Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis

Background: Current guidelines recommend the use of a combination of inhaled β 2 agonists and anticholinergics, particularly for patients with acute severe or life threatening asthma in the emergency setting. However, this statement is based on a relatively small number of randomised controlled trials and related systematic reviews. A review was undertaken to incorporate the more recent evidence available about the effectiveness of treatment with a combination of β 2 agonists and anticholinergics compared with β 2 agonists alone in the treatment of acute asthma. Methods: A search was conducted of all randomised controlled trials published before April 2005. Results: Data from 32 randomised controlled trials (n = 3611 subjects) showed significant reductions in hospital admissions in both children (RR = 0.73; 95% CI 0.63 to 0.85, p = 0.0001) and adults (RR = 0.68; 95% CI 0.53 to 0.86, p = 0.002) treated with inhaled anticholinergic agents. Combined treatment also produced a significant increase in spirometric parameters 60–120 minutes after the last treatment in both children (SMD = −0.54; 95% CI −0.28 to −0.81, p = 0.0001) and adults (SMD = −0.36; 95% CI −0.23 to −0.49, p = 0.00001). Conclusions: This review strongly suggests that the addition of multiple doses of inhaled ipratropium bromide to β 2 agonists is indicated as the standard treatment in children, adolescents, and adults with moderate to severe exacerbations of asthma in the emergency setting.