EnvironmentalProtection Agency

American Association for

Respiratory Care

Asthma Definition - 1997National Asthma Education and Prevention Program - NAEPP

• A disease characterized by the following:A disease characterized by the following:

– Airway inflammationAirway inflammation

• mast cells,eosinophils, T lymphocytes, neutrophils mast cells,eosinophils, T lymphocytes, neutrophils and epithelial cellsand epithelial cells

– Increased airway responsiveness to a variety of Increased airway responsiveness to a variety of stimulistimuli

– Airway obstruction that is reversible (at least to Airway obstruction that is reversible (at least to a significant degree)a significant degree)

Asthma in the United States

• 17.3 million Americans with Asthma17.3 million Americans with Asthma

• 4.8 million children < 18 with Asthma4.8 million children < 18 with Asthma

• Asthma prevalenceAsthma prevalence

– 5.8% of Americans5.8% of Americans

• 75% increase since 198075% increase since 1980

– 6.8% of preschool children 6.8% of preschool children

• 160% increase since 1980160% increase since 1980

Trends in asthma prevalence (1982-1994)

345678

1982

1984

1986

1988

1990

1992

1994

Year

Pre

vale

nce

(%

)

Under 18All Ages

National Health Interview SurveyNational Health Interview Survey

Asthma Prevalence

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 19920

1

2

3

4

5

6

7

8

Black

White

Pre

vale

nc

e (

%)

Year

Other

Prevalence of Asthma by Race Ages 5-34Prevalence of Asthma by Race Ages 5-34United States, 1982 - 1995United States, 1982 - 1995

Source: National Health Interview SurveySource: National Health Interview Survey

Race and Prevalence

Asthma Morbidity•Approximately 500,000 hospitalizationsApproximately 500,000 hospitalizations

•Approximately 1.9 million ER visitsApproximately 1.9 million ER visits

•10 million missed school days per year10 million missed school days per year

•Loss productivity is estimated at $1 billion Loss productivity is estimated at $1 billion per yearper year

82 83 84 85 86 87 88 89 90 91 920

100

200

300

400

500

600

Hospital Discharge Rates (per 100,000 Population) for Asthma asHospital Discharge Rates (per 100,000 Population) for Asthma as the First Listed Diagnosis, by Race, Age and Year, Age 5-34 Yearsthe First Listed Diagnosis, by Race, Age and Year, Age 5-34 Years

A-A (Age 5 through 14)

Rat

e

Year

A-A (Age 15 through 34)

Cauc. (Age 5 through 14)

Cauc. (Age 15 through 34)

National Hospital Discharge Survey - United States, 1982 - 1992National Hospital Discharge Survey - United States, 1982 - 1992

Morbidity

0

0.1

0.2

0.3

0.4

0.5

0.6

Year

Rat

e/10

0,00

0Asthma Mortality Rate Ages 5-34, Asthma Mortality Rate Ages 5-34,

United States, 1979-1995United States, 1979-1995

Asthma Mortality

0

2

4

6

8

10

12

14

16

18

1979 1981 1983 1985 1987 1989 1991 1993 1995

Year

rate

pe

r m

illi

on

po

pu

lati

on

African-AmericanAfrican-American

CaucasianCaucasian OtherOther

Asthma Annual Mortality Rates by: Race, Ages 5-34, U.S. 1979-1995

0 2 4 6 8 10 12 14 16

Estimated Costs in billions of dollars

1980

1985

1990

1995

2000

Yea

r

1980-1995 Costs of Asthma in the US Projection for the Year 2000

Costs

Smith D et al. AJRCCM 156:787-Smith D et al. AJRCCM 156:787-93,199793,1997

Direct Cost Estimates for Asthma

348(6.8)165(4.7)131(15.6)52(6.5)ED Visits

$ (col%) $ (col%) $ (col%) $ (col%)

