| Inhaled Short-Acting Beta2-Agonists |
| Albuterol |
 Nebulizer solution (5 mg/mL) | 2.5–5 mg every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed, or 10–15 mg/hour continuously | 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses, then 0.15–0.3 mg/kg up to 10 mg every 1–4 hours as needed, or 0.5 mg/kg/hour by continuous nebulization | Only selective beta2-agonists are recommended. For optimal delivery, dilute aerosols to minimum of 4 mL at gas flow of 6–8 L/min. |
| MDI (90 mcg/puff) | 4–8 puffs every 20 minutes up to 4 hours, then every 1–4 hours as needed as needed | 4–8 puffs every 20 minutes for 3 doses, then every 1–4 hours inhalation maneuver. Use spacer/holding chamber. | As effective as nebulized therapy if patient is able to coordinate |
| Bitolterol |
| Nebulizer solution (2 mg/mL) | See albuterol dose | See albuterol dose; thought to be half as potent as albuterol on a mg basis | Has not been studied in severe asthma exacerbations. Do not mix with other drugs. |
| MDI (370 mcg/puff) | See albuterol dose | See albuterol dose | Has not been studied in severe asthma exacerbations. |
| Pirbuterol |
| MDI (200 mcg/puff) | See albuterol dose | See albuterol dose; thought to be half as potent as albuterol on a mg basis | Has not been studied in severe asthma exacerbations. |
| Systemic (Injected) Beta2-Agonists |
| Epinephrine 1:1000 (1 mg/mL) | 0.3–0.5 mg every 20 minutes for 3 doses sq | 0.01 mg/kg up to 0.3–0.5 mg every 20 minutes for 3 doses sq | No proven advantage of systemic therapy over aerosol. |
| Terbutaline (1 mg/mL) | 0.25 mg every 20 minutes for 3 doses sq | 0.01 mg/kg every 20 minutes for 3 doses then every 2–6 hours as needed sq | No proven advantage of systemic therapy over aerosol. |
| Anticholinergics |
| Ipratropium bromide |
| Nebulizer solution (.25 mg/mL) | 0.5 mg every 30 minutes for 3 doses then every 2–4 hours as needed | .25 mg every 20 minutes for 3 doses, then every 2 to 4 hours | May mix in same nebulizer with albuterol. Should not be used as first-line therapy; should be added to beta2-agonist therapy. |
| MDI (18 mcg/puff) | 4–8 puffs as needed | 4–8 puffs as needed | Dose delivered from MDI is low and has not been studied in asthma exacerbations. |
| Corticosteroids |
| Prednisone Methylprednisolone Prednisolone | 120–180 mg/day in 3 or 4 divided doses for 48 hours, then 60–80 mg/day until PEF reaches 70% of predicted or personal best | 1 mg/kg every 6 hours for 48 hours then 1–2 mg/kg/day (maximum = 60 mg/day) in 2 divided doses until PEF 70% of predicted or personal best | For outpatient “burst” use 40–60 mg in single or 2 divided doses for adults (children: 1–2 mg/kg/day, maximum 60 mg/day) for 3–10 days |
| NOTE: |
| • No advantage has been found for higher dose corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired. The usual regimen is to continue the frequent multiple daily dosing until the patient achieves an FEV 1 or PEF of 50 percent of predicted or personal best and then lower the dose to twice daily. This usually occurs within 48 hours. Therapy following a hospitalization or emergency department visit may last from 3 to 10 days. If patients are then started on inhaled corticosteroids, studies indicate there is no need to taper the systemic corticosteroid dose. If the followup systemic corticosteroid therapy is to be given once daily, one study indicates that it may be more clinically effective to give the dose in the afternoon at 3:00 p.m., with no increase in adrenal suppression (Beam et al. 1992). |
