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

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Pediatric Pulmonology 2020 year in review: Asthma

Pediatric asthma is a heterogeneous and common chronic condition with significant morbidity and burden on the healthcare system. Despite advances in the field, the disease has proven to be increasingly complex to diagnose and management strategies are constantly evolving. Studies from 2020 have advanced the field even further, particularly with regard to new methods of diagnosis and monitoring, treatment of severe asthma, modifiable risk factors like exercise and obesity, aerosol delivery, and viral respiratory infections contributing to the development of asthma. Continued studies are needed to improve our care for children with asthma and we look forward to future advances. This article is part of our 2020 "Year in Review" series, in which we summarize publications in major topic areas, in the context of selected literature from other journals relevant to our discipline.

Combination of ipratropium bromide and salbutamol in children and adolescents with asthma: A meta-analysis

BACKGROUND

A combination of ipratropium bromide (IB) and salbutamol is commonly used to treat asthma in children and adolescents; however, there has been a lack of consistency in its usage in clinical practice.

OBJECTIVE

To evaluate the efficacy and safety of IB + salbutamol in the treatment of asthma in children and adolescents.

METHODS

The MEDLINE, Embase, and Cochrane Library as well as other Chinese biomedical databases (including China Biological Medicine Database, Chinese National Knowledge Infrastructure, Chongqing VIP, and Wanfang Chinese language bibliographic database) were systematically searched from the earliest record date to September 2020 for randomized controlled trials in children and adolescents (≤18 years) with asthma who received IB + salbutamol or salbutamol alone. The primary outcomes included hospital admission and adverse events. A random effects model with a 95% confidence interval (CI) was used. Subgroup analysis was performed according to age, severity of asthma, and co-interventions with other asthma controllers. This study was registered with PROSPERO.

RESULTS

Of the 1061 studies that were identified, 55 met the inclusion criteria and involved 6396 participants. IB + salbutamol significantly reduced the risk of hospital admission compared with salbutamol alone (risk ratio [RR] 0.79; 95% CI 0.66-0.95; p = 0.01; I2 = 40%). Subgroup analysis only showed significant difference in the risk of hospital admission in participants with severe asthma exacerbation (RR 0.73; 95% CI 0.60-0.88; p = 0.0009; I2 = 4%) and moderate-to-severe exacerbation (RR 0.69; 95% CI 0.50-0.96; p = 0.03; I2 = 3%). There were no significant differences in the risk of adverse events between IB + salbutamol group and salbutamol alone group (RR 1.77; 95% CI 0.63-4.98).

CONCLUSION

IB + salbutamol may be more effective than salbutamol alone for the treatment of asthma in children and adolescents, especially in those with severe and moderate to severe asthma exacerbation. The very low to high quality of evidence indicated that future well-designed double-blind RCTs with large sample are needed for research on evaluating the effectiveness of IB + salbutamol treatment for asthma in children and adolescents.

Variability in care for children with severe acute asthma in Latin America

BACKGROUND

Care variability for children with severe acute asthma has been well documented in high-income countries, yet data from low- and middle-income regions are lacking. We sought to characterize the magnitude of practice variability in the care of Latin American children to identify opportunities for standardization of care.

METHODS

A cross-sectional study performed through a retrospective analysis of contemporaneously collected data of children with severe acute asthma admitted to a center contributing to the LARed Network registry between May 2017 and May 2019. Centers were grouped by geographic location: Atlantic (AT), South Pacific (SP), and North Central (NC).

RESULTS

Among 434 children, most received care in hospitals in the AT group (54% [235/434]), followed by the NC (23% [101/434]) and SP (23% [98/434]) groups. The majority of children in the AT (92% [215/235]) and SP (91% [89/98]) groups received nebulized salbutamol/albuterol, while metered-dose inhalers were preferred in the NC group (72% [73/101]). There was a wide variation in the use of antibiotics: AT (57% [135/235]), SP (48% [47/98]), and NC (14% [14/101]). The same was true for ipratropium bromide: AT (67% [157/235]), SP (90% [88/98]), and NC (17% [17/101]), and aminophylline: AT (57% [135/235]), NC (5% [5/101]), and SP (0% [0/98]). High-flow nasal cannula was the preferred respiratory support modality in the AT (60% [141/235]) and NC (40% [40/101]) groups, while bilevel positive airway pressure (BiPAP) use was more common in the SP group (80% [78/98]).

CONCLUSION

We identified significant variability in care for severe acute asthma. Our findings will help to inform the design of future studies, quality improvement initiatives, and development of practice guidelines within Latin America.

