SALBUTRAL AC NEBU

ESTUDIOS CLÍNICOS

Combination of ipratropium bromide and salbutamol in children and adolescents with asthma: A meta-analysis.
Hongzhen Xu, Lin Tong, Peng Gao, Yan Hu, Huijuan Wang, Zhimin Chen, Luo Fang.

Background: A combination of ipratropium bromide (IB) and salbutamol is commonly used to treat asthma in children and adolescents; however, there has been a lack of consistency in its usage in clinical practice.
Objective: To evaluate the efficacy and safety of IB + salbutamol in the treatment of asthma in children and adolescents.
Methods: The MEDLINE, Embase, and Cochrane Library as well as other Chinese biomedical databases (including China Biological Medicine Database, Chinese National Knowledge Infrastructure, Chongqing VIP, and Wanfang Chinese language bibliographic database) were systematically searched from the earliest record date to September 2020 for randomized controlled trials in children and adolescents (≤ 18 years) with asthma who received IB + salbutamol or salbutamol alone. The primary outcomes included hospital admission and adverse events. A random effects model with a 95% confidence interval (CI) was used. Subgroup analysis was performed according to age, severity of asthma, and co-interventions with other asthma controllers. This study was registered with PROSPERO.
Results: Of the 1061 studies that were identified, 55 met the inclusion criteria and involved 6396 participants. IB + salbutamol significantly reduced the risk of hospital admission compared with salbutamol alone (risk ratio [RR] 0.79; 95% CI 0.66–0.95; p = 0.01; I 2 = 40%). Subgroup analysis only showed significant difference in the risk of hospital admission in participants with severe asthma exacerbation (RR 0.73; 95% CI 0.60–0.88; p = 0.0009; I 2 = 4%) and moderate-to-severe exacerbation (RR 0.69; 95% CI 0.50–0.96; p = 0.03; I 2 = 3%). There were no significant differences in the risk of adverse events between IB + salbutamol group and salbutamol alone group (RR 1.77; 95% CI 0.63–4.98).
Conclusion: IB + salbutamol may be more effective than salbutamol alone for the treatment of asthma in children and adolescents, especially in those with severe and moderate to severe asthma exacerbation. The very low to high quality of evidence indicated that future well-designed double-blind RCTs with large sample are needed for research on evaluating the effectiveness of IB + salbutamol treatment for asthma in children and adolescents.

Effect of nebulized ipratropium on the hospitalization rates of children with asthma.
Faiqa Qureshi, M.D., John Pestian, Ph.D., Paris Davis, B.A., And Arno Zaritsky, M.D.

Background: Anticholinergic medications such as ipratropium improve the pulmonary function of patients with acute exacerbations of asthma, but their effect on hospitalization rates is uncertain.
Methods: We conducted a randomized, double-blind, placebo-controlled study of 434 children (2 to 18 years old) who had acute exacerbations of moderate or severe asthma treated in the emergency department. All the children received a nebulized solution of albuterol (2.5 or 5 mg per dose, depending on body weight) every 20 minutes for three doses and then as needed. A corticosteroid (2 mg of prednisone or prednisolone per kilogram of body weight) was given orally with the second dose of albuterol. Children in the treatment group received 500 mg (2.5 ml) of ipratropium bromide with the second and third doses of albuterol; children in the control group received 2.5 ml of normal saline at these times.
Results: Overall, the rate of hospitalization was lower in the ipratropium group (59 of 215 children [27.4 percent]) than in the control group (80 of 219 [36.5 percent], P=0.05). For patients with moderate asthma (indicated by a peak expiratory flow rate of 50 to 70 percent of the predicted value or an asthma score of 8 to 11 on a 15-point scale), hospitalization rates were similar in the two groups (ipratropium: 8 of 79 children [10.1 percent]; control: 9 of 84 [10.7 percent]). For patients with severe asthma (defined as a peak expiratory flow rate of <50 percent of the predicted value or an asthma score of 12 to 15), the addition of ipratropium significantly reduced the need for hospitalization (51 of 136 children [37.5 percent], as compared with 71 of 135 [52.6 percent] in the control group; P=0.02).
Conclusions: Among children with a severe exacerbation of asthma, the addition of ipratropium bromide to albuterol and corticosteroid therapy significantly decreases the hospitalization rate. (N Engl J Med 1998;339:1030-5.)

Inhaled Salbutamol Plus Ipratropium in Moderate and Severe Asthma Crises in Children.
Ricardo Iramain, Ph.D., M.D., Jesús López-Herce, Ph.D., M.D., Julia Coronel, M.D., Cristopher Spitters, Ph.D., M.D., Jaime Guggiari, M.D., And Norma Bogado, M.D.

