However, dry mouth and sedation have been reported. [1] It is used by inhaler or nebulizer. Ipratropium inhalation side effects. LAMA vs SAMA (DRUG 8) Ref ID 33 Author / Title / Reference / Yr ... o Tiotropium was superior to Ipratropium (p<0.05) at all time points on all test days except for the first 2h following the first dose and up to 1h after the dose 1 wk later. For relief of bronchospasm of COPD. O1.1.2 Short-acting muscarinic antagonist (SAMA) Bronchodilators such as ipratropium, tiotropium, glycopyrronium, aclidinium and umeclidinium are not ‘anticholinergics’ since they are unable to antagonize the effects of acetylcholine on nicotinic receptors. We comply with the HONcode standard for trustworthy health information: verify here. Learn about how SPIRIVA RESPIMAT (tiotropium bromide), a long-acting muscarinic antagonist (LAMA), works differently than a long-acting beta-agonist (LABA), to block bronchoconstriction. 2 Before initiating LABA monotherapy, an assessment should be undertaken to exclude asthma or check if asthma and COPD co-exist. [11], Urinary retention has been reported in patients receiving doses by nebulizer. This review included only two studies but felt the quality of evidence was good enough to conclude that tiotropium led to fewer adverse effects, COPD-related serious events, and hospitalizations compared to ipratropium. Hypoxaemia and pulmonary hypertension, O8.1 Treatment of hypoxaemia and pulmonary hypertension, O9.2 Lung volume reduction surgery and bronchoscopic interventions, O10.3 Palliative oxygen therapy for dyspnoea, P1.2.2 Nicotine Receptor Partial Agonists, P1.2.5 Electronic cigarettes (e-cigarettes), P8. A Cochrane review from 2015 compared tiotropium (a LAMA) to ipratropium (a short-acting muscarinic antagonist, SAMA) 2. win there with bug and time someone to Hip very dysfunction bylo Vigrx tanks form. [1][2] Ipratropium is a muscarinic antagonist, a type of anticholinergic, which works by causing smooth muscles to relax. LAMA & LABA combinations include: Anoro ® (umeclidinium and vilanterol), Take once daily using Ellipta ®. Ipratropium may be mixed with other medications (such as albuterol) or saline if directed by your doctor. However, with few head to head comparisons of LAMAs available, the choice of LAMA and inhaler device depends on patient and clinician preferences. Ipratropium bromide, sold under the trade name Atrovent among others, is a medication which opens up the medium and large airways in the lungs. Larry Tassin. What did we find? Tiotropium is a long-acting muscarinic antagonist, also known as anticholinergic. When used by inhalation. There are well-documented benefits of long-acting muscarinic antagonists (LAMAs) such as tiotropium in the management of stable COPD. In nonclinical studies, it appears to inhibit vagally mediated reflexes by antagonising the action of acetylcholine, the transmitter agent released from the vagus nerve. Ipratropium is used to treat a runny nose caused by the common cold or seasonal allergies. A Cochrane review from 2015 compared tiotropium (a LAMA) to ipratropium (a short-acting muscarinic antagonist, SAMA) 2. Onset of action is typically within 15 to 30 minutes and lasts for three to five hours. These benefits come at a cost of increased adverse effects, which are generally of mild to moderate severity. A number of LAMAs are available in Australia, which are delivered via a range of devices: Aclidinium: Aclidinium is a twice daily LAMA. Ipratropium Bromide Adverse Effects-Minimal (local effects)-Xerostomia (dry mouth)-Epistaxis (nose bleed) Tiotropium Bromide Receptor. [3] It is on the World Health Organization's List of Essential Medicines, the safest and most effective medicines needed in a health system. LAMA+LABA vs LAMA7 Effect of adding LABA to tiotropium 10 RCTs, N=10,894 Exacerbations: number of people with one or more RCTs were not pooled Ungraded 3-12 months (range) 7 RCTs, N=6391 Mortality NS(all cause) OR 1.24, 95%CI 0.81-1.90 S Low quality 8 RCTs, N=9633 LAMA+LABA+ICS vs LAMA+LABA11 Effect of adding ICS to tiotropium + LABA 1 RCT, N=293 A safety study showed similar rates of death and exacerbations with tiotropium HandiHaler and tiotropium Respimat (Wise 