5,1473,514(100)839(100)792(100)Total Direct

Cost

2,800(54.4)1,926(54.8)286(34.1)586(74.1)Admissions

1,182(23) 841(23.9)235(28)105(13.4)Ambulatory

Visits

81(15.9)581(16.5)187(22.3)48(6.1)Prescribed Medicines

Total> 175-170-4Cost

Component

Age in YearsAge in Years

Risk Factors for Asthma• Host - IntrinsicHost - Intrinsic

– genetic: atopy, IgE, BHRgenetic: atopy, IgE, BHR– gender, race, pre-, perinatalgender, race, pre-, perinatal

• EnvironmentalEnvironmental– allergens, diet, air pollution allergens, diet, air pollution – Environmental tobacco smoke (ETS)Environmental tobacco smoke (ETS)– infectionsinfections

Asthma Definition - 1997National Asthma Education and Prevention Program - NAEPP

• A disease characterized by the following:A disease characterized by the following:

– Airway inflammationAirway inflammation• mast cells,eosinophils, T lymphocytes, mast cells,eosinophils, T lymphocytes,

neutrophils and epithelial cellsneutrophils and epithelial cells

– Increased airway responsiveness to a variety Increased airway responsiveness to a variety of stimuliof stimuli

– Airway obstruction that is reversible (at Airway obstruction that is reversible (at least to a significant degree) least to a significant degree)

Expert Panel Report 2:Four Components of Asthma Management

• Measures of Assessment and MonitoringMeasures of Assessment and Monitoring

• Control of Factors Contributing to Control of Factors Contributing to Asthma SeverityAsthma Severity

• Pharmacologic TherapyPharmacologic Therapy

• Education for a Partnership in Asthma CareEducation for a Partnership in Asthma Care

• All of the common asthma triggers are All of the common asthma triggers are found indoorsfound indoors

• Americans spend about 90% time indoorsAmericans spend about 90% time indoors

• Reducing exposure to indoor allergens and Reducing exposure to indoor allergens and irritants can reduce asthma symptomsirritants can reduce asthma symptoms

• Prevention is an important asthma Prevention is an important asthma management toolmanagement tool

What does the Indoor Environment have to do with Asthma?

Indoor Environment in the U.S.

• 8 of 10 people are exposed to mites

• 6 of 10 people are exposed to cat or dog dander

• Clinical studies have demonstrated the prevalence of cockroaches in the inner city, schools and Southern U.S.

What is the Indoor Environment...

• Home EnvironmentHome Environment

– BedroomBedroom

– KitchenKitchen

– BathroomBathroom

– BasementBasement

– Living AreaLiving Area

Triggers Away fron the Home Environment…...

• SchoolSchool

• WorkplaceWorkplace

• Public areasPublic areas

• Second hand smokeSecond hand smoke

* 5 major indoor asthma triggers* 5 major indoor asthma triggers

Common Asthma Triggers• AllergensAllergens

– molds, dust mites, molds, dust mites, cockroaches, animal cockroaches, animal danderdander, pollens,, pollens, foodsfoods

• IrritantsIrritants– secondhand smokesecondhand smoke, ,

strong odors, aerosols, strong odors, aerosols, volatile organic volatile organic compounds, ozone, compounds, ozone, particulate matterparticulate matter

• OtherOther– Viral respiratory infectionsViral respiratory infections

– Changes in weather Changes in weather (cold air, wind, humidity)(cold air, wind, humidity)

– ExerciseExercise

– MedicationMedication

– Endocrine factors Endocrine factors (menstrual period, (menstrual period, pregnancy, thyroid pregnancy, thyroid disease)disease)

Frequency of Positive Skin Tests

38

36

31

24

19

0 5 10 15 20 25 30 35 40

Alternaria

Roach

Mite

Cat

Rat

% Positive Tests

Most Common Indoor Environmental Triggers

Secondhand SmokeSecondhand Smoke

Dust Mites Dust Mites

MoldMold

PetsPets

CockroachesCockroaches

Secondhand Smoke

• Contains more than 4,000 substances Contains more than 4,000 substances (over 40 are carcinogenic)(over 40 are carcinogenic)

• Is particularly harmful to young childrenIs particularly harmful to young children

• Can trigger asthma attacks and cause Can trigger asthma attacks and cause young children to develop asthmayoung children to develop asthma

Avoiding Secondhand SmokeChoose not to smoke in your Choose not to smoke in your

home or car and do not allow home or car and do not allow others to do so eitherothers to do so either