Randomized pilot trial of ipratropium versus placebo in children with critical asthma

OBJECTIVE

To test the effects of inhaled ipratropium on clinical outcomes of critical asthma in the first randomized trial of this adjunctive therapy in critically ill children.

DESIGN

Pilot, placebo-controlled, double-blinded, and randomized-controlled trial PATIENTS: Thirty children (15 per group) with critical asthma receiving high-intensity albuterol per a standardized pathway utilizing objective assessments to wean patients to less frequent albuterol administration.

INTERVENTIONS

Subjects were randomized to receive either nebulized ipratropium bromide (500 µg in 0.9% saline per dose) or an equivalent volume of nebulized 0.9% saline every 6 h until the patient was successfully weaned to albuterol doses every 2 h ("q2 albuterol").

MEASUREMENTS AND MAIN RESULTS

Demographics, initial clinical severity score, and asthma histories were similar between groups. There was no significant difference in the median duration of high-intensity albuterol between the treatment group (17.5 [10.3-22.1] h) and placebo group (14.6 [12.7-24.5] days; p = .56). Similarly, there was no significant difference in pediatric intensive care unit length of stay (22.6 [21.1-33.6] vs. 21.4 [16.1-35.8] h; p = .74) or hospital length of stay (48.0 [41.8-59.8] vs. 47.3 [37.2-63.1] h; p = .67). In multivariate linear regression adjusting for identified confounders, treatment with ipratropium was not significantly associated with any of the three outcomes. Side effects were rare and occurred with equally between both groups CONCLUSIONS: Adjunctive therapy with ipratropium was not associated with decreased duration of high-intensity albuterol or shortened length of stay when compared to placebo. A larger, multicenter trial is warranted to confirm that ipratropium does not improve clinical outcomes.

Adjunctive Pharmacotherapies in Children With Asthma Exacerbations Requiring Continuous Albuterol Therapy: Findings From The Ohio Pediatric Asthma Repository

OBJECTIVES

To identify associations between use of ipratropium and/or intravenous magnesium and outcomes of children hospitalized with acute asthma exacerbations and treated with continuous albuterol.

METHODS

Secondary analysis of data from children prospectively enrolled in the multicenter Ohio Pediatric Asthma Repository restricted to only children who were treated with continuous albuterol in their initial inpatient location. Children were treated with adjunctive therapies per the clinical team.

RESULTS

Among 242 children who received continuous albuterol, 94 (39%) received ipratropium only, 13 (5%) received magnesium alone, 42 (17%) received both, and 93 (38%) received neither. The median duration of continuous albuterol was 7.0 (interquartile range [IQR]: 2.8-12.0) hours. Ipratropium use was associated with a shorter duration of continuous albuterol (4.9 [IQR: 2.0-10.0] hours) compared with dual therapy (11.0 [IQR: 5.6-28.6] hours; P = .001), but magnesium use was not (7.5 [IQR: 2.5-16.0] hours; P = .542). In Cox proportional models (adjusted for hospital, demographics, treatment location, and respiratory failure), magnesium was associated with longer durations of continuous albuterol (hazard ratio, 0.54 [95% confidence interval: 0.37-0.77]; P < .001) and hospitalization (hazard ratio, 0.41 [95% confidence interval: 0.28-0.60]; P < .001), but ipratropium was not.

CONCLUSIONS

Ipratropium and magnesium were both often used in children with severe asthma hospitalizations that required continuous albuterol therapy. Magnesium use was associated with unfavorable outcomes, possibly reflecting preferential treatment to patients with more severe cases and differing practices between centers. Given the high prevalence of asthma, wide variations in practice, and the potential to improve outcomes and costs, prospective trials of these adjunctive therapies are needed.

Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care

OBJECTIVE

In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost.

METHODS

Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods.

RESULTS

A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital.

CONCLUSIONS

Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.

Contemporary treatment of children with critical and near-fatal asthma

Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.

Management of Acute Exacerbation of Asthma and Chronic Obstructive Pulmonary Disease in the Emergency Department

Acute asthma and chronic obstructive pulmonary disease (COPD) exacerbations are the most common respiratory diseases requiring emergent medical evaluation and treatment. Asthma and COPD are chronic, debilitating disease processes that have been differentiated traditionally by the presence or absence of reversible airflow obstruction. Asthma and COPD exacerbations impose an enormous economic burden on the US health care budget. In daily clinical practice, it is difficult to differentiate these 2 obstructive processes based on their symptoms, and on their nearly identical acute treatment strategies; major differences are important when discussing anatomic sites involved, long-term prognosis, and the nature of inflammatory markers.

