Rodrigo GJ, Rodrigo C. Chest. 2002;121:1977–1987
Purpose of the Study.
To determine the evidence in the literature of randomized, controlled trials supporting the use of anticholinergics in the treatment of acute asthma. The study was a metanalysis of both pediatric and adult studies, but only results of the review of pediatric studies will be reported here.
Study subjects were between the ages of 1 and 17 years, and the studies were performed in the United States and Europe between 1985 and 2000. A total of 17 pediatric studies were included in the analysis.
The question that was proposed to answer from the literature search was: “Does the addition of inhaled anticholinergic agents to standard treatment of β2-agonist agents decrease the likelihood of hospital admission or improve pulmonary function in the course of the emergency department (ED) visit?” A literature review using MEDLINE 1966–2001, EMBASE 1980–2001, CINAHL 1982–2001, Cochrane Review, and hand-searching major journals with cross-searching of references was performed. Studies were ranked for level of evidence with highest rank given to large randomized, controlled trials or systematic reviews of randomized trials and lower ranks for cohort and case studies. Studies were analyzed for methodology and assigned a Jadad score based on quality, with scores of 3 or higher considered of good quality. Only studies performed on asthmatics in acute care settings such as EDs were included. The primary outcome assessed by the review was need for hospitalization and secondary outcomes included pulmonary function tests, clinical or physiologic results and adverse effects.
A total of 4 studies (2 systematic reviews and 2 randomized, controlled trials) involving pediatrics patients presenting to the ED with acute asthma who had been treated with anticholinergic agents were examined. The dose of nebulized ipatropium bromide used in these trials was usually 250 μg per dose every 20 minutes. Frequency of dosing versus β2-agonists was not noted in the analysis. Hospital admissions were reduced by about 30% in the subjects that were treated with multiple doses of anticholinergic agents in addition to β2-agonists. A moderate difference was noted between the groups for change in pulmonary function. There was less benefit to adding a single dose of an anticholinergic agent to the β2-agonists treatment of children with mild to moderate acute asthma (forced expiratory volume in 1 second [FEV1] >50%). No apparent increase in adverse events was noted.
The authors conclude that the addition of anticholinergic therapy to usual β2-agonist therapy was beneficial in pediatric patients presenting with acute asthma that was more severe by reducing the need for hospitalization and by improving lung function.
This metanalysis is further evidence to support the common practice in pediatric EDs of adding anticholinergic therapy to standard β2-agonist therapy in patients presenting with more severe acute asthma.