Tobacco Smoke

• Secondhand smoke is classified by the EPA Secondhand smoke is classified by the EPA as a known cause of lung canceras a known cause of lung cancer

• Is a serious asthma triggerIs a serious asthma trigger

• EPA estimates that between 200,000 - EPA estimates that between 200,000 - 1,000,000 asthmatic children are affected1,000,000 asthmatic children are affected

Smoking Interventions

• Stop smokingStop smoking

• Smoke outsideSmoke outside

• Enforce smoking bans on school propertyEnforce smoking bans on school property

• Enroll in a smoking cessation programEnroll in a smoking cessation program

• Get help from physicianGet help from physician

• Take the Smoke-Free PledgeTake the Smoke-Free Pledge

It’s Okay to Let People Know Smoking Around People with Asthma Is Not Cool

Remember Other Sources of Secondhand Smoke

Dust Mites

• Found in most homesFound in most homes

• Live in soft beddingLive in soft bedding

• Feed on skin flakesFeed on skin flakes

• Mites and mite Mites and mite droppings can be droppings can be asthma triggersasthma triggers

• Can cause children to Can cause children to develop asthmadevelop asthma

Dust Mites

• Evidence suggests that Evidence suggests that avoidance can effectively avoidance can effectively reduce allergic symptomsreduce allergic symptoms

• Dust mites feed on skin Dust mites feed on skin scales and organic scales and organic materials found in homesmaterials found in homes

• Need RH of 55% or moreNeed RH of 55% or more

NCICAS - Hospitalization, Allergy, Exposure

0

0.05

0.1

0.15

0.2

0.25

1. (-) low 2. (-) high 3. (+) low 4. (+) high

Rosenstreich et al. NEJM 1997; 336: 1556Rosenstreich et al. NEJM 1997; 336: 1556

p = 0.88p = 0.88

Dust Mites

Avoiding Dust Mite Triggers

• Wash sheets and Wash sheets and blankets once a week in blankets once a week in hot waterhot water

• Cover mattresses and Cover mattresses and pillows in dust-proof pillows in dust-proof (allergen-impermeable) (allergen-impermeable) zippered coverszippered covers

Avoiding Dust Mite Triggers

• Choose washable Choose washable stuffed toys, wash stuffed toys, wash them often in hot them often in hot water, and dry water, and dry thoroughly -- keep thoroughly -- keep stuffed toys off bedsstuffed toys off beds

– Freezing soft toys Freezing soft toys and small itemsand small items

Avoiding Dust Mite Triggers• Vacuum often (when Vacuum often (when

asthmatic is not present)asthmatic is not present)

• Maintain low indoor humidity, Maintain low indoor humidity, ideally between 30-50% ideally between 30-50% 

• Replace carpets, draperies, Replace carpets, draperies, and upholsteryand upholstery

Pets• Skin flakes, urine, and Skin flakes, urine, and

saliva of warm blooded saliva of warm blooded animals can be asthma animals can be asthma triggerstriggers

• Triggers can remain in the Triggers can remain in the home for several months home for several months after a pet is removed, even after a pet is removed, even with cleaningwith cleaning

Warm Blooded Animals Includes….

• DogsDogs

• CatsCats

• BirdsBirds

• CowsCows

• HorsesHorses

• RodentsRodents

Pet Interventions• Consider keeping pets outdoors or even finding Consider keeping pets outdoors or even finding

a new home for your pets, if necessarya new home for your pets, if necessary

• Wash weeklyWash weekly

Pet Interventions

• Keep out of Keep out of bedroombedroom

• Restrict to one Restrict to one areaarea

Pet Interventions

• Remove carpetingRemove carpeting

• Vacuum carpetingVacuum carpeting

• Use high-efficiency Use high-efficiency air cleanersair cleaners

Avoiding Pet Triggers• Keep pets away Keep pets away

from fabric-covered from fabric-covered furniture, carpets, furniture, carpets, and stuffed toysand stuffed toys

• If you remove an If you remove an animal from the animal from the home, clean the home, clean the home thoroughlyhome thoroughly

