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Known COPD on inhalers. Smoker. Needed Bipap x4 previously. Presented to Resus. 2/7 of SOB and cough productive of green sputum.$,-3 Case Study - ExaminationBreathless at rest. Unable to speak in full sentences or perform PEFR. Low grade pyrexia. Tachypnoeic. Poor AE generally and widespread wheeze. No consolidation or pneumothorax on CxR.>Z ?  .Case Study  Management  Three Part QuestionIn patients with [acute exacerbations of COPD], does [combined treatment with Salbutamol and Ipratropium Bromide nebulisers] rather than Salbutamol alone result in a [faster or greater improvement in lung function]?PG*2PM    E#Background (1)5Salbutamol and Ipratropium work in different ways. <3 36  %Background (2) In stable severe COPD studies have shown that combined treatment with Salbutamol and Ipratropium inhalers reduce the frequency of exacerbations. Therefore it is reasonable to expect a greater improvement with combination nebuliser treatment during acute exacerbations. $a>E  | ( Medline SearchKeywords: Salbutamol, Ipratropium Bromide, albuterol, anticholinergics, sympathomimetics, COPD, COAD, nebulisers. Limited to human, English, 1980-2000. 4 relevant randomised double-blind trials found. Patients group similar ie COPD patients not on home nebulisers or home O2. 6     p Rebuck at al. Nebulised anticolinergic and sympathomimetic treatment of Asthma and COAD in the ER. American J Med 1987;82:59-63.6GDouble-blind study. Subgroup of 51 patients with COPD. Randomised to receive nebulised Fenoterol 1.25mg or Ipratropium 500 mcg or both. All regimes produced significant bronchodilation but there was no difference between them. >M 2+Rebuck at al. Nebulised anticolinergic and sympathomimetic treatment of Asthma and COAD in the ER. American J Med 1987;82:59-63.6GO Driscoll et al. Nebulised Salbutamol with and without Ipratropium bromide in acute airflow obstruction. Lancet 1989;i:1418-20.6  >Double-blind study. Subgroup of 47 patients with COPD. Randomised to receive nebulised Salbutamol 10mg +/- Ipratropium Bromide 500mcg. >M    Koutsogiannis Z et al. Does high dose Ipratropium Bromide added to Salbutamol improve pulmonary function for patients with COAD in the emergency department? Aust NZ J Med 2000; 30:38-40.H  OzDouble-blind study. 50 patients with COPD. Randomised to receive nebulised Salbutamol 5mg or Ipratropium 500 mcg or both. ,A   Moayyedi P et al. Comparison of nebulised Salbutamol and ipratropium bromide with Salbutamol alone in the treatment of COPD. Thorax 1995; 50: 384-387.H   :Double-blind study. 70 patients with COPD. Randomised to receive nebulised Salbutamol 5mg +/- Ipratropium 500 mcg or both. No significance difference in symptom relief, FEV1 or length of stay.,A W! Moayyedi P et al. Comparison of nebulised Salbutamol and ipratropium bromide with Salbutamol alone in the treatment of COPD. Thorax 1995; 50: 384-387.H  ;$ CostsAlthough the cost of an individual Atrovent nebule is not great, patients are often continued on both Salbutamol and Atrovent nebulisers on the ward if it is started in A&E. The extra cost to the hospital per patient per 11.8 day stay would be 18. .ZZ>#3 x& Conclusions6The routine addition of Atrovent to Salbutamol has not been proven to be beneficial or cost-effective in the treament of acute exacerbation of COPD. However it should still however be used empirically as a second-line treatment before Aminophylline in patients who are not responding to Salbutamol nebulisers. b  > u&=  ` f3f3` ff̙` ___` ff` 3ff3f>?" dd@,?lPd@   Z l<@ d`"  n?" dd@   @@``@n?" dd@  @@``PR    @ ` ` p>> =5 (  VF y  y"Z  S B7 C DEHFPv @?q 6 6 n(dx  G b q %(@B y"2   `G1?"  T<gֳgֳ ?P < T Click to edit Master title style! !"  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