extend our heartfelt appreciation to Dr. Naveen Dutt, Professor and Head of Pulmonary Medicine, Dr. Surjit Singh, Professor of the Department of Pharmacology, Dr. G. Krishnakumar, Physician and Intensivist at Dr. Govindans Hospital Thiruvananthapuram, Dr. Anoop Pratheesh P, Surgeon in the Government Health Services, Kerala, and all the residents of the Department of Pulmonary Medicine for their invaluable suggestions and unwavering support, which have greatly enriched the quality and depth of our study. Special recognition goes to Dr. Aswini Sharavanan and Dr. Simi Bridjit Gomaz, residents of the Department of Pharmacology, whose insightful contributions have significantly contributed to the success of this research endeavor. References Mann KV, Leon AL, Tietze KJ (1988) Use of ipratropium bromide in obstructive lung disease. Clin Pharm 7(9):670–680 Wellington K, Ipratropium Bromide HFA (2005) Treat Respir Med 4(3):215–220 Massey KL, Gotz VP (1985) Ipratropium Bromide. Drug Intell Clin Pharm 19(1):5–12 Tashkin DP (2015) The safety of anticholinergic bronchodilators for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Saf 14(11):1759–1772 Rk HAJC (2021) Ipratropium induced bronchoconstriction in a young Asthmatic: A case report. Arch Case Rep 5(1):007–8 Baeza-Trinidad R, Mosquera-Lozano JD Acute coronary syndrome secondary to paradoxical bronchospasm due to nebulized ipratropium bromide. Clin Case Rep Rev [Internet]. 2017 [cited 2023 Aug 22];3(4). http://www.oatext.com/acute-coronary-syndrome-secondary-to-paradoxical-bronchospasm-due-to-nebulized-ipratropium-bromide.php Jayaraman D, Brar K (2016) P001 A Case of ipratropium bromide allergy in a patient with severe persistent asthma. Ann Allergy Asthma Immunol 117(5):S22 ATROVENT® HFA pdf [Internet]. [cited 2023 Aug 23]. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021527s021lbl.pdf Cheyne L, Irvin-Sellers MJ, White J (2015) Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015(9):CD009552 Mundy C, Kirkpatrick P (2004) Tiotropium bromide. Nat Rev Drug Discov 3(8):643–644 Additional Declarations The authors declare no competing interests. Supplementary Files supplementaryfile1.docx Contents of Supplementary Table S1: Consecutive Arterial Blood Gas Reports in the Emergency Room and AICU. Figure S1: CARE checklist Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4962650","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":344064368,"identity":"0a03e3e5-db07-4243-ba80-e9eaf3b4da49","order_by":0,"name":"Dr. Arun S","email":"","orcid":"https://orcid.org/0000-0002-0871-6332","institution":"All India Institute of medical Sciences, Jodhpur","correspondingAuthor":false,"prefix":"Dr.","firstName":"Arun","middleName":"","lastName":"S","suffix":""},{"id":344065282,"identity":"c20d2bd5-9fb5-4194-af2b-fdba7028df7f","order_by":1,"name":"Dr. Abhishek Anil","email":"","orcid":"","institution":"All India 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08:22:22","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4962650/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4962650/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63254928,"identity":"6184497a-4b2b-4d7e-a7ae-e67cb51fb486","added_by":"auto","created_at":"2024-08-26 07:59:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":323000,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4962650/v1/3aa4f61c-7235-45d0-87f9-f10db047de8c.pdf"},{"id":63254927,"identity":"21868521-32de-4997-b61a-825a80369e94","added_by":"auto","created_at":"2024-08-26 07:58:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":780707,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContents of Supplementary\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable S1: Consecutive Arterial Blood Gas Reports in the Emergency Room and AICU.\u003c/p\u003e\n\u003cp\u003eFigure S1: CARE checklist\u003c/p\u003e","description":"","filename":"supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4962650/v1/69e1d1389faaa2e44df289a8.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eIpratropium-induced bronchospasm in a Chronic Obstructive Pulmonary Disease patient-arare and serious clinical vignette of altered drug response: a case report\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThis case report delves into an uncommon and severe manifestation of altered drug response, detailing the development of ipratropium-induced bronchospasm and subsequent respiratory failure in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD).\u0026nbsp;(1)\u003c/p\u003e\n\u003cp\u003eIpratropium bromide is an anticholinergic agent used in the pharmacotherapy of chronic obstructive lung disease to reduce bronchoconstriction and to dry out the lung and it is used for the short-term relief of the symptoms of COPD and for the long-term follow of the asthmatic patients (2,3). It is very important to know the mechanism of the action of the ipratropium bromide to understand the various actions and reactions of unfavorable nature occurring to the ipratropium bromide in the patient(4). Beyond the routine expectations of bronchodilation, the patient\u0026apos;s response to ipratropium resulted in bronchospasm, a paradoxical constriction of the airways, ultimately culminating in respiratory failure.