1. Aschenbrenner, Diane S. MS, RN


* Aclidinium bromide (Tudorza Pressair) is a new powdered, inhaled anticholinergic that has been approved for the treatment of chronic obstructive pulmonary disease. The drug is used daily to prevent or minimize bronchospasms.


* Aclidinium bromide can produce paradoxical bronchospasms and immediate hypersensitivity reactions (especially in those with a history of hypersensitivity to atropine or milk proteins). If either of these occurs, the drug should be discontinued.



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The Food and Drug Administration recently approved aclidinium bromide (Tudorza Pressair), a new powdered anticholinergic, for the treatment of chronic obstructive pulmonary disease (COPD). Inhaled twice daily, aclidinium bromide is used as a maintenance drug to promote bronchial dilation; it's not a rescue drug and shouldn't be used during acute episodes of bronchospasm.


The drug's label carries warnings that aclidinium bromide may cause paradoxical bronchospasm. If it occurs, the drug should be discontinued. Additionally, aclidinium bromide can cause immediate hypersensitivity reactions. Because the chemical structure of aclidinium is similar to that of atropine, patients with a history of hypersensitivity reactions to atropine would be at high risk for a similar allergic response to aclidinium bromide. Also at high risk for severe allergic responses to the drug are patients with severe hypersensitivity to milk proteins because the drug contains lactose monohydrate.


Other warnings are related to the drug's anticholinergic effects; it can worsen narrow-angle glaucoma and urinary retention. There may also be additive effects if it's taken concurrently with other anticholinergic drugs, which can produce significant anticholinergic adverse effects (such as dry mouth or constipation). The most common adverse effects of aclidinium bromide are headache, nasopharyngitis, and cough.


Nurses should assess patients carefully before therapy with aclidinium bromide is started for allergy to atropine or milk proteins, narrow-angle glaucoma, urinary retention, and the use of other anticholinergic drugs, such as ipratropium or tiotropium used in treating COPD, or over-the-counter medications, such as cough and cold preparations. Although these other drugs aren't contraindicated, as noted above, they may produce additive anticholinergic effects that can be problematic for patients.


Nurses should make sure that patients prescribed aclidinium bromide know that when used regularly twice a day, the drug will promote bronchodilation. The full effect of the drug may not be apparent for several days. Doses should be taken 12 hours apart. If a dose is missed, the patient should skip that dose rather than take two doses at once.


Nurses need to teach patients how to use the inhaler that dispenses aclidinium bromide because it has some unique features. The inhaler has a green button to activate the dose and a control window that changes from red to green when the dose is ready to be inhaled. Before placing the inhaler in the mouth, the patient presses the green button to activate the dose, confirms that the control window has changed to green, and exhales; she or he then places the mouthpiece in the mouth and breathes in through the mouth quickly and deeply. A click will be heard during inhalation, which indicates correct use. After the medication has been inhaled completely, the control window returns to red. Each inhaler contains 60 doses. An indicator on the inhaler displays the number of doses remaining. Additionally, the device locks when it's empty to prevent further activation. Full directions for use are included with the package insert:


Nurses should also inform patients that the drug can cause paradoxical bronchospasms, with sudden shortness of breath and difficulty breathing. If they occur, patients should discontinue the drug, use a rescue inhaler, and contact their prescriber. If severe respiratory distress continues, patients should seek emergency medical care. Patients should know that eye pain or discomfort, blurred vision, visual halos, or colored images associated with red eyes from conjunctival congestion and corneal edema may be signs of acute narrow-angle glaucoma. Patients should be instructed to contact their provider immediately if such symptoms appear.


Patients should be taught to avoid getting the powder in their eyes because it can cause blurred vision and pupil dilation. Nurses should also teach patients that aclidinium bromide may cause difficulty passing urine and painful urination (either as a new problem or worsening of a current problem). If serious allergic reactions such as rash; hives; swelling of the face, mouth, and tongue; or difficulty breathing occur, the patient should receive emergency medical care.