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Question 5:

In the child with an asthma exacerbation in the ED, should albuterol with ipratropium vs. albuterol alone be used to prevent hospitalization, to decrease time in the ED, and/or to improve pulmonary function?

Asthma ED team recommendation:
 The Asthma ED Team strongly recommends the use of ipratropium for the treatment of severe asthma exacerbations in the ED. This recommendation is included in the EPR-3 (2007) recommendations and is further supported by a well performed randomized controlled trial (Chakraborti, 2006). The recommendation can apply to most patients in most instances. We value timely improvement in pulmonary function and decreased hospitalization rates that have been shown to occur when ipratropium is used in this scenario.

Literature supporting this recommendation:  Literature was searched since the publication of EPR-3. Six citations were found from the search with four citations appearing to answer the question; however, only one article, Chakraborti (2006), answered the question.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.