Multiple different bronchodilators unnecessary in acute COPD
Date First Published:
December 8, 2000
Last Updated:
July 12, 2001
Report by:
Magnus Harrison, Clinical Research Fellow (MRI)
Search checked by:
Ross Murphy, MRI
Three-Part Question:
In [patients presenting with an acute exacerbation of COPD] is nebulisation of [a beta 2 agonist alone, ipratropium bromide alone or a combination of the two] more effective at [controlling and improving symptoms]?
Clinical Scenario:
A 59 year old man presents with an exacerbation of COPD. You wonder whether it is better to nebulise salbutamol or ipratropium bromide alone, or a combination of the two.
Search Strategy:
Medline 1966-11/00 using the OVID interface.
Search Details:
{{[(exp chronic disease OR exp hospitals, chronic disease OR chronic.mp) AND (exp lung disease, obstructive OR obstructive.mp)] OR exp emphysema OR exp pulmonary emphysema OR emphysema.mp OR exp bronchitis OR bronchitis.mp OR exp COPD.mp OR COAD.mp OR airway obstruction.mp)} AND (acute.mp or exacerbation.mp)} AND (exp ipratropium OR ipratropium bromide.mp OR atrovent.mp OR antimuscarinic.mp OR exp. muscarinic antagonist OR exp brochodilators agents OR bronchodilators.mp OR exp albuterol OR salbutamol.mp OR beta 2 agonist.mp OR exp terbutaline) AND (exp nebulisers OR vaporises.mp OR exp respiratory therapy OR nebulisers.mp) NOT (exp child OR children.mp OR exp paediatrics OR paediatric.mp) LIMIT to human AND english.
Outcome:
162 papers found of which 157 were irrelevant or of insufficient quality. The remaining 5 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room. Rebuck AS, Chapman KR, Abboud R et al. 1987, Canada | 51 patients with an acute exacerbation of COPD (148 asthmatics also recruited) Ipratropium vs fenoterol vs both (all nebulised). |
PRCT | FVC, FEV1, MMEFR, PEFR, cardiovascular markers at 45 min | No significant difference | No sample size calculation. Small groups in each of the treatment arms, thus small differences may go undetected. |
| FVC, FEV1, MMEFR, PEFR, cardiovascular markers at 90 min | No significant difference | ||||
| Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction. O'Driscoll BR, Taylor RJ, Horsley MG et al. 1989, UK | 47 patients with COPD (an asthmatic group also recruited) Salbutamol vs salbutamol plus ipratropium bromide |
PRCT | PEFR on arrival and at one hour | No difference in improvement (P>0.55) | No sample size calculation, small groups in each treatment arm, thus important effects can be overlooked. No defined inclusion or exclusion criteria. 20 patients admitted, excluded from study. No actual figures given. |
| Decreased duration of emergency department treatment of chronic obstructive pulmonary disease exacerbations with the addition of ipratropium bromide to beta-agonist therapy. Shrestha M, O'Brien T, Haddox R et al 1991, USA | 55 COPD patients with an acute exacerbation (FEV1 <40% of predicted) Isoetharine plus placebo vs isoetharine plus ipratropium bromide (inhaled) |
PRCT | Times to discharge from ED. | Time to discharge 91 minutes less in the salbutamol plus ipratropium group (P<0.05) | No sample size calculation. Small numbers. Inhaled therapy |
| FVC, FEV1 | No difference | ||||
| Comparison of nebulised salbutamol and ipratropium bromide with salbutamol alone in the treatment of chronic obstructive pulmonary disease Moayyedi P, Congleton J, Page RL et al. 1995, UK | 62 COPD patients with an acute exacerbation Salbutamol vs salbutamol plus ipratropium bromide (nebulised) |
PRCT | Length of hospital stay | No significant difference | Power study retrospectively completed. |
| Duration of nebuliser therapy | No significant difference | ||||
| FVC, FEV1 | No significant difference | ||||
| Subjective improvement on days 1, 3, 7 and 14. | No significant difference | ||||
| Does high dose ipratropium bromide added to salbutamol improve pulmonary function for patients with chronic obstructive airways disease in the emergency department? Koutsogiannis Z, Kelly AM. 2000, Australia | ?patients presenting to ED with an acute exacerbation of COPD. All patients started with salbutamol and ipratropium nebulisers and then salbutamol vs ipratropium vs salbutamol plus ipratropium. |
PRCT | Absolute and percentage change in FEV1 at 90 min | No difference between the 2 groups. P=0.36 for absolute change, P=0.56 for % change) | No patient numbers given. No sample size calculation. Groups are small thus any differences may be overlooked. All patients had both drugs initially. |
Author Commentary:
There are 5 randomised trials that address the three-part question. All of the studies are of reasonable quality.
Bottom Line:
Initial therapy can be either salbutamol or ipratropium nebulisers alone. There is no evidence to suggest that using both has additional benefit.
References:
- Rebuck AS, Chapman KR, Abboud R et al.. Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room.
- O'Driscoll BR, Taylor RJ, Horsley MG et al.. Nebulised salbutamol with and without ipratropium bromide in acute airflow obstruction.
- Shrestha M, O'Brien T, Haddox R et al. Decreased duration of emergency department treatment of chronic obstructive pulmonary disease exacerbations with the addition of ipratropium bromide to beta-agonist therapy.
- Moayyedi P, Congleton J, Page RL et al.. Comparison of nebulised salbutamol and ipratropium bromide with salbutamol alone in the treatment of chronic obstructive pulmonary disease
- Koutsogiannis Z, Kelly AM.. Does high dose ipratropium bromide added to salbutamol improve pulmonary function for patients with chronic obstructive airways disease in the emergency department?