Continuous Inhalation of Ipratropium Bromide for Acute Asthma Refractory to β2-agonist Treatment

To present the case of a patient with persistent bronchospasm, refractory to treatment with β2-agonists, that resolved promptly with continuous inhalation of large dose (1000 mcg/hr) ipratropium bromide, and to discuss the possibility of tolerance to β2-agonists as the cause for his failure to respond to adrenergic medications. The patient had received multiple doses of albuterol, as well as subcutaneous terbutaline (0.3 mg), intravenous magnesium sulfate (1 g) and intravenous dexamethasone (10 mg) prior to his admission to the intensive care unit. He remained symptomatic despite systemic intravenous steroids, continuous intravenous terbutaline (up to 0.6 mcg/kg/min), and continuous nebulized albuterol (up to 20 mg/hr for 57 hr) followed by 49 hours of continuous levalbuterol (7 mg/hr). Due to the lack of response, all β2-agonists were discontinued at 106 hours post-admission, and he was started on large dose ipratropium bromide (1000 mcg/hr) by continuous nebulization. Clinical improvement was evident within 1 hour and complete resolution of his symptoms within 4 hours. Continuous inhalation of large dose ipratropium bromide may be an effective regimen for the treatment of patients hospitalized with acute asthma who are deemed to be nonresponsive and/or tolerant to β2-agonist therapy.

Anticholinergics/antimuscarinic drugs in asthma

Anticholinergic alkaloids have been used for thousands of years for the relief of bronchoconstriction and other respiratory symptoms, and their use in the treatment of chronic obstructive pulmonary disease is well established. Acetylcholine, acting through muscarinic receptor (M) receptor, modulates multiple physiologic functions pertinent to asthma including airway muscle tone, mucus gland secretion, and various parameters of inflammation and remodeling. In addition, activation of M receptors may inhibit beta2 adrenoreceptor. These observations offer the rationale for the use of M receptors antagonists in the treatment of asthma. Short-acting antimuscarinic agents may be effective alone or in combination with short-acting beta agonists for the relief of acute symptoms. Long-acting antimuscarinic agents have emerged as potentially useful in the long-term treatment of difficult-to-control asthma. This review will analyze the mechanisms of action and therapeutic role of antimuscarinic agents on asthma including current guidelines regarding antimuscarinic drugs, recent studies in asthma, special populations to consider, and possible predictors of response.

Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital

BACKGROUND

Inhaled anticholinergics given in addition to β2-agonists are effective in reducing hospital admissions in children presenting to the emergency department with a moderate to severe asthma exacerbation. It seems logical to assume a similar beneficial effect in children hospitalised for an acute asthma exacerbation.

OBJECTIVES

To assess the efficacy and safety of anticholinergics added to β2-agonists as inhaled or nebulised therapy in children hospitalised for an acute asthma exacerbation. To investigate the characteristics of patients or therapy, if any, that would influence the magnitude of response attributable to the addition of anticholinergics.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO and through handsearching of respiratory journals and meeting abstracts. The search is current to November 2013.

SELECTION CRITERIA

Randomised trials comparing the combination of inhaled or nebulised anticholinergics and short-acting β2-agonists versus short-acting β2-agonists alone in children one to 18 years of age hospitalised for an acute asthma exacerbation were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of trials and extracted data; disagreement was resolved by consensus or with the input of a third review author, when needed. Primary outcomes were duration of hospital stay and serious adverse events. Secondary outcomes included admission and duration of stay in the intensive care unit (ICU), ventilation assistance, time to short-acting β2-agonists spaced at four hours or longer, supplemental asthma therapy, duration of supplemental oxygen, change from baseline in asthma severity, relapse after discharge, adverse health effects and withdrawals.

MAIN RESULTS

Seven randomised trials were included, four of which reported usable data on 472 children with asthma one to 18 years of age who were admitted to paediatric wards. No trials included patients admitted to the ICU. The anticholinergic used, ipratropium bromide 250 μg, was given every one to eight hours over a period from four hours to the entire length of the hospital stay. Two of four trials (50%) contributing data were deemed of high methodological quality. The addition of anticholinergics to β2-agonists showed no evidence of effect on the duration of hospital admission (mean difference (MD) -0.28 hours, 95% confidence interval (CI) -5.07 to 4.52, 3 studies, 327 participants, moderate quality evidence) and no serious or non-serious adverse events were reported in any included trials. As a result of the similarity of trials, we could not explore the influence of age, admission site, intensity of anticholinergic treatment and co-interventions on primary outcomes. No statistically significant group difference was noted in other secondary outcomes, including the need for supplemental asthma therapy, time to short-acting β2-agonists spaced at four hours or longer, asthma clinical scores, lung function and overall withdrawals for any reason.

