Management of Acute Asthma Exacerbations in Urgent Care (Pharmacology CME)

Table of Contents

 

About This Issue

The diagnosis of an acute asthma exacerbation in urgent care is primarily clinical. Treatment modalities are guided by the severity of the exacerbation, and decisions regarding disposition for mild and moderate exacerbations will depend on the patient’s response to initial treatment. In this issue, you will learn:

The pathologies that have clinical features overlapping with asthma, including congestive heart failure, COPD, and pulmonary embolism.

The key features of mild, moderate, and severe exacerbations, and how management and disposition will differ depending on the classification.

How peak expiratory flow can be useful for stratification of an asthma exacerbation.

The latest recommendations on drug therapies for asthma exacerbations, including beta agonists, anticholinergics, corticosteroids, magnesium sulfate, epinephrine, and novel biologics.

The indications for referral to the emergency department for evaluation and care.

The unique considerations in the diagnosis and management of acute asthma exacerbation in pediatric patients.

CHARTING & CODING: Learn how to select the appropriate level of service for the management of acute asthma exacerbation in urgent care.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Epidemiology
   1. Prevalence of Asthma and Healthcare Costs
   2. Social Determinants and Risk Factors
6. Etiology and Pathophysiology
7. Differential Diagnosis
   1. Congestive Heart Failure
   2. Chronic Obstructive Pulmonary Disease
   3. Pulmonary Embolism
   4. Other Conditions in the Differential for Asthma
8. Urgent Care Evaluation
   1. History
   2. Physical Examination
      1. Classifications of Asthma Exacerbation
         • Mild Exacerbation
         • Moderate Exacerbation
         • Severe Exacerbation
9. Diagnostic Studies
   1. Laboratory Evaluation
   2. Point-of-Care Ultrasound
   3. Peak Expiratory Flow
   4. Chest Radiographs
10. Treatment
    1. Oxygen
    2. Pharmacologic Agents
       1. Beta Agonists
          • Metered-Dose Inhalers Versus Nebulizers
          • Intermittent Versus Continuous Nebulizer Treatments
       2. Anticholinergics
       3. Corticosteroids
       4. Magnesium Sulfate
       5. Epinephrine
11. Special Populations
    1. Pregnant Patients
    2. Asthma Patients With COVID-19
12. Controversies and Cutting-Edge
    1. Biologics
    2. Fractional Exhaled Nitric Oxide
    3. Heliox
    4. High-Flow Nasal Cannula
13. Disposition
    1. Indications for Referral for Emergency Department Evaluation
14. Risk Management Pitfalls for Management of Acute Asthma Exacerbations in Urgent Care
15. Time- and Cost-Effective Strategies
16. Summary
17. KidBits: Asthma in Pediatric Patients
    1. Urgent Care Diagnosis
    2. Treatment
    3. Discharge Planning
18. Critical Appraisal of the Literature
19. Case Conclusions
20. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
    4. Coding Challenge
21. Clinical Pathways
    1. Clinical Pathway for the Management of Asthma Exacberations in Adult Patients in the Urgent Care Setting
    2. Clinical Pathway for the Management of Asthma Exacberations in Pediatric Patients in the Urgent Care Setting
22. References
23. Acknowledgments

Abstract

Asthma is a disease of the airways characterized by inflammation, hyperresponsiveness, and bronchoconstriction. The diagnosis of acute asthma exacerbation is primarily a clinical one, based on a focused history and physical examination. It is important to differentiate it from other entities such as heart failure, pneumonia, and pulmonary embolism, which can present with similar respiratory signs. Radiographs are not routinely recommended, except in atypical or refractory cases, or if there is diagnostic uncertainty. The cornerstone of acute asthma treatment includes short-acting beta agonists, anticholinergics, and systemic corticosteroids. This issue reviews the latest evidence in diagnostic and treatment strategies, including other pharmacologic treatments and newer management strategies.

Case Presentations

A 40-year-old man with a history of frequent visits for asthma, including multiple admissions and intubations, is brought into the urgent care by his spouse...

• The patient is slightly tachypneic and not using accessory muscles to breathe.
• On auscultation, air entry is significantly diminished bilaterally, and he has faint expiratory wheezing bilaterally.
• His vital signs are: blood pressure is 155/85 mm Hg; heart rate, 120 beats/min; respiratory rate, 20 breaths/min; temperature, 36.9°C; and oxygen saturation, 91% on room air.
• You recognize that this patient needs ED evaluation but wonder if interventions are needed while you await transport…

A 20-year-old woman arrives at urgent care with complaints of difficulty breathing and dry cough...

• The patient says she discontinued her asthma medications because she has not used them in the past 2 years.
• Her vital signs are: blood pressure is 120/75 mm Hg; heart rate, 80 beats/min; respiratory rate, 18 breaths/min; and room-air pulse oximeter reading, 97%.
• On auscultation she has faint diffuse wheezing with good air movement.
• You consider the treatment options for this patient…

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Clinical Pathways

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

11. United States Centers for Disease Control and Prevention. Asthma as the underlying cause of death. (Government report)

12. World Health Organization. Asthma. Updated May 4, 2023. Accessed October 15, 2023. (Consensus statement)

13. * National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. United States Dept. of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute; 2007. (Clinical guidelines) DOI: 10.1016/j.jaci.2007.09.029

17. * Padem N, Saltoun C. Classification of asthma. Allergy Asthma Proc. 2019;40(6):385-388. (Review) DOI: 10.2500/aap.2019.40.4253

29. * Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2023. Updated July 2023. Accessed October 15, 2023. (Clinical guidelines)

31. American College of Emergency Physicians. Use of peak expiratory flow rate monitoring for the management of asthma in adults in the emergency department. 2019. (Clinical guidelines)

33. Scottish Intercollegiate Guidelines Network, British Thoracic Society. British Guideline on the Management of Asthma: A National Clinical Guideline. 2003. Revised July 2019. Accessed October 15, 2023. (Clinical guidelines)

71. United Stated Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). People with moderate to severe asthma. Updated September 21, 2023. Accessed October 15, 2023. (Government publication)

86. * Cloutier MM, Baptist AP, Blake KV, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270. (Guideline updates) DOI: 10.1016/j.jaci.2020.10.003

94. US Centers for Disease Control and Prevention. Asthma-related missed school days among children aged 5–17 years. Updated October 5, 2015. Accessed October 10, 2023. (CDC data)

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Keywords: asthma, exacerbation, wheezing, beta agonist, SABA, LABA, anticholinergic, ketamine, epinephrine, biologics, COPD, COVID-19, silent chest, nebulizer, metered-dose inhaler, corticosteroid, albuterol