Salbutamol and ipratropium in acute asthma. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. The importance of quality of primary studies in producing unbiased systematic reviews. Efficacy of nebulized ipratropium in severely asthmatic children. Frequent administration by inhalation of salbutamol and ipratropium bromide in the initial management of severe acute asthma in children. Bronchial responsiveness to hyperventilation in children with asthma: inhibition by ipratropium bromide. Response to bronchodilators assessed by lung mechanics. Nebulized salbutamol and ipratropium bromide in asthmatic children. Ipratropium Bromide Added to Asthma Treatment in the Pediatric Emergency Department Nebulised ipratropium and salbutamol in asthma. Inhaled ipratropium bromide and terbutaline in asthmatic children. Comparison of ipratropium solution, fenoterol solution, and their combination administered by nebulizer and face mask to children with acute asthma. Bronchodilator effects of clemastine, ipratropium, bromide, and salbutamol in preschool children with asthma. The Effects of Ipratropium Bromide and Fenoterol Nebulizer Solutions in Children with Asthma Randomized controlled trial of ipratropium bromide and frequent low doses of salbutamol in the management of mild and moderate acute pediatric asthma. Efficacy of frequent nebulized ipratropium bromide added to frequent high-dose albuterol therapy in severe childhood asthma. Publication bias: evidence of delayed publication in a cohort study of clinical research projects Additive effect of albuterol and ipratropium bromide in the treatment of bronchospasm in children. Efficacy of atropine methylnitrate alone and in combination with albuterol in children with asthma. Ipratropium bromide (Atrovent) in childhood asthma: a cumulative dose-response study. Ipratropium bromide in children with asthma. Determination of dose-response relationship for nebulized ipratropium in asthmatic children. Combined salbutamol and ipratropium bromide by inhalation in the treatment of severe acute asthma.
Thirty seven children with acute asthma were given nebulised ipratropium or placebo 30 minutes after their first dose of salbutamol and eight hourly thereafter . There were no significant differences between the two groups in clinical scores , peak expiratory flow rates , length of stay in hospital , or the need for oral steroids 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 r and omized , 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 microg ( 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 BACKGROUND Traditional and largely qualitative review s of evidence are now giving way to much more structured systematic overviews that use a quantitative method to calculate the overall effect of treatment . The latter approach is dependent on the quality of primary studies , which may introduce bias if they are of poor method ologic quality . OBJECTIVE To test the hypothesis that the inclusion of poor- quality trials in meta-analyses would bias the conclusions and produce incorrect estimates of treatment effect . METHODS An overview of r and omized trials of antiestrogen therapy in subfertile men with oligospermia was performed to test the hypothesis . Data sources included online search ing of MEDLINE and Science Citation Index data bases between 1966 and 1994 , scanning the bibliography of known primary studies and review articles , and contacting experts in the field . After independent , blind assessment , nine of 149 originally identified studies met the inclusion criteria and were selected . We assessed study quality independently . Outcome data from each study were pooled and statistically summarized . RESULTS There was a marginal improvement in pregnancy rate with antiestrogen treatment ( odds ratio , 1.6 ; 95 % confidence interval , 0.9 to 2.6 ) . Sensitivity analyses on the basis of method ologic quality demonstrated that poor- quality studies produced a positive effect with treatment , whereas no benefit was observed with high- quality studies . CONCLUSION The results of a meta- analysis are influenced by the quality of the primary studies included . Method ologically , poor studies tend to exaggerate the overall estimate of treatment effect and may lead to incorrect inferences STUDY OBJECTIVE To determine the effect of adding the nebulized anticholinergic drug ipratropium bromide to st and ard therapy compared with st and ard therapy alone for acute severe asthma ( peak expiratory flow rate [ PEFR ] < 50 % of predicted ) in children presenting to the emergency department . METHODS Ninety children aged 6 to 18 years were r and omly assigned to two groups in a prospect i ve , double-blind , placebo-controlled study performed in the ED of an urban children 's hospital . All children received nebulized albuterol solution ( .15 mg/kg ) every 30 minutes , and all received oral steroids with the second dose of albuterol . Children in group 1 received ipratropium bromide ( 500 micrograms/dose ) with the first and third dose of albuterol those in group 2 received saline placebo instead of ipratropium .  