AUTHORS' CONCLUSIONS

In children hospitalised for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulised anticholinergics were added to short-acting β2-agonists. No adverse health effects were reported, yet the small number of trials combined with inadequate reporting prevent firm reassurance regarding the safety of anticholinergics. In the absence of trials conducted in ICUs, no conclusion can be drawn regarding children with impending respiratory failure. These findings support current national and international recommendations indicating that healthcare practitioners should refrain from using anticholinergics in children hospitalised for acute asthma.

Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children

BACKGROUND

There are several treatment options for managing acute asthma exacerbations (sustained worsening of symptoms that do not subside with regular treatment and require a change in management). Guidelines advocate the use of inhaled short acting beta2-agonists (SABAs) in children experiencing an asthma exacerbation. Anticholinergic agents, such as ipratropium bromide and atropine sulfate, have a slower onset of action and weaker bronchodilating effect, but may specifically relieve cholinergic bronchomotor tone and decrease mucosal edema and secretions. Therefore, the combination of inhaled anticholinergics with SABAs may yield enhanced and prolonged bronchodilation.

OBJECTIVES

To determine whether the addition of inhaled anticholinergics to SABAs provides clinical improvement and affects the incidence of adverse effects in children with acute asthma exacerbations.

SEARCH METHODS

We searched MEDLINE (1966 to April 2000), EMBASE (1980 to April 2000), CINAHL (1982 to April 2000) and reference lists of studies of previous versions of this review. We also contacted drug manufacturers and trialists. For the 2012 review update, we undertook an 'all years' search of the Cochrane Airways Group's register on the 18 April 2012.

SELECTION CRITERIA

Randomized parallel trials comparing the combination of inhaled anticholinergics and SABAs with SABAs alone in children (aged 18 months to 18 years) with an acute asthma exacerbation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used the GRADE rating system to assess the quality of evidence for our primary outcome (hospital admission).

MAIN RESULTS

Twenty trials met the review eligibility criteria, generated 24 study comparisons and comprised 2697 randomised children aged one to 18 years, presenting predominantly with moderate or severe exacerbations. Most studies involved both preschool-aged children and school-aged children; three studies also included a small proportion of infants less than 18 months of age. Nine trials (45%) were at a low risk of bias. Most trials used a fixed-dose protocol of three doses of 250 mcg or two doses of 500 mcg of nebulized ipratropium bromide in combination with a SABA over 30 to 90 minutes while three trials used a single dose and two used a flexible-dose protocol according to the need for SABA.The addition of an anticholinergic to a SABA significantly reduced the risk of hospital admission (risk ratio (RR) 0.73; 95% confidence interval (CI) 0.63 to 0.85; 15 studies, 2497 children, high-quality evidence). In the group receiving only SABAs, 23 out of 100 children with acute asthma were admitted to hospital compared with 17 (95% CI 15 to 20) out of 100 children treated with SABAs plus anticholinergics. This represents an overall number needed to treat for an additional beneficial outcome (NNTB) of 16 (95% CI 12 to 29).Trends towards a greater effect with increased treatment intensity and with increased asthma severity were observed, but did not reach statistical significance. There was no effect modification due to concomitant use of oral corticosteroids and the effect of age could not be explored. However, exclusion of the one trial that included infants (< 18 months) and contributed data to the main outcome, did not affect the results. Statistically significant group differences favoring anticholinergic use were observed for lung function, clinical score at 120 minutes, oxygen saturation at 60 minutes, and the need for repeat use of bronchodilators prior to discharge from the emergency department. No significant group difference was seen in relapse rates.Fewer children treated with anticholinergics plus SABA reported nausea and tremor compared with SABA alone; no significant group difference was observed for vomiting.

AUTHORS' CONCLUSIONS

Children with an asthma exacerbation experience a lower risk of admission to hospital if they are treated with the combination of inhaled SABAs plus anticholinergic versus SABA alone. They also experience a greater improvement in lung function and less risk of nausea and tremor. Within this group, the findings suggested, but did not prove, the possibility of an effect modification, where intensity of anticholinergic treatment and asthma severity, could be associated with greater benefit.Further research is required to identify the characteristics of children that may benefit from anticholinergic use (e.g. age and asthma severity including mild exacerbation and impending respiratory failure) and the treatment modalities (dose, intensity, and duration) associated with most benefit from anticholinergic use better.

Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit

OBJECTIVES

An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients.

METHODS

Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980-2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital.

RESULTS

Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status.

CONCLUSIONS

Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.

Pediatric status asthmaticus

Status asthmaticus is a frequent cause of admission to a pediatric intensive care unit. Prompt assessment and aggressive treatment are critical. First-line or conventional treatment includes supplemental oxygen, aerosolized albuterol, and corticosteroids. There are several second-line treatments available; however, few comparative studies have been performed and in the absence of good evidence-based treatments, the use of these therapies is highly variable and dependent on local practice and provider preference. In this article the pathophysiology and treatment of status asthmaticus is discussed, and the literature regarding second-line treatments is critically assessed to apply an evidence basis to the treatment of this severe disease.

Anticholinergic therapy for acute asthma in children

BACKGROUND

Inhaled anticholinergics as single agent bronchodilators (or in combination with beta(2)-agonists) are one of the several medications available for the treatment of acute asthma in children.

OBJECTIVES

To determine the effectiveness of only inhaled anticholinergic drugs (i.e. administered alone), compared to a control in children over the age of two years with acute asthma.

SEARCH METHODS

The Cochrane Register of Controlled Trials (CENTRAL), and the Cochrane Airways Group Register of trials were searched by the Cochrane Airways Group. The latest search was performed in April 2011.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) in which inhaled anticholinergics were given as single therapy and compared with placebo or any other drug or drug combinations for children over the age of two years with acute asthma.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data and assessed trial quality.

MAIN RESULTS

Six studies met the inclusion criteria but were limited by small sample sizes, various treatment regimes used and outcomes assessed. The studies were overall of unclear quality. Data could only be pooled for the outcomes of treatment failure and hospitalisation. Other data could not be combined due to divergent outcome measurements. Meta-analysis revealed that children who received anticholinergics alone were significantly more likely to have treatment failure compared to those who received beta(2)-agonists from four trials on 171 children (odds ratio (OR) 2.27; 95% CI 1.08 to 4.75). Also, treatment failure on anticholinergics alone was more likely than when anticholinergics were combined with beta(2)-agonists from four trials on 173 children (OR 2.65; 95% CI 1.2 to 5.88). Data on clinical scores/symptoms that were measured on different scales were conflicting. Individual trials reported that lung function was superior in the combination group when compared with anticholinergic agents used alone. The use of anticholinergics was not found to be associated with significant side effects.

AUTHORS' CONCLUSIONS

In children over the age of two years with acute asthma exacerbations, inhaled anticholinergics as single agent bronchodilators were less efficacious than beta(2)-agonists. Inhaled anticholinergics were also less efficacious than inhaled anticholinergics combined with beta(2)-agonists. Inhaled anticholinergic drugs alone are not appropriate for use as a single agent in children with acute asthma exacerbations.

Asthma diagnosis and management

Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.

Pharmacologic approaches to life-threatening asthma

Following a peak in asthma mortality in the late 1980s and early 1990s, we have been fortunate to see a substantial decrease in asthma deaths in recent years. Although most asthma deaths occur outside the hospital, near-fatal events are commonplace, with anywhere from 2-20% of patients with acute asthma admitted to intensive care, and 2-4% intubated for respiratory failure. Standard therapies for acute severe and near-fatal asthma include administration of systemic corticosteroids, and frequent or continuous inhaled beta agonists. Controversy remains regarding the optimal therapy of those who fail to respond to these initial treatments, those who remain at risk of acute respiratory failure, and patients requiring mechanical ventilation. There remain significant gaps in our knowledge regarding relative benefits of intravenous versus oral corticosteroids, intermittent versus continuous beta agonists, and the role of various adjunctive treatments including intravenous magnesium, systemic beta agonists, aminophylline, and helium-oxygen mixtures. Using models and radiolabeled aerosols, there is a greater understanding regarding effective administration of inhaled beta-agonists in ventilated patients. There is limited available evidence for treatment of near-fatal asthma, a fact reflected by the significant variability in asthma critical care practice. Much of the data guiding treatment in this setting has been generalized from studies of acute asthma in the ED and from general populations of hospitalized patients with acute asthma. This review will focus on pharmacologic approaches to life-threatening asthma by reviewing current guideline recommendations, reviewing the scientific basis of the guidelines, and highlighting gaps in our knowledge in treatment of refractory acute or near-fatal asthma.

