Variations in peak nasal inspiratory flow among healthy students after using saline solutions / Variações do pico de fluxo inspiratório nasal entre escolares sadios após o uso de soluções salinas

ABSTRACT INTRODUCTION: Nasal hygiene with saline solutions has been shown to relieve congestion, reduce the thickening of the mucus and keep nasal cavity clean and moist. OBJECTIVE: Evaluating whether saline solutions improve nasal inspiratory flow among healthy children. METHODS: Students between 8 and 11 years of age underwent 6 procedures with saline solutions at different concentrations. The peak nasal inspiratory flow was measured before and 30 min after each procedure. Statistical analysis was performed by means of t test, analysis of variance, and Tukey's test, considering p < 0.05. RESULTS: We evaluated 124 children at all stages. There were differences on the way a same concentration was used. There was no difference between 0.9% saline solution and 3% saline solution by using a syringe. CONCLUSION: The 3% saline solution had higher averages of peak nasal inspiratory flow, but it was not significantly higher than the 0.9% saline solution. It is important to offer various options to patients.

RESUMO INTRODUÇÃO: A higiene nasal com soluções salinas tem sido indicada para aliviar a congestão, reduzir o espessamento do muco e manter a cavidade nasal limpa e úmida. OBJETIVO: Avaliar se as soluções salinas melhoram o fluxo inspiratório nasal entre crianças sadias. MÉTODO: Escolares com idades entre 8 e 11 anos foram submetidos a 6 procedimentos com soluções salinas em diferentes concentrações. O pico de fluxo inspiratório nasal foi medido antes e 30 minutos após cada procedimento. A análise estatística foi realizada por meio do teste t, análise de variância e teste de Tukey, considerando p < 0,05. RESULTADOS: Foram avaliadas 124 crianças em todas as etapas. Houve diferenças quanto à forma de uso de uma mesma concentração. Não houve diferença entre solução salina a 0,9% e solução salina a 3% por meio de seringa. CONCLUSÕES: A solução salina a 3% obteve maiores médias do pico de fluxo inspiratório nasal, porém não foi significativamente superior à solução salina a 0,9%. É importante oferecer diferentes opções aos pacientes.

Nebulized magnesium sulphate versus nebulized sallbutomol in acute bronchial asthma

The aim of this study is to investigate the efficacy of nebulized magnesium sulphate as a bronchodilator in acute asthma as compared to nebulized salbutamol. This was a randomized controlled study conducted in El-Giza Chest Hospital Emergency Department between January 2010 and June 2011. Randomization was achieved by closed envelope technique. This study involved 48 known bronchial asthma patients presenting with acute or subacute exacerbations. Patients were divided into Control group [A] and Study group [B]. Initial assessment of all patients included history, clinical examination [auscultation, respiratory rate [RR], heart rate [HR] and working of accessory muscles]. In addition to measurement of peak expiratory flow rate [PEFR] and oxygen saturation [SO2]. Patients received standard treatment for their acute attacks in the form of Sodium hydrocortisone hemisuccinate 100 mg every 6 hours, Supplemental oxygen and nebulized bronchodilator which was salbutamol in group [A] in the form of 4 doses of nebulized solution 0.5 gm% [each dose 1 ml containing 5 mg salbutamol] twenty minutes apart and Magnesium sulphate in group [B] in the form of 4 doses of nebulized solution 10 gm% [each dose 1 ml containing 100 mg magnesium sulphate] twenty minutes apart. Reassessment of the patients was performed after 2 hours to detect improvement. The percent change in PEFR in Group A was significantly higher than that in Group B [58.90% and 13.92% respectively, p value 0.00]. There was a statistically significant reduction in the final mean HR in Group B compared to Group A [85 bpm and 96.1 bpm respectively, p value 0.011]. There was a significant reduction in mean final RR in Group A compared to Group B [22.17 bpm. and 25 bpm respectively, p value 0.002].There was a significant increase in oxygen saturation [SO2] in both groups. The use of MgSO4 by nebulization in patients with acute asthma attacks results in improvement of clinical condition, increase in peak expiratory flow rate [PEFR], reduction in heart rate [HR], reduction in respiratory rate [RR] and improvement in oxygen saturation [SO2]. The increase in PEFR [bronchodilatory effect] was significantly less than that achieved in patients receiving the usual treatment with Short acting beta 2 agonists, e.g. salbutamol, when either agents were used alone

Sevoflurane causes less arrhythmias than desflurane after off-pump coronary artery bypass grafting: A pilot study.

Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher's exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery.

Acute severe asthma; salbutamol plus ipratropium bromide nebulization versus salbutamol nebulization alone

To compare the improvement in peak expiratory flow rate [PEFR] of patients presenting to the emergency department with acute severe asthma by using the following two regimens of broncho-dilator therapy. a] Salbutamol nebulization. b] Salbutamol plus Ipratropium bromide nebulization. c] To compare the hospital admission rates in the above mentioned two treatment groups. A comparative study. Military Hospital Rawalpindi, Feb 2002 to Dec 2002. Sixty adult asthmatic patients with peak expiratory flow rate [PEFR] less than 200 liters per minute were randomly assigned to nebulization treatment with salbutamol [5.0 mg initial dose followed by 2 more doses at 30 and 60 minutes] or the same salbutamol regimen plus ipratropium bromide [0.5 mg]. The primary end point was change in PEFR. The PEFR was measured at 30 minutes, 60 minutes and 90 minutes after the onset of study protocol. The proportion of admission in the two groups was examined as secondary end point. The increase in PEFR over time was significantly greater in combined ipratropium plus salbutamol group [p = 0.01] also the proportion of admitted patients was less in combined salbutamol plus ipratropium bromide group 4/30 vs 11/30, p = 0.036. The data suggested that combined iratropium bromide plus salbutamol nebulization was superior to salbutamol nebulization alone and it should be used in the initial management of patients who present with acute severe asthma

Effects of Personal Exposure to Nitrogen Dioxide on Peak Expiratory Flow in Asthmatic Patients / 예방의학회지

OBJECTIVES: Nitrogen dioxide (NO2) has been inconsistently associated with gradual decreases in lung function. Here, we studied the effects of NO2 exposure in asthmatics by examining the association between changes in lung function and concentrations of NO2 which were personally measured. METHODS: Peak expiratory flow (PEF) and daily personal exposures to NO2 were recorded on 28 patients with asthma (confirmed by methacholine provocation test) over 4 weeks. We used generalized estimating equations to assess the relationship between personal NO2 exposure and PEF, adjusting for potential confounders such as age, gender, outdoor particulate matter, temperature, humidity, and exposure to environmental tobacco smoke. RESULTS: The personal NO2 exposures were higher than the corresponding ambient levels. The mean personal: ambient ratio for NO2 was 1.48. The personal NO2 exposures were not associated with the morning PEF, evening PEF, or the diurnal PEF variability. However, environmental tobacco smoke was negatively associated with both the morning and evening PEF. CONCLUSIONS: Among the asthmatic adults who participated in this study, we found no apparent impact of personal NO2 exposures on the peak expiratory flow.

Effect of household exposure to environmental tobacco smoke on airflow mechanics in asymptomatic healthy women.

BACKGROUND & OBJECTIVES: Exposure to environmental tobacco smoke (ETS) can lead to airflow limitation, similar to that seen in smokers. However, the effects have not been conclusively proven. In the present study an attempt was made to characterize the effect of ETS exposure at home on airflow mechanics in asymptomatic healthy women. METHODS: Fifty women volunteers with no apparent health related problem, exposed to household ETS (group I), and 50 age-matched women not exposed (group II) were studied. Vital capacity (VC), forced expiratory flow in first second (FEV1), FEV1/VC ratio, peak expiratory flow (PEF), maximal midexpiratory flow (FEF(25-75%)), airway resistance (R(aw)) and specific airway conductance (sG(aw)) were measured, and compared between the two groups. Conditional logistic and linear regression analysis were done to assess contribution of household ETS exposure to decreased lung function. RESULTS: FEV1 and PEF values were marginally lower among women in group I (mean difference 0.13 l and 0.20 l/sec respectively). FEF(25-75%), R(aw) and sG(aw) were significantly impaired in this group. Ten (20.0%) women in group I and five (10.0%) in group II had abnormal R(aw) (adjusted odds ratio 6.72, 95% confidence limits 1.15-39.42), while eight (16.0%) women in group I and one (2.0%) in group II had abnormal sG(aw) (adjusted odds ratio 21.08, 95% confidence limits 1.30-341.05). Cumulative life time ETS exposure was, not significantly related to a reduction in FEV1, VC, PEF, FEF(25-75%), R(aw) or sG(aw) after adjustments for potential confounders. INTERPRETATION & CONCLUSION: Exposure to household ETS resulted in subtle impairment of airflow mechanics in asymptomatic women, possibly attributed to small airway narrowing. Further investigations are required to study the progression of this impairment with time.