Pulmonary functions ( PEFR and 1-second forced expiratory volume [ FEV1 ] ) and physiologic measurements were assessed every 30 minutes up to 120 minutes . By chance , the baseline values for percent of predicted PEFR and FEV1 differed between the two groups . Therefore a multivariate model accounting for both time and baseline effects was used to compare the response between groups . RESULTS On average , and adjusting for baseline measures , children in the ipratropium group had a significantly greater improvement in percent of predicted PEFR than did children in the placebo group at 60 minutes ( P = .02 ) , 90 minutes ( P = .002 ) , and 120 minutes ( P < .0001 ) . The improvement in percent predicted FEV1 was significantly greater for children in the ipratropium group only at 120 minutes ( P = .013 ) . Nine children ( 20 % ) from the ipratropium group and 14 ( 31.1 % ) from the control group were admitted ( P = .33 , chi 2 ) . There were no significant adverse effects attributable to the ipratropium , and there was no relation between ipratropium use and changes in pulse , respiratory rate , blood pressure , or oxygen saturation . CONCLUSION We detected significant improvement in pulmonary function studies over 120 minutes in children with severe asthma who were given nebulized ipratropium combined with albuterol and oral steroids , compared with children who received the st and ard therapy . Further study is needed to determine whether early use of ipratropium decreases the need for hospitalization A study was performed to compare the efficacy and safety of two therapeutic regimens for the treatment of children presenting to the emergency department with acute asthma . A regimen of inhaled salbutamol alone was compared to inhaled salbutamol combined with ipratropium bromide .  Twenty-five children ranging in age from 5 to 15 years were enrolled in the study . Children with FEV1 less than or equal to 55 % predicted were eligible to participate in the study . Subjects were r and omized in a double-blind fashion into one of two treatment groups . Both groups received an initial dose of salbutamol by nebulizer of 150 micrograms/kg ( 0.03 cc/kg ) , followed by six consecutive doses of 50 micrograms/kg ( 0.01 cc/kg ) at 20-minute intervals . In one group of subjects , 250 micrograms ( 1.0 ml ) of ipratropium bromide respirator solution was added to the salbutamol administered at the time of the initial inhalation , and at 40 and 80 minutes , whereas the remaining subjects received a placebo with salbutamol at those times . Formal one-way statistical ANOVA with change in percent predicted FEV1 as a response variable confirmed there was a statistically significant difference at all time points caused by drug regimen during the 150-minute observation period . There was no significant difference in side effects reported in the two groups . Significant additional bronchodilation achieved with salbutamol and ipratropium bromide together indicates that there is likely a substantial cholinergic element to the bronchospasm observed in acute exacerbations of asthma in the pediatric age group Isocapnic hyperventilation dose response curves were constructed for 11 asthmatic children before and after pretreatment with placebo or ipratropium bromide , 40 - 1500 micrograms given by inhalation , on three separate days . The response before and after placebo was highly reproducible ( within subject coefficient of variation 7.5 % , 18 % , and 22 % for intervals of two hours , within two weeks , and over two weeks ) . It was independent of baseline lung function . Complete protection against hyperventilation induced asthma was achieved by ipratropium bromide 40 micrograms in six children and by 200 micrograms or more in a further four . The remaining child was unaffected by any dose of ipratropium up to 1500 micrograms . The dose of ipratropium required for protection was better related to the subjects ' requirement for regular medication than to their sensitivity to hyperventilation or baseline lung function Abnormalities of compliance and functional residual capacity were shown in eight young children aged 2 - 8 years with asthma during an acute attack . In a r and omised , placebo controlled study treatment with bronchodilator ( salbutamol ) was associated with a significant improvement in compliance and lessening of hyperinflation as shown by a reduction in functional residual capacity Varying doses of nebulized salbutamol , ipratropium bromide and a combination of both were given to 20 asthmatic children . All therapies produced effective bronchodilation . Ten mg salbutamol caused elevation of pulse rate and finger tremor whilst the duration of action of 0.6 mg salbutamol was too short . Dose-response effects were clearly seen with salbutamol but not with ipratropium bromide . A summation effect was not demonstrated when the medications were combined 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 st and ardized 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 r and omized to receive either ipratropium ( 250 μg/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 review ed 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 r and omized 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 Treatment with nebulised salbutamol or a mixture of salbutamol and ipratropium was given to 138 children .  Length of hospital stay and number of nebulised doses required did not differ . In severe asthma response was greater with salbutamol alone . In mild asthma response was greater with combined treatment Inhaled bronchodilator therapy in young asthmatic children reduces symptoms and improves lung function . After a single dose of therapy , however , lung function may still be abnormal , as evidence d by an elevated function residual capacity ( FRC ) . The aims of this study were to assess if a second dose of bronchodilator therapy result ed in further improvement in lung function and to determine whether additional therapy was more effective if given as a second dose of a beta-adrenergic agonist or if instead an anticholinergic was used . Twenty-one asthmatics ( median age 7.5 years ) received in r and om order on two separate occasions , 1 week apart , either two doses of terbutaline ( 500 micrograms ) or terbutaline plus ipratropium bromide ( 20 micrograms ) . FRC and peak expiratory flow rate ( PEFR ) were measured immediately prior to and then 20 min after each dose of bronchodilator therapy . In the group , overall FRC and PEFR improved after the first and second dose of bronchodilator , regardless of regime used , the response to the second dose , however , was smaller than the first dose . There was no significant difference overall between the two regimes in baseline FRC or PEFR , or FRC and PEFR measured after each dose of bronchodilator . Eight children failed to show a significant change in FRC following two doses of terbutaline , but seven of these eight did have a significant change in FRC in response to the combination of terbutaline and ipratropium bromide . We conclude that a second dose of bronchodilator therapy does further improve lung function . Our results suggest the more efficacious regime consists of a combination of single doses of ipratropium bromide and terbutaline In a r and omized , double-blind , parallel-group trial , 47 children with acute asthma received a combination of ipratropium bromide solution ( 250 micrograms ) and fenoterol hydrobromide solution ( 625 micrograms ) , fenoterol solution ( 625 micrograms ) alone , or ipratropium solution ( 250 micrograms ) alone , administered by face mask and nebulizer , with the dose repeated 60 minutes later . The groups did not differ significantly with regard to age , pulmonary function at baseline , or any other variable . They were monitored at 30 , 60 , 90 , and 120 minutes by use of a clinical score , oxygen saturation , and pulmonary function tests . At the end of the study , albuterol was administered to assess residual bronchoconstriction . Clinical scores improved significantly after treatment in all groups at all times compared with baseline . The greatest improvement in FEV1 was seen in the patients treated with ipratropium/fenoterol , whether considered as absolute change , change in percent predicted , or percent change from baseline .  