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insufficient improvement with multiple albuterol and ipratropium treatments.
Adjunctive therapies such as magnesium sulfate and heliox can be administered
in conjunction with ongoing inhaled bronchodilators, and timing may vary
according to severity. Frequent reassessments during initial treatment for those
with severe exacerbations, anticipating the need for adjunctive therapy, are
essential to avoid delays.
Continuous nebulized albuterol treatment is recommended for patients with
severe exacerbations or poor response to initial inhaled bronchodilator treatment.
A systematic review found that continuous albuterol was associated with greater
improvement in peak expiratory flow rate (PEFR) and lower hospitalization rate,
particularly among those with moderate or severe exacerbations, with no increase
in adverse effects.
Magnesium sulfate causes bronchodilation by relaxing respiratory smooth
muscle. It is administered as a single IV bolus with a recommended dose of 50 to
75 mg/kg (maximum 2 g). Use of this therapy has been associated with improved
pulmonary function and reduced hospitalization rates. Magnesium can be
administered early in the course of patients with more severe exacerbations.
Others utilize magnesium after insufficient improvement from standard acute
therapy with multiple SABA and ipratropium doses, and such patients often
require hospitalization (frequently intensive care) although some patients may
improve enough to allow discharge. Ultimately, disposition following magnesium
administration is determined by the severity of the presentation and the response
to treatment.
Heliox is a mixture of helium and oxygen, thought to improve drug delivery in
obstructed airways due to its lower density and airflow resistance. The commonly
used mixtures (helium:oxygen) are 70:30 or 80:20, but use in patients with
significant hypoxemia may be limited. Contraindications for Heliox are
pneumothorax, pneumopericardium, or pneumoperitoneum; therefore a chest
radiograph (CXR) should be obtained prior to initiation.
Parenteral β-agonists are also options to consider for adjunctive therapy.
Epinephrine administered intramuscularly may be an option for severe

exacerbations, particularly as initial treatment for patients with significant airway
obstruction when delivery of inhaled medications to the lower airways may be
limited. Epinephrine autoinjectors used to treat anaphylaxis are readily available
in most EDs and can be used. Terbutaline may be administered subcutaneously or
intravenously as a bolus and continued as an IV infusion. Although commonly
included in many pediatric protocols for refractory asthma, pediatric studies
regarding use are limited.