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Key Educational Messages for Patients:Key Educational Messages for Patients:Environmental ManagementEnvironmental Management
of Asthmaof Asthma
April 21, 2009April 21, 2009
Karen Meyerson, MSN, RN, FNP-C, AE-CKaren Meyerson, MSN, RN, FNP-C, AE-CAsthma Network of West MichiganAsthma Network of West Michigan
Patient EducationPatient Education
The goal of all patient education is to The goal of all patient education is to help patients take the actions needed help patients take the actions needed
to control their asthma.to control their asthma.
Key Educational Messages Key Educational Messages
Teach and reinforce at every opportunityTeach and reinforce at every opportunity Basic facts about asthmaBasic facts about asthma
Differences between the airways of those with and without asthmaDifferences between the airways of those with and without asthma
Role of inflammationRole of inflammation
What happens to the airways during an asthma attackWhat happens to the airways during an asthma attack Role of MedicationsRole of Medications
Long-term controlLong-term control• Prevent symptoms, often by reducing inflammationPrevent symptoms, often by reducing inflammation• Must be taken dailyMust be taken daily• Do not expect them to provide quick reliefDo not expect them to provide quick relief
Quick-reliefQuick-relief• SABAs relax airway muscles to provide quick reliefSABAs relax airway muscles to provide quick relief• Do not expect them to provide long-term controlDo not expect them to provide long-term control• Using SABAs Using SABAs >> 2 times/week indicates the need for starting or 2 times/week indicates the need for starting or
increasing long-term controlincreasing long-term control
Key Educational Messages Key Educational Messages continuedcontinued
Patient SkillsPatient Skills Taking medications correctlyTaking medications correctly
• Inhaler technique and use of devicesInhaler technique and use of devices
Identifying and avoiding environmental exposuresIdentifying and avoiding environmental exposures• AllergensAllergens• Irritants – including smokeIrritants – including smoke
Self-monitoringSelf-monitoring• Assess level of controlAssess level of control• Monitor symptoms Monitor symptoms ++PEFPEF• Recognizes early s/s of worsening asthma Recognizes early s/s of worsening asthma
Using a written asthma action plan to know when and how to:Using a written asthma action plan to know when and how to:• Take daily actions to control asthmaTake daily actions to control asthma• Adjust medications in response to worsening asthmaAdjust medications in response to worsening asthma
Seeking medical care as appropriateSeeking medical care as appropriate
Simple??Simple??
Basic facts about asthmaBasic facts about asthma
3 items3 items Role of medicationsRole of medications
2 items2 items
Each with 3 sub-itemsEach with 3 sub-items Patient skillsPatient skills
5 items5 items• 8 sub-items with several sub-items8 sub-items with several sub-items
= 22 items!= 22 items!
How to Approach When Many Items?How to Approach When Many Items?
““Chunking”Chunking”
Basic facts about asthmaBasic facts about asthma• Differences between the airways of those with and without Differences between the airways of those with and without
asthmaasthma• Role of inflammationRole of inflammation• What happens to the airways during an asthma attackWhat happens to the airways during an asthma attack
Build on life experiencesBuild on life experiences
Use problem-based learningUse problem-based learning
Focus on “need to know”Focus on “need to know”
Deliver important messages up front and repeat at the Deliver important messages up front and repeat at the end of the visit/callend of the visit/call
How to Approach When Concepts are How to Approach When Concepts are Complex?Complex?
Orient to discernable human anatomyOrient to discernable human anatomy Use analogiesUse analogies
TitanicTitanic
Burn on skinBurn on skin
Relate to other life experiencesRelate to other life experiences Diabetes, hypertension are “silent” but damage is occurringDiabetes, hypertension are “silent” but damage is occurring
What is Health Literacy?What is Health Literacy?
The ability to read, understand, and effectively use basic The ability to read, understand, and effectively use basic medical instructions and information. Low health literacy can medical instructions and information. Low health literacy can affect anyone of any age, ethnicity, background or education affect anyone of any age, ethnicity, background or education level.level.
People with low health literacy:People with low health literacy: Often less likely to comply with prescribed treatment and self-care Often less likely to comply with prescribed treatment and self-care
regimensregimens
Fail to seek preventive care and are at higher (more than double) risk Fail to seek preventive care and are at higher (more than double) risk for hospitalizationfor hospitalization
Remain in the hospital nearly two days longer than adults with higher Remain in the hospital nearly two days longer than adults with higher health literacyhealth literacy
Often require additional care that results in annual health care costs Often require additional care that results in annual health care costs that are four times higher than those with higher literacy skills.that are four times higher than those with higher literacy skills.
Health Literacy and Social DemandsHealth Literacy and Social Demands
Health literacy is a function of individuals’ skills and social Health literacy is a function of individuals’ skills and social demandsdemands
Sophisticated vocabularySophisticated vocabulary Legal jargonLegal jargon
Medical jargonMedical jargon
Conceptual understanding of risks and benefitsConceptual understanding of risks and benefits Use of scales and measuresUse of scales and measures Decision making under unusual circumstancesDecision making under unusual circumstances Comfort with asking questions (question authority)Comfort with asking questions (question authority) Offer informed consentOffer informed consent
The Harvard School of Public Health: Health Literacy The Harvard School of Public Health: Health Literacy Studies Web Site. Studies Web Site.
http:www.hsph.harvard.edu/healthliteracy. http:www.hsph.harvard.edu/healthliteracy.
Health LiteracyHealth Literacy
You may not know which patients have low health literacy You may not know which patients have low health literacy because:because: They are often embarrassed or ashamed to admit they have difficulty They are often embarrassed or ashamed to admit they have difficulty
understanding health information and instructions.understanding health information and instructions.
