Managing Asthma In Minnesota Managing Asthma In Minnesota SchoolsSchools

“A Comprehensive Resource & “A Comprehensive Resource & Training for School PersonnelTraining for School Personnel””

Developed and Provided by:Developed and Provided by:

Presenter For TodayPresenter For Today

Susan K. Ross RN, AE-CSusan K. Ross RN, AE-C

MDH Asthma Program StaffMDH Asthma Program Staff651-201-5629 651-201-5629

Susan.Ross@health.state.mn.usSusan.Ross@health.state.mn.us

Minnesota Department of Minnesota Department of HealthHealth

www.health.state.mn.us/asthmawww.health.state.mn.us/asthma

Our Advisory Group consisted of participants Our Advisory Group consisted of participants from every region of the state!from every region of the state!See the acknowledgements page at the See the acknowledgements page at the beginning of the manual.beginning of the manual.

Special thanks to:Special thanks to: Denise Herrmann from SPPSDenise Herrmann from SPPSCecelia Erickson from MPSCecelia Erickson from MPS

““Healthy Learners Asthma Initiative”Healthy Learners Asthma Initiative”Cheryl Smoot MDHCheryl Smoot MDH

Funding grant awarded by:Funding grant awarded by: Centers for Disease Control and Prevention Centers for Disease Control and Prevention

(CDC(CDC) )

AcknowledgementsAcknowledgements

Thanks To:Thanks To:

• GlaxoSmith Kline PharmaceuticalsGlaxoSmith Kline Pharmaceuticals• AstraZeneca PharmaceuticalsAstraZeneca Pharmaceuticals• Starbright FoundationStarbright Foundation• Hennepin County Medical CenterHennepin County Medical Center For contributing PFM’s, Spacers, For contributing PFM’s, Spacers,

Diskus, asthma booklets and CD-Rom Diskus, asthma booklets and CD-Rom games for our participantsgames for our participants

Overview of TodayOverview of Today Asthma BasicsAsthma Basics

Asthma triggers and irritantsAsthma triggers and irritants Diagnostic/ assessment processDiagnostic/ assessment process NIH/NHLBI/NAEPP asthma guideline NIH/NHLBI/NAEPP asthma guideline

overviewoverview Severity level workoutSeverity level workout

Medication OverviewMedication Overview Asthma “gadgets”Asthma “gadgets”

Controlling AsthmaControlling Asthma Tools available (MDH website-Manual)Tools available (MDH website-Manual) Coordinated School HealthCoordinated School Health

Post Tests - Post Tests - Evaluations C.E.U’sEvaluations C.E.U’s

Complete the post testComplete the post testComplete the program Complete the program evaluationevaluationComplete your goals sheetComplete your goals sheetHand everything in before you Hand everything in before you leaveleaveYou will receive credit for 7.2 You will receive credit for 7.2 C.E.U’s C.E.U’s

after attending today's after attending today's presentationpresentation

As We Go Through This As We Go Through This ProgramProgram

Consider how you would use the Consider how you would use the tools provided today.tools provided today.

How can you take this information How can you take this information and use it to establish an asthma and use it to establish an asthma program in your school or district?program in your school or district?

How can you promote involvement How can you promote involvement by other school personnel outside by other school personnel outside the health office?the health office?

How To Use This ManualHow To Use This Manual

Resource and Training documentResource and Training document Each Section is all-inclusive to each staff Each Section is all-inclusive to each staff

member’s rolemember’s role Lift out the entire section - copy it and use as Lift out the entire section - copy it and use as

a basis for teaching about asthmaa basis for teaching about asthma Supplemental forms/handouts are in the Supplemental forms/handouts are in the

back folders and provided on CD and websiteback folders and provided on CD and website Full resources section w/websites are listedFull resources section w/websites are listed Power Point presentations are also on our Power Point presentations are also on our

asthma website and CD in back of your asthma website and CD in back of your manualmanual

You Should Know!You Should Know!

This manual contains This manual contains suggestionssuggestions for action and you are strongly urged for action and you are strongly urged to consult your school district policies to consult your school district policies and guidelines before implementing and guidelines before implementing these suggestions.these suggestions.

Staffing ModelsStaffing Models

School health staffing varies greatly School health staffing varies greatly across the entire stateacross the entire state

The manual provides a few The manual provides a few suggested staffing models in the suggested staffing models in the “All Health Staff” section“All Health Staff” section

Today’s program is based on a Today’s program is based on a school that has at least school that has at least somesome LSN/PHN/RN staffing in the school LSN/PHN/RN staffing in the school on regular basison regular basis

PRE- TEST

Mikey’s Mom Didn’t Mikey’s Mom Didn’t Know Asthma Could Know Asthma Could

Kill…Kill…

From GlaxoSmithKline andFrom GlaxoSmithKline andAllergy & Asthma Network, Mothers of Allergy & Asthma Network, Mothers of

Asthmatics (AANMA)Asthmatics (AANMA)

Did You Know..Did You Know..