Trends in admissions for pediatric status asthmaticus in New Jersey over a 15-year period

OBJECTIVE

Status asthmaticus accounts for a large portion of the morbidity and mortality associated with asthma, but we know little about its epidemiology. We describe here the hospitalization characteristics of children with status asthmaticus, how they changed over time, and how they differed between hospitals with and without PICUs.

PATIENTS AND METHODS

We used administrative data from New Jersey that included all hospitalizations in the state from 1992, 1995, and 1999-2006. We identified children with status asthmaticus by using International Classification of Diseases, Ninth Revision, diagnosis codes that indicate status asthmaticus and the use of mechanical ventilation by using procedure codes. We designated hospitals with a PICU as "PICU hospitals" and those without as "adult hospitals."

RESULTS

We identified 28 309 admissions of children with status asthmaticus (22.8% of all asthma hospitalizations). From 1992 to 2006, the rate of hospital admissions decreased by half (from 1.98 in 1000 to 0.93 in 1000 children), and there was a 70% decrease in the number of children admitted to adult hospitals. The rate of ICU care in PICU hospitals more than tripled. However, the rate of mechanical ventilation remained low, and the number of deaths was small and unchanged (n=14 total). Hospital costs climbed from $6.6 million to $9.5 million.

CONCLUSIONS

Although fewer children are being admitted with status asthmaticus, the proportion of patients managed in PICUs is climbing. There has been no substantial change in rates of mechanical ventilation or death. Additional research is needed to better understand how patients and physicians decide on the appropriate site for hospital care and how that choice affects outcome.

Anticholinergic treatment in airways diseases

The prevalence of chronic airways diseases such as chronic obstructive pulmonary disease and asthma is increasing. They lead to symptoms such as a cough and shortness of breath, partially through bronchoconstriction. Inhaled anticholinergics are one of a number of treatments designed to treat bronchoconstriction in airways disease. Both short-acting and long-acting agents are now available and this review highlights their efficacy and adverse event profile in chronic airways diseases.

Quality of care for children hospitalized with asthma

OBJECTIVES

The goals were (1) to identify evidence-based clinical process measures that are appropriate, feasible, and reliable for assessing the quality of inpatient asthma care for children and (2) to evaluate provider compliance with these measures.

METHODS

Key asthma quality measures were identified by using a modified Rand appropriateness method, combining a literature review of asthma care evidence with a consensus panel. The feasibility and reliability of obtaining these measures were determined through manual chart review. Provider compliance with these measures was evaluated through retrospective manual chart review of data for 252 children between 2 and 17 years of age who were admitted to a tertiary care children's hospital in 2005 because of asthma exacerbations.

RESULTS

Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance with these measures was as follows: acute asthma severity assessment at admission, 39%; use of systemic corticosteroid therapy, 98%; use of oral (not intravenous) systemic corticosteroid therapy, 87%; use of ipratropium bromide restricted to <24 hours after admission, 71%; use of albuterol delivered with a metered-dose inhaler (not nebulizer) for children >5 years of age, 20%; documented chronic asthma severity assessment, 22%; parental participation in an asthma education class, 33%; written asthma action plan, 5%; scheduled follow-up appointment with the primary care provider at discharge, 22%.

CONCLUSIONS

Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance across these measures was highly variable but generally low. Our study highlights opportunities for improvement in the provision of asthma care for hospitalized children. Future studies are needed to confirm these findings in other inpatient settings.

The value of care algorithms

The use of protocols or care algorithms in medical facilities has increased in the managed care environment. The definition and application of care algorithms, with a particular focus on the treatment of acute bronchospasm, are explored in this review. The benefits and goals of using protocols, especially in the treatment of asthma, to standardize patient care based on clinical guidelines and evidence-based medicine are explained. Ideally, evidence-based protocols should translate research findings into best medical practices that would serve to better educate patients and their medical providers who are administering these protocols. Protocols should include evaluation components that can monitor, through some mechanism of quality assurance, the success and failure of the instrument so that modifications can be made as necessary. The development and design of an asthma care algorithm can be accomplished by using a four-phase approach: phase 1, identifying demographics, outcomes, and measurement tools; phase 2, reviewing, negotiating, and standardizing best practice; phase 3, testing and implementing the instrument and collecting data; and phase 4, analyzing the data and identifying areas of improvement and future research. The experiences of one medical institution that implemented an asthma care algorithm in the treatment of pediatric asthma are described. Their care algorithms served as tools for decision makers to provide optimal asthma treatment in children. In addition, the studies that used the asthma care algorithm to determine the efficacy and safety of ipratropium bromide and levalbuterol in children with asthma are described.

