Nebulized Ipratropium in the Treatment of Acute Asthma

Following the introduction of the newer anticholin- ergic antimuscarinic agents, a number of studies have investigated the use of such drugs in the treat­ment of acute asthma. Ipratropium is the most widely used of these newer agents, and it has been the most widely investigated, although the number of studies supporting its use is small.

Ipratropium has been shown to be an effective bronchodilator medication in acute asthma. Three studies have suggested that sequential use of both an adrenoceptor agonist and an antimuscarinic agent is superior to one agent given alone, although there was conflicting evidence as to whether salbutamol should be given first in the sequence or last.

Interpretation of the reports which support sequen­tial administration may be biased because two active bronchodilators were administered sequentially. The second agent may cause further bronchodilatation because of its improved lung penetration which results from the effect of the first drug. This problem of design was addressed by two studies in which a comparison was undertaken between beta-agonist followed by an antimuscarinic and the beta-agonist given twice. Both suggested sequential treatment with the different drugs was superior, but in one, the group of patients who received two doses of beta- agonist probably had more severe asthma than those who received sequential treatment.

The above reports comprised relatively small num­bers of patients, ranging from 12 to 28 patients in each. There were two studies of larger numbers of patients. In one study, 40 patients were allocated to two treatments of either salbutamol alone, or salbu­tamol combined with ipratropium. There was no difference in peak flow between the two groups at four hours. In another study of 148 asthmatic patients from four centers, patients were randomly allocated to three treatment groups and received a single nebulized treatment containing either fenoterol alone, ipratro­pium alone, or fenoterol/ipratropium in combination. At 90 minutes after treatment, the combination was superior to either agent given alone. viagra 50 mg

We have undertaken a study to confirm that ipratro­pium is an effective bronchodilator in acute asthma, and to examine whether ipratropium should be given before, with, or after salbutamol for maximal treat­ment benefit in this setting.