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The frequency in which exacerbations happen vary widely depending on the severity of disease,[15] the degree of control with prophylactic medications,[16] and exposure to triggers. In a multicenter study from the US,[17] the admission rate of all comers to the emergency department (ED) with acute asthma was 23%. On the other hand, a European study showed that only about 7% of all patients with acute asthma exacerbation required hospitalization. Examination of patients with acute asthma may reveal increased respiratory rate, retractions (accessory respiratory muscle use), wheezing, oxygen desaturation on pulse oximetry and in more severe cases, inability to speak, silent chest, with reduced respiratory lung volumes, cyanosis, and change in mental status. Asthma exacerbations can be classified as mild, moderate, or severe based on the assessment of a group of signs and symptoms as illustrated in Table 1. General classification of asthma severity. In patients with mild asthma exacerbation, inhaled ?2-agonists like albuterol (salbutamol) are usually sufficient in resolving symptoms. The dose can be repeated 3 times every 15-20 min. Levalbuterol, the (R)-enantiomer of albuterol is the effective form of the drug, but clinical trials did not show any advantage of using it over albuterol in terms of efficacy or side-effects. However, it is recommended that patients who take them regularly or patients who fail initial treatment with albuterol should be given systemic corticosteroids. Current guidelines recommend that patients with moderate exacerbation should receive three doses of inhaled or nebulized ?2-agonist every 15-20 min in the 1 st h. All those patients should be treated with systemic corticosteroids at a dose of 2 mg/kg or a maximum dose of 80 mg early in the course of management as it takes at least 4 h to start working. Systemic corticosteroids were found to speed resolution of symptoms, decrease the rate of admission and decrease the rate of relapse if administered for 3-5 days after the acute exacerbation. More detailed discussion about the use of systemic corticosteroids in the treatment of acute asthma can be found below. Patients with severe asthma exacerbation should obviously be treated more aggressively. High dose inhaled (8-12 puffs) or nebulized ?2-agonist should be given every 15-20 min at least in the 1 st h, which could be repeated for up to 4 h as required. Data are conflicting whether continuous nebulization using 2-agonist is superior to intermittent nebulization., trenbo a 100 mg injectable steroids trenbolone acetate. Ipratropium bromide has been shown to decrease the rate of hospitalization and shorten the stay in the ED in patients with severe or moderate to severe asthma exacerbation in many clinical trials. 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