SOURCE

Griffiths B, Ducharme FM. (2013) Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children.Cochrane Database Syst Rev21;8:CD000060.

CONTEXT

In an asthma attack, breathing difficulties occur as a result of airway narrowing secondary to inflammation, smooth muscle spasm and mucus secretion. Guidelines recommend the use of inhaled short-acting beta₂-agonist (SABA) as the initial treatment for children with an acute severe asthma exacerbation.

Anticholinergic agents have a slower onset of action. They have a weaker bronchodilator effect, relieving cholinergic bronchomotor tone and decreasing mucosal edema and secretions. Combined with SABA, they prolong and enhance bronchodilation.

CLINICAL QUESTION

In children (age one to 18 years) with acute asthma exacerbation presenting to the emergency department, does treatment with combined inhaled anticholinergic and SABAimprove clinical outcome compared to treatment with SABA alone?

BOTTOM LINE

For children with moderated or severe asthma exacerbations, the addition of an inhaled anticholinergic to SABAsignificantlyreduces the risk of hospital admission (high-level quality evidence). This effect is independent of the administration of systematic corticosteroids.

Combined inhaled anticholinergic and SABA treatment significantly improved lung function, change in clinical score at 120 minutes and oxygen saturation at 60 minutes. The number of children who required additional bronchodilator treatment at the conclusion of the study protocol was significantly decreased by the use of combined therapy.

Children treated with the addition of an inhaled anticholinergic were significantly less likely to experience tremor or nausea compared to those treated with inhaled SABA alone.

CAVEAT

Most studies were graded as high quality. The majority used a “multiple fixed-dose protocol”.   The dose of Ipratropium varied from 250 or 500 µg and the number of doses ranged from two to six given over 30 to 90 minutes.

AUTHOR INFORMATION

Julie DUMOUCHEL
Centre Hospitalo-Universitaire de Tours
Tours, France
dumouchel.julie76@yahoo.fr

Daniel MEYRAN
Groupement Sant̩ РBataillon de Marins Pompiers de Marseille
Marseille, France
daniel.meyran@me.com

Kirk MAGEE
Dalhousie University – Halifax Infirmary
Nova Scotia, Canada
kirk.magee@dal.ca