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Three Part Question

[In adult patients with an exacerbation of COPD] does [intravenous administration of magnesium] improves [airflow obstruction secondary to bronchial spasm]?

Clinical Scenario

70 years old patient has been brought in to the resuscitation area with an exacerbation of COPD. Nebulizers and steroids have been given and had little effect. You wonder if you could use intravenous magnesium sulfate to improve his airflow.

Search Strategy

Medline using the pubmed interface
[Intravenous OR Infusion] AND [Magnesium OR Magnesium Sulfate OR Magnesium Sulphate] AND [Chronic Obstructive Pulmonary Disease OR COPD OR Chronic Obstructive Airway Disease OR COAD OR Chronic Bronchitis OR Emphysema]

Search Outcome

12 articles found, of which 4 were relevant. One relevant paper was in German and offline. It was not included in the evidence. 2 original articles and one BestBET were included.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Juan Abreu González October 2006 Spain	24 patients with exacerbation of COPD were randomized to 2 groups in a double-blind crossover. Those who received magnesium sulphate the first day were given placebo the second day, and vice versa. Spirometry was done 15, 30 & 45min after IV injection. Then 400mcg of Salbutamol inhaler was given and final spirometry was done in 15 min.	Double blind Randomized Placebo controlled Crossover	No change in FEV1 in 15, 30 & 45min after magnesium sulphate.	The administration of intravenous magnesium sulphate in patients with COPD exacerbations has no bronchodilating effect in itself.	Unicentral Male bias
			Statistically significant increase of FEV1 in combination of magnesium sulphate with salbutal.	However, it does enhance the effect of inhaled â 2 –agonists (P=0.008).
Skorodin MS March 1995 USA	72 patients with exacerbation of COPD were randomized in 2 groups and received magnesium sulphate (1.2gr, IV) or placebo after nebulised â 2 –agonists.	Double blind Randomized	Statistically significant increase in PEFR in 30 & 45min. No significant increase in placebo group	The PEFR increased from 136.7 +/- 69.7 L/min to 162.3 +/- 76.6 L/min at 30 minutes and 161.3 +/- 78.7 L/min at 45 minutes with magnesium sulphate treatment (P=0.01).	Male bias
			Decrease in length of hospitalization, but statistically not significant	28.1% in magnesium group vs. 41.9% in placebo group - P =0.25

Comment(s)

First paper is a uni-central randomized placebo-controlled double-blind crossover trial enrolling 24 men, which is a strong point. Patients with pneumonia, heart failure, arrhythmias, kidney failure or poor cooperation were excluded. Infection is one of the most common causes of exacerbation of COPD, and patients with high levels of CO2 are usually confused and drowsy and not very cooperative. Second study is a small group of male patients as well, which has excluded infective exacerbation. However still supports usefulness of intravenous magnesium in acute exacerbation of COPD. Larger studies with higher number of patients and narrower exclusion criteria are needed in this area.

Clinical Bottom Line

Intra venous magnesium sulphate (1.2 - 2 grs/IV) worth considering as second line treatment, when there is no improvement with first line treatments (Nebulizers, Steroids, Oxygen). It might boosts effect of first line treatment and improves air flow.

References

1. Juan Abreu González, Concepción Hernández García, Pedro Abreu González et al. Effect of Intravenous Magnesium Sulphate on Chronic Obstructive Pulmonary Disease Exacerbations Requiring Hospitalization: A Randomized Placebo-Controlled Trial. Arch Bronconeumol 2006; 42: 384 - 387
2. Skorodin MS, Tenholder MF, Yetter B et al. Magnesium sulphate in exacerbations of chronic obstructive pulmonary disease. Arch Intern Med 1995;155(5):496-501