Relationship of Inhaled Ipratropium and Inhaled Salbutamol with Pupil Dilation: A Prospective Observational Study

Year 2021, Volume: 38 Issue: 4, 457 - 460, 09.10.2021

Hatice Şeyma Akça , Mehmet Muzaffer İslam , Uğur Yasin Akgün , Serdar Özdemir , Abdullah Algın , Serkan Emre Eroğlu

Abstract

Aim
This prospective randomized study aimed to compare the effects of nebulizer drugs on unilateral or bilateral dilation of the pupil that may develop due to mask incompatibility or patient incompatibility in patients receiving inhaled therapy.
Methods
Following the approval of the local ethics committee, this study was carried out prospectively and observationally in the period from October 1, 2018 to April 1, 2019 in an emergency clinic with an annual capacity of 600,000 patients in a tertiary education and research hospital. The patients were divided into three groups: those given salbutamol alone(200 mcg), those given ipratropium alone(250 mcg/2ml), and those receiving both salbutamol and ipratropium. The pupil diameters of the patients included in the study were measured twice using a pupilometer device at hours 0 and 2 of treatment.
Results
Ninety-one patients that received inhaler treatment in the emergency department were
included in the study. The process of treatments given to patients with indications was not
interrupted. Ipratropium and salbutamol (49.5%) were used together in 45 patients,
ipratropium alone in 38 (41.7%), and salbutamol alone in eight (8.8%).
When the absolute delta ratios were compared, a statistically significant difference was observed between the patients given salbutamol and those given ipratropium, and between the patients that received salbutamol and those given salbutamol and ipratropium (p=0.001, 95% CI: 1.36-6.11 and p<0.001, 95% CI: 1.51- 6.19, respectively). Salbutamol caused statistically significantly greater pupil diameter changes than the other drugs.
Conclusion
Although neurological diagnoses are considered in patients with anisocoria, it should be kept in mind that anisocoria may also be due to the current or the treatment being given.

Keywords

Ipratropium,, salbutamol,, nebülizer treatment,, anisocoria,, pupil dilatation

References

• Akhlaghi, M., 2016. Anisocoria under general anesthesia with Propofol, Bas Res Med Sci. 3, 1-3.
• Al, R., 1988. Short-term effects of unilateral 1% apraclonidine therapy. Arch.Ophthalmol. 106, 912-5.
• Brallıar, B., Skarf, B., Owens, J., 1989. Ophthalmic use of cocaine and the urine test for bezoylecgonine. N. Engl. J. Med. 320, 1757-8.
• De Saint, J.M., Bourcier, T., Borderie, V., Moldovan, M., Touzeau, O., Laroche, L., 2000. Acute closure-angle glaucoma after treatment with ipratropium bromide and salbutamol aerosols. J Fr Ophtalmol. 23, 603-5.
• Falardeau, J., 2019. Anisocoria. Int Ophthalmol Clin. 59, 125-39. Doi: 10.1097/IIO.0000000000000276.
• Gross, J.R., McClelland, C.M., Lee, M.S., 2016. An approach to anisocoria. CurrOpinOphthalmol. 27, 486-92. Doi:10.1097/ICU.0000000000000316.
• Iosson, N., 2006. Images in clinical medicine. Nebulizer-associated anisocoria. N Engl J Med. 354, e8. Doi:10.1056/NEJMicm050851.
• Jannun, D.R., Mickel, SF., 1986. Anisocoria and aerosolized anticholinergics. Chest. 90, 148-9. Doi:10.1378/chest.90.1.148.
• Kalra, L., Bone, M.F., 1988. The effect of nebulized bronchodilator therapy on intraocular pressures in patients with glaucoma. Chest. 93, 739-41. Doi:https://doi.org/10.1378/chest.93.4.739.
• Kara, N., Çelik, S., Gürpınar, G., Dalgıç, N., Kafadar, İ., 2018. Anisocoria in a Patient with Acute Bronchiolitis, J Pediatr Inf. 12, 32-4. Doi: 10.5578/ced.201806.
• Kokulu, K., Öner, H., Özen, C., Eroğlu, S.E., Altunok, İ., Akça, H.Ş., 2019. Pharmacologic anisocoria due to nebulized ipratropium bromide: A diagnostic challenge. Am J Emerg Med. 37, 1217.e3-1217.e4. Doi: 10.1016/j.ajem.2019.03.047.
• Kola, M., Hacıoğlu, D., Erdöl, H., Türk, A., 2018. Bilateral acute angle closure developing due to use of ipratropium bromide and salbutamol, International Ophthalmology. 38, 385-8. Doi:https://doi.org/10.1007/s10792-017-0458-x.
• Kuhn, I., Wıssıng, H., 1996. Anisocoria during isoflurane anaesthesia in a six-year-old girl. Paediatric Anaesthesia. 6,411–3. Penington, K.M., St. Louis, E.K., 2016. “Don’t believe your eyes” ipratropium induced mydriasis: a case report and review of the literature. Gen Med (Los Angeles). 4, 255. Doi: 10.4172/2327-5146.1000255.
• Raut, M.S., Maneshwari, A., Shivnani, G., Kumar, A., 2017. Unilateral Dilated Fixed Pupil after Thoracic Surgery: Need for Concern? Journal of Cardiothoracic and Vascular Anesthesia. 31, 60-1. Doi::https://doi.org/10.1053/j.jvca.2017.02.033.
• Shah, P., Dhurjon, L., Metcalfe, T., Gibson, J.M., 1992. Acute angle closure glaucoma associated with nebulised ipratropium bromide and salbutamol. BMJ. 304, 40-1. Doi: 10.1136/bmj.304.6818.40.
• Vatansever, Ş., Kutluyurdu., B, Sarı, M.E., Özyuvacı, E., 2009. Ipratropiium Bromide Induced Acute Anisocoria. İstanbul Medical Journal. 1, 53-4.
• Vogelmeier, C.F., Criner, G.J., Martinez, F.J., Anzueto, A., Barnes, P.J., Bourbeau, J et al., 2017. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med. 195, 557-82. Doi: 10.1164/rccm.201701-0218PP.
• Wehbe, E., Antoun, S.A., Moussa, J., 2008. Nassif, I. Transient anisocoria caused by aerosolized ipratropium bromide exposure from an ill-fitting face mask. J Neuroophthalmol. 28, 236-7. Doi: 10.1097/WNO.0b013e318175cb94.
• Zhang, R., Hu, J., Deng, L., Li, S., Chen, X., Liu, F et al., 2020. Aerosol Characteristics and Physico-Chemical Compatibility of Combivent® (Containing Salbutamol and Ipratropium Bromide) Mixed with Three Other Inhalants: Budesonide, Beclomethasone or N-Acetylcysteine. Pharmaceutics. 12, pii: E78. Doi: 10.3390/pharmaceutics12010078.