Current management of status asthmaticus in the pediatric ICU

Status asthmaticus (SA) in the pediatric ICU (PICU) can progress to a life-threatening emergency. The goal of management is to improve hypoxemia, improve bronchoconstriction, and decrease airway edema through the administration of continuous nebulized beta2 adrenergic agonist with intermittent anticholinergics, corticosteroids, and oxygen. Adjunctive therapies, such as magnesium, methylxanthines, intravenous beta-agonists, heliox, and noninvasive ventilation should be considered in the child who fails to respond to initial therapies. The restoration of adequate pulmonary functions, resolution of airway obstruction, and avoidance of mechanical ventilation should guide management. This article reviews the pathophysiology, assessment, and management of the child who has SA in the PICU to provide the critical care nurse with current information to facilitate optimal care.

Respiratory distress

Preparation for pediatric pulmonary emergencies in the office setting includes adequate training for all medical staff, properly sized and working equipment, and medications to help alleviate respiratory distress when indicated. Status asthmaticus, viral bronchiolitis, and croup account for the vast majority of respiratory emergencies encountered in the pediatric office setting. Timely application of proven approaches to assessment and treatment of these illnesses can prevent hospitalization, decrease length of hospitalizations, and save lives.

Acute asthma in children and adolescents: should inhaled anticholinergics be added to beta(2)-agonists?

Children and adolescents experiencing acute exacerbations of asthma benefit from the use of beta(2)-adrenoceptor agonists (beta(2)-agonists) and systemic corticosteroids. However, there have been conflicting reports regarding the efficacy of inhaled anticholinergic agents. This article summarizes the evidence provided by randomized controlled trials studying the efficacy of adding inhaled anticholinergic agents to beta(2)-agonists in nonhospitalized children and adolescents with acute exacerbations of asthma. This systematic review of randomized controlled trials suggests that the addition of inhaled anticholinergic agents to beta(2)-agonists is beneficial in children and adolescents, particularly those with severe exacerbations of asthma. When given in repeated doses, the addition of inhaled anticholinergic agents to beta(2)-agonists improves lung function and reduces the risk of hospital admission by 25%. Several treatment regimens, namely ipratropium bromide (250 or 500 microg per dose) every 20-60 minutes for two to three doses have been tested with similar beneficial effects. The addition of a single dose of an inhaled anticholinergic agent to beta(2)-agonists improves lung function but does not prevent hospital admission. The review did not identify any beneficial effects of anticholinergic agents in children with nonsevere asthma. Use of anticholinergic agents was not associated with increase in the incidence of nausea, vomiting or tremor. In conclusion, the addition of repeated doses of an inhaled anticholinergic agent to inhaled beta(2)-agonist is indicated in the emergency room management of children and adolescents with acute asthma, particularly those with severe exacerbations.

Comparison of racemic albuterol and levalbuterol for treatment of acute asthma

OBJECTIVE

To determine whether levalbuterol resulted in fewer hospital admissions than racemic albuterol when used for treatment of acute asthma. Study design A randomized, double-blind, controlled trial was conducted in the emergency department (ED) and inpatient asthma care unit of an urban tertiary children's hospital. Children age 1 to 18 years (n=482) provided a total of 547 enrollments. Patients received a nebulized solution of either 2.5 mg racemic albuterol or 1.25 mg levalbuterol every 20 minutes (maximum six doses). Patients admitted to the asthma care unit were treated in a standardized fashion by using the same blinded drug assigned in the ED. Hospitalization rate was the primary outcome.

RESULTS

Hospitalization rate was significantly lower in the levalbuterol group (36%) than in the racemic albuterol group (45 %, P=.02). The adjusted relative risk of admission in the racemic group compared with the levalbuterol group was 1.25 (95% confidence interval, 1.01-1.57). Hospital length of stay was not significantly shorter in the levalbuterol group (levalbuterol, 44.9 hours; racemic albuterol, 50.3 hours; P=.63). No significant adverse events occurred in either group.

CONCLUSIONS

Substituting levalbuterol for racemic albuterol in the ED management of acute asthma significantly reduced the number of hospitalizations.

Anticholinergic therapy for chronic asthma in children over two years of age

BACKGROUND

In the intrinsic system of controlling airway calibre, the cholinergic (muscarinic) sympathetic nervous system has an important role. Anticholinergic, anti muscarinic bronchodilators such as ipratropium bromide are frequently used in the management of childhood airway disease. In asthma, ipratropium is a less potent bronchodilator than beta-2 adrenergic agents but it is known to be a useful adjunct to other therapies, particularly in status asthmaticus. What remains unclear is the role of anticholinergic drugs in the maintenance treatment of chronic asthma.

