BMJ 1998;317:971-977 ( 10 October )

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Should inhaled anticholinergics be added to ₂ agonists for treating acute childhood and adolescent asthma? A systematic review

Laurie H Plotnick, fellow, ^a Francine M Ducharme, associate professor. ^b

^a Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec H3H 1P3, Canada, ^b Department of Pediatrics, Montreal Children's Hospital

Correspondence to: Dr Ducharme fduccpr{at}mch.mcgill.ca

Objectives To estimate the therapeutic and adverse effects of addition of inhaled anticholinergics to ₂ agonists in acute asthma in children and adolescents.
Design Systematic review of randomised controlled trials of children and adolescents taking ₂ agonists for acute asthma with or without the addition of inhaled anticholinergics.
Main outcome measures Hospital admission, pulmonary function tests, number of nebulised treatments, relapse, and adverse effects.
Results Of 37 identified trials, 10 were relevant and six of these were of high quality. The addition of a single dose of anticholinergic to ₂ agonist did not reduce hospital admission (relative risk 0.93, 95% confidence interval 0.65 to 1.32). However, significant group differences in lung function supporting the combination treatment were observed 60 minutes (standardised mean difference 0.57, 0.93 to 0.21) and 120 minutes (0.53, 0.90 to 0.17) after the dose of anticholinergic. In contrast, the addition of multiple doses of anticholinergics to ₂ agonists, mainly in children and adolescents with severe exacerbations, reduced the risk of hospital admission by 30% (relative risk 0.72, 0.53 to 0.99). Eleven (95% confidence interval 5 to 250) children would need to be treated to avoid one admission. A parallel improvement in lung function (standardised mean difference 0.66, 0.95 to 0.37) was noted 60 minutes after the last combined inhalation. In the single study where anticholinergics were systematically added to every ₂ agonist inhalation, irrespective of asthma severity, no group differences were observed for the few available outcomes. There was no increase in the amount of nausea, vomiting, or tremor in patients treated with anticholinergics.
Conclusions Adding multiple doses of anticholinergics to ₂ agonists seems safe, improves lung function, and may avoid hospital admission in 1 of 11 such treated patients. Although multiple doses should be preferred to single doses of anticholinergics, the available evidence only supports their use in school aged children and adolescents with severe asthma exacerbation.

Key messages The addition of multiple doses of anticholinergics to 2 agonist inhalations seems indicated in the initial management of children and adolescents with severe exacerbations of asthma (55% of predicted FEV1) For the larger group of children and adolescents with mild to moderate asthma exacerbations, there is no apparent benefit from adding a dose of anticholinergics to 2 agonists Little evidence exists to support the systematic addition of anticholinergics to every 2 agonist inhalation, irrespective of patients' disease severity

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