The Role of Ipratropium Bromide in the Emergency Management of Acute Asthma Exacerbation: A Metaanalysis of Randomized Clinical Trials

Stoodley, R.Gordon; Aaron, Shawn D.; Dales, Robert

doi:10.1016/s0196-0644(99)70266-0

Cited by 133 publications

(75 citation statements)

References 49 publications

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“…The present results suggest that the effects of b-agonist tolerance in such patients may be accentuated and result in resistance to acutely administered b-agonist therapy. Indirect evidence to support this has been obtained from studies that describe the benefit of combined salbutamol/ipratropium compared to salbutamol alone in acute asthma [18][19][20]. These investigations showed that the increase in FEV1 with combination therapy was most marked in patients with the most severe asthma at presentation.…”

Section: Discussionmentioning

confidence: 99%

Bronchodilator tolerance: the impact of increasing bronchoconstriction

Wraight

Hancox²,

Herbison³

et al. 2003

Eur Respir J

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Chronic exposure to b-agonists causes tolerance to their bronchodilator effects, which is best demonstrated during acute bronchoconstriction. The aim of the present study was to assess whether tolerance becomes more evident with increasing bronchoconstriction, as might occur in acute asthma.In a randomised, double-blind, placebo-controlled, crossover study comprising 15 patients, the treatments were salbutamol 400 mg q.i.d. or placebo given via Diskhaler1 for 28 days with a 2-week washout between treatments. Patients attended on days 14, 21 and 28. Bronchoconstriction was induced on two of these three occasions to achieve a reduction in the forced expiratory volume in one second (FEV1) of 0 (no methacholine), 15 and 30% (using methacholine) in a randomised order. Immediately after this, salbutamol 100 mg, 100 mg and 200 mg was inhaled at 0, 5, and 10 min. FEV1 was measured over 40 min. Dose/response curves were plotted and values for the area under the curve (AUC)0-40 FEV1 were compared between treatments and by degree of bronchoconstriction.Regular salbutamol resulted in attenuation of the acute response to b-agonist, which was increasingly evident with greater bronchoconstriction. With a reduction in FEV1 of 0, 15 and 30%, the AUC0-40 FEV1 with salbutamol were 11.2, -14.6 and -35.7% respectively, compared to placebo. There was a linear relationship between the magnitude of bronchoconstriction and the between-treatment differences in AUC0-40 FEV1.Increasing bronchoconstriction conferred greater susceptibility to the effects of bronchodilator tolerance. b-agonists are widely prescribed for symptomatic relief in asthma. They are very effective as bronchodilators and as functional antagonists against a wide range of constricting stimuli. However, chronic exposure of b-adrenoceptors (b-AR) to b-agonist drugs leads to reduced responsiveness (desensitisation) and a decrease in the number of receptors (downregulation) [1].In the clinical setting, tolerance to the nonbronchodilator effects of b-agonists is readily demonstrated [2,3]. However, it has been more difficult to demonstrate tolerance to their bronchodilator effects. Reduced bronchodilator response after regular short-and long-acting b-agonists has been reported [4][5][6][7] but the findings have been inconsistent [8][9][10][11]. A possible explanation for these negative results is that bronchodilator responses were measured in patients with stable asthma in whom the margin from baseline to maximum bronchodilatation was not sufficient for the effects of tolerance to be detected.Recently, HANCOX et al. [12] have described a method that reliably demonstrates bronchodilator tolerance to b-agonists. In that study, a 36% reduction in the area under the curve (AUC) for forced expiratory volume (FEV1) was observed in patients who had been using regular inhaled b-agonist compared to placebo. Subsequently, other authors have used the same methodology to show similar effects in patients using long-acting b-agonists [13,14]. In both of these studies, measuring...

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Section: Discussionmentioning

confidence: 99%

Bronchodilator tolerance: the impact of increasing bronchoconstriction

Wraight

Hancox²,

Herbison³

et al. 2003

Eur Respir J

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“…When considering Budesonide low dose is up to 400mcg, medium dose is up 800mcg while high dose is 800mcg and above. 32 HCWs should familiarize with these doses because different asthma severity grades require different ICS dose even of the same inhaler.…”

Section: 423mentioning

confidence: 99%

“…Ipratropium may be added to the nebulization chamber along with salbutamol because this has been found to lead to better improvement than salbutamol nebulization alone. 2,32,42 An alternative for facilities where nebulization cannot be done is use of intravenous theophylline and frequent SABA inhaler use. It must be noted that use aminophylline is not currently recommended because of lack additional benefit after administration of inhaled beta agonist and due to increased side effects.…”

mentioning

confidence: 99%

Guidance on the diagnosis and management of asthma among adults in resource limited settings

Kirenga¹,

Schwartz²,

Jong³

et al. 2016

Afr H. Sci.

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Background: Optimal management of asthma in resource limited settings is hindered by lack of resources, making it difficult for health providers to adhere to international guidelines. The purpose of this review is to identify steps for asthma diagnosis and management in resource limited settings. Methods: Review of international asthma guidelines and other published studies on diagnosis and management of asthma. Results: We establish that clinical diagnosis of asthma can be made if recurrent respiratory symptoms especially current wheeze or wheeze in the last 12 months are present. Presence of a trigger, other allergic diseases, personal or family history of asthma; clinical improvement and increase in the peak flow and forced expiratory volume in one second of ≥12% after salbutamol administration increases the likelihood of asthma. At diagnosis severity grading, patient education, removal or reduction of trigger should be done. Follow up 2-6 weeks and assessment of control during therapy is essential. Therapy should be adjusted up or down depending on control levels. Patients should be instructed to increase the frequency of their bronchodilators and/or steroids therapy when they start to experience worsening symptoms. Conclusion: Good quality asthma care can be achieved in resource limited settings by use of clinical data and simple tests.

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“…• Na crise grave, a primeira escolha deve ser a associação dos anticolinérgicos aos β 2 -agonistas (57)(58)(59)(60) .…”

Section: Tratamento Medicamentosounclassified

Capítulo III - tratamento

2002

J. Pneumologia

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The Role of Ipratropium Bromide in the Emergency Management of Acute Asthma Exacerbation: A Metaanalysis of Randomized Clinical Trials

Cited by 133 publications

References 49 publications

Bronchodilator tolerance: the impact of increasing bronchoconstriction

Bronchodilator tolerance: the impact of increasing bronchoconstriction

Guidance on the diagnosis and management of asthma among adults in resource limited settings

Capítulo III - tratamento

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