Ipratropium bromide added to beta2-agonists in acute childhood asthma

A Cochrane review «Combined inhaled anticholinergics and short‐acting beta2‐agonists for initial treatment of acute asthma in children»1 «PGriffiths B, Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Cochrane Database Syst Rev 2013;(8):CD000060. »1 included 20 studies with a total of 2 697 children aged 1 to 18 years, presenting predominantly with moderate or severe exacerbations. Most studies used a fixed-dose protocol of 3 doses of 250 mcg or 2 doses of 500 mcg of nebulized ipratropium bromide in combination with a short-acting beta2-agonists (SABA) over 30 to 90 minutes while 3 studies used a single dose and 2 used a flexible-dose protocol according to the need for SABA.

The addition of an anticholinergic to SABA significantly reduced the risk of hospital admission (table «Anticholinergic and short-acting beta2-agonists (SABA) versus SABA alone for initial treatment of acute asthma in children.»1). Number needed to treat for an additional beneficial outcome (NNTB) was 16 (95% CI 12 to 29). Trends towards a greater effect with increased treatment intensity and with increased asthma severity were observed, but did not reach statistical significance. There was no effect modification due to concomitant use of oral corticosteroids and the effect of age could not be explored. Statistically significant group differences favoring anticholinergic use were observed for lung function, clinical score at 120 minutes, oxygen saturation at 60 minutes, and the need for repeat use of bronchodilators prior to discharge from the emergency department. No significant group difference was seen in relapse rates. Fewer children treated with anticholinergics plus SABA reported nausea and tremor compared with SABA alone; no significant group difference was observed for vomiting.