Original Articles
Ipratropium bromide plus nebulized albuterol for the treatment of hospitalized children with acute asthma

https://doi.org/10.1067/mpd.2001.110120Get rights and content

Abstract

Objective: To determine whether the addition of repeated doses of nebulized ipratropium bromide (IB) to a standardized inpatient asthma care algorithm (ACA) for children with status asthmaticus improves clinical outcome. Study design: Children with acute asthma (N = 210) age 1 to 18 years admitted to the ACA were assigned to the intervention or placebo group in randomized double-blind fashion. Both groups received nebulized albuterol, systemic corticosteroids, and oxygen according to the ACA. The intervention group received 250 μg IB combined with 2.5 mg albuterol by jet nebulization in a dosing schedule determined by the ACA phase. The placebo group received isotonic saline solution substituted for IB. Progression through each ACA phase occurred based on assessments of oxygenation, air exchange, wheezing, accessory muscle use, and respiratory rate performed at prescribed intervals. Results: No significant differences were observed between treatment groups in hospital length of stay (P =.46), asthma carepath progression (P =.37), requirement for additional therapy, or adverse effects. Children >6 years (N = 70) treated with IB had shorter mean hospital length of stay (P =.03) and more rapid mean asthma carepath progression (P =.02) than children in the placebo group. However, after adjustment was done for baseline group differences, the observed benefit of IB therapy in older children no longer reached statistical significance. Conclusion: The routine addition of repeated doses of nebulized IB to a standardized regimen of systemic corticosteroids and frequently administered β-2 agonists confers no significant enhancement of clinical outcome for the treatment of hospitalized children with status asthmaticus. (J Pediatr 2001;138:51-8)

Section snippets

Study Population

Rainbow Babies and Childrens Hospital is a university-affiliated tertiary care children’s hospital in Cleveland, Ohio. In 1996, the asthma care algorithm was universally implemented in a dedicated inpatient asthma care unit to treat children aged 1 to 18 years with acute asthma.8 The ACA excludes children who require supplemental home oxygen or have cystic fibrosis, cyanotic congenital heart disease, chronic neonatal lung disease, or pulmonary hypertension. Children entered in the ACA were

Baseline Characteristics

Of 491 eligible children, 210 were enrolled during the 40-week study period from December 15, 1996, to September 21, 1997. Twelve children were enrolled more than once. Study participants and eligible nonparticipants who refused enrollment were similar with regard to sex, age, race, number of previous asthma-related hospitalizations, and the proportion of children who required supplemental oxygen in the ED. Enrolled children were significantly more likely to have been prescribed inhaled

Discussion

For children hospitalized with status asthmaticus managed with a standardized regimen of systemic corticosteroids, frequent nebulized β-agonists, and subcutaneous epinephrine and IB as needed, the addition of repeated doses of nebulized IB provided no significant benefit. For children >6 years old, combination therapy produced a trend toward shorter LOS and more rapid ACA-P that did not reach statistical significance.

Previous randomized clinical trials comparing combined nebulized

Acknowledgements

We are indebted to Dr Mike Reed and the RBC Center for Drug Research for supplying, coding, and monitoring the sterility of the study medications; to Kathy Spaude, Cheryl Velotta, Marsha Rogers, Cal Dorton, and the other respiratory therapists in the Rainbow inpatient asthma unit for their dedication to patient enrollment and care.

References (25)

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    Anticholinergics are not recommended for hospitalized patients.20 Two randomized controlled trials did not show significant benefit from ipratropium for hospitalized patients with severe asthma.81,82 Acute asthma is characterized by airway edema, mucus hypersecretion, and cellular infiltration, in addition to bronchospasm.

  • Wheezing in Older Children

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Reprint requests: Daniel Craven, MD, Division of Pediatric Pulmonology, Rainbow Babies and Childrens Hospital, 11100 Euclid Ave, Cleveland, OH 44106.

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