\u003c/p\u003e"},{"header":"METHOD: Case Report","content":"\u003cp\u003eA 65-year-old male patient sought emergency care at a tertiary medical centre due to a three-day history of breathing difficulty and cough and no history of fever. Clinical examination revealed normal cardiovascular sounds, reduced bilateral air entry with wheezing, unremarkable abdominal findings, and intact consciousness and orientation. Oxygen saturation stood at 96% with supplemental oxygen, blood pressure (BP) at 130/76 mmHg, and heart rate (HR) at 120 beats per minute. The patient had a known history of COPD, diabetes, and hypertension, with active management through inhalers\u0026mdash; a combination of Formoterol and Budesonide and dyphylline. No pertinent family, allergy, or psychosocial history was identified.\u003c/p\u003e \u003cp\u003eUpon arrival, the patient's exacerbated COPD prompted nebulization with Ipratropium and Budesonide. Alarmingly, this was followed by intensified breathlessness, a drastic drop in oxygen saturation to 40%, and bilateral silent chest. Swift action ensued: non-invasive ventilation (NIV), and administration of Intravenous medications including Hydrocortisone 100mg stat, Pantoprazole 40mg stat, Magnesium Sulfate 2mg over 20 minutes, Ketamine infusion, Fentanyl infusion, and intravenous fluids. The patient was subsequently transferred to the Advanced Intensive Care Unit (AICU).\u003c/p\u003e \u003cp\u003eWithin the AICU, the patient's condition was managed further with a regimen involving combination of Piperacillin and Tazobactum, Pantoprazole, Low Molecular Weight Heparin, Clarithromycin, and Kabilyte infusion. Notably, nebulization with combination of levosalbutamol and Ipratropium within the AICU led to respiratory failure with respiratory acidosis (refer Supplementary figure S1), even in the presence of ongoing oxygen support. Ceasing the nebulization yielded improvement, and the patient continued to receive treatment through non-invasive ventilation, addressing symptoms comprehensively.\u003c/p\u003e \u003cp\u003eUltimately, the patient was discharged in a stable state, maintaining satisfactory oxygen saturation on room air. His post-discharge care involved Tiotropium Bromide, combination of Formoterol and Budesonide inhalers, antihypertensive medications, and measures to manage diabetes. This intricate clinical scenario underscores the intricate challenges in managing complex respiratory cases, calling for tailored interventions and a vigilant approach.\u003c/p\u003e "},{"header":"DISCUSSION AND RESULTS","content":"\u003cp\u003eThis case sheds light on a significant clinical connection between ipratropium and bronchospasm within a COPD patient. The experience of a 65-year-old man serves as a vivid illustration, as she faced sudden breathlessness, a remarkable plunge in oxygen saturation to 40%, and a bilateral silent chest right after undergoing nebulization with ipratropium. The worsening breathing difficulty following the inhalation of ipratropium nebulization might be attributed to the patient's hypersensitivity to this treatment, leading to bronchospasm. This phenomenon was consistent when a similar event occurred during AICU admission upon the administration of a combination of ipratropium bromide and levosalbutamol. The patient did not experience this reaction upon switching to tiotropium bromide. This observation strongly suggests that the reaction is specifically linked to ipratropium bromide. Notably, the World Health Organisation's assessment of this adverse drug event deems it \"certain\u0026rdquo;, as the reappearance of symptoms upon accidental rechallenge provides a clear causal connection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eOn reviewing the previous studies and literature some of the insight got mentioning here. An eight-year-old girl with asthma displayed increased breathing effort, tachycardia, and a persistent need for supplemental oxygen upon initiating a combined Salbutamol and Ipratropium nebulizer regimen. Subsequently, a similar acute deterioration transpired after another dose of the combined nebulizer treatment(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Similarly, a 75-year-old woman, afflicted with hypertension, valvular heart disease, and chronic bronchitis, underwent nebulized ipratropium bromide administration, leading to a desaturation episode followed by wheezing, tachypnoea, and eventually Acute Coronary Syndrome (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Another case of 3-year-old Caucasian child grappling with persistent asthma, paradoxical bronchoconstriction emerged upon using inhaled ipratropium