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symptom burden and rescue medication use). While such detailed assessment
may not be commonly performed in a formal manner using all of the questions
outlined in the NAEPP or Asthma Control Test, clinicians can query about
frequency of days or nights with increased asthma symptoms and use of albuterol.
Patients with 2 or more days/nights of symptoms and/or albuterol use per week
likely have chronic asthma severity in the “persistent” range and prescribing or
continuing inhaled steroids is recommended.
Management
Treatment involves weight-based dosing of SABA (most commonly albuterol in
the United States), anticholinergics (usually ipratropium bromide), and systemic
corticosteroids
(dexamethasone,
prednisone,
prednisolone,
or
methylprednisolone).
Inhaled SABA causes bronchodilation of airway smooth muscle through
activation of β2 -adrenergic receptors. Albuterol is the most commonly used
SABA. It is a racemic mixture of two enantiomers—R-albuterol (binds β2 receptor and causes bronchodilation and adverse effects of tachycardia and
tremor) and S-albuterol (considered to have some degree of detrimental effect on
airway function). Levalbuterol contains the R-enantiomer alone, and is marketed
as an alternative to racemic albuterol with fewer adverse effects (e.g., less
tachycardia). However, studies are inconsistent regarding clinical superiority of
levalbuterol over racemic albuterol, and the increased cost of levalbuterol must be
considered. The NAEPP guidelines list levalbuterol as an option for SABA
treatment at half the dose of nebulized albuterol.
Albuterol can be administered using metered-dose inhalers (MDIs) with valved
holding chambers (spacers) or by nebulizers. Use of both requires proper
technique. While there are potential differences in lung deposition between
devices, studies have found equivalency or favor MDI with spacer with regard to
ED LOS and tachycardia. Although nebulizers have traditionally been the

preferred devices, MDI with spacer may be considered an option for children
with mild and moderate exacerbations. Studies on MDI with spacer for severe
asthma exacerbations are limited. Patients with severe exacerbations have
significant lower airway obstruction, which limits drug deposition in the lung,
and higher overall albuterol doses using nebulizer are often necessary.
For those with mild exacerbations, it is reasonable to administer one SABA
treatment and assess need for additional therapy. Patients with moderate or severe
exacerbations should receive multiple doses of SABA and anticholinergics (e.g.,
ipratropium) in addition to systemic steroids.