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Am Fam Physician. 1999;59(5):1276-1280

Children who present to the emergency department during a severe exacerbation of asthma are typically treated with inhaled beta agonists and corticosteroids. Despite optimal use of these agents, many children require hospital admission for continued treatment. Several studies have shown that pulmonary function improves when the anticholinergic agent ipratropium bromide is given with a beta agonist, such as albuterol. Qureshi and colleagues conducted a randomized, double-blind, placebo-controlled trial to evaluate whether the addition of inhaled ipratropium decreased hospitalization rates in children who presented to the emergency department with an acute episode of asthma.

Children between the ages of two and 18 years who presented to the emergency department with an acute episode of asthma were eligible for the study. The severity of the asthma at presentation was classified according to the predicted peak expiratory flow rate. A peak expiratory flow rate of more than 70 percent was classified as mild, 50 to 70 percent of predicted value was classified as moderate and less than 50 percent of predicted value was considered severe. Only those with moderate or severe exacerbations were included in the study.

All children participating in the study were initially treated with three doses of either 2.5 or 5.0 mg of nebulized albuterol, depending on weight, and 2 mg per kg of oral prednisone with the second dose of nebulized albuterol. Patients in the treatment group received 500 mg of ipratropium with the second and third doses of albuterol, while those in the control group received 2.5 mL of normal saline solution. Peak expiratory flow rates, asthma score, respiratory rate, pulse rate and oxygen saturation were assessed at baseline and recorded after each treatment. After 60 minutes, additional albuterol was given at the physician's discretion until a decision was made to admit or discharge the patient. The decision to admit the patient was made on the basis of clinical and pulmonary function, along with an oxygen saturation level within a specific range.

A total of 434 children completed the study. Mean age was 8.3 years, and approximately 75 percent of the patients were black. The proportion of girls was higher in the treatment group than in the control group, but otherwise there were no significant differences between the two groups. Overall hospitalization rates were lower in the treatment group (27.4 percent) than in the control group (36.5 percent). There was no significant difference in hospitalization rates between groups in children with moderate asthma. However, among children with severe asthma, 37.5 percent of the treatment group was hospitalized, compared with 52.6 percent of the control group. The absolute reduction in the rate of hospitalization between the two groups was 15.1 percent, which means that approximately seven children would need to be given ipratropium to prevent one hospitalization. None of the children experienced increased heart rate, decreased respiratory function or any other adverse event that required the study protocol to be discontinued.

The authors conclude that the addition of ipratropium bromide to treatment with albuterol and corticosteroids significantly decreases the rate of hospitalization in children with acute exacerbations of severe asthma. Although approximately seven children would have to be treated with ipratropium to prevent one hospitalization, this rate still represents a significant savings, as ipratropium costs approximately $3 per 500-mg dose, compared with an average hospitalization cost per child of $3,267 at the study institution.

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Copyright © 1999 by the American Academy of Family Physicians.

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