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Ipratropium bromide causes bronchodilation by blocking muscarinic
cholinergic receptors. Adding anticholinergics to SABA is associated with
improved pulmonary function and, reduced hospitalization rates for those with
severe exacerbations, particularly using multiple-dose protocols. Many protocols
recommend its use for moderate severity as well.
Corticosteroids block formation of potent inflammatory mediators and reduce
airway inflammation. Systemic corticosteroids are associated with improved
pulmonary function and reduced hospitalizations. The effect on reducing
hospitalizations is time dependent, maximized with early administration. A
common metric regarding optimal asthma care is administration of systemic
corticosteroids within 60 minutes of arrival. Administration of systemic
corticosteroids is also associated with fewer ED relapse visits and hospitalization
at such return visits.
Systemic corticosteroid options include dexamethasone, prednisone,
prednisolone, or methylprednisolone. Dexamethasone has recently become more
popular with recent studies and systematic reviews reporting similar outcomes
and less vomiting compared to prednisone or prednisolone, though there was
heterogeneity among treatment regimens. Dexamethasone, prednisone, and
prednisolone have good oral bioavailability and tolerability, and oral route has
similar effectiveness compared to IV route. If patients are in severe distress or
actively vomiting, methylprednisolone or dexamethasone (IV or intramuscular)
should be considered. Other than these exceptions, oral corticosteroids are
preferred for milder exacerbations. For patients discharged from the ED, those
who received dexamethasone may not require additional doses considering its
longer duration of action compared to prednisone/prednisolone; those who
received prednisone/prednisolone are usually prescribed treatment for 3 to 5 days.
After initial therapy, it is important to reassess the need for continued and
adjunctive medications. Response to therapy can be categorized as good,
incomplete, or poor. Patients with good response have improvement with mild
features and can be observed briefly and subsequently discharged if not requiring
frequent SABA or having other indications for admission. Those with incomplete

or poor response continue to have moderate or severe features. They should
receive frequent, possibly continuous, albuterol, and adjunctive therapies such as
magnesium sulfate, heliox, or parenteral bronchodilator therapy should be
considered.
Many studies have evaluated use of medications considered adjunctive (e.g.,
continuous albuterol, magnesium sulfate, heliox) in comparison to initial standard
albuterol treatment, though, in practice, most clinicians administer them after