ASTHMA

Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis

G J Rodrigo¹, J A Castro-Rodriguez²

¹ Departamento de Emergencia, Hospital Central de las FF.AA, Av 8 de Octubre 3050, Montevideo 11600 and Clinica Respirar, Benito Nardone 2310, Montevideo 11300, Uruguay
² Pediatric Pulmonary Section, Department of Pediatrics, School of Medicine, University of Chile, Santiago, Chile

Correspondence to:
Dr G J Rodrigo
Departamento de Emergencia, Hospital Central de las FF.AA, Av 8 de octubre 3020, Montevideo 11600, Uruguay; gurodrig{at}adinet.com.uy

Background: Current guidelines recommend the use of a combination of inhaled β₂ agonists and anticholinergics, particularly for patients with acute severe or life threatening asthma in the emergency setting. However, this statement is based on a relatively small number of randomised controlled trials and related systematic reviews. A review was undertaken to incorporate the more recent evidence available about the effectiveness of treatment with a combination of β₂ agonists and anticholinergics compared with β₂ agonists alone in the treatment of acute asthma.

Methods: A search was conducted of all randomised controlled trials published before April 2005.

Results: Data from 32 randomised controlled trials (n = 3611 subjects) showed significant reductions in hospital admissions in both children (RR = 0.73; 95% CI 0.63 to 0.85, p = 0.0001) and adults (RR = 0.68; 95% CI 0.53 to 0.86, p = 0.002) treated with inhaled anticholinergic agents. Combined treatment also produced a significant increase in spirometric parameters 60–120 minutes after the last treatment in both children (SMD = –0.54; 95% CI –0.28 to –0.81, p = 0.0001) and adults (SMD = –0.36; 95% CI –0.23 to –0.49, p = 0.00001).

Conclusions: This review strongly suggests that the addition of multiple doses of inhaled ipratropium bromide to β₂ agonists is indicated as the standard treatment in children, adolescents, and adults with moderate to severe exacerbations of asthma in the emergency setting.

Abbreviations: CCS, corticosteroids; ED, emergency department; FEV₁, forced expiratory volume in 1 second; NNT, number of patients needed to treat; PEF, peak expiratory flow; RR, relative risk; SMD, standardised mean difference; WMD, weighted mean difference

Keywords: anticholinergics; β2 agonists; ipratropium bromide; oxitropium bromide; glycopyrrolate; acute asthma; children

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This article has been cited by other articles:

• Camargo, C. A. Jr., Rachelefsky, G., Schatz, M. (2009). Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations. Proc Am Thorac Soc 6: 357-366 [Full Text]  
• Reddel, H. K., Taylor, D. R., Bateman, E. D., Boulet, L.-P., Boushey, H. A., Busse, W. W., Casale, T. B., Chanez, P., Enright, P. L., Gibson, P. G., de Jongste, J. C., Kerstjens, H. A. M., Lazarus, S. C., Levy, M. L., O'Byrne, P. M., Partridge, M. R., Pavord, I. D., Sears, M. R., Sterk, P. J., Stoloff, S. W., Sullivan, S. D., Szefler, S. J., Thomas, M. D., Wenzel, S. E., on behalf of the American Thoracic Society/Europea, (2009). An Official American Thoracic Society/European Respiratory Society Statement: Asthma Control and Exacerbations: Standardizing Endpoints for Clinical Asthma Trials and Clinical Practice. Am. J. Respir. Crit. Care Med. 180: 59-99 [Abstract] [Full Text]  
• Fanta, C. H. (2009). Asthma. NEJM 360: 1002-1014 [Full Text]  
• Chang, J., Mosenifar, Z. (2007). Differentiating COPD From Asthma in Clinical Practice. J Intensive Care Med 22: 300-309 [Abstract]  
• Salpeter, S. R. (2006). Safety of Long-Acting {beta}-Agonists.. ANN INTERN MED 145: 708-710 [Full Text]  
• Stoloff, S. W. (2006). Safety of long-acting beta-agonists.. ANN INTERN MED 145: 707-707 [Full Text]  
• Salpeter, S. R., Buckley, N. S., Ormiston, T. M., Salpeter, E. E. (2006). Meta-Analysis: Effect of Long-Acting {beta}-Agonists on Severe Asthma Exacerbations and Asthma-Related Deaths. ANN INTERN MED 144: 904-912 [Abstract] [Full Text]