title: Combined inhaled anticholinergic agents and beta-2-agonists for initial treatment of acute asthma in children.
abstract: BACKGROUND
  Anti-cholinergic agents and beta2-agonist drugs are both bronchodilators used to reverse acute bronchospasm in children with asthma. These drugs have different modes of action, so may have complementary or additive effects.
  
  
  OBJECTIVE
  The objective of this review was to assess the effects of adding inhaled anti-cholinergics to beta2-agonists in acute paediatric asthma.
  
  
  METHODS
  We searched Medline (1966 to 1996), Embase (1980 to 1995), Cinahl (1982 to 1995) and reference lists of studies. We also contacted drug manufacturers and researchers.
  
  
  METHODS
  Randomised trials comparing the combination of inhaled anti-cholinergics and beta2-agonists with beta2-agonists alone in children aged 18 months to 17 years with acute asthma.
  
  
  METHODS
  Assessments of trial quality and data extraction were done by two reviewers independently.
  
  
  RESULTS
  Ten trials involving a total of 836 children were included. Most trials were of high quality. When only one dose of anti-cholinergic inhalation was added to beta2-agonist therapy, there was an improvement in forced expiratory volume in one second after 60 minutes with combination therapy (weighted mean difference 16.1%, 95% confidence interval 5.5 to 26. 7% reduction). There was no reduction in hospital admission (odds ratio 0.80, 95% confidence interval 0.35 to 1.82, using a random effects model). For multiple doses in children with severe asthma, there was a reduction in forced expiratory volume in 1 second (weighted mean difference 9.8% predicted, 95% confidence interval 6. 5 to 13.1% predicted). There may also be a reduction in hospital admission (odds ratio 0.62, 95% confidence interval 0.38 to 0.99). Eleven children would need to be given multiple doses of anti-cholinergics in combination with beta2-agonists to avoid one hospital admission compared to children given beta2-agonists alone.
  
  
  CONCLUSIONS
  In children with acute asthma, the addition of multiple doses of anti-cholinergics to inhaled beta2-agonists appears to improve lung function modestly and may decrease hospital admission. There is no associated increase in adverse effects. Single doses of anti-cholinergics may improve lung function in children with severe asthma, but do not appear to reduce hospital admissions.
authors.affiliation: The Montreal Childrens' Hospital, Room C538E, 2300 Tupper Street, Montreal, Quebec, Canada, H3H 1P3. drlaurie@total.net
authors.forename: L H
authors.initials: LH
authors.lastname: Plotnick
authors.forename: F M
authors.initials: FM
authors.lastname: Ducharme
mesh_terms: D000280:Administration, Inhalation; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D018680:Cholinergic Antagonists / Q000008:administration & dosage / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006801:Humans
chemical_list: D000318:Adrenergic beta-Agonists; D018680:Cholinergic Antagonists