Efficacy and tolerability of Ketotifen in Nepalese asthmatic children: a clinical study.

OBJECTIVE: To assess the efficacy of Ketotifen in asthmatic children and to record its adverse effects, if any. DESIGN: Prospective clinical trial. SETTING: Pediatric asthma follow up clinic of a teaching hospital. PARTICIPANTS: 23 asthmatic children between 3 and 15 years; 100% completed the trial on full protocol. INTERVENTIONS: Ketotifen 1mg (adjusted according to body weight, 50 mcg/kg/dose) orally twice daily for 9 months. MAIN OUTCOME MEASURES: Primary outcome: Decrease in frequency of asthmatic attacks and severity of exacerbations with improvements in peak expiratory flow rates (PEFR). Other measures included decrease in bronchodilator requirement, steroid doses and parental perception regarding patient quality of life. RESULTS: 34.78% children were symptom free by the end of 2nd 3 months and 65.21% had no further attack by the end of 3rd 3 months of Ketotifen prophylaxis. Those children with activity and sleep 'affected' (8.69%) and 'may be affected' (30.43%) together improved to 'may be affected' group (21.73%) by the end of 2nd 3 months and further reduced to 8.69% by the conclusion of 3rd 3 months. The duration of exacerbations was reduced in the remaining cases. Variability of PEFR decreased from 26.08% to 8.69% of children after the 3rd 3 months of Ketotifen prophylaxis. No significant adverse effect of therapy was observed during the study. CONCLUSION: Oral Ketotifen is effective and well tolerated for use in prophylactic treatment of bronchial asthma in children.

Role of allergy in the therapeutic response of nasal polyps.

The objective of this study was to determine whether the allergy factor affects therapeutic response of nasal polyps. A total of 68 patients were enrolled between 1 October 1999 and 1 January 2002 at the Allergy and Rhinology Clinic, Faculty of Medicine, Songklanagarind Hospital. Allergy skin prick test was performed in order to divide patients into a positive skin test group and a negative skin test group. Their medical history was recorded including age, sex, nasal symptoms, concomitant diseases and medications. Patients in both groups were treated over a 6 week period with Budesonide nasal spray. Nasal symptoms, polyp size, nasal and oral expiratory peak flow were evaluated at each visit. Overall assessment of treatment efficacy was evaluated by patients at 3 and 6 weeks after treatment. The mean value of these variables during treatment and a baseline period were compared within and between groups. After 3 and 6 weeks of treatment of nasal polyps with topical Budesonide nasal spray, nasal symptoms, polyp size, nasal and oral expiratory peak flow index and overall response to treatment were improved within both groups. Comparing the two groups, there were greater improvements in the negative skin test group compared to the positive skin test group in all variables. These differences in variable scores between groups showed a tendency to increase overtime after treatment was terminated. The results demonstrate that nasal polyps with positive allergen skin test had less improvement compared to nasal polyps with negative allergen skin test in all nasal signs and symptoms and these differences in improvement showed a tendency to increase over time after treatment.

Effect of oral contraceptives on respiratory function.