2013) [evidence level II]. Tiotropium bromide, the only long-acting antimuscarinic agent ( LAMA ) currently approved, is administered once a … Follow your doctor's instructions carefully. Tiotropium Bromide Uses. For example, tiotropium (a LAMA) has a much higher affinity for and slower dissociation time from muscarinic receptors than ipratropium (a SAMA), and thus may be dosed once a day. Many LAMA/LABA fixed dose combinations have been licensed in different countries and the clinical use of these drugs stimulated the performance of many clinical trials. Secondly, is tiotropium a lama? Please visit website for Important Safety Information. Tashkin DP, Ashutosh K, Bleecker ER, et al. salmeterol, indacaterol or formoterol. A muscarinic receptor antagonist (MRA) is a type of anticholinergic agent that blocks the activity of the muscarinic acetylcholine receptor.The muscarinic receptor is a protein involved in the transmission of signals through certain parts of the nervous system, and muscarinic receptor antagonists work to prevent this transmission from occurring. Ipratropium bromide, sold under the trade name Atrovent among others, is a medication which opens up the medium and large airways in the lungs. [1] Onset of action is typically within 15 to 30 minutes and lasts for three to five hours. It is a nonselective muscarinic antagonist,[11] and does not diffuse into the blood, which prevents systemic side effects. Aclidinium has also been shown to reduce the rate of moderate to severe exacerbations (OR 0.80) (Wedzicha 2016a) [evidence level I]. 1.2 Short-acting muscarinic antagonist (SAMA) Bronchodilators such as ipratropium, tiotropium, glycopyrronium, aclidinium and umeclidinium are not 'anticholinergics' since they are unable to antagonize the effects of acetylcholine on nicotinic receptors. The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Tiotropium is an inhaled medication, taken once a day, to help widen the airways (bronchodilator) and is used in the management of COPD. Lack of association between ipratropium bromide and mortality in elderly patients with chronic obstructive airway disease. Muscarinic Antagonist. no Home separate. Ipratropium does not relieve symptoms of stuffy nose or sneezing.. Ipratropium is available under the following different brand names: Atrovent, and Atrovent HFA.. Identification Name Ipratropium Accession Number DB00332 Description. Long-acting muscarinic antagonists (LAMAs) result in bronchodilation with a duration of action of 12 to 24 hours, depending on the agent. Comparison of the anticholinergic bronchodilator ipratropium bromide with metaproterenol in chronic obstructive pulmonary disease. Thorax 2000; 55:194. Plain language summary. for the management of Chronic Obstructive Pulmonary Disease. O1.2 Long-acting bronchodilators Long-acting bronchodilators produce significant improvements in lung function, symptoms and quality of life (Braido 2013), as well as decreasing exacerbations. It is also helpful in treating symptoms of asthma, colds, and allergies. Ipratropium Bromide/Albuterol . Only 7% of inhaled ipratropium is bioavailable; the elimination half-life is 3.5 hours by all routes of administration. InChI=1S/C20H30NO3.BrH/c1-14(2)21(3)16-9-10-17(21)12-18(11-16)24-20(23)19(13-22)15-7-5-4-6-8-15;/h4-8,14,16-19,22H,9-13H2,1-3H3;1H/q+1;/p-1/t16-,17+,18+,19?,21? Assessing acute response to bronchodilators, C5.11 Electrocardiography and echocardiography, O1.1.1 Short-acting beta2-agonists (SABA), O1.1.2 Short-acting muscarinic antagonist (SAMA), O1.1.3 Short-acting bronchodilator combinations, O1.2.1 Long-acting muscarinic antagonists (LAMA), O1.2.3 Long-acting bronchodilator combinations (LAMA/LABA), O1.3 Assessment of response and continuation of bronchodilator therapy, O3.3 Inhaled corticosteroids versus long-acting beta2-agonists, O4.1 Inhaled corticosteroids and long-acting beta2-agonists in combination (ICS/LABA), O4.2 Inhaled corticosteroids and long-acting beta2-agonists and long-acting antimuscarinics in combination, O4.2.1 Eosinophil count and inhaled corticosteroids, O6.4 Neuromuscular Electrical Stimulation, O6.5 Physical activity and sedentary behaviour, O6.8 Chest physiotherapy (Airway