Life-threatening asthma, part 2: Strategies for management

β-Agonists, administered by metered-dose inhaler or nebulizer, are still the mainstay of therapy for asthma exacerbations. A trial of a subcutaneous β-agonist should be considered in patients who fail to respond to inhaled medications. Levalbuterol may play a role in managing refractory asthma, particularly in patients with ischemic heart disease or severe tachycardia. Systemic corticosteroids should be administered to all patients presenting to the hospital with asthma unless their peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEV ₁) is at least 80% of predicted after 1 hour of treatment; this therapy should be instituted within 1 hour of presentation. For patients with severe obstruction, the combined use of an anticholinergic and a β-agonist improves PEFR and FEV ₁ more than β-agonists alone and significantly decreases the risk of hospital admission.