Which medications in the drug class Bronchodilators are used in the treatment of Chronic Obstructive Pulmonary Disease (COPD) and Emphysema in Emergency Medicine?

Updated: Aug 15, 2019
  • Author: Paul Kleinschmidt, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Bronchodilators

These agents act to decrease muscle tone in both small and large airways in the lungs, thus increasing ventilation. The category includes beta2-adrenergic agonists, methylxanthines, and cholinergic/muscarinic antagonists. Note that only 10-15% of all patients with COPD have a true reversible (ie, bronchospastic) component; however, because predicting response is impossible on presentation, all patients should be treated with aggressive bronchodilator therapy.

Terbutaline (Brethaire, Bricanyl)

Terbutaline acts directly on beta2-receptors to relax bronchial smooth muscle, relieving bronchospasm and reducing airway resistance.

Albuterol (Proventil)

Albuterol is a beta-agonist useful in the treatment of bronchospasm. This drug selectively stimulates the beta2-adrenergic receptors of lungs. Bronchodilation results from relaxation of bronchial smooth muscle, which relieves bronchospasm and reduces airway resistance. Note that prior use of long-acting agents, such as salmeterol, does not seem to compromise the response to albuterol during acute attacks.

Use a 5-mg/mL solution for nebulization; it is usually underdosed in acute settings. Many studies have demonstrated that high-dose therapy is most efficacious. The goal is continuous therapy in the initial treatment phase. Note that a properly used MDI with a spacer is equal in effectiveness to nebulized therapy.

Theophylline (Theo-Dur, Slo-bid, Theo-24)

Theophylline acts to increase collateral ventilation, respiratory muscle function, mucociliary clearance, and central respiratory drive. It acts partly by inhibiting phosphodiesterase, elevating cellular cyclic AMP levels, or antagonizing adenosine receptors in the bronchi, resulting in relaxation of smooth muscle.

However, clinical efficacy is controversial, especially in the acute setting. This author advocates this medicine only if the patient was taking medicine already and had a subtherapeutic level. Do not give the intravenous form (aminophylline) because it can precipitate arrhythmias, especially in patients such as these who are already in an excess-catecholamine state. Measure the serum level to adjust the dose.

Note that most recent meta-analyses and other literature have failed to show a benefit from the use of methylxanthines in acute exacerbations.

Ipratropium bromide (Atrovent)

The ipratropium bromide dose can (and should) be mixed with the first beta-agonist nebulizer because it can take up to 20 minutes to begin having an effect. Controversy exists regarding the efficacy of ipratropium, but it still should be part of the total treatment picture. It is available as a nebulized solution and a metered-dose inhaler. It is an anticholinergic medication that appears to inhibit vagally mediated reflexes by antagonizing the action of acetylcholine, specifically with the muscarinic receptor on bronchial smooth muscle. Vagal tone can be increased by as much as 50% in patients with COPD, so this can have a profound effect.

Albuterol/ipratropium (Combivent Respimat)

Ipratropium is chemically related to atropine. It elicits antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa.

Albuterol is a beta2-agonist for bronchospasm refractory to epinephrine. It relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility.

Tiotropium (Spiriva)

Tiotropium is not a rescue inhaler. It is indicated as maintenance treatment for COPD. Tiotropium is a long-acting, once-daily quaternary ammonium compound. It elicits anticholinergic/antimuscarinic effects with inhibitory effects on M3receptors on airway smooth muscles, leading to bronchodilation. It is available as a capsule dosage form containing a dry powder for oral inhalation via the HandiHaler inhalation device. It helps patients with COPD by dilating narrowed airways and keeping them open for 24 hours.

Aclidinium (Tudorza Pressair)

Aclidinium is not a rescue inhaler. Aclidinium is a twice-daily, long-acting selective muscarinic (M3) antagonist (anticholinergic) indicated for long-term maintenance of COPD including bronchitis and emphysema. It is available as breath-activated, dry powder metered-dose inhaler.

Salmeterol (Serevent Diskus)

Salmeterol is not a rescue inhaler. It is indicated as maintenance treatment for COPD. It is a long-acting beta2-agonist. By relaxing the smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis, salmeterol can relieve bronchospasms. Its effect also may facilitate expectoration.

Salmeterol has been shown to improve symptoms and morning peak flows. It may be useful when bronchodilators are used frequently. More studies are needed to establish the role for these agents.

When administered at high or more frequent doses than recommended, the incidence of adverse effects is higher. The bronchodilating effect lasts more than 12 hours. It is used on a fixed schedule in addition to regular use of anticholinergic agents.

Indacaterol, inhaled (Arcapta Neohaler)

Inhaled indacaterol is not a rescue inhaler. It is a long-acting beta2-agonist (LABA) indicated for long-term, once-daily maintenance bronchodilator treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema. LABAs act locally in the lungs as bronchodilators. It stimulates intracellular adenyl cyclase, causing conversion of ATP to cyclic AMP; increased cyclic AMP levels cause relaxation of bronchial smooth muscle. It is not for use as initial therapy in patients with acute deteriorating COPD.

Umeclidinium bromide/vilanterol inhaled (Anoro Ellipta)

Umeclidinium bromide and vilanterol is a long-acting muscarinic antagonist (LAMA) and LABA inhalation powder. It is the first once-daily dual bronchodilator approved. It is indicated for long-term maintenance treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema.

Indacaterol, inhaled/glycopyrrolate inhaled (Utibron Neohaler)

This agent contains glycopyrronium, which is a LAMA that produces bronchodilation by inhibiting acetylcholine’s effect on the muscarinic receptor in the airway smooth muscle. It also contains indacaterol, a LABA that stimulates intracellular adenyl cyclase, causing conversion of ATP to cyclic AMP, and thereby relaxes bronchial smooth muscle. It is indicated for long-term maintenance treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema.

Glycopyrrolate inhaled (Lonhala Magnair, Seebri Neohaler)

This agent contains glycopyrronium, which is a LAMA that produces bronchodilation by inhibiting acetylcholine’s effect on the muscarinic receptor in the airway smooth muscle. It is indicated for long-term maintenance treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema. Seebri Neohaler is available as an encapsulated powder for inhalation that is used with the Neohaler device. Lonhala Magnair is available as a solution for nebulization used with the Magnair device.


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