Molds

• Molds grow on damp materialsMolds grow on damp materials

• Found in basements, bathrooms, kitchens, Found in basements, bathrooms, kitchens, outdoorsoutdoors

Molds• Can be found almost anywhere and can grow on Can be found almost anywhere and can grow on

virtually any damp substancevirtually any damp substance• Key to mold control is moisture controlKey to mold control is moisture control• Clean up the mold Clean up the mold andand get rid of excess water or get rid of excess water or

moisturemoisture• Reducing moisture also helps reduce other Reducing moisture also helps reduce other

triggers, such as dust mites and cockroachestriggers, such as dust mites and cockroaches

Mold Intervention

• Use dehumidifiersUse dehumidifiers

• Provide adequate Provide adequate

ventilationventilation

• Use exhaust fans when Use exhaust fans when

cookingcooking

• No carpeting over No carpeting over

cement flooringcement flooring

Mold Intervention• Vent showersVent showers

• Do allow standing Do allow standing

waterwater

• Frequent inspections Frequent inspections

for moldfor mold

Avoiding Mold Triggers• Wash mold off hard surfaces Wash mold off hard surfaces

and dry completelyand dry completely

• Absorbent materials (ceiling Absorbent materials (ceiling tiles and carpet) may need to tiles and carpet) may need to be replacedbe replaced

• Fix leaky plumbing or other Fix leaky plumbing or other sources of watersources of water

• Keep drip pans in your air Keep drip pans in your air conditioner, refrigerator, and conditioner, refrigerator, and dehumidifier clean and drydehumidifier clean and dry

• Use exhaust fans or open Use exhaust fans or open windows in kitchens and windows in kitchens and bathrooms when showering, bathrooms when showering, cooking, or using the cooking, or using the dishwasherdishwasher

• Vent clothes dryers to the Vent clothes dryers to the outsideoutside

• Maintain low indoor Maintain low indoor humidity (between 30-50% humidity (between 30-50% relative humidity)relative humidity)

Cockroaches• Require a water/food sourceRequire a water/food source

• Over 3500 different speciesOver 3500 different species

• An inner city problem (85% of homes with An inner city problem (85% of homes with

children)children)

• Inner city schools also a concern (Baltimore Inner city schools also a concern (Baltimore

69% of dust samples)69% of dust samples)

• Become airborne (similar to dust mites)Become airborne (similar to dust mites)

Cockroaches

• Droppings or body parts of Droppings or body parts of cockroaches can be asthma triggerscockroaches can be asthma triggers

• Cockroaches likely contribute Cockroaches likely contribute significantly to asthma problems in significantly to asthma problems in inner city areainner city area

• Free your home of places for pests to Free your home of places for pests to hide and sources of food and waterhide and sources of food and water

NCICAS - Asthma Morbidity - ED Visits

0

0.5

1

1.5

2

2.5

1. (-) low 2. (-) high 3. (+) low 4. (+) high

p < 0.001p < 0.001

CockroachCockroach

Rosenstreich et al. NEJM 1997; 336: 1556Rosenstreich et al. NEJM 1997; 336: 1556

NCICAS - Hospitalization, Allergy, Exposure

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

1. (-) low 2. (-) high 3. (+) low 4. (+) high

Rosenstreich et al. NEJM 1997; 336: 1556Rosenstreich et al. NEJM 1997; 336: 1556

p = 0.001p = 0.001

CockroachCockroach

Relations Among Skin Test and Morbidity

• Children with sensitization and high Children with sensitization and high exposure to cockroach have:exposure to cockroach have:– More symptomatic daysMore symptomatic days– More nights of lost sleepMore nights of lost sleep– More school days missedMore school days missed– More days of caregiver change in plansMore days of caregiver change in plans

Cockroach Intervention• Education that emphasizes:Education that emphasizes:

– Do not leave food or garbage Do not leave food or garbage out out

• Place trash outside Place trash outside

– Store food in airtight Store food in airtight containerscontainers

– Clean all food crumbs or Clean all food crumbs or spilled liquids right away spilled liquids right away