Ipratropium/fenoterol  was significantly better than fenoterol alone only when considered as percent change from baseline . Improvement in flow at mid and low lung volumes was significantly greater for the  ipratropium/fenoterol combination than for  ipratropium alone ; no significant differences were noted between ipratropium/fenoterol and fenoterol for flow at mid and low lung volumes . Treatment with albuterol did not significantly improve pulmonary function in the groups receiving ipratropium/fenoterol or fenoterol alone , but it did increase flow at all lung volumes in the group receiving ipratropium alone . No patient complained spontaneously of any adverse reactions , and no clinical ly significant changes in heart rate or systolic or diastolic blood pressures occurred . ( ABSTRACT TRUNCATED AT 250 WORDS The bronchodilator activity in nebulised salbutamol , ipratropium bromide , clemastine , and a placebo was studied in 14 asthmatic children aged between 3 and 5 years . Changes in lung function were monitored by measuring peak expiratory flow rate and total respiratory resistance using a modification of the forced oscillation technique . Ipratropium bromide produced a degree of bronchodilation similar to that of salbutamol , but the bronchodilatory activity of clemastine was not appreciably better than for the placebo The effects of nebulized solutions of ipratropium bromide and fenoterol combined were compared with the response to either preparation alone in single dose and longer-term administration in children who had asthma . The combination produced a slightly greater response than either alone , especially in peak expiratory flow . Over a 1-month period , there were no significant differences in symptom scores or lung function parameters between the combination of ipratropium bromide and fenoterol and fenoterol alone in a group of children who had asthma . It is possible that the addition of ipratropium bromide to a sympathomimetic drug may be useful in a subgroup of asthmatics , particularly if there is a considerable large airway contribution to bronchial narrowing OBJECTIVES To compare the effectiveness and safety of alternative nebulized drug protocol s in children with mild or moderate asthma exacerbations . METHODS We conducted a blinded , r and omized , controlled trial with a 2 x 2 factorial design . Two interventions , nebulized salbutamol in frequent low doses ( 0.075 mg/kg every 30 minutes ) and the addition of ipratropium bromide ( 250 micrograms ) , were compared with salbutamol in hourly high doses ( 0.15 mg/kg every 60 minutes ) in children with mild or moderate acute asthma . The primary end point was the improvement in respiratory resistance . Secondary end points included oxygen saturation , corticosteroid use , patient disposition , and relapse status . RESULTS A total of 298 participants aged 3 to 17 years were studied , and 15 % were admitted to the hospital ; 14 % of the children had  relapses . No increased bronchodilation was associated with frequent low doses versus hourly high doses of salbutamol ( RR = 0.9 [ 95 % confidence interval 0.7 , 1.3 ] ) or the addition of ipratropium bromide versus placebo ( RR = 1.0 [ 0.8 , 1.3 ] ) . No group differences were observed in secondary end points . Salbutamol in frequent low doses was associated with increased vomiting ( RR = 2.5 [ 1.1 , 6.0 ] ) . CONCLUSION Our results do not support the use of frequent low doses of nebulized salbutamol or the addition of ipratropium bromide compared with hourly high doses of salbutamol in children with mild or moderate asthma OBJECTIVE The objective of this trial was to determine the efficacy of frequent nebulized ipratropium added to high-dose albuterol therapy in children with severe asthma . METHODS One hundred twenty children ( 5 to 17 years ) of age ) with severe acute asthma ( forced expiratory volume in 1 second ( FEV1 ) , < 50 % of the predicted value ) were enrolled into a r and omized double-blind three-arm placebo-controlled trial comparing three groups : group 1 , three doses of nebulized ipratropium bromide within 60 minutes ( 250 micrograms/dose ) ; group 2 , one dose of ipratropium ; group 3 , no ipratropium . All patients were also treated with three doses of nebulized albuterol within 60 minutes ( 0.15 mg/kg per dose ) . Pulmonary function and clinical measures were assessed every 20 minutes for up to 120 minutes . RESULTS The groups were comparable at baseline . At 120 minutes , the mean percentage of predicted FEV1 improved from 33.4 % to 56.7 % in group 1 , from 34.2 % to 52.3 % in group 2 , and from 35.4 % to 48.4 % in group 3 ( p = 0.0001 ) . The differences between groups were larger in those children with a baseline FEV1 < or = 30 % of the predicted value : FEV1 increased from 24.5 % to 50.9 % in group 1 , from 25.0 % to 39.8 % in group 2 , and from 25.9 % to 36.5 % in group 3 ( p = 0.0001 ) . In group 1 , 38 % of the patients were hospitalized after the study , 44 % in group 2 , and 46 % in group 3 ( p value not significant ) . However , in patients with FEV1 < or = 30 % , the hospitalization rates were 27 % in group 1 , 56 % in group 2 , and 83 % in group 3 ( p = 0.027 ) . There were no toxic effects