Should inhaled anticholinergics be added to beta 2 agonists for treating acute childhood and adolescent asthma? A systematic review

Abstract

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.

Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit

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Comparação entre o tratamento farmacológico aplicado em crianças de zero a cinco anos atendidas em uma unidade de emergência e as diretrizes do III Consenso Brasileiro no Manejo da Asma

“…However, a quite different perspective was provided by a systematic review published in the same year. (23) The authors of that review evaluated four studies involving children or adolescents and did not identify any benefit of the use of ipratropium bromide in the treatment of mild or moderate asthma attacks. It is important to highlight that, in Brazil, ipratropium bromide is approximately ten times more expensive than fenoterol.…”

Regulación del tono bronquial en la enfermedad pulmonar obstructiva crónica (EPOC): papel de los receptores muscarínicos

“…Por este motivo, los β-agonistas son más eficaces en el asma, ya que inhiben por igual la constricción de las vías aére-as grandes y pequeñas, a diferencia de los fármacos antimuscarí-nicos que actúan principalmente sobre la constricción de las vías aéreas grandes. No obstante, los anticolinérgicos pueden proporcionar un beneficio adicional asociados a los β 2 -adrenérgicos, especialmente en el tratamiento del asma aguda tanto en niños y adolescentes como en adultos, ya que mejoran la función pulmonar y reducen la necesidad de ingreso hospitalario (20,21). Por el contrario, la EPOC se caracteriza por la destrucción de las paredes de las vías aéreas, lo que produce obstrucción irreversible, y, en este caso, la relajación del tono vagal puede todavía producir una mejoría del calibre de las vías aéreas (2).…”