They are using well-practiced coping mechanisms that effectively mask They are using well-practiced coping mechanisms that effectively mask their problem.their problem.
The average American reads at the 8th-9th grade level; The average American reads at the 8th-9th grade level; however, health information is usually written at a higher however, health information is usually written at a higher reading level.reading level.
Most patients - regardless of their reading or language skills - Most patients - regardless of their reading or language skills - prefer medical information that is simple and easy to prefer medical information that is simple and easy to understand.understand.
Additional factors that may hinder understanding include: Additional factors that may hinder understanding include: Intimidation, fear, vulnerability Intimidation, fear, vulnerability
Extenuating stress within the patient's family Extenuating stress within the patient's family
Multiple health conditions to understand and treat Multiple health conditions to understand and treat
Foreign languageForeign language: Some words have several : Some words have several meanings – trigger, peak flow, scale, meanings – trigger, peak flow, scale, environment, normal, symptomsenvironment, normal, symptoms
Reading labelsReading labels: We rarely say “pass the sodium”: We rarely say “pass the sodium”
Informed ConsentInformed Consent: “I have discussed the likelihood of : “I have discussed the likelihood of major risks or complications from this procedure (if major risks or complications from this procedure (if applicable) but not limited to…”applicable) but not limited to…”
Reading instructionsReading instructions: “Take one teaspoon by : “Take one teaspoon by mouth”… can everyone recognize a teaspoon?mouth”… can everyone recognize a teaspoon?
Pictures as tools?Pictures as tools? One interpretation: “After One interpretation: “After exposure to radiation, it is important to consider exposure to radiation, it is important to consider that you may have mutated to gigantic that you may have mutated to gigantic dimensions; watch your head…”dimensions; watch your head…”
Health Literacy BarriersHealth Literacy Barriers
Health Literacy: What Can We Do?Health Literacy: What Can We Do?Ask Me 3Ask Me 3
Ask Me 3Ask Me 3 promotes three simple but essential questions promotes three simple but essential questions that patients should ask their providers in every health that patients should ask their providers in every health care interaction. Providers should always encourage their care interaction. Providers should always encourage their patients to understand the answers to: patients to understand the answers to:
1.1. What is my main problem?What is my main problem?
2.2. What do I need to do?What do I need to do?
3.3. Why is it important for me to Why is it important for me to
do this?do this?
www.askme3.org
Asthma TriggersAsthma Triggers
A variety of stimuli or “triggers” can A variety of stimuli or “triggers” can cause airway inflammation (swelling) cause airway inflammation (swelling) and bring on an asthma flareand bring on an asthma flare
Eliminating or reducing exposure to Eliminating or reducing exposure to these triggers will decrease the need these triggers will decrease the need for asthma medications and reduce for asthma medications and reduce symptomssymptoms
Asthma TriggersAsthma Triggers
Description:Description: Agent or factor that Agent or factor that
contributes to asthma contributes to asthma
severityseverity Additive in natureAdditive in nature Variable sensitivityVariable sensitivity Trigger locations: home, school, Trigger locations: home, school,
workplace, outdoors, workplace, outdoors,
car, entertainmentcar, entertainment Step-wise levels of control:Step-wise levels of control:
• Keep bedroom “asthma-safe”Keep bedroom “asthma-safe”
Categories of TriggersCategories of Triggers
AllergensAllergens IrritantsIrritants Respiratory Infections (colds)Respiratory Infections (colds) ExerciseExercise Weather ChangesWeather Changes StressStress Other TriggersOther Triggers
Classification of Environmental TriggersClassification of Environmental Triggers
AllergensAllergens IrritantsIrritants
IndoorIndoor
AnimalsAnimals Dust mitesDust mites CockroachesCockroaches MoldsMolds
OutdoorOutdoor
PollensPollens
-- Trees-- Trees
-- Grasses-- Grasses
-- Weeds-- Weeds MoldsMolds
Environmental Environmental tobacco smoketobacco smoke
Combustion by-Combustion by-products - wood products - wood smokesmoke
Outdoor air pollutantsOutdoor air pollutants Scented or unscented Scented or unscented
consumer products consumer products Cold airCold air
Why Indoor Air?Why Indoor Air?
>90% of time is spent indoors – “Annette Funicello >90% of time is spent indoors – “Annette Funicello Phenomenon”Phenomenon”
Outdoor air pollutants come insideOutdoor air pollutants come inside
Pollutants are added to indoor airPollutants are added to indoor air
Health effectsHealth effects Respiratory irritantsRespiratory irritants
AllergensAllergens
Fetal effectsFetal effects
Reducing exposure to indoor allergens and irritants Reducing exposure to indoor allergens and irritants can reduce asthma symptomscan reduce asthma symptoms
Prevention is an important asthma management toolPrevention is an important asthma management tool
Common Indoor Air PollutantsCommon Indoor Air Pollutants
Asthma triggersAsthma triggers• Chemical Chemical
• BiologicalBiological
Second-hand SmokeSecond-hand Smoke Cleaners, fragrancesCleaners, fragrances Products of Incomplete combustionProducts of Incomplete combustion
• Carbon MonoxideCarbon Monoxide
Outdoor air pollutants entering homeOutdoor air pollutants entering home MoldsMolds
Triggers - AllergensTriggers - Allergens
““An allergy is a condition in which the body’s An allergy is a condition in which the body’s immune system overreacts to a foreign substance immune system overreacts to a foreign substance that has been breathed in, swallowed, touched, or that has been breathed in, swallowed, touched, or injected.”injected.”11
Allergic reaction - body identifies a normally Allergic reaction - body identifies a normally harmless object as an invader and reacts.harmless object as an invader and reacts.11
Approximately 70% to 90% of children with Approximately 70% to 90% of children with asthma have allergyasthma have allergy22, and 50% of adults with , and 50% of adults with asthma have allergies.asthma have allergies.11
11Plaut, T, Asthma Guide for People of All Ages, 1999, p. 58.Plaut, T, Asthma Guide for People of All Ages, 1999, p. 58.2 2 Pediatric Asthma Guide for Managing Asthma in Children, 1999. Pediatric Asthma Guide for Managing Asthma in Children, 1999.
