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Evidence-Based Pediatrics Web Site

Atrovent Is Useful for Acute Asthma Exacerbations in Children

Question

  • Does the use of ipratropium bromide in children suffering from an acute asthma exacerbation reduce the likelihood of hospitalization?

Clinical Bottom Lines

  1. Patients with mild asthma may receive only a modest benefit and the data does not suggest that Atrovent is useful in treatment of acute asthma exacerbations.
  2. Severe acute asthma exacerbations should be treated with Atrovent early and with higher doses (500 mcg per dose).
  3. Patients with moderate acute asthma exacerbations will likely have some benefit, especially those trending toward the moderate-severe spectrum.
  4. Marginal cost of administering Atrovent is negligible compared to the cost of potential hospitalization (NNT = 7 to 11).
  5. Atrovent is very well tolerated and has few side effects.


Summary of Key Evidence

Pediatrics1

 
Control
Ipratroprium
P
All subjects
n=216
n=211
--
    Admitted to hospital (%)
22
18
0.33
    Admitted to ICU (%)
1
1
0.6
Discharged home from ED
n=169
n=173
--
Time to discharge (min)
213+/-82
185+/-69
0.001
Returned to ED within 72 hrs
1
1
0.6
Median number of albuterol doses
4
3
0.01

NEJM2

 
Hospitalization Rates
     
Patient group
Atrovent
Control
RRR
ARR
NNT
All patients
27.4%
36.5%
25%
9.1%
11
Moderate Asthma
10.1%
10.7%
  --
  --
  --
Severe Asthma
37.5%
52.6%
29%
15%
7

Additional Comments

  • Pediatrics1
      • Double-blind placebo randomized controlled trial.
      • Reasonable study protocol, treatment intervention, and follow-up.
      • 11% population was less than 2 years of age.
      • Dosage of ipratropium bromide was 250 mcg per dose.
      • Corticosteroids were administered at different times within the first hour depending on the physician.
      • Eight patients in the control group received ipratropium bromide outside the study protocol and were subsequently discharged home.
      • Outcome measures (e.g., time to ER disposition; number of treatments needed) are difficult to translate into clinical outcomes.
    • NEJM2
      • Double-blind randomized placebo controlled trial of children with moderate to severe asthma.
      • Reasonable patient population, protocol, and treatment intervention.
      • Patients less than 2 years of age and those with mild disease were excluded.  Dosing of albuterol and Atrovent was higher per kg body weight than most studies.
      • More girls were present in the treatment group compared to controls, p=0.04.

Citation

  1. Zorc J, Pusic M, Ogborn J, Lebet R, Duggan A.  Ipratropium bromide added to asthma treatment in the pediatric emergency department.  Pediatrics 1999;103(4):747-752.
  2. Qureshi F, Pestian J, Davis P, Zaritsky A.  Effect of nebulized ipratropium on the hospitalization rates of children with asthma.  New England Journal of Medicine 1998; 339(15)1030-1035.
  3. Brophy C, Ahmed B, Bayston S, Arnold A, McGivern D, Greenstone M.  How long should Atrovent be given in acute asthma.  Thorax1998; 53:363-367.
  4. Stoodley RG, Aaron S, Dales R.  The role of ipratropium bromide in the emergency management of acute asthma exacerbation: A meta-analysis of randomized clinical trials. Annals of Emergency Medicine 1999;34(1):8-18.
  5. Rowe B, Travers A, Holroyd B, Kelly K, Bota G.  Nebulized ipratropium bromide in acute pediatric asthma: Does it reduce hospital admissions among children presenting to the emergency department.  Annals of Emergency Medicine 1999; 34(1):75-85

CAT Author: Michael P. Lukela, MD

CAT Appraisers: John G. Frohna, MD

Date appraised: June 12, 2000

Last updated March 23, 2003
Department of Pediatrics and Communicable Diseases
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