A 73-year-old male with chest tightness unresponsive to three MDI doses; what is the next best step?

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When a patient with suspected bronchospasm or COPD/asthma exacerbation does not respond to inhaled bronchodilators, the next step is to add systemic anti-inflammatory treatment. Administering methylprednisolone intravenously helps reduce airway inflammation and edema, which can improve responsiveness to bronchodilators and prevent worsening of the attack. Securing IV access is important to deliver the steroid promptly and to facilitate further treatment and monitoring. While continuing bronchodilators may still be appropriate, the corticosteroid addresses the underlying inflammatory component and is a key escalation in this scenario. Ventilatory support is reserved for signs of impending respiratory failure, and isolated anticholinergic therapy would be less effective as an immediate escalation after failure of inhaled beta-agonists.