Pets: Leashing the DanderPets: Leashing the Dander
Dander, urine, feces, and salivaDander, urine, feces, and saliva
Allergens are present even in homes and public Allergens are present even in homes and public places that do not contain animals.places that do not contain animals.
Keep pet out of main living areas and bedrooms.Keep pet out of main living areas and bedrooms.
Install HEPA air cleaners in main living areas and Install HEPA air cleaners in main living areas and bedrooms.bedrooms.
Avoid furry and feathered pets and products Avoid furry and feathered pets and products made with feathers - e.g., pillows and comfortersmade with feathers - e.g., pillows and comforters
Pets: Leashing the DanderPets: Leashing the Dander
Use a vacuum cleaner with integral Use a vacuum cleaner with integral HEPA filter and double-thickness bagsHEPA filter and double-thickness bags
Remove pet from home, if necessaryRemove pet from home, if necessary
www.petfinder.org - website for adoption/ foster - website for adoption/ foster care, will not destroy animals if no home is foundcare, will not destroy animals if no home is found
Even if clean aggressively after removal, allergen Even if clean aggressively after removal, allergen levels fall over a period of weeks to monthslevels fall over a period of weeks to months
Controversial: Some studies have found pet Controversial: Some studies have found pet washing ineffectivewashing ineffective
RodentsRodents Rodent proteins are potent sources of Rodent proteins are potent sources of
allergensallergens
Major allergens are found in urineMajor allergens are found in urine
Rodent allergens accumulate in high quantities in the Rodent allergens accumulate in high quantities in the litter, which is a major source of airborne allergenlitter, which is a major source of airborne allergen
NCICASNCICAS 33% inner city homes33% inner city homes
21% rat sensitivity21% rat sensitivity
21% in bedroom21% in bedroom
Related to missed school, ER visits, hospitalizationsRelated to missed school, ER visits, hospitalizationsJ Allergy Clin Immun, Aug 03J Allergy Clin Immun, Aug 03
Managing the MitesManaging the Mites The #1 indoor allergenThe #1 indoor allergen
Perennial with seasonal increases in summer and fallPerennial with seasonal increases in summer and fall
Major allergen contained in fecal pelletsMajor allergen contained in fecal pellets
Particles settle quickly after disturbance such that most Particles settle quickly after disturbance such that most mite exposure occurs when we are in intimate contact with mite exposure occurs when we are in intimate contact with themthem
Make bedroom “asthma safe”Make bedroom “asthma safe”
• Encase mattress, pillow, and box springs in allergen-Encase mattress, pillow, and box springs in allergen-impermeable coverimpermeable cover
• Reduce clutterReduce clutter
• Clean and dust weeklyClean and dust weekly
• Replace carpets with linoleum or woodReplace carpets with linoleum or wood
Managing the MitesManaging the Mites
Reduce indoor humidity to < 50% (air conditioning Reduce indoor humidity to < 50% (air conditioning or a dehumidifier - esp. in basement - may be or a dehumidifier - esp. in basement - may be helpful)helpful)
Use humidifiers/vaporizers with caution Use humidifiers/vaporizers with caution Wash bed linens weekly in hot water (Wash bed linens weekly in hot water (>> 130°F). 130°F). Minimize upholstered furnitureMinimize upholstered furniture Replace blinds with shades or easily washable Replace blinds with shades or easily washable
curtainscurtains Hot wash/freeze soft toysHot wash/freeze soft toys Remove carpets from the bedroom, and carpets in Remove carpets from the bedroom, and carpets in
other rooms laid on concreteother rooms laid on concrete
CockroachesCockroaches
Cockroach saliva, feces, skin shedding, Cockroach saliva, feces, skin shedding, and dead bodies decay and become airborneand dead bodies decay and become airborne
Levels in bedroom may be most associated with Levels in bedroom may be most associated with sensitization and diseasesensitization and disease
Significant levels have been found in inner-city Significant levels have been found in inner-city schoolsschools
Cockroach is Cockroach is thethe dominant indoor allergen in many dominant indoor allergen in many urban areas – sensitivity found in 30-50% of inner-urban areas – sensitivity found in 30-50% of inner-city children with asthmacity children with asthma
Exposure and sensitivity is BEST predictor of Exposure and sensitivity is BEST predictor of asthma morbidity in the NCICAS (asthma study)asthma morbidity in the NCICAS (asthma study)
Controlling CockroachesControlling Cockroaches
Block their entrances - caulk or seal cracks Block their entrances - caulk or seal cracks in plaster, flooringin plaster, flooring
Dry them out - reduce humidityDry them out - reduce humidity
Do not leave garbage or food exposedDo not leave garbage or food exposed
Use poison bait, gel, or traps to controlUse poison bait, gel, or traps to control
Use professional extermination services, if necessary – keep Use professional extermination services, if necessary – keep person with asthma outperson with asthma out
Thorough cleaning after exterminationThorough cleaning after extermination
Extermination of neighborhood dwellingsExtermination of neighborhood dwellings
Possible to reduce allergen levels but not reduce disease Possible to reduce allergen levels but not reduce disease due to the degree of infestationdue to the degree of infestation
To Reduce Pests and Pesticide UseTo Reduce Pests and Pesticide UseIntegrated Pest ManagementIntegrated Pest Management
Dry them out Dry them out (reduce sources of water)(reduce sources of water)
SStarve them out tarve them out (reduce sources of food)(reduce sources of food)
