| 1. Beta2-agonist bronchodilator (nebulized or metered-dose inhaler) |
| Albuterol by MDI 4 to 8 puffs every 20 minutes up to 1 hour, then every 1 to 4 hours, as needed |
| Albuterol by nebulizer 0.083 percent (2.5 mg/3 mL), 2.5 to 5 mg every 20 minutes for 3 doses and then 2.5 to 5 mg every 1 to 4 hours, as needed |
| Albuterol by continuous nebulization, administering 10 to 15 mg per hour |
| 2. Ipratropium |
| By nebulizer, 500 mcg every 20 minutes for 3 doses, then as needed. Can be given simultaneously with beta2-agonist. |
| By MDI, 4 to 8 inhalations every 20 minutes for 3 doses, then as needed |
| 3. Systemic glucocorticoids (for those with a poor response to treatment after one hour, or with initial therapy for patients on chronic oral glucocorticoids) |
| For patients who can be managed at home: prednisone 40 to 60 mg per day in a single or divided dose |
| For patients who require hospitalization: prednisone 40 to 80 mg daily in a single or divided dose (or the equivalent dose of methylprednisolone* intravenously) until peak flow reaches 70 percent of predicted or personal best, and then taper as patient improves |
| For patients who have a life-threatening exacerbation, a higher initial dose of methylprednisolone*, 60 to 80 mg every 6 to 12 hours, may be given intravenously, and then tapered as the patient improves, as above |
| 4. For patients not responding to above therapies, consider adjunct therapies |
| Intravenous magnesium sulfate 2 g infused over 20 minutes, in absence of renal insufficiency¶ |
| Subcutaneous terbutaline 0.25 mg every 20 minutes for up to 3 doses |