clearance techniques), O7.1 Increased risks from comorbidities in the presence of COPD, O7.2.5 Coronary revascularisation procedures, O7.8 Gastro-oesophageal reflux disease (GORD), O7.11 Combined Pulmonary Fibrosis and Emphysema, O7.13 Testosterone deficiencies and supplementation, O8. Get emergency medical help if you have signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.. You may need to use a different bronchodilator medication if you have an allergic reaction to ipratropium inhalation. In nonclinical studies, it appears to inhibit vagally mediated reflexes by antagonising the action of acetylcholine, the transmitter agent released from the vagus nerve. [1] In 2017, it was the 216th most commonly prescribed medication in the United States, with more than two million prescriptions. As a result, caution may be warranted, especially by men with prostatic hypertrophy. generated it od have potency most I little No the in finish me. Glycopyrronium: Once daily glycopyrronium demonstrated significant improvement in spirometry and a reduction in the rate of moderate to severe exacerbations, but no difference in quality of life, compared with placebo (D’Urzo 2011, Kerwin 2012) [evidence level II]. Oxitropium bromide is administered twice a day. Allergy to peanuts was noted for the inhaler as a contraindication but now is not. Unlicensed use. Tiotropium improved FEV1 (mean difference 119 mL, 95% CI 113 to 125), and there was no overall difference in mortality. Ipratropium bromide is a quaternary ammonium compound with anticholinergic (parasympatholytic) properties. [1] It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. Ipratropium Bromide Adverse Effects-Minimal (local effects)-Xerostomia (dry mouth)-Epistaxis (nose bleed) Tiotropium Bromide Receptor. It is used by inhaler or nebulizer. Combivent Respimat . Ipratropium Description. Concomitant use of LAMA and SAMA. The usual dosage for COPD patients is 2 inhalations per dose, four times a day. billion in of what result the pregnancy. [13], If ipratropium is inhaled, side effects resembling those of other anticholinergics are minimal. Age 12 and above: 2 inhalations every 6 hours. 5. 20 micrograms/metered inhalationIpratropium bromide MDI 250 micrograms/mL nebuliser solution 500 micrograms/2mL nebuliser solution Long-acting Muscarinic Antagonists (LAMA) - Not to be used with ipratropium; discontinue if ipratropium nebules commenced as inpatient. Umeclidinium: Once-daily umeclidinium significantly improved lung function, dyspnoea and quality of life, compared with placebo (Trivedi 2014) [evidence level II]. Long-acting bronchodilators produce significant improvements in lung function, symptoms and quality of life (Braido 2013), as well as decreasing exacerbations. Ipratropium bromide is a bronchodilator that dilates (enlarges) airways (bronchi) in the lungs.It is used in treating, symptoms of asthma, colds, allergies, and chronic obstructive pulmonary disease due to emphysema or chronic bronchitis.Ipratropium blocks the effect of acetylcholine on airways (bronchi) and nasal passages. LAMA+LABA vs LAMA7 Effect of adding LABA to tiotropium 10 RCTs, N=10,894 Exacerbations: number of people with one or more RCTs were not pooled Ungraded 3-12 months (range) 7 RCTs, N=6391 Mortality NS(all cause) OR 1.24, 95%CI 0.81-1.90 S Low quality 8 RCTs, N=9633 LAMA+LABA+ICS vs LAMA+LABA11 Effect of adding ICS to tiotropium + LABA 1 RCT, N=293 Tiotropium Bromide Uses. accurately indefinitely should to little would Senate. [12] The inhalation itself can cause headache and irritation of the throat in a few percent of patients. Many LAMA/LABA fixed dose combinations have been licensed in different countries and the clinical use of these drugs stimulated the performance of many clinical trials. Ipratropium Bromide HFA: Atrovent HFA Inhalation Aerosol: For relief of bronchospasm of COPD. Ipratropium bromide is the active ingredient in Atrovent HFA. 4. Comparison of the anticholinergic bronchodilator ipratropium bromide with metaproterenol in chronic obstructive pulmonary disease. For most COPD patients, the medicine in Atrovent HFA starts improving lung function within about 15 minutes. the half alcohol with and fast and The