The present study was carried out to assess the lung functions in oral contraceptive administered women. Lung function tests were carried out with Spirometer (Vitallograph Compact II). A significant increase in vital capacity (VC) was observed in these women as compared to normal control. There was also a significant decrease in forced expiratory volume in 1 sec./vital capacity (FEV1/VC%) and forced expiratory volume in 1 sec./forced vital capacity (FEV1/FVC%) among oral contraceptive administered women as compared to controls. Further, a significant increase in peak expiratory flow rate (PEF), reduction in forced expiratory flow rate (FEF75-85%) and FEF75% were observed among oral contraceptive administered women as compared to controls. The increase in VC and PEF might be due to the synthetic form of progesterone (progestins) present in oral contraceptive pills which causes hyperventilatory changes. Synthetic progesterone during luteal phase of menstrual cycle might increase the static and dynamic volumes of lung i.e. VC and PEF. But FEF75% showed a decrease which might be due to the lower neuromuscular coordination during breathing.

Relationship between symptoms and objective measures of airway obstruction in asthmatic patients.

The objective of this study was to determine the relationship between asthma symptoms and the degree of airway obstruction as measured by the forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) in a group of 64 asthmatic patients with clinically stable disease attending a university-based urban asthma clinic. Asthma symptoms did not correlate with the degree of airway obstruction as measured by prebronchodilator PEFR (total asthma symptom score vs PEFR: r = -0.214, p = 0.104, n = 59) and only correlated poorly with prebronchodilator FEV1 (total asthma symptom score vs FEV1: r = -0.256, p = 0.041, n = 64). These results lend support to the recommendation that airway obstruction should be measured objectively when assessing patients with chronic persistent asthma.

Paper spacers coupled to metered dose inhalers in family practice.

OBJECTIVES: 1. To assess the clinical efficacy of drug delivery using paper spacer devices coupled to metered dose inhalers (MDI). 2. To compare the effectiveness of paper spacers with the standard volumatic spacer. DESIGN: Randomised double-blind placebo controlled clinical trial. SETTING: Asthma clinic of a family practice at Kalutara. PATIENTS: 134 patients over 12 years of age, who attended the clinic with an acute episode of wheezing. METHOD: All patients over 12 years of age with an acute episode of wheezing who could speak a sentence of over 5 words were randomly allocated into 4 groups and administered salbutamol inhalations through a MDI coupled to a spacer. The first group used a 6-inch paper spacer, second group an 8-inch paper spacer, the third group a 10-inch paper spacer and the fourth group used a standard 750 ml volumatic spacer. MEASUREMENTS: In each subject, the peak expiratory flow rate (PFR) was recorded at the start, after placebo inhalation and after salbutamol inhalation. An increase of PFR of over 20% from the basal value was assessed as a good response. RESULTS: The number of patients who showed a good response after salbutamol inhalations in all four groups were very significant compared with the responses after placebo inhalations (p < 0.001). No significant differences were found in the effectiveness of salbutamol among the four other groups (p > 0.1). CONCLUSIONS: 1. All devices show equal efficacy. Metered dose inhalers and all 3 paper devices are as effective as the standard volumatic spacer. 2. The cost of a paper spacer device is negligible compared to that of the volumatic spacer. 3. The use of paper spacers in Sri Lankan family practices makes inhaled MDI therapy much cheaper without decreasing the effectiveness of drug delivery.

Correlates of peak expiratory flow rate: a study of sand stone quarry workers in desert.

The study assesses the relationship between selected demographic, anthropometeric, radiological, work-history and smoking-history related variables with Peak Expiratory Flow Rate (PEFR) in a sample of 286 sand stone quarry workers from a desert region. Age, height, profusion of radiological opacities, age at beginning of work, duration of work and duration of smoking were found significantly associated with PEFR while duration of exposure to dust, nature of job and number of biries smoked per day failed to establish their significant association. Mean PEFR of these workers was found significantly lower than the same among healthy adults from the study area. The subset of predictors of PEFR only included age, height and profusion of radiological opacities as identified by multiple regression analysis.

