The use of ipratropium bromide for the management of acute asthma exacerbation in adults and children: A systematic review

Ipratropium bromide is a quaternary anticholinergic bronchodilator that is commonly used to treat obstructive lung disease. Although ipratropium is no t usually employed as a first-line bronchodilator to treat chronic asthma, it has been used extensively in hospital emergency departments as adjunctiv e therapy for the emergency treatment of acute asthma exacerbation. This re view will summarize the physiological actions of ipratropium and the ration ale for its use as an anticholinergic bronchodilator. Evidence available fr om randomized trials and from two meta-analyses is summarized to determine whether the addition of inhaled ipratropium to inhaled beta(2)-agonist ther apy is effective in the treatment of acute asthma exacerbation in children and adults. Published reports of randomized, controlled trials assessing th e use of ipratropium and concurrent beta(2)-agonists in adult acute asthma exacerbation were identified by a search of electronic databases, as well a s by hand searching. Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted- average method. Use of nebulized ipratropium/beta(2)-agonist combination th erapy was associated with a pooled 7.3% improvement in forced expiratory vo lume in I see [95% confidence interval (CI), 3.8-10.9%] and a 22.1% improve ment in peak expiratory flow (95% CI, 11.0-33.2%) compared with patients wh o received beta(2)-agonist without ipratropium. For the three trials in adu lts reporting hospital admission data (n=1064), adult patients receiving ip ratropium had a relative risk of hospitalization of 0.80 (95% CI, 0.61-1.06 ). Similarly, randomized controlled studies of pediatric asthma exacerbatio n and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta(2)-agonists improves lung function and also decreases hospit alization rates, especially among children with severe exacerbations of ast hma. The adult and pediatric studies did not report any severe adverse effe cts attributable to ipratropium when it was used in conjunction with beta(2 )-agonists. In conclusion, there is a modest statistical improvement in air flow obstruction when ipratropium is used as an adjunctive to beta(2)-agoni sts for the treatment of acute asthma exacerbation. In pediatric asthma exa cerbation, use of ipratropium also appears to improve clinical outcomes; ho wever, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta(2)-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects.