Bronchodilator therapy in the management of acute asthma

Bronchodilator management of acute severe asthma has evolved considerably in recent years. beta-adrenergic agonists have emerged as the single most potent class of bronchodilator available, and the inhalational route of administration has proven to be the most effective and least toxic method of delivery except among apneic or highly uncooperative patients. Other bronchodilators, including aminophylline, inhaled anticholinergics, and intravenous magnesium sulfate, are significantly less potent drugs for reversal of bronchoconstriction. In most patients these agents do not promote significant bronchodilation beyond that achieved with an intensive regimen of inhaled beta agonists; subsets of patients that might benefit from these other agents remain to be identified. Questions remain as to the optimal dose, frequency of administration, and mode of inhalational delivery of the beta agonists in acute asthma. Finally, it is important to remember that bronchodilator therapy constitutes only one component in the treatment of acute severe asthma. Treatment of airway inflammation with systemic corticosteroids is another vital component, as are supplemental oxygen in the hypoxemic patient, close monitoring of lung function, attention to the possibility of hypercapnic respiratory failure, patient education, and a plan of care following emergency department discharge.