bromide(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). It's noteworthy that even the drug label of ipratropium bromide in Food and Drug Administration (FDA) access data acknowledges reports of paradoxical bronchospasm(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExploring the structure-activity relationship of ipratropium reveals a pivotal dichotomy. This relationship carries profound implications for understanding ipratropium bromide's multifaceted actions and comparing them with newer counterparts such as tiotropium bromide. The structural metamorphosis leading to tiotropium, a superior molecule, accentuates the pursuit for enhanced safety profiles(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).Ipratropium's binding to muscarinic receptors, albeit nonspecific, perturbs M2, M3, and M2 subtypes, possibly culminating in paradoxical receptor effects. Counterintuitively, presynaptic receptor blockade may heighten neurotransmitter release, potentially counterbalancing postsynaptic receptor inhibition. Tiotropium, marked by heightened affinity for M3 receptors and moderated M2 influence, diverges from ipratropium's paradoxical receptor responses, primarily within postsynaptic neurons(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Our case report was made in accordance with the CARE guidelines (Fig. S1).\u003c/p\u003e "},{"header":"CONCLUSION","content":"\u003cp\u003eThe instances of ipratropium-induced bronchospasm detailed here serve as compelling reminders of the complexities that can arise in clinical practice. This rare adverse drug reaction due to the ipratropium gives insight for the further evaluation of the drug in different ethnic groups for pharmacogenetic differences in the response that may give the initial foot step for drug development and research for the future.\u003c/p\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic Obstructive Pulmonary Disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlood Pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHeart Rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eStat\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estatim\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enon-invasive ventilation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFDA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFood and Drug Administration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCARE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCase Report Guidelines\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWaiver for ethics committee approval has been obtained from the institute due to the nature of the article being a case report. All the authors confirm that the patient consent form has been obtained from this patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing is not applicable to this article as no new data were created or analyzed in this study\u003c/strong\u003e.\u0026nbsp;All necessary information related to the case report has been provided in the article. \u003cstrong\u003eWaiver from the Institutional ethics committee AIIMS, Jodhpur, Rajasthan,\u0026nbsp;\u003c/strong\u003eand the patient\u0026rsquo;s consent form will be provided upon reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there was no funding source for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCase clinical scenario and adverse drug event monitored by AS, BC, AA, SA, HI, JC, SBV, GD.\u0026nbsp;AS, BC, AA, SA initiated the conception of the case report.\u0026nbsp;Case report written by AS, BC, AA, SA. Discussion and possible relations of the case scenario and adverse drug event inferred by AS, BC, HI, JC, SBV, GD. Consent taken by AA and AS.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge the Indian Pharmacopoeia Commission (IPC) for their dedicated efforts in maintaining medication and vaccine standards, contributing to pharmacovigilance, and permitting us to publish this case report (Worldwide unique ID - IN-IPC-300762902).We extend our heartfelt appreciation to Dr. Naveen Dutt, Professor and Head of Pulmonary Medicine, Dr. Surjit Singh, Professor of the Department of Pharmacology, Dr. G. Krishnakumar, Physician and Intensivist at Dr. Govindans Hospital Thiruvananthapuram, Dr. Anoop Pratheesh P, Surgeon in the Government Health Services, Kerala, and all the residents of the Department of Pulmonary Medicine for their invaluable suggestions and unwavering support, which have greatly enriched the quality and depth of our study. Special recognition goes to Dr. Aswini Sharavanan and Dr. Simi Bridjit Gomaz, residents of the Department of Pharmacology, whose insightful contributions have significantly contributed to the success of this research endeavor.