– Washing dishes dailyWashing dishes daily

– Seal off ports of entrySeal off ports of entry

– Remove standing waterRemove standing water

Cockroaches Eradication• Try using poison baits, boric acid,

or traps first before using pesticide sprays

• If sprays are used:

• Limit the spray to infested area

• Carefully follow instructions on the label

• Make sure there is plenty of fresh air when you spray, and keep the person with asthma out of the room

Allergen Exposure Sources• SchoolsSchools

– Cockroach allergenCockroach allergen• detectable in 69% of samples from 4 urban schools detectable in 69% of samples from 4 urban schools

(Sarpong, et al. JACI 1997; 99:486)(Sarpong, et al. JACI 1997; 99:486)

• elevated in mostelevated in most

– CatCat– Dust mite ??Dust mite ??

• Infestation/TransportedInfestation/Transported

Targeting the Indoor Environment...

• Home EnvironmentHome Environment

– BedroomBedroom

– KitchenKitchen

– BathroomBathroom

– BasementBasement

– Living AreaLiving Area

Bedroom

•Access to animalsAccess to animals

•Pillow and beddingPillow and bedding

•Stuffed animalsStuffed animals

•DustDust

Bathroom / Kitchen

• Moldy surfacesMoldy surfaces

• Standing garbageStanding garbage

• Food containers left Food containers left

unopenedunopened

• Venting of cooking Venting of cooking

fumes/vaporfumes/vapor

Living Area

• Sofa and upholstered Sofa and upholstered

chairschairs

• CarpetingCarpeting

• FireplaceFireplace

Basement

• Moldy surfacesMoldy surfaces

• Carpeting over Carpeting over

cement floorcement floor

• Filtering at furnaceFiltering at furnace

Outdoor Environment

• GrassesGrasses

• PollensPollens

• PollutionPollution

• Time of dayTime of day

• TemperatureTemperature

Respiratory Therapist Interventions

• Symptom assessmentSymptom assessment

• Asthma historyAsthma history

• Scoring of symptoms and triggersScoring of symptoms and triggers

• Environmental assessmentEnvironmental assessment

• Skill/knowledge assessmentSkill/knowledge assessment

• Patient focused educationPatient focused education

• Action planAction plan

Resources and InformationEnvironmental Protection Agency Asthma Website

www.epa.gov/iaq/asthma

EPA Indoor Air Quality Information Clearinghouse (800) 438-4318

Allergy and Asthma Network/Mothers of Asthmatics (800) 878-4403 www.aanma.org

American Academy of Allergy, Asthma and Immunology (800) 822-2762 www.aaaai.org

American Lung Association (800) LUNG-USA

www.lungusa.org

Asthma and Allergy Foundation of America (800) 7-ASTHMA www.aafa.org

American Association for Respiratory Care (972) 243-2272

www.aarc.org

REPORTS

Clearing the Air: Asthma and Indoor Air Exposures, National Academy of Sciences http://books.nap.edu/books/0309064961/html

Guidelines for the Diagnosis and Management of Asthma, 1997, National Asthma Education and Prevention Program

(301) 592-8573

Getting Others To Take Action

• Take the recommended actions, and encourage others to do Take the recommended actions, and encourage others to do

so tooso too

• Smoke-Free Home Pledge (800) 513-1157Smoke-Free Home Pledge (800) 513-1157

• Indoor Air Quality Tools For Schools (800) 438-4318Indoor Air Quality Tools For Schools (800) 438-4318

• Secondhand Smoke Community Action Kit (800) 438-4318Secondhand Smoke Community Action Kit (800) 438-4318

• ALA ALA Open AirwaysOpen Airways for schools (800) LUNG-USA for schools (800) LUNG-USA

• ALA ALA A is for AsthmaA is for Asthma in local Headstart or daycare center in local Headstart or daycare center

• AAFA Childcare trainingAAFA Childcare training

US Environmental

Protection Agency

Indoor Air Quality

Clearinghouse

www.epa.gov/asthma

800-438-4318

US Environmental

Protection Agency

Indoor Air Quality

Clearinghouse

www.epa.gov/asthma

800-438-4318

American Association For

Respiratory Care

www.aarc.org

972 243-2272

American Association For

Respiratory Care

www.aarc.org

972 243-2272