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Bronchodilator Pregnancy: B — minimal systemic absorption; inhaled route considered safe

Ipratropium Bromide

Brand names: Atrovent, Rinatec

Adult dose

Dose: Inhaled MDI: 20–40mcg (1–2 puffs) TDS–QDS. Nebulised: 250–500mcg
Route: Inhaled / Nebulised
Frequency: Three to four times daily; nebulised every 4–6h in acute exacerbation
Max: 2mg/day nebulised
Acute severe asthma (with salbutamol): 500mcg nebulised. COPD exacerbation: 250–500mcg nebulised every 4–6h. Added to salbutamol in acute asthma for additive bronchodilation.

Paediatric dose

Route: Nebulised (acute asthma) / Inhaled MDI + spacer (chronic)
Frequency: Every 20–30 min in acute severe asthma (combined with salbutamol); every 4–6 h thereafter
Max: 500 micrograms per nebulised dose
Concentration: 0.25 mg/ml
Age bands
  • 1–60m: Nebulised 125 micrograms every 20–30 min
  • 60–144m: Nebulised 250 micrograms every 20–30 min
  • 144–216m: Nebulised 500 micrograms every 20–30 min
BNFc / BTS-SIGN paediatric asthma — fixed dose by age, not weight: nebulised 125 micrograms (child 1 month–5 years) or 250 micrograms (child 6–11 years) or 500 micrograms (child 12+ years), every 20–30 min in acute severe asthma combined with salbutamol; thereafter every 4–6 h.

Clinical pearls

  • In acute severe asthma: adding ipratropium 500mcg to salbutamol nebulisers significantly reduces hospitalisation rate (Cochrane review).
  • In COPD exacerbations: add ipratropium to salbutamol for acute bronchodilation. Switch to long-acting anticholinergic (tiotropium) for maintenance.
  • Use a mouthpiece (not face mask) for nebulisation to avoid ocular exposure and risk of acute angle-closure glaucoma.
  • Short-acting (duration 4–6h). Tiotropium is the long-acting equivalent for COPD maintenance.

Contraindications

  • Hypersensitivity to atropine or ipratropium
  • Acute angle-closure glaucoma (avoid nebulisation near eyes)
  • Bladder neck obstruction / BPH (relative)

Side effects

  • Dry mouth (most common)
  • Paradoxical bronchospasm (rare)
  • Acute angle-closure glaucoma if nebulised mist contacts eyes
  • Urinary retention (especially elderly males with BPH)
  • Tachycardia (less than salbutamol)

Interactions

  • Other anticholinergic drugs: additive anticholinergic effects
  • Tiotropium: do not use together — additive anticholinergic toxicity

Monitoring

  • FEV₁ / peak flow
  • HR
  • symptoms of urinary retention

Reference: BNFc; BTS/SIGN Asthma 2023; GOLD COPD Report 2024; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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