attributable to ipratropium . CONCLUSION The addition of repeated doses of nebulized ipratropium to frequent high-dose albuterol therapy in patients with acute severe asthma is both safe and more effective than albuterol alone ; its use in patients with very severe asthma may reduce hospitalizations Abstract Objectives : To determine the extent to which publication is influenced by study outcome . Design : A cohort of studies su bmi tted to a hospital ethics committee over 10 years were examined retrospectively by review ing the protocol s and by question naire . The primary method of analysis was Cox 's proportional hazards model . Setting : University hospital , Sydney , Australia . Studies : 748 eligible studies su bmi tted to Royal Prince Alfred Hospital Ethics Committee between 1979 and 1988 . Main outcome measures : Time to publication . Results : Response to the question naire was received for 520 ( 70 % ) of the eligible studies . Of the 218 studies analysed with tests of significance , those with positive results ( P<0.05 ) were much more likely to be published than those with negative results ( P0.10 ) ( hazard ratio 2.32 ( 95 % confidence interval 1.47 to 3.66 ) , P=0.0003 ) , with a significantly shorter time to publication ( median 4.8 v 8.0 years ) . This finding was even stronger for the group of 130 clinical trials ( hazard ratio 3.13 ( 1.76 to 5.58 ) , P=0.0001 ) , with median times to publication of 4.7 and 8.0 years respectively . These results were not material ly changed after adjusting for other significant predictors of publication . Studies with indefinite conclusions ( 0.05 P<0.10 ) tended to have an even lower publication rate and longer time to publication than studies with negative results ( hazard ratio 0.39 ( 0.13 to 1.12 ) , P=0.08 ) . For the 103 studies in which outcome was rated qualitatively , there was no clear cut evidence of publication bias , although the number of studies in this group was not large . Conclusions : This study confirms the evidence of publication bias found in other studies and identifies delay in publication as an additional important factor . The study results support the need for prospect i ve registration of trials to avoid publication bias and also support restricting the selection of trials to those started before a common date in undertaking systematic review s. Key messages This retrospective cohort study of clinical research projects confirms the findings of publication bias found in previous studies Delay in the publication of studies with negative results has been identified as an additional important factor in publication bias With the recognised importance of evidence based medicine , these results have important implication s for the selection of studies included in systematic review s Prospect i ve registration of clinical research projects will avoid many of the problems associated with publication bias However , it is also important to restrict inclusion in systematic review s to studies started before a certain date to allow for the delay in completing studies with negative Inhaled albuterol ( A ) ( salbutamol ) alone and albuterol plus ipratropium bromide ( IB ) were administered to 12 asthmatic children . Following administration of A alone or in combination with IB , there was a significant increase in FEV1 and FEF . Significant statistical difference in favor of the association A plus IB was observed at 120 and 240 minutes for FEV1 and in the period 120 , 180 , and 240 minutes for FEF . The additive effect was present both in the large and small airways . The short-lived additive effect of A plus IB suggests the opportunity to increase the frequency of drug administration in patients with severe bronchial obstruction The bronchodilator effect of nebulized AMN , albuterol and their combination was evaluated in 16 steroid-dependent asthmatic children . In phase 1 , maximal bronchodilation was determined by dose-response studies on separate days . Maximal bronchodilator dose of each drug was administered either alone or in combination during phase 2 . In phase 1 , 0.11 + /- 0.01 mg/kg of albuterol and 0.03 mg/kg of AMN produced maximum bronchodilation . In phase 2 , the peak response to albuterol occurred within 30 min and to AMN , at 60 min . Maximal FEV1 achieved after AMN was 90 percent of the maximal achieved after albuterol . AMN FEV1 response was better than for placebo for 3 h ; that for albuterol was better for 4 h. Combination therapy produced a peak response similar to that of albuterol but was better than albuterol by 6 h. Thus , the maximum bronchodilator effect of AMN is less than that of albuterol in asthmatic children , but the combination may extend the period of bronchodilatation Thirteen children with perennial bronchial asthma , with a mean age of 11.2 years , were studied concerning the bronchodilatory effect of ipratropium bromide in cumulative doses . All the children had reduced basal forced expiratory flow ( FEV1 ) and bronchial reversibility of at least 20 % after inhalation of salbutamol . The study had a double-blind design with a crossover technique . The inhaled dose of ipratropium bromide solution was increased stepwise from 25 micrograms to 500 micrograms and saline was used as the placebo .  