Delta pico flujo espiratorio, hiperreactividad bronquial y proteína catiónica del eosinófilo en asmáticos tratados con diferentes dosis de budesonida / Delta peak flow expiratoryhyperreactivity bronchial and cationic protein of the eosinophil in asthmatic treatmentwith different dose of Budesonide

Objetivo: Determinar la acción de distintas dosis de budesonida (BUD) sobre la evolución clínica del asma, la hiperreactividad bronquial (HRB) al aire frío y la proteína catiónica eosinofílica (PCE) sérica en un grupo de pacientes asmáticos atópicos, versus un grupo control tratado sólo con ß2 a demanda. Material y métodos: Se estudiaron 30 pacientes (p) con asma moderada persistente, edad X=25,5 años. Se les determinó: espirometría basal, HRB con aire frío, niveles séricos de PCE (valores normales: 2,6 a 16 mg/l) y monitoreo del pico flujo espiratorio (PFE) matinal y vespertino durante los distintos regímenes terapéuticos. Se los dividió en dos grupos: grupo 1 (23 p): se los medicó con BUD 800 mg/día durante 3 semanas; y grupo 2 (7 p): recibieron solamente ß2 a demanda por 3 semanas. al cabo de las mismas se volvieron a evaluar los mismos parámetros a los fines de determinar diferencias entre los dos tratamientos. Seguidamente al grupo 1 se redujo la dosis de BUD a 400 mg/día durante 2 semanas y a 200 mg/día otras dos semanas, evaluando HRB y valores de delta PEF (PEF) al final de cada tratamiento. Resultados: 1 a) La HRB al aire frío disminuyó en el grupo 1 (BUD) de una PD inicial X=16,4 a una PD X=7,62 luego de 3 semanas de tratamiento con 800 mg/d, mientras que en el grupo 2 (ß2) la PD inicial fue de X=15,8 y la PD final de X=15 (diferencia BUD vs. ß2: p<0,005). 1 b) El promedio semanal de  PFE diarios mayores al 10 por ciento en el grupo 1 fue de X=2,91 al inicio y de X=2 luego de las 3 semanas, mientras que en el grupo 2 subió de X=2,91 al inicio a X=5 al final del tratamiento (p<0,005). 1 c) La PCE sérica en el grupo 1 fue de X=32,5 µg/l al inicio y de X=23 µg/l al final, disminuyendo en 16/23 pacientes, mientras en el grupo 2 fue de X=28 µg/l al inicio y de X=21,2 µg/l al final de las 3 semanas (p<0,18). 2 a) En el grupo 1, la HRB durante el tratamiento con 400 µg/día bajó de una PD X=7,62 a una PD X=3,57 (p<0,005), aumentado nuevamente a una PD X=4,67 al disminuir la dosis a 200 µg/día. 2 b) Los  PEF mayores al 10 por ciento, durante el tratamiento con 400 µg/día bajaron de un X=2 a un X=1,74, volviendo a aumentar a X=2,2 con 200 µg/día. Conclusiones: Al disminuir la dosis del fármaco, este efecto se mantiene hasta una dosis de 400 µg/día, disminuyendo al utilizar 200 µg/día.

Is driving oxygen flow rate clinically important for nebulizer therapy in patients with COPD?

Our study suggests that the administration of bronchodilator drug via nebulizer powered by flow rate 6 L/min is more suitable in COPD patients. The oxygen flow rates should not be given more than 6 L/min. In this study, we recruited COPD patients in a stable stage, in whom the risk of hyperoxic induced hypercarbia is less than in the acute exacerbation stage. Thus, in acute exacerbation stage of the COPD patients, the rise of carbondioxide should be higher. We recommend that the COPD patients should receive bronchodilator drug via the nebulizer, especially in acute exacerbation stage, with oxygen flow rate not more than 6 L/min. The medical personnel must closely observe the clinical signs of the patients to prevent the hazard of carbondioxide retention.

Study of ipratropium bromide inhalation in stable asthma.

