Review
A meta-analysis of the effects of ipratropium bromide in adults with acute asthma

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Abstract

Purpose: To review the literature to determine whether inhaled ipratropium bromide provides additive benefits to adults with acute asthma who are being treated with beta-agonists in an emergency department.

SUBJECTS AND METHODS: English-language studies, both published (1978 to 1999) and unpublished, were retrieved using Medline, Science Citation Index, Current Contents, bibliographic reviews of primary research, review articles, consultation with experts, and the register of Medical Editors’ Trial Amnesty. Only randomized, double-blind, controlled trials that enrolled patients having an exacerbation of asthma were included. The main outcome measure was pulmonary function; hospital admission rate was also evaluated.

RESULTS: Ten studies including 1,483 adults with acute asthma were selected (mean age 32 ± 13 years, 36% men). The overall effect size in SD units of pulmonary function showed a significant benefit from ipratropium (effect size 0.14, 95% confidence interval [CI]: 0.04 to 0.24, P = 0.008). Study-specific effect sizes ranged from 0.03 to 0.63. This pooled effect size was equivalent to a 10% (95% CI: 2% to 18%) increase in forced expiratory volume in 1 second (FEV1) or peak expiratory flow in the ipratropium group compared with the control group. Analysis of the four studies that included patients with extreme obstruction (FEV1 or peak flow <35% of predicted at presentation) showed substantial improvement with ipratropium therapy (effect size 0.38, 95% CI: 0.09 to 0.67). In the five trials (1,186 patients) that studied the effect of ipratropium administration on hospital admissions, pooled results revealed that ipratropium reduced admission rates significantly (odds ratio 0.62, 95% CI: 0.44 to 0.88, P = 0.007).

CONCLUSIONS: The addition of ipratropium to beta-agonist therapy offers a statistically significant, albeit modest, improvement in pulmonary function, as well as a reduction in the rate of hospital admissions.

Section snippets

Literature search and selection of studies

A computerized search was conducted to identify literature on the topic of ipratropium bromide use in patients with acute adult asthma. We searched for studies using MEDLINE for the years 1978 to 1999 (April). The following MeSH terms were used in the search: N-isopropylatropine or ipratropium bromide and adult, acute asthma or status asthmaticus. The limits were English language, adults >16 years old, and clinical trials. Other sources of relevant articles were Current Contents, Science

Results

Sixty-five articles were identified in the initial Medline search (1978 to 1999); Science Citation and Current Contents identified 43 citations, with substantial overlap. Of these, reviewers thought that 23 papers were potentially eligible; most of the others were excluded because they were not clinical trials of patients with acute asthma. Reasons for subsequent exclusion were nonrandomized trial (n = 1) (17), pooled analysis of three previous trials (n = 1) (44), study conducted in

Discussion

The purpose of this meta-analysis was to determine whether inhaled ipratropium bromide provides an additive benefit to adults with acute asthma who are treated with beta-agonists. A secondary goal was to determine whether the admission rate is influenced by the combined treatment. Our analysis showed that ipratropium therapy resulted in a significant 10% improvement in FEV1 or peak flow. This result is similar to that seen in two meta-analyses of the treatment of children with acute asthma 53,

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