Keep them out Keep them out
(reduce shelter)(reduce shelter) Least amount of least toxic pesticides, when needed Least amount of least toxic pesticides, when needed
(judicious, careful use of pesticides when needed (judicious, careful use of pesticides when needed and always Read the LABEL and use accordinglyand always Read the LABEL and use accordingly))
MoldsMolds
Molds are fungi that appear as cottony tuftsMolds are fungi that appear as cottony tufts
Reproduce by making and releasing spores, Reproduce by making and releasing spores, which range in size from 2 to 100 which range in size from 2 to 100 micrometersmicrometers
Spores become airborne when released by Spores become airborne when released by the mold or when disturbed through physical the mold or when disturbed through physical contactcontact
Certain molds contain substances called Certain molds contain substances called mycotoxins that act as irritants in both mycotoxins that act as irritants in both allergic and non-allergic peopleallergic and non-allergic people
MoldsMolds
Many molds are allergensMany molds are allergens
Mold allergy is related to asthma and asthma Mold allergy is related to asthma and asthma severity in children and adultsseverity in children and adults
Mold allergy is related to rhinitisMold allergy is related to rhinitis
Interior water damage is related to Interior water damage is related to respiratory disease in infants and childrenrespiratory disease in infants and children
High humidity and dampness in home permit High humidity and dampness in home permit the growth in heating, ventilating, and air the growth in heating, ventilating, and air conditioning (HVAC) units, dehumidifiers, conditioning (HVAC) units, dehumidifiers, damp insulation, plaster/drywall, and carpetsdamp insulation, plaster/drywall, and carpets
Managing MoldsManaging Molds
Repair leaks, clean moldy surfacesRepair leaks, clean moldy surfaces
Reduce indoor humidity to < 50% Reduce indoor humidity to < 50%
Avoid carpeting on cement floorsAvoid carpeting on cement floors
Use bathroom and kitchen exhaust fansUse bathroom and kitchen exhaust fans
Avoid handling wet leaves, compost piles, Avoid handling wet leaves, compost piles, wet newspapers, garden debris or soilwet newspapers, garden debris or soil
Professional mold testing may be indicatedProfessional mold testing may be indicated
Triggers - IrritantsTriggers - Irritants
Airway irritants are those inhaled substances that Airway irritants are those inhaled substances that trigger inflammation and resulting bronchospasm trigger inflammation and resulting bronchospasm in the hyperresponsive airways of those individuals in the hyperresponsive airways of those individuals with asthma (i.e., no IgE involvement).with asthma (i.e., no IgE involvement).
Tobacco SmokeTobacco Smoke
Tobacco Smoke-Universal IrritantTobacco Smoke-Universal Irritant
ActiveActive (Primary)(Primary)
• Direct assault on lungs (and Direct assault on lungs (and
throughout the body)throughout the body)
Passive (Secondary)Passive (Secondary)
• Environmental Tobacco Smoke (ETS) Environmental Tobacco Smoke (ETS)
Non Smokers’ Movement of Australia, 1997 - 2001.Non Smokers’ Movement of Australia, 1997 - 2001.U.S.Environmental Protection Agency. Fact Sheet: U.S.Environmental Protection Agency. Fact Sheet: Respiratory Health Effects of Passive SmokingRespiratory Health Effects of Passive Smoking” 1993” 1993
Tobacco SmokeTobacco Smoke
Tobacco Smoke - effects of active and passive (ETS) Tobacco Smoke - effects of active and passive (ETS) exposure on asthma patients:exposure on asthma patients:
Contains more than 4,000 substances (over 40 Contains more than 4,000 substances (over 40 are carcinogenic)are carcinogenic)
Profound irritation of the upper airwayProfound irritation of the upper airway
Increased incidence of lower respiratory tract Increased incidence of lower respiratory tract infectionsinfections
Increased frequency of asthma exacerbationsIncreased frequency of asthma exacerbations
Can lead to development of asthma in pre-Can lead to development of asthma in pre-school age childrenschool age children
Tobacco Control MeasuresTobacco Control Measures
Realistic, supportive approachRealistic, supportive approach Impact of health care professional’s warning - Do Impact of health care professional’s warning - Do
not smokenot smoke Educate about negative health effects of ETS Educate about negative health effects of ETS
exposureexposure Practical plan of control:Practical plan of control:
• Smoke outdoorsSmoke outdoors
• Use “smoking jacket”Use “smoking jacket”
• Never allow smoking in carNever allow smoking in car
• Choose smoke-free child care settingsChoose smoke-free child care settings
CotinineCotinine Cotinine* is a major metabolite of nicotineCotinine* is a major metabolite of nicotine
Exposure to nicotine can be measured by Exposure to nicotine can be measured by analyzing cotinine levels in the blood, saliva, or analyzing cotinine levels in the blood, saliva, or urineurine
Nicotine is highly specific for tobacco smoke so Nicotine is highly specific for tobacco smoke so serum cotinine levels track exposure to tobacco serum cotinine levels track exposure to tobacco smoke and its toxic constituentssmoke and its toxic constituents
Recent study (Mannino, et al. CHEST 2002) Recent study (Mannino, et al. CHEST 2002) found that asthmatic children with high levels of found that asthmatic children with high levels of smoke exposure (compared to those with low smoke exposure (compared to those with low levels) were more likely to have moderate or levels) were more likely to have moderate or severe asthmasevere asthma
*CDC Fact Sheet – Exposure to Environmental Tobacco Smoke and Cotinine Levels, 2002.
Cotinine LevelsCotinine Levels
0.050 ng/mL 0.050 ng/mL limit of detectionlimit of detection 0.050 – 0.115 ng/mL 0.050 – 0.115 ng/mL low levellow level 0.116 – 0.6390.116 – 0.639 intermediate levelintermediate level 0.640 – 20 ng/mL 0.640 – 20 ng/mL high levelhigh level
Identifying Other IrritantsIdentifying Other Irritants
Other sources of smoke (e.g., Other sources of smoke (e.g., fireplaces, unvented stoves or heaters, wood fireplaces, unvented stoves or heaters, wood burning stoves, kerosene heaters, camp fires, burning stoves, kerosene heaters, camp fires, etc.)etc.)
Avoid outdoor fires, incl. leaf and grass firesAvoid outdoor fires, incl. leaf and grass fires
Outdoor or industrial pollutantsOutdoor or industrial pollutants
Other irritants (e.g., perfumes, cleaning Other irritants (e.g., perfumes, cleaning agents, sprays, cold air, etc.)agents, sprays, cold air, etc.)
Chemical OdorsChemical Odors
Given off from a variety of materials: Given off from a variety of materials: PaintPaint
SolventsSolvents
PesticidesPesticides
AdhesivesAdhesives
ParticleboardParticleboard
Vinyl flooring and tilesVinyl flooring and tiles
Dry-cleaned clothesDry-cleaned clothes
Toner from photocopiersToner from photocopiers
Cleaning agents used in homeCleaning agents used in home
Work-Related AsthmaWork-Related Asthma
Breathing for a Living:Breathing for a Living:
Definition:Definition: asthma caused by exposure to an asthma caused by exposure to an agent encountered in the work environmentagent encountered in the work environment
SensitizersSensitizers (e.g., isocyanates, plant or animal (e.g., isocyanates, plant or animal products)products)
IrritantsIrritants or physical stimuli (e.g., cold/heat, or physical stimuli (e.g., cold/heat, dust, humidity, smoke)dust, humidity, smoke)
Most common occupational respiratory Most common occupational respiratory disorder in industrialized countries.disorder in industrialized countries.
Global Initiative for AsthmaGlobal Initiative for Asthma, National Institutes of Health, 2002., National Institutes of Health, 2002.
Work-Related AsthmaWork-Related Asthma
Recognize patterns of symptoms:Recognize patterns of symptoms:
Timing of symptoms Timing of symptoms • Improvement during vacations or days off Improvement during vacations or days off
may take a week or moremay take a week or more• Symptoms worsen as work week progresses Symptoms worsen as work week progresses
Initial symptoms may occur after high-level Initial symptoms may occur after high-level exposure (e.g., “WTC cough,” Gulf War)exposure (e.g., “WTC cough,” Gulf War)
PEF variability of >20% between work and non-PEF variability of >20% between work and non-work suggests occupational asthmawork suggests occupational asthma
Work-Related AsthmaWork-Related Asthma Common triggers in the work or school setting:Common triggers in the work or school setting:
Mold and fungi (air ducts, plants, and books)Mold and fungi (air ducts, plants, and books)
Dust and dust mites (blinds, boxes, and papers in Dust and dust mites (blinds, boxes, and papers in storage rooms, and in carpeting)storage rooms, and in carpeting)
Copier fumes (from improperly vented machines)Copier fumes (from improperly vented machines)
Perfumes and colognes (from co-workers)Perfumes and colognes (from co-workers)
Tobacco smoke (may travel through air vents or flow Tobacco smoke (may travel through air vents or flow from smokers’ lounge)from smokers’ lounge)
CockroachesCockroaches
Cleaning productsCleaning products
Animals (classrooms)Animals (classrooms)
Work-Related AsthmaWork-Related Asthma
Discussion points:Discussion points:
Tobacco-free environmentTobacco-free environment
AvoidanceAvoidance• Change in job function or locationChange in job function or location• Adequate ventilationAdequate ventilation• Respiration protectionRespiration protection
Seek occupational asthma specialistsSeek occupational asthma specialists
Complete cessation of exposure to agent (not Complete cessation of exposure to agent (not always realistic) always realistic)
Polishing off the PollensPolishing off the Pollens
Limit exposure during season by staying indoors Limit exposure during season by staying indoors with windows closedwith windows closed
Monitor local weather forecast - monitor pollen Monitor local weather forecast - monitor pollen countcount
Use air conditioning, if possibleUse air conditioning, if possible
Optimize antihistamines and other allergy medsOptimize antihistamines and other allergy meds
Bathe the body - wash hands, face, and hair Bathe the body - wash hands, face, and hair after being outsideafter being outside
RhinitisRhinitis
Studies indicate that inflammation of the Studies indicate that inflammation of the upper airway contributes to lower airway upper airway contributes to lower airway hyperresponsiveness and asthma symptomshyperresponsiveness and asthma symptoms
Treatment of the upper respiratory tract is an Treatment of the upper respiratory tract is an integral part of asthma managementintegral part of asthma management
Symptoms include sneezing, runny or itchy nose Symptoms include sneezing, runny or itchy nose or congestion or congestion Exam: Clear discharge, crease in nose, dark circles Exam: Clear discharge, crease in nose, dark circles
under eyesunder eyes
The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.
RhinitisRhinitis
Allergic rhinitis - inflammation of tissue lining the Allergic rhinitis - inflammation of tissue lining the inside of the noseinside of the nose
Provoked by allergens and can be seasonal Provoked by allergens and can be seasonal (grasses, weeds, and trees), or year-round (molds, (grasses, weeds, and trees), or year-round (molds, dust mites, animal danders)dust mites, animal danders)
May increase sensitivity to triggersMay increase sensitivity to triggers
Treatment: avoid offending allergens, nasal Treatment: avoid offending allergens, nasal irrigation with saline, oral antihistamines and irrigation with saline, oral antihistamines and decongestants, inhaled nasal steroidsdecongestants, inhaled nasal steroids
The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.
Signs and Symptoms of Signs and Symptoms of Allergic RhinitisAllergic Rhinitis
Itchy, watery eyesItchy, watery eyes Red eyesRed eyes Itchy noseItchy nose SneezingSneezing Postnasal dripPostnasal drip Sore throatSore throat Sinus headachesSinus headaches Nasal obstructionNasal obstruction
CongestionCongestion Allergic shinersAllergic shiners Allergic creaseAllergic crease Watery, profuse nasal Watery, profuse nasal
dischargedischarge Ocular symptomsOcular symptoms FatigueFatigue
Joint Task Force RecommendationsJoint Task Force Recommendations
““Nasal steroids provide the most effective symptom Nasal steroids provide the most effective symptom relief of allergic rhinitis.”relief of allergic rhinitis.”
Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, November 1998.
Weather ChangesWeather Changes
Effect of weather is not the same in all seasons:Effect of weather is not the same in all seasons:
Fall - noticeable effect on asthma, esp. following Fall - noticeable effect on asthma, esp. following the first cold mass to come in the fallthe first cold mass to come in the fall
Summer - lowest number of ED visits because Summer - lowest number of ED visits because weather is least variable though high pollen and weather is least variable though high pollen and air pollutionair pollution
Spring - some day to day variability though not as Spring - some day to day variability though not as extreme as fall - high tree pollenextreme as fall - high tree pollen
American Lung Association, 2002.American Lung Association, 2002.
Weather ChangesWeather Changes
Cold air - airway irritant (esp. for those with EIB)Cold air - airway irritant (esp. for those with EIB)
Hot, humid air - patients report some SOB with Hot, humid air - patients report some SOB with increased humidity though mechanism unclear - increased humidity though mechanism unclear - molds?molds?
Wind - pollen and mold spores become airborne Wind - pollen and mold spores become airborne and more likely to be breathed in by susceptible and more likely to be breathed in by susceptible individualsindividuals
American Lung Association, 2002American Lung Association, 2002
Weather ChangesWeather Changes
Thunderstorms - Thunderstorms - (J of Epid and Comm Health, 1997)(J of Epid and Comm Health, 1997) 10 times the asthma-related calls made on the night of 10 times the asthma-related calls made on the night of storms compared to night of clear weatherstorms compared to night of clear weather Mechanism: winds blow in large amounts of allergens from Mechanism: winds blow in large amounts of allergens from
the countrysidethe countryside
Also, ozone is created by thunderstorms - well established Also, ozone is created by thunderstorms - well established asthma triggerasthma trigger
Barometric Pressure - patients refer to it as a “change Barometric Pressure - patients refer to it as a “change in weather.” Many anecdotal reports but lack of in weather.” Many anecdotal reports but lack of studies. studies. Key may be temperature fluctuations Key may be temperature fluctuations along withalong with increased increased
barometric pressure - need more data.barometric pressure - need more data. American Lung Association, 2002American Lung Association, 2002
Air PollutionAir Pollution
Consider the effect of weather on pollution:Consider the effect of weather on pollution:
““Inversion”: a weather system where air sits Inversion”: a weather system where air sits stillstill
Concentrates all the airborne pollutantsConcentrates all the airborne pollutants
Pollutants worsen asthma - act as irritantsPollutants worsen asthma - act as irritants
When heat and sunlight react with pollutants, When heat and sunlight react with pollutants, creates a large amount of ground-level creates a large amount of ground-level ozone - a well known asthma triggerozone - a well known asthma trigger
More likely to occur in larger citiesMore likely to occur in larger citiesAmerican Lung Association, 2002American Lung Association, 2002
Watching the WeatherWatching the Weather
Watching the WeatherWatching the Weather
Monitor the daily local weather forecastMonitor the daily local weather forecast
Monitor pollen count and smog indexMonitor pollen count and smog index
Limit exertion in cold, dry airLimit exertion in cold, dry air
Wear a scarf or mask over the nose and mouth when Wear a scarf or mask over the nose and mouth when outside in very cold weatheroutside in very cold weather
Stay indoors with windows closed on peak pollen days Stay indoors with windows closed on peak pollen days and especially on windy days during pollen seasonand especially on windy days during pollen season
Keep symptom diaryKeep symptom diaryAmerican Lung Association, 2002American Lung Association, 2002
Other Common Asthma Other Common Asthma TriggersTriggers
Exercise, GERD, Exercise, GERD, Pregnancy, Nocturnal Pregnancy, Nocturnal
Asthma, and Asthma, and Respiratory InfectionsRespiratory Infections
Exercise Induced Bronchospasm (EIB)Exercise Induced Bronchospasm (EIB)
Approximately 90% of asthmatics have exercise Approximately 90% of asthmatics have exercise as a triggeras a trigger
Caused by loss of heat and water from the Caused by loss of heat and water from the airways during exercise resulting in transient airways during exercise resulting in transient airflow obstructionairflow obstruction
Initially, bronchodilation occurs when Initially, bronchodilation occurs when catecholamines are releasedcatecholamines are released
This is followed by an after-exercise fall in PEFR This is followed by an after-exercise fall in PEFR associated with bronchoconstrictionassociated with bronchoconstriction
Sx: cough, SOB, chest pain/tightness, wheezing Sx: cough, SOB, chest pain/tightness, wheezing or endurance problems during exerciseor endurance problems during exercise
Canadian Lung Association, 2002.Canadian Lung Association, 2002.
