The Use of Ipratropium Bromide for the Management of Acute Asthma Exacerbation in Adults and Children: A Systematic Review

Abstract

Ipratropium bromide is a quaternary anticholinergic bronchodilator that is commonly used to treat obstructive lung disease. Although ipratropium is not usually employed as a first-line bronchodilator to treat chronic asthma, it has been used extensively in hospital emergency departments as adjunctive therapy for the emergency treatment of acute asthma exacerbation. This review will summarize the physiological actions of ipratropium and the rationale for its use as an anticholinergic bronchodilator. Evidence available from randomized trials and from two meta-analyses is summarized to determine whether the addition of inhaled ipratropium to inhaled beta₂-agonist therapy is effective in the treatment of acute asthma exacerbation in children and adults. Published reports of randomized, controlled trials assessing the use of ipratropium and concurrent beta₂-agonists in adult acute asthma exacerbation were identified by a search of electronic databases, as well as by hand searching. Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted-average method. Use of nebulized ipratropium/beta₂-agonist combination therapy was associated with a pooled 7.3% improvement in forced expiratory volume in 1 sec [95% confidence interval (CI), 3.8–10.9%] and a 22.1% improvement in peak expiratory flow (95% CI, 11.0–33.2%) compared with patients who received beta₂-agonist without ipratropium. For the three trials in adults reporting hospital admission data (n = 1064), adult patients receiving ipratropium had a relative risk of hospitalization of 0.80 (95% CI, 0.61–1.06). Similarly, randomized controlled studies of pediatric asthma exacerbation and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta₂-agonists improves lung function and also decreases hospitalization rates, especially among children with severe exacerbations of asthma. The adult and pediatric studies did not report any severe adverse effects attributable to ipratropium when it was used in conjunction with beta₂-agonists. In conclusion, there is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive to beta₂-agonists for the treatment of acute asthma exacerbation. In pediatric asthma exacerbation, use of ipratropium also appears to improve clinical outcomes; however, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta₂-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects.