The use of nebulized ipratropium in combination with beta agonists in the management of acute asthma in adults is controversial. The National Asthma Education Program Expert Panel's most recent guidelines, published in April 1997 by the National Institutes of Health, suggest only that anticholinergics may be considered in acute asthma management. Lin and associates conducted a double-blind, placebo-controlled study to evaluate the use of nebulized ipratropium bromide and albuterol compared with albuterol alone in the treatment of acute asthma in adults.

Fifty-five patients were included in the study. All patients were 18 years or older and had presented to the emergency department because of acute bronchospasm resulting from asthma. All of them had a peak expiratory flow rate (PEFR) of less than 200 L per minute. Patients were randomly assigned to receive either albuterol alone or albuterol plus ipratropium. Vital signs and symptomatic complaints were monitored during treatment. The treating physician was allowed to administer 125 mg of parenteral methylprednisolone if the patient's response to treatment was inadequate.

PEFR values were significantly higher in patients receiving ipratropium and albuterol. At 60 minutes, the median PEFR in patients who received combination therapy was 285 L per minute, compared with 240 L per minute in patients who received albuterol alone. In addition, the proportion of patients requiring hospital admission was significantly higher among the albuterol-only group. Ten of the 28 patients (36 percent) in the albuterol-only group required admission, compared with three of the 27 patients (11 percent) in the combination therapy group. Thirty-two percent of patients in the albuterol-only group required parenteral steroids compared with only 15 percent of patients receiving combination therapy. Patients in the two groups did not differ with respect to heart rate acceleration, tremor, agitation or accessory muscle use.

The authors conclude that initial treatment with ipratropium bromide and albuterol results in more bronchodilation than treatment with albuterol alone in adult patients with acute asthma.