51 nary ammonium derivative of atropine that is poorly absorbed from mucosal surfaces. Laboratory pulmonary func- tion tests demonstrate enhanced bron- chodilation from β-agonists when given in combination with IB. 1 Evi- dence from clinical trials, however, does not uniformly support the routine addition of inhaled anticholinergic therapy to β-agonists for the manage- ment of acute asthma. 2-5 In the emer- gency department setting, some ran- domized placebo-controlled trials demonstrate modest benefits from combined IB-β agonist therapy for at least a subset of patients. 6,7 Although anticholinergic agents are often used in the hospital treatment of patients with status asthmaticus, their efficacy in this setting remains uncertain. We con- ducted a randomized, double-blind, placebo-controlled trial to examine the effect on hospital length of stay, asth- ma carepath progression, requirement for additional therapy, and side effects resulting from the addition of repeated doses of nebulized IB with standard- ized β-agonist and systemic cortico- steroid therapy for hospitalized children with acute asthma. METHODS Study Population Rainbow Babies and Childrens Hos- pital is a university-affiliated tertiary Although repeated doses of inhaled β-agonists and early administration of systemic corticosteroids are effective treatment for status asthmaticus, re- Ipratropium bromide plus nebulized albuterol for the treatment of hospitalized children with acute asthma Daniel Craven, MD, Carolyn M. Kercsmar, MD, Timothy R. Myers, BS, RRT, Mary Ann O’Riordan, PhD, Gregory Golonka, MD, and Scott Moore, MD finements continue to occur regarding the optimal combination, delivery, and dose of therapies for acute severe asth- ma. Ipratropium bromide is a quater- From the Divisions of Pediatric Pulmonology, Pediatric Respiratory Therapy, General Academic Pediatrics and Clinical Epidemiology, Department of Pediatrics, University Hospitals of Cleveland, Rainbow Babies and Childrens Hospital, Case Western Reserve University, Cleveland, Ohio. Submitted for publication Jan 19, 2000; revision received June 1, 2000; accepted July 12, 2000. Reprint requests: Daniel Craven, MD, Division of Pediatric Pulmonology, Rainbow Babies and Childrens Hospital, 11100 Euclid Ave, Cleveland, OH 44106. Copyright © 2001 by Mosby, Inc. 0022-3476/2001/$35.00 + 0 9/21/110120 doi:10.1067/mpd.2001.110120 ACA Asthma care algorithm ACA-P Asthma carepath progression ED Emergency department FEV 1 Forced expiratory volume in 1 second IB Ipratropium bromide LOS Hospital length of stay Objective: To determine whether the addition of repeated doses of nebu- lized ipratropium bromide (IB) to a standardized inpatient asthma care algo- rithm (ACA) for children with status asthmaticus improves clinical outcome. Study design: Children with acute asthma (N = 210) age 1 to 18 years admit- ted to the ACA were assigned to the intervention or placebo group in random- ized double-blind fashion. Both groups received nebulized albuterol, systemic corticosteroids, and oxygen according to the ACA. The intervention group re- ceived 250 μg IB combined with 2.5 mg albuterol by jet nebulization in a dos- ing schedule determined by the ACA phase. The placebo group received iso- tonic saline solution substituted for IB. Progression through each ACA phase occurred based on assessments of oxygenation, air exchange, wheezing, acces- sory muscle use, and respiratory rate performed at prescribed intervals. Results: No significant differences were observed between treatment groups in hospital length of stay (P = .46), asthma carepath progression (P = .37), requirement for additional therapy, or adverse effects. Children >6 years (N = 70) treated with IB had shorter mean hospital length of stay (P = .03) and more rapid mean asthma carepath progression (P = .02) than children in the placebo group. However, after adjustment was done for baseline group differences, the observed benefit of IB therapy in older chil- dren no longer reached statistical significance. Conclusion: The routine addition of repeated doses of nebulized IB to a standardized regimen of systemic corticosteroids and frequently adminis- tered β-2 agonists confers no significant enhancement of clinical outcome for the treatment of hospitalized children with status asthmaticus. (J Pediatr 2001;138:51-8)