Can we justify ipratropium therapy as initial management of acute exacerbations of COPD?

Although inhaled ipratropium is commonly accepted as the drug of choice for long-term management of chronic bronchitis and emphysema, little evidence is available to promote its administration in conjunction with a beta(2)-ag onist as part of initial management of exacerbations of chronic obstructive pulmonary disease (COPD) in the acute care setting. Reasons for its widesp read acceptance for acutely ill patients may include its status asa first-l ine agent for long-term therapy, its relative safety, and attempts to provi de optimal patient care. Since inhaled ipratropium is beneficial as immedia te therapy For asthma in the emergency department, some practitioners attem pted to extrapolate these findings to treatment of COPD. Review of availabl e studies reveals wide variability in methodologies and results. Although s ome studies reported improvement in pulmonary function rests, no clinically significant differences in patient outcomes, including shorter hospitaliza tion, were evident. In patients who fail traditional therapies, inhaled ipr atropium is reasonable. Double-blind, randomized, placebo-controlled trials in patients receiving emergency department care and in hospitalized patien ts that reveal shorter length of stay or other improved outcomes, are neces sary to establish routine addition of inhaled ipratropium to beta(2)-agonis ts in the initial management of acute COPD.