EIBEIB
Dx.: exercise challenge or PEF or FEVDx.: exercise challenge or PEF or FEV11 (15% (15% decrease before and after exercise at 5 min. intervals decrease before and after exercise at 5 min. intervals for 20 - 30 min. is compatible with EIB).for 20 - 30 min. is compatible with EIB).
Early phase:Early phase: Usually begins during exercise and peaks 5 - 10 minutes Usually begins during exercise and peaks 5 - 10 minutes
after stopping the activityafter stopping the activity
Refractory period (“grace period”):Refractory period (“grace period”): After the initial bout of EIB, there may be less bronchospasm After the initial bout of EIB, there may be less bronchospasm
for up to 2 hoursfor up to 2 hours
Late phase:Late phase: Symptoms may occur again, beginning 3 to 10 hours after Symptoms may occur again, beginning 3 to 10 hours after
exercise exercise Canadian Lung Association, 2002.Canadian Lung Association, 2002.
Factors that Influence EIBFactors that Influence EIB
Cold air, low humidity, pollutantsCold air, low humidity, pollutants
Duration, type, and intensity of exerciseDuration, type, and intensity of exercise
Poor physical conditioningPoor physical conditioning
Inhaled allergens (in sensitive individuals)Inhaled allergens (in sensitive individuals)
Respiratory infectionsRespiratory infections
Poor level of asthma controlPoor level of asthma control
Emotional stress/fatigueEmotional stress/fatigue
Canadian Lung Association, 2002.Canadian Lung Association, 2002.
Ways to Reduce EIBWays to Reduce EIB Avoid exercise if symptoms are presentAvoid exercise if symptoms are present
Pre-medicate per doctor’s instructionsPre-medicate per doctor’s instructions
Adequate warm-up - at least 10 - 15 minutesAdequate warm-up - at least 10 - 15 minutes
Modified exerciseModified exercise
Avoid triggers that may cause or worsen EIB, i.e., cold air, high pollen Avoid triggers that may cause or worsen EIB, i.e., cold air, high pollen countcount
Adequate cool down - at least 10 minutesAdequate cool down - at least 10 minutes
Breathe through nose, if possible, to warm airBreathe through nose, if possible, to warm air
Exercise regularlyExercise regularly
Get adequate rest and drink plenty of fluidsGet adequate rest and drink plenty of fluidsCanadian Lung Association, 2002.Canadian Lung Association, 2002.
GERDGERD
Gastroesophageal reflux disease (GERD) - Gastroesophageal reflux disease (GERD) - acid from stomach contents stimulates nerve acid from stomach contents stimulates nerve endings in esophagus causing chronic coughendings in esophagus causing chronic cough
Symptoms include heartburn and sour tasteSymptoms include heartburn and sour taste
Acidic materials may also enter the airways Acidic materials may also enter the airways and trigger the asthma reaction - possible and trigger the asthma reaction - possible cause of nocturnal asthmacause of nocturnal asthma
Possible Causes of GERDPossible Causes of GERD
Combination of Combination of conditions that increase conditions that increase the presence of acid the presence of acid reflux in the esophagusreflux in the esophagus
Transient relaxation of Transient relaxation of the sphincter, delayed the sphincter, delayed gastric emptying, gastric emptying, decreased salivation decreased salivation and impaired and impaired esophageal clearanceesophageal clearance
Lifestyle factorsLifestyle factors
Risk Factors for GERDRisk Factors for GERD
SmokingSmoking Large mealsLarge meals Fatty foodsFatty foods CaffeineCaffeine PregnancyPregnancy ObesityObesity Body positionBody position DrugsDrugs HormonesHormones
How Does GERD How Does GERD Trigger Asthma?Trigger Asthma?
Refluxed material gets past the upper esophageal sphincter, it Refluxed material gets past the upper esophageal sphincter, it can aspirated into the larynx and tracheobronchial treecan aspirated into the larynx and tracheobronchial tree
Pulmonary symptoms may be caused by:Pulmonary symptoms may be caused by:
DirectDirect aspiration of acid into the bronchial tree (micro aspiration of acid into the bronchial tree (micro aspiration of stomach contents – usually during sleep)aspiration of stomach contents – usually during sleep)
IndirectlyIndirectly - acid leaking from the lower esophagus - acid leaking from the lower esophagus stimulates the vagus nerve which triggers stimulates the vagus nerve which triggers bronchoconstriction (even if symptoms of GERD are not bronchoconstriction (even if symptoms of GERD are not grossly apparent)grossly apparent)
Combination of two is also very likelyCombination of two is also very likely
GERD TreatmentGERD Treatment
Don’t smoke or drink alcoholic Don’t smoke or drink alcoholic beverages – they increase stomach acid beverages – they increase stomach acid production and cause irritationproduction and cause irritation
Avoid caffeine and chocolate – caffeine is a Avoid caffeine and chocolate – caffeine is a muscle relaxant and weakens the LES tonemuscle relaxant and weakens the LES tone
Avoid carbonated drinks, citrus, onions, Avoid carbonated drinks, citrus, onions, tomatoes, fatty and fried foods, peppermint, and tomatoes, fatty and fried foods, peppermint, and spicy foodsspicy foods
Wait 2 – 4 hours after eating before bending Wait 2 – 4 hours after eating before bending over, lying down or going to sleepover, lying down or going to sleep
GERD TreatmentGERD Treatment
Thick feedings – infantsThick feedings – infants
Elevate the head of your bed 6 – 8”Elevate the head of your bed 6 – 8”
Wear loose clothingWear loose clothing
Eat smaller meals more frequentlyEat smaller meals more frequently
Weight loss, if appropriateWeight loss, if appropriate
Use appropriate pharmacotherapyUse appropriate pharmacotherapy
Surgery for refractory cases – Nissen Surgery for refractory cases – Nissen fundoplicationfundoplication
Nocturnal AsthmaNocturnal Asthma
Normal fluctuations in circadian rhythmNormal fluctuations in circadian rhythm
Chemical and temperature changes in the body Chemical and temperature changes in the body during the night increase inflammation and during the night increase inflammation and narrowing of the airwaysnarrowing of the airways
Delayed allergic responses can occur from Delayed allergic responses can occur from exposure to allergens during the dayexposure to allergens during the day
Toward the early morning, the effect of inhaled Toward the early morning, the effect of inhaled medications may wear off and cause an medications may wear off and cause an exacerbationexacerbation
PregnancyPregnancy
Poorly controlled asthma during pregnancy can Poorly controlled asthma during pregnancy can result in increased perinatal mortality, increased result in increased perinatal mortality, increased prematurity, and low birth weight.prematurity, and low birth weight.
