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Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma?

Three Part Question

In [children with acute asthma who present to the Emergency Department] is [salbutamol and ipratropium better than salbutamol alone] at [producing a clinical improvement and reducing hospital stay]?

Clinical Scenario

A seven year old boy with moderately well controlled asthma since his last admission 10 months ago presents to the Emergency Department with an acute exacerbation. You ask the nurse to administer salbutamol and ipratropium 5mg and 0.25mg as a nebuliser. She questions the value of adding an anti-cholinergic, despite your theoretical knowledge that the mechanism of action of both drugs should be additive you are left wondering about the clinical evidence to support this.

Search Strategy

OVID Medline 1966 to March Week 4 2006
OVID Embase 1980 to 2006 Week 12
The Cochrane Library 2006 Issue 1
Medline:[(exp asthma/ OR asthma mp) AND (exp albutarol/ OR AND (exp atropine derivatives/ OR exp ipratropium/).OR [*"Adrenergic beta-Agonists"/ AND *"Cholinergic Antagonists"/ AND "Drug Therapy, Combination"/] LIMIT to Humans and English Language and BestBETs paediatric filter
Embase:[(exp asthma/ OR asthma mp) AND (exp Salbutamol/ or AND (exp atropine derivative/ OR exp ipratropium bromide/) OR [exp Beta Adrenergic Receptor Stimulating Agent/ AND exp Cholinergic Receptor Blocking Agent/ AND exp Drug Combination/] AND (exp Emergency Ward/). LIMIT to Human and English Language AND (infant or child or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>)
Cochrane:[Ipratropium [MeSH] AND Albutarol [MeSH] AND [Child [MeSH] 40 articles

Search Outcome

148 articles from all 3 databases of which 1 presented the best evidence and is tabulated below

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Rodrigo GJ and Castro-Rodriuez JA,
Uruguay and Chile,
16 RCTsMeta-analysisNNT to prevent one admission (1786 children in 10 trials)13Significant heterogeneity in spirometric analysis
SMD of Improvement in pooled spirometric parameters- 0.54 (- 0.28 - - 0.81) P < 0.0001


Other outcomes including pulse, blood pressure and oxygen saturation showed no significant differences. Reduced admission rates can only be considered a gross measure of combined drug efficacy. Reproducible results may be more likely given the following 1.An agreed method of assessing the severity of asthma 2.An increased use of peak flow meters among the background population of known asthmatics. 3. Delineation of clinical pathways for treatment, including admission criteria.

Clinical Bottom Line

Adding inhaled anti-cholinergics to beta 2-agonists in the treatment of acute asthma in children presenting to the Emergency Department reduces time to recovery and discharge and may reduce admissions for moderate to severe groups.


  1. Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute asthma: a systematic review. Thorax 2005;60:740-6.