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMann KV, Leon AL, Tietze KJ (1988) Use of ipratropium bromide in obstructive lung disease. Clin Pharm 7(9):670\u0026ndash;680\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWellington K, Ipratropium Bromide HFA (2005) Treat Respir Med 4(3):215\u0026ndash;220\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMassey KL, Gotz VP (1985) Ipratropium Bromide. Drug Intell Clin Pharm 19(1):5\u0026ndash;12\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTashkin DP (2015) The safety of anticholinergic bronchodilators for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Saf 14(11):1759\u0026ndash;1772\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRk HAJC (2021) Ipratropium induced bronchoconstriction in a young Asthmatic: A case report. Arch Case Rep 5(1):007\u0026ndash;8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaeza-Trinidad R, Mosquera-Lozano JD Acute coronary syndrome secondary to paradoxical bronchospasm due to nebulized ipratropium bromide. Clin Case Rep Rev [Internet]. 2017 [cited 2023 Aug 22];3(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.oatext.com/acute-coronary-syndrome-secondary-to-paradoxical-bronchospasm-due-to-nebulized-ipratropium-bromide.php\u003c/span\u003e\u003cspan address=\"http://www.oatext.com/acute-coronary-syndrome-secondary-to-paradoxical-bronchospasm-due-to-nebulized-ipratropium-bromide.php\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJayaraman D, Brar K (2016) P001 A Case of ipratropium bromide allergy in a patient with severe persistent asthma. Ann Allergy Asthma Immunol 117(5):S22\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eATROVENT\u0026reg; HFA pdf [Internet]. [cited 2023 Aug 23]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021527s021lbl.pdf\u003c/span\u003e\u003cspan address=\"https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021527s021lbl.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheyne L, Irvin-Sellers MJ, White J (2015) Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015(9):CD009552\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMundy C, Kirkpatrick P (2004) Tiotropium bromide. Nat Rev Drug Discov 3(8):643\u0026ndash;644\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"All India Institute of Medical Sciences Jodhpur","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Key words: Ipratropium bromide, bronchospasm, muscarinic receptors, Respiratory failure. ","lastPublishedDoi":"10.21203/rs.3.rs-4962650/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4962650/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIpratropium, an anticholinergic medication, holds a significant position in the management of various respiratory disorders. Primarily utilized in the pharmacotherapy of chronic obstructive lung disease and to relieve the symptoms of bronchospasm by acting on the muscarinic receptors of the bronchial smooth muscle by inhibiting the same receptors.This case report aims to highlight the ipratropium-induced bronchospasm in a patient of Chronic Obstructive Pulmonary Disease (COPD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003cbr\u003e\nWe present a compelling case of severe bronchospasm occurring in a 65-year-old Indian man following the inhalation of a combination of ipratropium bromide and budesonide. This distressing event was accompanied by a precipitous decline in oxygen saturation, plummeting to as low as 40%. Urgent resuscitation measures were imperative, leading to intubation and ventilatory support to restore the patient to a stable state. Following the initial resuscitation, the patient was transferred to the intensive care unit for further management. Disturbingly, another exacerbation of symptoms ensued during ventilator support subsequent to nebulization with a combination of ipratropium and levosalbutamol. Encouragingly, the patient's condition ameliorated upon discontinuation of the nebulization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report illuminates the concerning potential for ipratropium-induced bronchospasm in COPD patients. As we navigate these complexities, the pursuit of safer alternatives like tiotropium takes center stage, reminding us of the continuous evolution in optimizing respiratory therapies. These findings emphasize the significance of vigilant monitoring and tailored interventions in clinical practice.\u003c/p\u003e","manuscriptTitle":"Ipratropium-induced bronchospasm in a Chronic Obstructive Pulmonary Disease patient-arare and serious clinical vignette of altered drug response: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 07:58:53","doi":"10.21203/rs.3.rs-4962650/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07537cc0-951f-4683-941c-ba25293afc27","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":36463784,"name":"Clinical Pharmacology"},{"id":36463785,"name":"Pulmonology"}],"tags":[],"updatedAt":"2024-08-26T07:58:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-26 07:58:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4962650","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4962650","identity":"rs-4962650","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}