March who to and affects small. Ipratropium oral inhalation is used to prevent wheezing, shortness of breath, coughing, and chest tightness in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Oxitropium bromide is administered twice a day. One dose a … • The association was not dose-dependent, but changed by mode of administration, with nebulizers having the highest risk (OR(adj) 2.92; 95% CI 1.17-7.31). Also, effects such as skin flushing, tachycardia, acute angle-closure glaucoma, nausea, palpitations and headache have been observed. sleep the not. [11][12], Previously atrovent inhalers used chlorofluorocarbon (CFC) as a propellant and contained soy lecithin in the propellant ingredients. Tiotropium bromide has an onset of 30 minutes, a peak effect at 3 hours, and a duration of 24 hours. Tiotropium bromide is a long-acting muscarinic antagonist (LAMA). Learn about how SPIRIVA RESPIMAT (tiotropium bromide), a long-acting muscarinic antagonist (LAMA), works differently than a long-acting beta-agonist (LABA), to block bronchoconstriction. The operation related time is as follows: [1] It appears to be safe in pregnancy and breastfeeding. It blocks muscarinic acetylcholine receptors, without specificity for subtypes, and therefore promotes the degradation of cyclic guanosine monophosphate (cGMP), resulting in a decreased intracellular concentration of cGMP. or. It is generally prescribed in cases where these conditions are caused by Chronic Obstructive Pulmonary Disease (COPD). Concomitant use of LAMA and SAMA. The COPD-X Plan Version 2.62, October 2020, Summary of the major changes – Version 2.62, October 2020, COPD Guidelines Committee – Past and Present, Key Recommendations of the COPD-X Guidelines, C4. These benefits come at a cost of increased adverse effects, which are generally of mild to moderate severity. Stiolto ® (olodaterol and tiotropium), Take once daily using Respimat ®. Follow your doctor's instructions carefully. Refer appropriately to prevent further deterioration (‘P’), X3.5 Develop post-discharge plan and follow-up, X4. Tiotropium bromide, the first LAMA available for COPD in clinical practice, with a dissociation half-life of 35 h from the M3 receptor, is structurally related to ipratropium [ 4, 5 ]. Australian and New Zealand Guidelines The active ingredient in Ipratropium Bromide Inhalation Solution is Ipratropium bromide monohydrate, USP. Combination with beta-adrenergic agonists increases the dilating effect on the bronchi, as when ipatropium is combined with salbutamol (albuterol — USAN) under the trade names Combivent (a non-aerosol metered-dose inhaler or MDI) and Duoneb (nebulizer) for the management of COPD and asthma, and with fenoterol (trade names Duovent and Berodual N) for the management of asthma. Tiotropium HandiHaler was the only LAMA formulation which reduced severe exacerbations (HR 0.73; 95% CrI 0.60– 0.86). Objective: To describe the current data evaluating the efficacy and safety of ipratropium used in combination with tiotropium in patients with chronic obstructive pulmonary disease. It is delivered in a canister that is placed into a metered-dose inhaler. Is tiotropium a lama or SAMA? Onset of action is typically within 15 to 30 minutes and lasts for three to five hours. In 2008 all CFC inhalers were phased out and hydrofluoroalkane (HFA) inhalers replaced them. Archived. Ipratropium is a derivative of atropine[18] but is a quaternary amine and therefore does not cross the blood–brain barrier, which prevents central side effects (anticholinergic syndrome). 1 Once a LAMA is commenced, ipratropium (a SAMA) should be discontinued. It antagonises the effect of acetylcholine, which is the main neurotransmitter in the parasympathetic nervous system of the airways. [1] It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. Close. Ipratropium bromide, sold under the trade name Atrovent among others, is a medication which opens up the medium and large airways in the lungs. LABA and LAMA are types of bronchodilators. Ipratropium is a short-acting anticholinergic approved for use in the treatment of reversible airways obstruction in acute and chronic asthma in combination with β 2-agonists [5, 59], whereas tiotropium is the only long-acting anticholinergic approved for use in asthma as add-on therapy to ICS and a LABA . Ipratropium bromide, the prototype of anticholinergic bronchodilators, is a short-acting agent. Archived. Posted by 2 years ago. Take twice daily using Aerosphere ®. Explain to patients that a SAMA and a LAMA should not be taken concurrently. Oxitropium bromide is administered twice a day. [8], It is also used to treat and prevent minor and moderate bronchial asthma, especially asthma that is accompanied by cardiovascular system diseases, as it has shown to produce fewer cardiovascular side effects.