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Three Part Question

In [infants with acute bronchiolitis] does [treatment with nebulised ipratropium bromide] reduce [the clinical severity or the length of stay]?

Clinical Scenario

A 6 month old baby with 3 day history of coryzal symptoms, increasing cough and wheeze presents to the emergency department. Your clinical diagnosis is bronchiolitis. You wonder whether the addition of nebulised ipratropium will improve the clinical condition.

Search Strategy

Medline 1966-07/99 using the OVID interface.
({exp bronchiolitis OR exp bronchiolitis, viral OR exp respiratory syncitial virus infections OR exp respiratory syncitial virus, human OR RSV.mp OR bronchiolitis.mp} AND {atrovent.mp OR exp ipratropium OR ipratropium.mp}) LIMIT to human AND english.

Search Outcome

13 papers found of which 8 were irrelevant or of insufficient quality. The remaining 5 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Henry R, et al. 1983. UK.	66 infants (7-52 wks). Ipratropium vs saline.	PRCT	Clinical severity score	No significant improvement	Randomisation and blinding not explained. No basic data or results presented.
			Parental/nurse subjective assessment	No significant difference
Wang E, et al. 1992. Canada.	62 children (2 months to 2 years). Salbutamol or placebo vs ipratropium or placebo.	PRCT	Pulse oximetry	No significant change	Possible selection bias as all patients received emergency room treatment. Infrequent observations.
			Clinical severity score	No significant change
			Hospitalisation	No significant difference
Schuh S, et al. 1992. Canada.	69 children (6 weeks to 2 years). Albuterol and saline vs albuterol and ipratropium.	PRCT	Respiratory rate	No significant difference
			Accessory muscle score	No significant difference
			Wheeze score	No significant difference
			Oxygen saturation	No significant difference
			Hospitalization rate	17 vs 10
Chowdhury D, et al. 1994. Saudi Arabia.	89 children (6 wks-24 mon). Ipratropium alone vs salbutamol alone vs ipratropium and salbutamol vs saline.	PRCT	Clinical severity score	No significant difference in all groups	Small groups with no blinding. Not all patients included.
			Admission days	No significant difference in all groups
Goh A, et al. 1997. Singapore.	89 children. Neb salbutamol vs neb ipratropium vs neb saline vs humidified oxygen.	PRCT	Clinical severity score	No significant difference	Small numbers with possible type 2 error. Second control group added later.
			Length of stay	No significant difference

Comment(s)

All the trials found have faults, however not one showed a benefit from nebulised ipratropium in this condition.

Clinical Bottom Line

Nebulised ipratropium bromide is not indicated in bronchiolitis.

References

1. Henry RL, Milner AD, Stokes GM. Ineffectiveness of ipratropium bromide in acute bronchiolitis. Arch Dis Child 1983;58(11):925-6.
2. Wang EE, Milner R, Allen U, Maj H. Bronchodilators for treatment of mild bronchiolitis: a factorial randomised trial. Arch Dis Child 1992;67(3):289-93.
3. Schuh S, Johnson D, Canny G, et al. Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis. Pediatrics 1992;90(6):920-3.
4. Chowdhury D, al Howasi M, Khalil M, al-Frayh AS, Chowdhury S, Ramia S. The role of bronchodilators in the management of bronchiolitis: a clinical trial. Ann Trop Paediatrics 1995;15(1):77-84.
5. Goh A, Chay OM, Foo AL, Ong EK. Efficacy of bronchodilators in the treatment of bronchiolitis. Singapore Med J 1997;38(8):326-8.