Asthma: exacerbation: high-dose ipratropium and albuterol reduced hospital admissions and improved pulmonary function better than albuterol alone

Clinical bottom line (level 1b)

  1. Patients attending an emergency department with acute asthma who received high-dose ipratropium and albuterol compared with high-dose albuterol and placebo were less likely to be admitted to hospital (NN T = 5 at 3 hours) , but more likely to develop a dry mouth (NN H = 3 at 3 hours) .
  2. Patients give ipratropium had a 20% greater increase in PEFR than those given placebo.
Rodrigo and Rodrigo: American Journal of Respiratory and Critical Care Medicine 2000; 161 : 1862-1868
Expires October 2003

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: emergency department, acute hospital, Uraguay

180 patients (aged mean 34, 64% male) with acute asthma (FEV1 < 50% predicted: mean 32% predicted)

Excluded if
  • pregnancy
  • glaucoma, bladder dysfunction, prostatism or other medical diseases
  • aged < 18, > 50
  • fever 38C or higher
  • history of chronic cough
  • cardiac, hepatic or renal disease

    Control Group: (n = 88, 88 analysed): albuterol 480 microgram and placebo via metered dose inhaler and spacer at 10 minute intervals
    Experimental Group: (n = 92, 92 analysed): ipratropium 84 microgram and albuterol 480 microgram via metered dose inhaler and spacer at 10 minute intervals
    Patients were not allowed to receive steroids, aminophylline, or oxygen unless SaO 2 < 92%
    100% followed for 3 hours

    The evidence

    Outcome Time to outcome CER EER RRR
    (95% CI)    		 ARR
    (95% CI)    		 NN T
    (95% CI)
    admission to hospital 3 hours 36
    (39.1%)    		 18
    (20.5%)    		 48%
    (51% to 68%)    		 18.7%
    (5.62% to 31.7%)    		 5
    (3 to 18)
    dry mouth 3 hours 22
    (23.9%)    		 50
    (56.8%)    		 -140%
    (-260% to -58%)    		 -32.9%
    (-46.4% to -19.4%)    		 -3
    (-5 to -2)

  • Patients given ipratropium had a greater improvement in PEFR (20%: 95% CI: 2.6% to 38%)

    Comments

    1. Patients were discharged home if accessory muscle use had abated, if they were free of dyspnoea, and FEV1 or PEFR was > 60% predicted

    Citation

    1. Rodrigo GJ, and Rodrigo C: first-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. American Journal of Respiratory and Critical Care Medicine 2000; 161 : 1862-1868
    Search Terms: from ACP Journal Club other articles noted
    Contributor: Chris Ball, October 2001
    Reviewer:

    Clinical Question.
    Patient acute asthma attending emergency department
    Intervention or Exposure ipratropium plus albuterol
    Comparison albuterol plus placebo
    Outcome pulmonary function, hospital admission