Acute airways disease: fenoterol and ipratropium improve FEV1 .

Clinical bottom line (level 1b-)

  1. In patients with acute asthma or exacerbation of COPD, ipratropium, fenoterol and ipratropium plus fenoterol all increased the FEV 1 significantly by 45 minutes.
  2. Ipratropium plus fenoterol may be more effective in asthmatics than ipratropium alone, but there was no clear difference between the other regimens.
Rebuck et al: American Journal of Medicine 1987; 82: 59-64
Expires June 2003

The study

Double-blinded concealed randomised trial without intention-to-treat
Setting: four university hospitals, Canada

202 patients (aged ?, ?% male) presented at emergency room for treatment of acute asthma or acute exacerbations of chronic obstructive pulmonary disease

Excluded if
  • aged <18 years
  • unable to perform forced expiratory test
  • FEV 1 >70% of predicted
  • complicating medical illnesses
  • pregnant or nursing mothers
  • received nebulised bronchodilator solution in previous six hours
  • required treatment with drugs other than those specified in protocol


    • Note:
  • Patients were stratified by centre.
  • Each centre had 50 enrolled patients.
  • 150 (148 analysed) patients had asthma and 52 (51 analysed) had chronic obstructive pulmonary disease (COPD)


    • Control Group: (n = 68, 65 analysed): ipratropium bromide , 0.5 mg
    Experimental Group: (n = 68, 68 analysed): fenoterol hydrobromide , 1.25 mg
    Experimental Group: (n = 66, 66 analysed): 0.5 mg ipratropium plus 1.25 mg fenoterol
    Treatment with iv aminophylline or iv corticosteroids was given at the discretion of the attending physicians.
    99% followed for 90 minutes

    The evidence

    ipratropium vs fenoterol in asthmatics at 45 minutes
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV 1 (litres) 1.42
    (0.78)     		1.46
    (0.80)     		0.04
    (-0.28 to 0.36)

    ipratropium vs fenoterol in COPD at 45 minutes
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV 1 (litres) 0.82
    (0.34)     		0.86
    (0.37)     		0.04
    (-0.21 to 0.29)

    fenoterol vs fenoterol plus ipratropium in asthmatics at 45 minutes
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV 1 (litres) 1.46
    (0.80)     		1.75
    (0.88)     		0.29
    (-0.049 to 0.63)

    fenoterol vs fenoterol plus ipratropium in COPD at 45 minutes
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV 1 (litres) 0.86
    (0.37)     		0.79
    (0.41)     		-0.07
    (-0.33 to 0.19)

    ipratropium vs fenoterol plus ipratropium in asthmatics at 45 minutes
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV 1 1.42
    (0.78)     		1.75
    (0.88)     		0.33
    (0.00 to 0.66)

    ipratropium vs fenoterol plus ipratropium in COPD at 45 minutes
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    FEV 1 0.82
    (0.34)     		0.79
    (0.41)     		-0.03
    (-0.31 to 0.25)

  • All three regimens produced significant increases in FEV1 from baseline.
  • There was no clear difference in FEV1 at 90 minutes.

    • Comments

    1. Theis is of historical interest as fenoterol is no longer available (as safety concerns have been raised).
    2. Cochrane reviews have shown a similar slight benefit to adding ipratropium to beta-agonist therapy.

    Citation

    1. Rebuck AS, Chapman KR, Abboud R, et al: Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room. American Journal of Medicine 1987; 82: 59-64
    Contributor: Clare Wotton and Musab Hayatli, June 2000
    Reviewer: Gerard Ryan

    Clinical Question.
    Patient acute airways obstruction
    Intervention or Exposure ipratropium bromide, fenoterol or both
    Outcome forced expiratory volume in one second