Background: The combination of inhaled β2 agonists and anticholinergics is recommended for children with acute asthma, although there are few randomized controlled trials. The aim of the study was to determine whether salbutamol plus ipratropium bromide improves oxygenation and lung function and reduces the frequency of hospitalization in children with asthma crises.
Methods: A prospective, randomized, double-blind study of children aged 2–18 years with moderate to severe asthma crises. Patients were evaluated using the asthma score and spirometry. They received six nebulizations of salbutamol plus placebo or salbutamol plus ipratropium and were reevaluated at 30, 60, 90, 120, and 240 minutes, at which time it was decided whether they were to be admitted.
Results: A total of 97 patients completed the study, 49 in the salbutamol plus ipratropium group and 48 in the salbutamol-only group. There were no differences in the status at baseline between the two groups. Children treated with salbutamol plus ipratropium presented a greater improvement in clinical state and lung function and required hospitalization less frequently (18.4%) than children in the salbutamol group (43.8%) (p = .007). Improvement was more marked in children with severe asthma crises than in those with moderate crises. The effect of salbutamol plus ipratropium was similar in children over 8 years of age and in younger children.
Conclusions: Salbutamol plus ipratropium bromide improves lung function in asthmatic children with moderate to severe asthma crises, independently of age. The effect is greater in children with severe crises, with a substantial reduction in the need for hospitalization.

Ipratropium Bromide Added to Asthma Treatment in the Pediatric Emergency Department.
Joseph J. Zorc, MD; Martin V. Pusic, MD; C. Jean Ogborn, MD; Ruth Lebet, RN, MSN; and Anne K. Duggan, ScD.

Objective: To determine if the addition of ipratropium bromide to the emergency department (ED) treatment of childhood asthma reduces time to discharge, number of nebulizer treatments before discharge, and the rate of hospitalization.
Methods: Patients >12 months of age were eligible if they were to be treated according to a standardized ED protocol for acute asthma with nebulized albuterol (2.5 mg/dose if weight <30 kg, otherwise 5 mg/dose) and oral prednisone or prednisolone (2 mg/kg up to 80 mg). Subjects were randomized to receive either ipratropium (250 mg/dose) or normal saline (1 mL/dose) with each of the first three nebulized albuterol doses. Further treatment after the first hour was determined by physicians blinded to subject group assignment. Records were reviewed to determine the length of time to discharge home from the ED, number of doses of albuterol given before discharge, and the number of patients admitted to the hospital.
Results: Four hundred twenty-seven patients were randomized to ipratropium or control groups; these groups were similar in all baseline measures. Among patients discharged from the ED, ipratropium group subjects had 13% shorter treatment time (mean, 185 minutes, vs control, 213 minutes) and fewer total albuterol doses (median, three, vs control, four). Admission rates did not differ significantly (18%, vs control, 22%).
Conclusions: The addition of three doses of ipratropium to an ED treatment protocol for acute asthma was associated with reductions in duration and amount of treatment before discharge. Pediatrics 1999;103:748–752; asthma, ipratropium, albuterol, randomized controlled trial, emergencies, child, adolescence, critical pathway, practice guidelines.

Nebulized Salbutamol Vs Salbutamol and Ipratropium Combination in Asthma.
Anita Sharma and Arvind Madaan.

Objective: To see the additional benefit of combined frequent nebulization with salbutamol and ipratropium bromide in acute attack of asthma with moderate severity.
Methods: Fifty asthmatic children in the age range of 6-14 years were divided into two equal groups. Group I children were nebulized with three doses of Salbutamol alone (0.03 ml/kg/dose) and Group II children were given combined nebulization of Salbutamol (dose as in group I) and Ipratropium bromide (250 pgrn/dose for three doses) at 20 minutes interval. Children were observed at 15, 30, 60, 120, 180 and 240 minutes interval.
Results: A significant improvement in % of PEFR starting at 30 minutes and lasting the entire study period of 4 hours was noted in both the groups. However on analysis of varience the results were better in group I1.
Conclusion: Frequent combined nebulization with Salbutamol and Ipratropium bromide is beneficial in acute asthma of moderate severity.

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary.
K Mackway-Jones.

Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.
The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETs shown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org.3 Four BETs are included in this issue of the journal.
• Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma.
• Delivery of bronchodilators in acute asthma in children.
• Lorazepam or diazepam in paediatric status epilepticus.
• Tibial fractures in very young children and child abuse.