FEV1 was recorded 20 , 40 , and 60 minutes after inhalation of the test solution . At the lower ipratropium bromide dose levels no bronchodilatory effect was seen , but 60 minutes after the inhalation of 500 micrograms ipratropium bromide the increase in the FEV1 was significantly greater than that after placebo . Additional inhalation of salbutamol caused no further rise in FEV1 . At the 500-micrograms level a fall in the heart rate was noted . No side effects occurred . We concluded that ipratropium bromide has bronchodilatory properties in childhood asthma when given in sufficiently high doses Eighteen children between 6 and 14 years of age with perennial asthma were studied over two four-week treatment periods . Ipratropium bromide , given in addition to their current treatment , was compared with placebo using a double-blind crossover technique . The period of treatment with ipratropium was associated with a significant reduction in symptoms during both day and night and significantly higher morning peak expiratory flow rates IPRATROPIUM BROMIDE is a quaternary isopropyl derivative of the muscarinic antagonist atropine that has bronchodilator properties when administered topically via the respiratory airways . Because of its quaternary nature , it is poorly absorbed into the bloodstream after direct application into the bronchial tree ; the cardiovascular side effects are thus minimal . For these reasons ipratropium could represent a significant advance in therapy , especially considering its alternative mode of action via blockade of the cholinergic system rather than stimulation of ~adrenoceptors . Initial information on ipratropium solution has indicated that a dose of 250 # g can be given safely to preschool children with asthma and that the bronchodilation is comparable to that achieved by salbutamol . ~ The purpose of our study was to determine the optimal dosage of ipratropium solution  when administered by aqueous nebulization , by constructing a dose-response curve in children of school age . NEBULIZED specific beta-2 agonists such as salbutamol ( albuterol ) are widely preferred as the first-line drugs of choice for treating acute asthma in Children . Many studies have shown their efficacy as well as convenience in delivery ) , 2 Administration of frequent small doses ( 50 t ~ g/kg/dose every 20 minutes ) of nebulized salbutamol is safe and superior to the more conventional hourly dosing ( 150 /~g/kg/dose ) , producing a smoother rise in forced expiratory volume in 1 second and an earlier peak response without deterioration between doses ) However , even with this aggressive approach , significant residual airways obstruction remains despite additional doses of salbutamol . This suggests that the residual airways obstruction is related to factors unresponsive to beta-2 bronchodilators , such as mucosal edema , secretions , or cholinergic bronchomotor .tone . Ipratropium bromide is a quaternary ammonium derivative of atropine . When delivered by inhalation , it produces a local anticholinergic effect with no systemic absorption ? . 5 It is a potent bronchodilator , comparable to beta-2 agonists , and has been found to be very Useful , especially in adults with chronic bronchitis ? . 5 Our study was design ed to determine whether ipratropium bromide , by its anticholinergic action , could improve the residual airways obstruction seen after treatment with salbutamol alone .
BACKGROUND Several r and omized controlled trials have examined , with conflicting results , the efficacy of the addition of anticholinergics to beta2 agonists in acute pediatric asthma .
The pooling for a larger number of r and omized controlled trials may provide not only greater power for detecting group differences and also provide better insight into the influence of patients ' characteristics and treatment modalities on efficacy .
OBJECTIVES The aims of this study were to estimate the therapeutic and adverse effects attributable to the addition of inhaled anticholinergics to beta2 agonists in acute pediatric asthma .