An open two weeks short term trial of Ipratropium Bromide (IB) inhalation (0.02 mg per dose) was carried out in 20 stable asthamatics to study its efficacy and safety. Early significant rise in PEFR (P < 0.001) and FEV1 (P < 0.05) was observed after 15 min of IB inhalation and reached significant peak (P < 0.01) after 1 hour which was persistent beyond three hours after IB inhalation. No side effects were observed. It was concluded that Ipratropium Bromide Imhalation is safe and has efficient bronchodilatory effect on short term basis in stable asthmatics.

Some hitherto unreported findings on the extragenital effects of progesterone in human females--a clinical study.

40 women suffering from 'dysfunctional uterine bleeding' (DUB) were treated by progesterone (P) and signs and symptoms of 'extragenital effects' of P were noted. In addition to the previous ones reported from this laboratory, a new crop of effects, which, as far as we are aware of, have never been reported in the literature, were found and included: (i) Changes in the frequency of EEG waves, (ii) changes in the ECG (iii) changes in psychoanalytical scoring. Further (iv) with most of the parametres, the intensity of the changes showed considerable waning with passage time, despite the fact that the subjects were still receiving P. Blood P levels similarly fell considerably in the initial phase of the therapy, but recovered to some extent afterwards, despite the continuance of P therapy.

Ease of handling and efficacy of Bricanyl Turbuhaler in Asian asthmatic children.

Ease of handling as well as efficacy of a new terbutaline inhalation device--Bricanyl Turbuhaler--were evaluated among eighty-six Asian children with mild to moderate asthma with a mean age of 8.7 years (range 5 to 14 years) in an open, non-comparative trial. Clinical evaluations were performed on four occasions, ie at the beginning of the run-in period, at the start of the study medication, after 2 weeks of treatment and after a total of 4 weeks of treatment. Appraisal of handling technique was performed by the investigator at the start and end of treatment. Peak expiratory flow rate (PEF) was determined at each visit. Diaries were also kept throughout this time; PEF and asthma symptom scores were recorded every morning and evening. Maximum scores for inhalation technique were achieved by 73% of patients after combined written and verbal instructions at the start of the study and 99% of patients achieved this score at the end of the 4 week treatment period with Bricanyl Turbuhaler. Assessment revealed that approximately 90% of the patients considered loading, inhalation and handling of the Turbuhaler device to be easy, and 90% considered it to be effective in affording symptom relief. Improvements in PEF and reductions in asthma symptoms were observed during the Bricanyl Turbuhaler treatment, as compared to baseline values. All patients tolerated the study medication well without any serious adverse events. We concluded that this group of Asian children were able to use this new "Turbuhaler" device of terbutaline without any difficulty.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative study of bronchodilator actions of ipratropium bromide (atrovent) & salbutamol (ventolin) on exercise induced bronchial asthma.

The bronchodilator actions of salbutamol and ipratropium bromide were compared in 30 established cases of bronchial asthma, before and after exercise. It was noticed that after exercise (brisk walk for 3 min.) the PFT values of FVC, PEFR and FEV-1, decreased remarkably from the basal values, the mean fall of 17.91%, 10.68% & 14.8% respectively was noticed. Salbutamol showed improvement in FVC, PEFR, FEV-1, of 20.86%, 15.96% & 17.98% respectively from basal values, while Ipratropium bromide showed improvement by 18.31%, 13.01% & 20.90% respectively. It was also noted that salbutamol is a better drug amongst smokers, patients with family history of bronchial asthma, and in younger age groups. Ipratropium bromide was better in elderly patients (> 40 yrs.) and in those with eosinophillia.

Effect of ipratropium bromide in bronchial asthma.

The effect of inhalation of ipratropium bromide was evaluated in 20 patients with bronchial asthma. It was observed that there was no significant improvement in the forced vital capacity and the forced expired volume in one second, while there was significant improvement in the peak expiratory flow rate (PEFR) measured at 9 pm, after inhalation of 2 puffs of ipratropium bromide aerosol (0.02mg/puff) three to four times a day for 2 weeks. Since PEFR is a measure of large airway function and cholinergic mechanisms are primarily involved for airflow obstruction at large airways, improvement in PEFR by ipratropium bromide highlights its role as a useful bronchodilator in patients in whom vagal reflexes are responsible for the provocation of bronchoconstriction.