Pharmacological anisocoria is a rare but benign condition. This paper presents an eleven-year-old patient with asthma who developed ipratropium bromide-associated anisocoria during nebulizer treatment. Hypotheses regarding the possible causes of anisocoria are discussed and precautions to be taken during treatment are presented. To prevent the development of anisocoria, it was found that it is important to use the appropriate mask during nebulizer treatment, to place the mask on the face properly, and, if possible, to administer drugs by closing the eyes. Further, it is recommended that patients undergo an ophthalmological examination before discharge and that they and their families be informed that the condition is temporary.

Background: Selecting the most effective and less toxic drug in treatment of chemically injured patients of the imposed war is of great importance in therapy. Objective: To compare the therapeutic effect of salbutamol spray with combivent (combination of salbutamol with ipratropium bromide) in pulmonary function tests of lung injured patients of the imposed war. Method: In this study, 30 chemically injured patients of war under -went spirometry on the Baseline of VC , FEV1/FVC and MMEF . The patients were studied in two different sessions. In the first session, they were given sulbutamol spray (200 mcg) and spirometry was taken after 20 and 180 minutes. In the second session, all patients were given combivent and spirometry was taken in 20 and 180 minutes. Findings: The findings indicated that combivent is more effective than salbutamol alone in improving VC, FEV1/FVC and MMEF. The effects were more remarkable in 180 minute in  comparison to minute. Conclusion: It seems that combination of sulbutamol with ipratropum bromide has better action in bronchodilation in comparison with salbutamol alone in chemically injured war victims.      

Background: Asthma could be diagnosed by its characteristic presentation. Spirometry can help the diagnosis by revealing post-bronchodilator response. Classically, salbutamol (albuterol) is used for evaluating post-bronchodilator response. This drug causes paradoxical bronchospasm in less than 10% of asthmatic patients. This study aimed to evaluate the frequency of paradoxical bronchospasm with salbutamol during spirometry and compare it with other drugs that did not reveal paradoxical bronchospasm such as levalbuterol and ipratropium.Materials and Methods: One hundred-Ninety two asthmatic subjects were entered in this clinical trial. All patients showed clinical manifestations of asthma and revealed obstructive pattern during spirometry. They were randomly assigned into three groups of drugs included: salbutamol, levalbuterol and ipratropium. Two puffs of these drugs were administered via a spacer and patients waited for fifteen minutes for the maximal effect to take place. Then spirometry was obtained again and postbronchodilator FEV1 and its alterations were compared among the three groups.Results: The mean±SD age of patients was 49.40±17.4 years; the mean age, demographic data, clinical findings and spirometry results showed no significant difference among groups. FEV1 percent of predicted was 58.6±19.5 which proved that most subjects were suffering from severe asthma. Improvement of FEV1 by salbutamol (22.2±3%) and levalbuterol (16±18%) was significantly more compared with ipratropium (9.4±11%) (t=2.5, P=0.01 and t=2.2, P=0.01, respectively). Paradoxical bronchospasm (more than 12% decrease in FEV1) was seen in two (3%), one (1.5%) and four (6%) subjects of salbutamol, ipratropium and levalbuterol groups, respectively. Regarding clinical improvement, levalbuterol resulted in the higher frequency of clinical improvement compared to salbutamol and ipratropium.Conclusion: With the dosage recommended for reversibility testing during spirometry, salbutamol showed comparable bronchodilator response and paradoxical bronchospasm frequency compared to levalbuterol and ipratropium.

A 60-year-old woman was admitted due to persistent right-sided vague chest pain since two months ago. She also complained of 5 kg weight loss and productive cough.On admission, she was stable and afebrile with mild crackles in both lungs without tachypnea or remarkable respiratory distress.She lived in a rural region in southwest of Iran and was being treated with combined fluticasone-salmeterol and ipratropium bromide due to chronic bronchitis since five years ago. Exposure to biomass fuels used for cooking and heating was a possible etiology for her chronic respiratory symptoms. She denied using systemic corticosteroids in recent months.

