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Ipratropium bromide causes bronchodilation by blocking muscarinic cholinergic receptors Adding anticholinergics to SABA is associated with improved pulmonary function and, reduced hospitalization rates for those with severe exacerbations, particularly using multiple-dose protocols Many protocols recommend its use for moderate severity as well Corticosteroids block formation of potent inflammatory mediators and reduce airway inflammation Systemic corticosteroids are associated with improved pulmonary function and reduced hospitalizations The effect on reducing hospitalizations is time dependent, maximized with early administration A common metric regarding optimal asthma care is administration of systemic corticosteroids within 60 minutes of arrival Administration of systemic corticosteroids is also associated with fewer ED relapse visits and hospitalization at such return visits Systemic corticosteroid options include dexamethasone, prednisone, prednisolone, or methylprednisolone Dexamethasone has recently become more popular with recent studies and systematic reviews reporting similar outcomes and less vomiting compared to prednisone or prednisolone, though there was heterogeneity among treatment regimens Dexamethasone, prednisone, and prednisolone have good oral bioavailability and tolerability, and oral route has similar effectiveness compared to IV route If patients are in severe distress or actively vomiting, methylprednisolone or dexamethasone (IV or intramuscular) should be considered Other than these exceptions, oral corticosteroids are preferred for milder exacerbations For patients discharged from the ED, those who received dexamethasone may not require additional doses considering its longer duration of action compared to prednisone/prednisolone; those who received prednisone/prednisolone are usually prescribed treatment for to days After initial therapy, it is important to reassess the need for continued and adjunctive medications Response to therapy can be categorized as good, incomplete, or poor Patients with good response have improvement with mild features and can be observed briefly and subsequently discharged if not requiring frequent SABA or having other indications for admission Those with incomplete or poor response continue to have moderate or severe features They should receive frequent, possibly continuous, albuterol, and adjunctive therapies such as magnesium sulfate, heliox, or parenteral bronchodilator therapy should be considered Many studies have evaluated use of medications considered adjunctive (e.g., continuous albuterol, magnesium sulfate, heliox) in comparison to initial standard albuterol treatment, though, in practice, most clinicians administer them after