A total of 177 patients were entered into the study. Of those, 117 completed the study protocol in full, 40 in group A, 41 in group B, and 36 in group C. Sixty subjects were excluded for varying reasons. Forty one patients were either given the wrong trial preparation, or the full number of peak flow measurements were not made, documentation was inadequate, or peak flow readings showed unacceptable variation (>10 per­cent), suggesting poor technique. Eleven patients improved symptomatically following the first nebuli- zation and refused to receive the second treatment (three from group A, four each from groups В and C). Eight were withdrawn by the attending physicians because of worsening asthma (three each from groups A and B, two from group C). One of this latter group was withdrawn after deteriorating acutely while re­ceiving nebulized ipratropium.

Eleven patients received steroid supplements (group A, four; group B, two; group C, five). Six patients in group A received intravenous theophylline: three in group B, and seven in group C. One patient in group С was given intravenous salbutamol. No patient deteriorated to such a degree as to require artificial ventilation. None of the 177 patients who was entered subsequently died from asthma. Demo­graphic data and initial peak flow readings of each group are shown in Table 1.

Table 1—Demographic Data and Mean Baseline Peak Expiratory Flow Rates for Each Group

Group A*

Group
В

Group
С

Male

16

18

13

Female

24

23

23

Mean age, yrs

32.1

31.9

31.9

Mean baseline

PEFR, L/min

175.75

189.68

194.3

( + /-
SEM)

(11.78)

(13.77)

(16.48)

In group A, two patients deteriorated within 15 minutes of receiving salbutamol (greater than 10 percent fall in PEFR), one patient deteriorated within 15 minutes after ipratropium, and one after 60 min­utes. Four patients failed to improve (but did not worsen) after administration of ipratropium. In group B, three patients deteriorated 15 minutes after administration of ipratropium. One patient deteriorated after instillation of nebulized saline solution.
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FIGURE 1. Peak expiratory flow rate (L/min) for each group plotted against time. Bars represent 1 standard error of the mean (SEM).

There was a significant rise (p <0.001 unless stated) in PEFR after each nebulized treatment; in group A between AO and A15, and A60 and A75; in group В between B0 and B15, B15 and B60 (p <0.025), and B60 and B75; in group С between CO and С15, and between C60 and C75 (Fig 1 and 2). Figure 1 shows the absolute values of PEFR for each group plotted against time. There was no difference between the baseline values of the three groups. There were no significant differences in the AUCs for the three groups; the mean AUC for group A was 4721 L/min; for group В, 4627 L/min; and for group C, 5015 U min.

FIGURE 2. Peak expiratory flow rate expressed as percentage increase from baseline, plotted against time. Bars represent 1 SEM.

Figure 2 shows the results expressed as percentage rise of PEFR from baseline plotted against time. Ipratropium was effective when given as the initial treatment, but at one hour, there was no difference in peak flow between the combination of drugs and either drug given alone. The effect of ipratropium given after salbutamol was no different from that of saline solution given after the combination of drugs. Salbutamol had an equivalent bronchodilator effect whether it was given as the first or the second agent. At the end of the two-hour study period, there was no difference in PEFR between the groups.

FIGURE 3. Peak expiratory flow rate (L/min) for each group plotted against time, excluding data from subjects who received intravenous aminophylline or salbutamol. Bars represent 1 SEM.

Analysis did not differ when subjects who received intravenous aminophylline or intravenous salbutamol were excluded from the study. The absolute PEFR readings for this group are shown in Figure 3. The data expressed as percentage rise of PEFR from baseline plotted against time are shown for these subjects in Figure 4.

FIGURE 4. Peak expiratory flow rate expressed as percentage increase from baseline, plotted against time, and excluding data from subjects who received intravenous aminophylline or salbutamol. Bars represent 1 SEM.