Though intravenous (IV) Magnesium Sulphate (MgSO4) has additive effect to beta-2 agonists, its additive benefit in face of combination therapy with beta-2-agonists and ipratropium (standard therapy of severe acute exacerbation of asthma) remains unaddressed. The aim of this investigation was to evaluate the role of IV MgSO4 when used as an adjunct to standard therapy of severe exacerbations of asthma.Randomized, single blinded, placebo-controlled study was carried out in Emergency Department (ED). Patients aged 18-60 years presenting with acute asthma and FEV1£ 30 % predicted (pred.) were included. All patients received IV Hydrocortisone on arrival. In group1 (controls), patients were nebulised with salbutamol and ipratropium thrice at 20 minutes interval and were given 2g IV MgSO4 at 30 minutes. In group2 patients were nebulised similarly, but were given IV normal saline at 30 minutes for blinding. FEV1 Was evaluated at baseline and at 30 minutes intervals. The primary efficacy end point was FEV1%pred. at 120 mins and pooled discharge rate (derived from comparing proportion of groups attaining PEFR ³60% pred. and relief in dyspnea at 30, 60, 90, 120 minutes). Both groups of 30 patients each, were matched with respect to demographic and pulmonary parameters (Baseline FEV1% 22.07±5.1% in group 2 vs. 22.07±5.2% in group1, p=0.87). At 120 minutes, there was a higher mean FEV1%pred (62.84±4.73% vs 56.7±4.5%) and %improvement from baseline of (40.7±9.2%vs 34.77±7.3%), in group 2 as compared to group1 (Mean Difference= 6.07%, C.I.1.87-10.62., p<0.01).The pooled discharge rate in group2 with respect to group1 was positive and significant (log rank=6.8, p<0.05). Thus IV MgSO4 improves pulmonary function and discharge rates, when used as an adjunct to standard therapy in severe acute asthma. Magnesium sulfate as an adjunct to standard therapy in patients with severe exacerbation of asthma could cause improvement in pulmonary function and decrease in hospital admission.

Introduction: Most household cleaners contain chlorine, an irritating chemical commonly used to purify water. The inhalation of chlorine causes chemical pneumonitis and the treatment of inhalation injuries from this chemical is difficult due to the lack of evidence and human studies. We will discuss a case of a man, who developed chemical pneumonitis after being exposed to chlorine fumes while cleaning swimming pool. Case Presentation: A 30-year-old man showed up after being exposed to 33% hydrochloric fumes at work and developed coughing, sore throat, and dyspnea immediately. He received initial treatment at nearby clinic and referred to the emergency department. In emergency department, he was in respiratory distress. His respiratory rate was 28 breaths per minute and oxygen saturation was 81% with a 15 L/min non-rebreathing mask. Lung auscultation showed crepitation in both lower zones with expiratory rhonchi. Noninvasive ventilation support was initiated with continuous nebulization of salbutamol, ipratropium bromide, and sodium bicarbonate. His initial blood gases showed type 1 respiratory failure. He was then intubated for severe acute respiratory distress syndrome. The patient was then admitted to the intensive care unit for further treatment and discharged after 18 days of hospitalization. Conclusion: Acute exposure to chemical irritants can cause asthma exacerbation, chronic bronchitis, bronchial hypersensitivity, and ARDS. There are no biomarkers for the inhalation of HCL gas. Medical history, clinical symptoms, and radiographic findings are decisive factors in the diagnosis. Treatment usually focuses on supportive care such as oxygen therapy, broncholytic therapy, and sodium bicarbonate, inhaled or systemic corticosteroids.

Intractable asthma is a challenging clinical problem. This study was conducted to determine whether a subset of patients with Intractable asthma may be misdiagnosed and have a form of bronchiolitis instead and also to determine the effectiveness of macrolide therapy in these patients. Seventy six patients with Intractable asthma were re-treated with recommended maximal doses of oral prednisolone for 5 days, beclomethasone, cromolyn sodium, salbutamol and ipratropium bromide for 30 days. Thirty five patients were considered as unresponsive and constituted the study group. They underwent high-resolution CT (HRCT) scan following which they were offered with video-assisted thoracoscopic surgical biopsy. Group 1 (n=27) refused biopsy and each was treated with macrolide therapy, while Group 2 (n=8) underwent biopsy, and then received macrolide therapy. The patients were treated and followed for three months. The study group consisted of 27 patients, with a mean age of 46.9±11.1 years. The mean duration of time between the onset of symptoms and the start of this study was 8.1 years. In group 2, no patient had pathologic findings of asthma, and 7/8 had a form of bronchiolitis. There was significant improvement in dyspnea, cough and pulmonary function indices at the end of the 3-month in both groups (p<0.001). Our results suggest that patients with Intractable asthma could be misdiagnosed and some of them have some forms of chronic bronchiolitis. We believe that any patient who does not respond to standard treatments for Intractable asthma should be evaluated with expiratory HRCT; those with significant air trapping should be considered for a course of macrolide therapy or biopsy for better identification of the underlying disease.