To present the case of a patient with persistent
bronchospasm, refractory to treatment with β2-agonists, that resolved promptly with continuous inhalation of large dose (1000 mcg/hr)
ipratropium bromide, and to discuss the possibility of tolerance to β2-agonists as the cause for his failure to respond to
adrenergic medications. The patient had received multiple doses of
albuterol, as well as subcutaneous
terbutaline (0.3 mg), intravenous
magnesium sulfate (1 g) and intravenous
dexamethasone (10 mg) prior to his admission to the intensive care unit. He remained symptomatic despite systemic intravenous
steroids, continuous intravenous
terbutaline (up to 0.6 mcg/kg/min), and continuous nebulized
albuterol (up to 20 mg/hr for 57 hr) followed by 49 hours of continuous
levalbuterol (7 mg/hr). Due to the lack of response, all β2-agonists were discontinued at 106 hours post-admission, and he was started on large dose
ipratropium bromide (1000 mcg/hr) by continuous nebulization. Clinical improvement was evident within 1 hour and complete resolution of his symptoms within 4 hours. Continuous inhalation of large dose
ipratropium bromide may be an effective regimen for the treatment of patients hospitalized with acute
asthma who are deemed to be nonresponsive and/or tolerant to β2-agonist
therapy.