Objectives To estimate the therapeutic and adverse effects of addition of inhaled anticholinergics to 2 agonists in acute asthma in children and adolescents. Design Systematic review of randomised controlled trials of children and adolescents taking 2 agonists for acute asthma with or without the addition of inhaled anticholinergics. Main outcome measures Hospital admission, pulmonary function tests, number of nebulised treatments, relapse, and adverse effects. Results Of 37 identified trials, 10 were relevant and six of these were of high quality. The addition of a single dose of anticholinergic to 2 agonist did not reduce hospital admission (relative risk 0.93, 95% confidence interval 0.65 to 1.32). However, significant group differences in lung function supporting the combination treatment were observed 60 minutes (standardised mean difference − 0.57, − 0.93 to − 0.21) and 120 minutes ( − 0.53, − 0.90 to − 0.17) after the dose of anticholinergic. In contrast, the addition of multiple doses of anticholinergics to 2 agonists, mainly in children and adolescents with severe exacerbations, reduced the risk of hospital admission by 30% (relative risk 0.72, 0.53 to 0.99). Eleven (95% confidence interval 5 to 250) children would need to be treated to avoid one admission. A parallel improvement in lung function (standardised mean difference − 0.66, − 0.95 to − 0.37) was noted 60 minutes after the last combined inhalation.
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