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insufficient improvement with multiple albuterol and ipratropium treatments Adjunctive therapies such as magnesium sulfate and heliox can be administered in conjunction with ongoing inhaled bronchodilators, and timing may vary according to severity Frequent reassessments during initial treatment for those with severe exacerbations, anticipating the need for adjunctive therapy, are essential to avoid delays Continuous nebulized albuterol treatment is recommended for patients with severe exacerbations or poor response to initial inhaled bronchodilator treatment A systematic review found that continuous albuterol was associated with greater improvement in peak expiratory flow rate (PEFR) and lower hospitalization rate, particularly among those with moderate or severe exacerbations, with no increase in adverse effects Magnesium sulfate causes bronchodilation by relaxing respiratory smooth muscle It is administered as a single IV bolus with a recommended dose of 50 to 75 mg/kg (maximum g) Use of this therapy has been associated with improved pulmonary function and reduced hospitalization rates Magnesium can be administered early in the course of patients with more severe exacerbations Others utilize magnesium after insufficient improvement from standard acute therapy with multiple SABA and ipratropium doses, and such patients often require hospitalization (frequently intensive care) although some patients may improve enough to allow discharge Ultimately, disposition following magnesium administration is determined by the severity of the presentation and the response to treatment Heliox is a mixture of helium and oxygen, thought to improve drug delivery in obstructed airways due to its lower density and airflow resistance The commonly used mixtures (helium:oxygen) are 70:30 or 80:20, but use in patients with significant hypoxemia may be limited Contraindications for Heliox are pneumothorax, pneumopericardium, or pneumoperitoneum; therefore a chest radiograph (CXR) should be obtained prior to initiation Parenteral β-agonists are also options to consider for adjunctive therapy Epinephrine administered intramuscularly may be an option for severe exacerbations, particularly as initial treatment for patients with significant airway obstruction when delivery of inhaled medications to the lower airways may be limited Epinephrine autoinjectors used to treat anaphylaxis are readily available in most EDs and can be used Terbutaline may be administered subcutaneously or intravenously as a bolus and continued as an IV infusion Although commonly included in many pediatric protocols for refractory asthma, pediatric studies regarding use are limited
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