Maintaining sufficient lung function and blood Maintaining sufficient lung function and blood oxygenation to ensure adequate oxygen blood oxygenation to ensure adequate oxygen blood supply to the fetus is essential.supply to the fetus is essential.
For most medications used to treat asthma and For most medications used to treat asthma and rhinitis, there are little data to suggest an increased rhinitis, there are little data to suggest an increased risk to the fetus.risk to the fetus.
PregnancyPregnancy Most asthma medications are as safe to use in Most asthma medications are as safe to use in
pregnancy as in the non-pregnant state.pregnancy as in the non-pregnant state.
Budesonide is preferred ICS because more data Budesonide is preferred ICS because more data are available on its use in pregnant women.are available on its use in pregnant women.
Other ICS may be continued in patients who were Other ICS may be continued in patients who were well controlled on by these agents prior to well controlled on by these agents prior to pregnancy.pregnancy.
Little data on LTM during pregnancy but Little data on LTM during pregnancy but reassuring animal data; LABA safety profile similar reassuring animal data; LABA safety profile similar to albuterol (safety data available).to albuterol (safety data available).
It is safer for pregnant women with asthma to be It is safer for pregnant women with asthma to be treated with asthma medications than to have treated with asthma medications than to have asthma symptoms and exacerbations.asthma symptoms and exacerbations.
PregnancyPregnancy
Treating asthma is paramount. All long-term control Treating asthma is paramount. All long-term control medications and short-acting betamedications and short-acting beta22-agonists appear to be -agonists appear to be safe in pregnancy.safe in pregnancy. Inhaled meds preferred to oral agentsInhaled meds preferred to oral agents Exacerbations more common at the endExacerbations more common at the end of 2of 2ndnd trimester and the trimester and the
early 3early 3rdrd trimester trimester Medications with some possibility of risk to the fetus include:Medications with some possibility of risk to the fetus include:
Decongestants, some antibiotics, live virus vaccines, iodides, Decongestants, some antibiotics, live virus vaccines, iodides, brompheniramine, epinephrinebrompheniramine, epinephrine
For more information, see For more information, see Managing Asthma During Managing Asthma During Pregnancy: Recommendations for Pharmacologic Pregnancy: Recommendations for Pharmacologic Treatment Treatment (NAEPP, 2004)(NAEPP, 2004)
http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdfhttp://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdf
Nocturnal AsthmaNocturnal Asthma
An increase in acid reflux during the night may An increase in acid reflux during the night may cause airway constriction.cause airway constriction.
Postnasal drip that occurs during sleep may Postnasal drip that occurs during sleep may contribute to higher nighttime risk.contribute to higher nighttime risk.
Airway cooling secondary to drop in body Airway cooling secondary to drop in body temperature during sleep.temperature during sleep.
Sleep apnea in the upper airways may trigger Sleep apnea in the upper airways may trigger asthma exacerbation in the lower airways.asthma exacerbation in the lower airways.
Hormones have been found to follow the Hormones have been found to follow the circadian cycle that corresponds to changes in circadian cycle that corresponds to changes in lung function at night.lung function at night.
Respiratory InfectionsRespiratory Infections
Mechanisms:Mechanisms:
RSV, rhinovirus, and influenza virus have been RSV, rhinovirus, and influenza virus have been implicated.implicated.
May cause epithelial damage and airway May cause epithelial damage and airway inflammation.inflammation.
May be responsible for the generation and release May be responsible for the generation and release of allergic mediators. of allergic mediators.
Viruses have been shown to potentiate the allergic Viruses have been shown to potentiate the allergic response to allergens by increasing the release of response to allergens by increasing the release of inflammatory mediators. inflammatory mediators.
Global Initiative for AsthmaGlobal Initiative for Asthma, National Institutes of Health, 2002., National Institutes of Health, 2002.
Respiratory InfectionsRespiratory Infections
Risk for Patients with AsthmaRisk for Patients with Asthma May increase airway hyper-responsiveness for weeksMay increase airway hyper-responsiveness for weeks
Prevention/Control Prevention/Control Proper nutrition and restProper nutrition and rest
Annual influenza vaccine – injection, not nasal sprayAnnual influenza vaccine – injection, not nasal spray
Hand washingHand washing
keep hands away from facekeep hands away from face
Avoid those with active respiratory infectionAvoid those with active respiratory infection
Use antibiotics when appropriate for bacterial infectionsUse antibiotics when appropriate for bacterial infections