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1 -Adrenergic agents Short-acting inhaled -adrenergic agonists are clearly the most effective bronchodilators during exacerbations -adrenergic agonists should be used in all patients to treat acute symptoms These agents relax airway smooth muscle and cause a prompt increase in airflow and reduction of symptoms Administration before exercise effectively prevents exercise-induced bronchoconstriction There is no convincing evidence to support the use of one agent over another 2-selective agents may produce less cardiac stimulation than those with mixed 1 and 2 activities, although clinical trials have not consistently demonstrated this finding Currently available short-acting 2selective adrenergic agonists include albuterol, bitolterol, pirbuterol, and terbutaline Inhaled -adrenergic agonist therapy is as effective as oral or parenteral therapy in relaxing airway smooth muscle and improving acute asthma and offers the advantages of rapid onset of action (< 5 minutes) with fewer systemic side effects Repetitive administration produces incremental bronchodilation Intravenous and subcutaneous routes of administration should be reserved for patients who because of age or mechanical factors are unable to inhale medications One or two inhalations of a short-acting inhaled 2agonist from an MDI are usually sufficient for mild to moderate symptoms Severe exacerbations frequently require higher doses: equivalent bronchodilation can be achieved by high doses (6 12 puffs every 30 60 minutes) of a 2-agonist by MDI with an inhalation chamber or by nebulizer therapy Administration by wet nebulization does not offer more effective delivery than MDIs but it is given in higher doses With most 2agonists, the recommended dose by nebulizer for acute asthma (albuterol, 25 mg) is 25 30 times that delivered by a single activation of the MDI (albuterol, 009 mg) This difference suggests that the standard use of inhalations from an MDI will often be insufficient in the setting of an acute exacerbation Independent of dose, nebulizer therapy may be more effective in patients who are unable to coordinate inhalation of medication from an MDI because of age, agitation, or severity of the exacerbation Scheduled daily use of short-acting 2-agonists is not generally recommended Increased use (more than one canister a month) or lack of expected effect indicates diminished asthma control and dictates the need for additional long-term control therapy 2 Anticholinergics Anticholinergic agents reverse vagally mediated bronchospasm but not allergen- or exerciseinduced bronchospasm They may decrease mucus gland hypersecretion seen in asthma Ipratropium bromide, a quaternary derivative of atropine free of atropine s side effects, reverses acute bronchospasm and is the inhaled alternative for patients with intolerance to 2-agonists Ipratropium bromide may be a useful adjunct to inhaled short-acting 2-agonists and considered in patients with moderate to severe asthma exacerbations High doses of inhaled ipratropium bromide (05 mg) cause additional bronchodilation in some patients with severe airway.

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