Question 1: For pediatric asthma, does albuterol and ipratropium (combined) show benefit over albuterol alone?
Depending on where you practice, inhaled short-acting beta-agonists (SABAs) such as albuterol/salbutamol combined with an anticholinergic such as ipratropium go by numerous names (Duoneb, Combivent, A&A, Breva, Duolin, etc). They come in both nebulized and meter-dosed inhaler (MDI) formulations. In kids with asthma exacerbations, practitioners may or may not supplement SABAs with anticholinergic medication (eg, ipratropium bromide). Does something this simple potentially make a difference?
A 2013 Cochrane systematic review and meta-analysis by Griffiths and Ducharme explored, in particular, whether the addition of anticholinergics to SABAs—when compared to SABAs alone—reduced hospital admissions when treating initial asthma exacerbations.1 This meta-analysis included 19 studies (N = 2,497 total patients), and ipratropium bromide was the anticholinergic of choice in 18 of these 19 randomized studies. Sixteen of the 19 studies involved multiple doses (predominantly two or three doses), and the patients’ ages ranged from 18 months to 18 years. In regard to the primary outcome of hospital admission, the risk ratio of SABA/anticholinergic to SABA alone was 0.73 (95% CI, 0.63–0.85), suggesting that the addition of an anticholinergic (eg, ipratropium) to SABA (eg, albuterol) decreases hospital admissions. The number needed to treat (NNT) for beneficial effect was 16, and most children treated demonstrated moderate to severe asthma exacerbations at presentation. A previous systematic review by Rowe et al had found similar results regarding hospital admissions.2