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symptom burden and rescue medication use) While such detailed assessment may not be commonly performed in a formal manner using all of the questions outlined in the NAEPP or Asthma Control Test, clinicians can query about frequency of days or nights with increased asthma symptoms and use of albuterol Patients with or more days/nights of symptoms and/or albuterol use per week likely have chronic asthma severity in the “persistent” range and prescribing or continuing inhaled steroids is recommended Management Treatment involves weight-based dosing of SABA (most commonly albuterol in the United States), anticholinergics (usually ipratropium bromide), and systemic corticosteroids (dexamethasone, prednisone, prednisolone, or methylprednisolone) Inhaled SABA causes bronchodilation of airway smooth muscle through activation of β2 -adrenergic receptors Albuterol is the most commonly used SABA It is a racemic mixture of two enantiomers—R-albuterol (binds β2 receptor and causes bronchodilation and adverse effects of tachycardia and tremor) and S-albuterol (considered to have some degree of detrimental effect on airway function) Levalbuterol contains the R-enantiomer alone, and is marketed as an alternative to racemic albuterol with fewer adverse effects (e.g., less tachycardia) However, studies are inconsistent regarding clinical superiority of levalbuterol over racemic albuterol, and the increased cost of levalbuterol must be considered The NAEPP guidelines list levalbuterol as an option for SABA treatment at half the dose of nebulized albuterol Albuterol can be administered using metered-dose inhalers (MDIs) with valved holding chambers (spacers) or by nebulizers Use of both requires proper technique While there are potential differences in lung deposition between devices, studies have found equivalency or favor MDI with spacer with regard to ED LOS and tachycardia Although nebulizers have traditionally been the preferred devices, MDI with spacer may be considered an option for children with mild and moderate exacerbations Studies on MDI with spacer for severe asthma exacerbations are limited Patients with severe exacerbations have significant lower airway obstruction, which limits drug deposition in the lung, and higher overall albuterol doses using nebulizer are often necessary For those with mild exacerbations, it is reasonable to administer one SABA treatment and assess need for additional therapy Patients with moderate or severe exacerbations should receive multiple doses of SABA and anticholinergics (e.g., ipratropium) in addition to systemic steroids