Nebulised ipratropium bromide is not indicated in bronchiolitis.
Date First Published:
March 1, 2000
Last Updated:
May 16, 2001
Report by:
Martin Smith, Specialist Registrar (Manchester Royal Infirmary)
Search checked by:
Mohammed Al Zarad, Manchester Royal Infirmary
Three-Part Question:
In [infants with acute bronchiolitis] does [treatment with nebulised ipratropium bromide] reduce [the clinical severity or the length of stay]?
Clinical Scenario:
A 6 month old baby with 3 day history of coryzal symptoms, increasing cough and wheeze presents to the emergency department. Your clinical diagnosis is bronchiolitis. You wonder whether the addition of nebulised ipratropium will improve the clinical condition.
Search Strategy:
Medline 1966-07/99 using the OVID interface.
Search Details:
({exp bronchiolitis OR exp bronchiolitis, viral OR exp respiratory syncitial virus infections OR exp respiratory syncitial virus, human OR RSV.mp OR bronchiolitis.mp} AND {atrovent.mp OR exp ipratropium OR ipratropium.mp}) LIMIT to human AND english.
Outcome:
13 papers found of which 8 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 |
|---|---|---|---|---|---|
| Ineffectiveness of ipratropium bromide in acute bronchiolitis. Henry RL, Milner AD, Stokes GM. 1983 UK. | 66 infants (7-52 wks). Ipratropium vs saline. |
PRCT | Clinical severity score | No significant improvement | Randomisation and blinding not explained. No basic data or results presented. |
| Parental/nurse subjective assessment | No significant difference | ||||
| Bronchodilators for treatment of mild bronchiolitis: a factorial randomised trial. Wang EE, Milner R, Allen U, Maj H. 1992 Canada. | 62 children (2 months to 2 years). Salbutamol or placebo vs ipratropium or placebo. |
PRCT | Pulse oximetry | No significant change | Possible selection bias as all patients received emergency room treatment. Infrequent observations. |
| Clinical severity score | No significant change | ||||
| Hospitalisation | No significant difference | ||||
| Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis. Schuh S, Johnson D, Canny G, et al. 1992 Canada. | 69 children (6 weeks to 2 years). Albuterol and saline vs albuterol and ipratropium. |
PRCT | Respiratory rate | No significant difference | |
| Accessory muscle score | No significant difference | ||||
| Wheeze score | No significant difference | ||||
| Oxygen saturation | No significant difference | ||||
| Hospitalization rate | 17 vs 10 | ||||
| The role of bronchodilators in the management of bronchiolitis: a clinical trial. Chowdhury D, al Howasi M, Khalil M, al-Frayh AS, Chowdhury S, Ramia S. 1994 Saudi Arabia. | 89 children (6 wks-24 mon). Ipratropium alone vs salbutamol alone vs ipratropium and salbutamol vs saline. |
PRCT | Clinical severity score | No significant difference in all groups | Small groups with no blinding. Not all patients included. |
| Admission days | No significant difference in all groups | ||||
| Efficacy of bronchodilators in the treatment of bronchiolitis. Goh A, Chay OM, Foo AL, Ong EK. 1997 Singapore. | 89 children. Neb salbutamol vs neb ipratropium vs neb saline vs humidified oxygen. |
PRCT | Clinical severity score | No significant difference | Small numbers with possible type 2 error. Second control group added later. |
| Length of stay | No significant difference |
Author Commentary:
All the trials found have faults, however not one showed a benefit from nebulised ipratropium in this condition.
Bottom Line:
Nebulised ipratropium bromide is not indicated in bronchiolitis.
References:
- Henry RL, Milner AD, Stokes GM.. Ineffectiveness of ipratropium bromide in acute bronchiolitis.
- Wang EE, Milner R, Allen U, Maj H.. Bronchodilators for treatment of mild bronchiolitis: a factorial randomised trial.
- Schuh S, Johnson D, Canny G, et al.. Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis.
- Chowdhury D, al Howasi M, Khalil M, al-Frayh AS, Chowdhury S, Ramia S.. The role of bronchodilators in the management of bronchiolitis: a clinical trial.
- Goh A, Chay OM, Foo AL, Ong EK.. Efficacy of bronchodilators in the treatment of bronchiolitis.