OBJECTIVES

To determine the effectiveness of anticholinergic drugs in chronic asthma in children over the age of 2 years.

SEARCH STRATEGY

The Cochrane Airways Group trials register and reference lists of articles were searched in January 2002.

SELECTION CRITERIA

Randomised controlled trials in which anticholinergic drugs were given for chronic asthma in children over 2 years of age were included. Studies including comparison of: anticholinergics with placebo, and anticholinergics with any other drug were included.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion and quality of trials were assessed independently by two reviewers.

MAIN RESULTS

Eight studies met the inclusion criteria.Three papers compared the effects of anticholinergic drugs with placebo, and a meta-analysis of these results demonstrated no statistically significant benefit of the use of anticholinergic drugs over placebo in any of the outcome measures used. The results of one of these trials could not be included in the meta-analysis but the authors did report significantly lower symptom scores with inhaled anticholinergics compared with placebo. However, there was no significant difference between ipratropium bromide and placebo in the percentage of symptom-free nights or days. Two trials studied the effects of anticholinergics on bronchial hyper responsiveness to histamine, by measuring the provocation dose of histamine needed to cause a fall of 20 % in FEV1 (PD 20). One study (comparing anticholinergics with placebo) reported a statistically significant increase in PD 20 but this was not found in another study (comparing anticholinergics with a beta-2 agonist). Both trials also examined the effect of anticholinergic drugs on diurnal variation in peak expiratory flow rate (PEFR) and reported no significant effect. Two studies compared the addition of an anticholinergic drug to a beta-2 agonist with the beta-2 agonist alone. Both trials failed to show any significant benefit from the long term use of combined anticholinergics with beta-2 agonists compared with beta-2 agonists alone. One trial compared the effects of oral and inhaled anticholinergic drugs with placebo. No statistically significant differences were found in any of the outcome measures except for a higher FEV1 / VC ratio and RV / TLC ratio with oral anticholinergic therapy when compared with placebo.

REVIEWER'S CONCLUSIONS

The present review summarises the best evidence available to date. Although there were some small beneficial findings in favour of anticholinergic therapy, there is insufficient data to support the use of anticholinergic drugs in the maintenance treatment of chronic asthma in children.

Management of acute pediatric asthma

Pediatric asthma prevalence, morbidity, and severity are increasing. Direct costs associated with providing emergency department and inpatient care account for more than 40% of overall dollars spent for this disease in the United States. Physicians in many health care settings may be required to treat a child in severe respiratory distress caused by acute asthma. This article reviews the pathophysiology, evaluation, and treatment of severe asthma exacerbations, or status asthmaticus.

Clinical pathways in treatment of asthma

Although the number of medications for the treatment of status asthmaticus is relatively limited, strategies for the management of acute asthma vary widely both among and within institutions. The choice of drugs, doses, timing of administration, duration of treatment, and assessment measures are often left to the discretion of individual physicians; plans are often not formulated on the basis of data showing efficacy, but rather on local availability and the experience and preference of physicians. The elimination of treatment that adds cost but not improved quality of care can be an effective strategy to optimize the care of acute asthma.

[Benefits of ipratropium bromide in the management of asthmatic crises in the emergency department]

BACKGROUND

To determine if the addition of ipratropium bromide in the emergency department (ED) for the treatment of childhood asthma reduces rates of hospitalization and relapses for moderate and severe exacerbations.

METHODS

Patients were given an oral corticosteroid treatment (2 mg/kg) and received every 20 minutes either three nebulizations with albuterol (0.15 mg/kg) and ipratropium bromide (250 micrograms) or six nebulizations with albuterol alone (control group). The primary end point was the need for hospitalization, additional nebulizations or a relapse during the following week. Secondary end point included the effect of age.

RESULTS

One hundred and forty three children, two to 15 years old, were randomized to ipratropium or control groups and 121 were evaluated on day seven. As a whole, the control group was less often hospitalized or in relapse than those treated with three nebulizations of albuterol and ipratropium (17.5% vs 37.9%, p < 0.02). The ipratropium group reached the same result after three additional albuterol nebulizations. The benefit of anticholinergic therapy was observed for children less than six years of age who had a similar rate of success (73.5 vs 75.7%).

CONCLUSION

The association of ipratropium bromide to the first three doses of the albuterol protocol for acute asthma did not act as well as six nebulizations of albuterol alone. The effect was age dependent and two to six years old children needed more attention. Nevertheless the hospitalization rate did not support the use of ipratropium compared with repeated albuterol nebulizations.