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• W2163519613 abstract "We thank Drs. Chassany and Fullerton for their letter. They disagree with the inclusion of the study by O’Driscoll et al (1O’Driscoll B.R. Taylor R.J. Horsley M.G. et al.Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction.Lancet. 1989; 1: 1418-1420Abstract PubMed Scopus (156) Google Scholar) in our review of the effects of ipratropium bromide in adults with acute asthma (2Rodrigo G. Rodrigo C. Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma.Am J Med. 1999; 107: 363-370Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar). This study was included because it fulfilled our criteria: it was a randomized, double-blind, controlled trial in which ipratropium was used as an adjunctive therapy to beta-agonists in adults with acute asthma exacerbations who presented to an acute care setting. A previous systematic review of the use of ipratropium bromide in the emergency care of adults with acute asthma also included the study by O’Driscoll et al (3Stoodley R.G. Aaron S.D. Dales R.E. The role of ipratropium bromide in the emergency management of acute asthma exacerbation a meta-analysis of randomized clinical trials.Ann Emerg Med. 1999; 34: 8-18Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar). There are many scoring systems designed to assess the methodologic quality of studies, and they vary in validity. Although there is no firm evidence of the value of our instrument, it appears to have been appropriate: of the 10 studies selected, the only one that received the lowest quality score was the trial by O’Driscoll et al. The results of our review were consistent; all selected studies showed that treatment with ipratropium had some degree of favorable effect on pulmonary function or admission rate. Thus, pooled results from the five high-quality studies, which accounted for 80% of the studied sample, revealed that ipratropium reduced admission rates significantly (odds ratio = 0.62, 95% confidence interval [CI]: 0.44 to 0.88), and the number needed to treat to prevent one hospital admission was 18 patients (95% CI: 11 to 77). The discordance between small differences in pulmonary function and important differences in clinical endpoints, such as hospitalization, was similar to that found in other studies. For example, the meta-analysis by Stoodley et al (3Stoodley R.G. Aaron S.D. Dales R.E. The role of ipratropium bromide in the emergency management of acute asthma exacerbation a meta-analysis of randomized clinical trials.Ann Emerg Med. 1999; 34: 8-18Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar) reported modest differences in airflow improvement (effect size = 0.35, 95% CI: 0.24 to 0.47), associated with a substantial reduction in hospital admission rate (relative risk = 0.73, 95% CI: 0.53 to 0.99; number needed to treat = 20, 95% CI: 11 to 30). In four studies (three low quality and one high quality), patients with severe asthma showed substantial improvement following treatment with ipratropium (effect size = 0.38, 95% CI: 0.09 to 0.69). Again, this finding is consistent with previous data in adults (3Stoodley R.G. Aaron S.D. Dales R.E. The role of ipratropium bromide in the emergency management of acute asthma exacerbation a meta-analysis of randomized clinical trials.Ann Emerg Med. 1999; 34: 8-18Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar) and children (4Plotnick L.H. Ducharme F.M. Should inhaled anticholinergics be added to β2 agonists for treating acute childhood and adolescent asthma? A systematic review.BMJ. 1998; 317: 971-977Crossref PubMed Scopus (88) Google Scholar, 5Qureshi F. Pestian J. Davies P. Zaritsky A. Effect of nebulized ipratropium bromide on the hospitalization rates of children with asthma.NEJM. 1998; 339: 1030-1035Crossref PubMed Scopus (224) Google Scholar). However, our most important finding was that the therapeutic protocol in almost all of the studies consisted of a single dose of ipratropium mixed with beta-agonists, rather than the multiple doses recommended in current consensus reports. This may explain why the observed benefit was modest. Nevertheless, there is substantial evidence that patients with acute asthma respond to increasing doses of bronchodilators, and that this finding can be applied to ipratropium use. Plotnick and Ducharme (4Plotnick L.H. Ducharme F.M. Should inhaled anticholinergics be added to β2 agonists for treating acute childhood and adolescent asthma? A systematic review.BMJ. 1998; 317: 971-977Crossref PubMed Scopus (88) Google Scholar) found that the addition of multiple doses of anticholinergic agents to beta-agonists, mainly in children and adolescents with severe exacerbations, produced a significant improvement in spirometry (effect size = 0.66, 95% CI: 0.37 to 0.95) and reduced the risk of hospital admission (relative risk = 0.72, 95% CI: 0.53 to 0.99). Finally, in a study that is currently in press (6Rodrigo GJ, Rodrigo C. First-line therapy for adult acute asthma patients with a multiple dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. In press.Google Scholar), we found that patients treated with high doses of ipratropium and beta-agonists had a 48% (95% CI: 20% to 76%) greater improvement in FEV1 than the control group and were about half as likely to be admitted to the hospital (relative risk = 0.51, 95% CI: 0.31 to 0.83). Five (95% CI: 3 to 17) patients would need to be treated with high doses of ipratropium bromide to prevent a single admission. A subgroup analysis showed that the patients most likely to benefit from the addition of high doses of ipratropium bromide were those with more severe obstruction (FEV1 ≤30% of predicted) and a long duration of symptoms (≥24 hours) before presentation to the emergency department." @default.
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• W2163519613 title "Meta-analysis of the effects of ipratropium bromide in adults with acute asthma: The reply" @default.
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