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Is intravenous aminophylline better than intravenous salbutamol in the treatment of moderate to severe asthma?
  1. Andrew Munro, Registrar,
  2. Michelle Jacobs, Specialist Registrar
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jonesman.ac.uk

    Abstract

    A short cut review was carried out to establish whether intravenous salbutamol or intravenous aminophylline offers the quickest and least complicated treatment for patients with moderate to severe asthma not responding to inhaled therapy. Altogether 71 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Andrew Munro, RegistrarChecked by Michelle Jacobs, Specialist Registrar

    Clinical scenario

    A 20 year old man is brought to the emergency department in acute respiratory distress with asthma. He has a history of poor compliance with unstable asthma and several hospital admissions in the past. His old notes are available and you notice whenever intravenous treatment has been started he has been given aminophylline. You feel that the best drug is a β2 agonist and that if it is not getting to the receptors via the airways then intravenous is the next best route. There is some dismay among the nursing staff when you formulate an intravenous regimen. They say they have never given it before. You wonder whether your approach is evidence based.

    Three part question

    In [patients with moderate to severe asthma resistant to inhaled β2 agonists] does [IV aminophylline or IV salbutamol] result in [quicker relief with less side effects]?

    Search strategy

    Medline 1966-10/03 using the OVID interface. [(exp albuterol/OR salbutamol.mp) AND intravenous.mp] AND [exp asthma/OR exp bronchial spasm/OR exp bronchoconstriction/OR bronchoconstriction.mp] AND [exp aminophylline/OR aminophylline.mp OR exp theophylline/OR theophylline.mp] LIMIT to human AND English.

    Search outcome

    Altogether 71 papers found of which 62 were considered irrelevant or of insufficient quality for inclusion. The remaining nine papers are shown in table 5.

    Table 5

    Comment(s)

    Multiple small trials of reasonable quality show intravenous salbutamol to be as good if not better at reversing obstructive airflow in asthmatic patients. Those studies that were equivocal used drug regimens that could be considered sub-therapeutic or confounded. Side effects, although present seem to be well tolerated. Recent or high powered trials comparing the two drugs do not exist.

    CLINICAL BOTTOM LINE

    Intravenous salbutamol should be considered a first line agent in the acute management of severe asthma in adults.

    Report by Andrew Munro, RegistrarChecked by Michelle Jacobs, Specialist Registrar

    References

    View Abstract

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