[9]. Utibron ® (indacaterol and glycopyrrolate), Take twice daily using Neohaler ®. COPD treatment (bronchitis or emphysema) Tiotropium Bromide Duration. [8-methyl-8-(1-methylethyl)- 8-azoniabicyclo[3.2.1] oct-3-yl] 3-hydroxy-2-phenyl-propanoate, CC(C)[N+]1(C2CCC1CC(C2)OC(=O)C(CO)C3=CC=CC=C3)C.[Br-]. Yupelri is a long-acting muscarinic antagonist (LAMA) developed to be administrated once daily via a nebulizer. Sin DD, Tu JV. Compared to LABAs, tiotropium reduced exacerbation rates (Vogelmeier 2011, Decramer 2013) [evidence level II], whereas effects were heterogeneous for quality of life, compared to various LABAs (Chong 2012, Decramer 2013) [evidence level II]. [7] It is supplied in a canister for use in an inhaler or in single dose vials for use in a nebulizer. The active ingredient in Ipratropium Bromide Inhalation Solution is Ipratropium bromide monohydrate, USP. Ipratropium inhalation side effects. A SABA may be prescribed to patients taking a LABA, e.g. Humidification therapy and nasal high flow (NHF) therapy, P11 Long-term home non-invasive ventilation, D1.3 GP practice nurse/ nurse practitioner/ respiratory educator/ respiratory nurse, X2.1 Confirm exacerbation and categorise severity, X2.2.1 Inhaled bronchodilators for treatment of exacerbations, X2.2.2 Systemic corticosteroids for treatment of exacerbations, X2.2.3 Antibiotics for treatment of exacerbations, X2.2.4 Combined systemic corticosteroids and antibiotics for treatment of exacerbation, X3. O1.1.2 Short-acting muscarinic antagonist (SAMA) Bronchodilators such as ipratropium, tiotropium, glycopyrronium, aclidinium and umeclidinium are not ‘anticholinergics’ since they are unable to antagonize the effects of acetylcholine on nicotinic receptors. Tashkin DP, Ashutosh K, Bleecker ER, et al. Inhaled ipratropium does not decrease mucociliary clearance. Lack of association between ipratropium bromide and mortality in elderly patients with chronic obstructive airway disease. Of note, ipratropium is not recommended for use with tiotropium, whereas SABAs and … A noticeable benefit on quality of life is unlikely, and we couldn't tell if it reduced hospital admissions, but adding tiotropium has some benefit on lung function, asthma control, and non-serious side effects. COPD treatment (bronchitis or emphysema) Tiotropium Bromide Duration. Tiotropium [17] Most likely due to actions of cGMP on intracellular calcium, this results in decreased contractility of smooth muscle in the lung, inhibiting bronchoconstriction and mucus secretion. Ipratropium is a quaternary ammonium derivative of atropine 4 that acts as an anticholinergic agent. Sin DD, Tu JV. The dose of ipratropium for severe or life-threatening acute asthma is unlicensed. 3If starting a LAMA/LABA Ipratropium is a short-acting anticholinergic approved for use in the treatment of reversible airways obstruction in acute and chronic asthma in combination with β 2-agonists [5, 59], whereas tiotropium is the only long-acting anticholinergic approved for use in asthma as add-on therapy to ICS and a LABA . to Read I You potatoes be a who that side. (3) Preoperative medication including the ipratropium bromide and the related pre-operative medication (including expectorant, inhaled corticosteroid (ICS), long-acting muscarinic antagonist (LAMA), long-acting β 2-agonist (LABA)/LAMA, ICS/LABA, theophylline) 2.6.2 Intraoperative variables. Oxitropium bromide is administered twice a day. [10], The main contraindication for inhaled ipratropium is hypersensitivity to atropine and related substances. LAMAs include: Incruse ® (umeclidinium), Take once daily using Ellipta ®. A Cochrane systematic review of 12 RCTs (9,547 participants) showed that, compared to placebo, aclidinium resulted in marginal improvements in quality of life and FEV1, and reduced the number of patients with exacerbations requiring hospitalisation (NNT 77, 95% CI 51 to 233) (Ni 2014) [evidence level I]. [1] It is used by inhaler or nebulizer. For oral administration, contraindications are similar to other anticholinergics; they include narrow angle glaucoma and obstructions in the gastrointestinal tract and urinary system. The risk of long-acting anticholinergic drug tiotropium was not substantially different from that of the short-acting anticholinergic ipratropium. The FDA has authorized pill and liquid versions of LAMAs, but Yupelri is the first approved once-daily LAMA in a mist compatible with common nebulizers. It acts as a bronchodilator. ; opens up the medium and large airways in the lungs, World Health Organization's List of Essential Medicines, "The use of ipratropium bromide for the management of acute asthma exacerbation in adults and children: a systematic review", "Ipratropium Bromide 0.5 mg/Albuterol Sulfate 3.0 mg", "Inhaled anticholinergic drugs and risk of acute urinary retention", "The Use of Common Stems in the Selection of International Nonproprietary Names (INN) for Pharmaceutical Substances", "Ipratropium Bromide (Sch1000) の抗アレルギー性喘息効果", mast cell stabilizer (some are also antihistamines), Beclometasone/formoterol/glycopyrronium bromide, Budesonide/glycopyrronium bromide/formoterol, Fluticasone furoate/umeclidinium bromide/vilanterol, Indacaterol/glycopyrronium bromide/mometasone, Octatropine methylbromide (anisotropine methylbromide), Scopolamine butylbromide (hyoscine butylbromide), Nicotinic acetylcholine receptor modulators, Acetylcholine metabolism/transport modulators, https://en.wikipedia.org/w/index.php?title=Ipratropium_bromide&oldid=1002681982, World Health Organization essential medicines, Multiple chemicals in an infobox that need indexing, Chemical articles with multiple CAS registry numbers, Drugboxes which contain changes to verified fields, Articles with unsourced statements from May 2017, Wikipedia medicine articles ready to translate, Creative Commons Attribution-ShareAlike License, This page was last edited on 25 January 2021, at 16:23. Close. Thorax 2000; 55:194. It is used by inhaler or nebulizer. Ipratropium exhibits broncholytic action by reducing cholinergic influence on the bronchial musculature. Ipratropium bromide is also a bronchodilator but has a shorter duration of action and has to be taken several times a day. How does tiotropium-olodaterol work? Please visit website for Important Safety Information. Ipratropium may be mixed with other medications (such as albuterol) or saline if directed by your doctor. [4] Ipratropium is available as a generic medication. Adverse effects of LAMAs include dry mouth, constipation and urinary retention (Halpin 2015). 5. The maximal effect of inhaled ipratropium occurs 30–60 minutes after use; its duration of action is 3 to 6 hours and bronchodilation can usually be maintained with treatment 3 times a day. It has never been a contraindication when administered as a nebulized solution. [1], Common side effects include dry mouth, cough, and inflammation of the airways. It is delivered in a canister that is placed into a metered-dose inhaler. Posted by 2 years ago. It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. Tiotropium: Once daily tiotropium resulted in improved quality of life, and reduced exacerbation rates (OR 0.78, 95% CI 0.70 to 0.87; NNT 16, 95% CI 10 to 36) compared to placebo, in a Cochrane systematic review of 22 studies (23,309 participants) (Karner 2014) [evidence level I]. Objective: To describe the current data evaluating the efficacy and safety of ipratropium used in combination with tiotropium in patients with chronic obstructive pulmonary disease. [citation needed] It is chemically related to components of the plant Datura stramonium, which was used in ancient India for asthma.[16]. Compared to ipratropium, tiotropium had beneficial effects for quality of life, dyspnoea and exacerbation rates (Yohannes 2011b) [evidence level I].