Asthma kills people equally regardless Asthma kills people equally regardless of severity levelof severity level

1/3 of deaths are in those with 1/3 of deaths are in those with mildmild asthma asthma 1/3 of deaths are in those with 1/3 of deaths are in those with moderatemoderate

asthmaasthma 1/3 of deaths are in those with 1/3 of deaths are in those with severesevere

asthmaasthma

Asthma:Asthma: Accounts for 14 million lost school days Accounts for 14 million lost school days

annuallyannually33

Is the most common chronic disease Is the most common chronic disease causing absence from schoolcausing absence from school22

Is the 3Is the 3rdrd leading cause of hospitalizations leading cause of hospitalizations among children under 15among children under 1522

1 in 13 school children have asthma1 in 13 school children have asthma11

6.3 million children under 18 have asthma6.3 million children under 18 have asthma11

1 Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC1 Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC2 Morbidity and Mortality Report, National Center for Health Statistics (NCHS), U.S. CDC, 20032 Morbidity and Mortality Report, National Center for Health Statistics (NCHS), U.S. CDC, 2003

3 Surveillance for Asthma - United States, 1980-99, MMWR Surveillance Summaries, CDC, March 29, 20023 Surveillance for Asthma - United States, 1980-99, MMWR Surveillance Summaries, CDC, March 29, 2002

Minnesota ChildrenMinnesota Children

In a 2003 MDH survey of more than 5,000 In a 2003 MDH survey of more than 5,000 7th & 8th graders at 15 junior highs outside 7th & 8th graders at 15 junior highs outside

the metro area- the metro area-

1 in 121 in 12 reported they currently have reported they currently have asthmaasthma

In a 2001 MDH survey of 13,000, 9th - 11th In a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN-graders in rural MN-

1 in 111 in 11 reported they currently have reported they currently have asthmaasthma

This meansThis means....In a class of 30 children, you can In a class of 30 children, you can

expect expect

2 to 3 students 2 to 3 students WILLWILL have asthma have asthma

This number varies depending on age This number varies depending on age and geographical locationand geographical location

“ “ Healthy Children Learn Healthy Children Learn BetterBetter””

Do School Children Do School Children HaveHave Asthma Action Plans?Asthma Action Plans?

In MDH’s survey of 7th and 8th graders in In MDH’s survey of 7th and 8th graders in greater Minnesota:greater Minnesota:

37% of the children who had asthma did not 37% of the children who had asthma did not knowknow if they had a written asthma action if they had a written asthma action planplan

28% did not 28% did not havehave an asthma action plan an asthma action plan

Overall, only 34% of children who have Overall, only 34% of children who have asthma actually asthma actually hadhad asthma action plansasthma action plans

Asthma & ExerciseAsthma & Exercise

Of the 7th & 8th graders with asthma:Of the 7th & 8th graders with asthma: 80% reported wheezing 80% reported wheezing “sometimes“sometimes” or “” or “a a

lotlot” during or after running, playing sports ” during or after running, playing sports or exercisingor exercising

36% reported missing recess, sports or 36% reported missing recess, sports or other physical activities due to asthma other physical activities due to asthma symptomssymptoms

24% reported missing a day or more of 24% reported missing a day or more of school in the past year due to asthma school in the past year due to asthma symptomssymptoms

66% reported wheezing “66% reported wheezing “sometimessometimes” or “” or “a a lotlot””

Survey ConclusionsSurvey Conclusions

There is substantial uncontrolled asthma There is substantial uncontrolled asthma among school children in this age groupamong school children in this age group

This lack of control is manifested by the high This lack of control is manifested by the high rate of morbidity as measured by school rate of morbidity as measured by school absence and missed activities among absence and missed activities among children who have been diagnosed with children who have been diagnosed with asthmaasthma

The survey also suggests that there may be The survey also suggests that there may be substantial undiagnosed asthmasubstantial undiagnosed asthma

Impact Of Asthma On Impact Of Asthma On StudentsStudents

School Performance:School Performance:

Poorly controlled asthma has a Poorly controlled asthma has a negative impact on school negative impact on school performance in both academic performance in both academic achievement and physical educationachievement and physical education

Impact Of Asthma On Students Impact Of Asthma On Students cont...cont...

Psychosocial:Psychosocial: Poor self-esteemPoor self-esteem Anxiety about asthmaAnxiety about asthma Fear of becoming ill at schoolFear of becoming ill at school Anxiety about exercise at schoolAnxiety about exercise at school Fear of being differentFear of being different

YOU Can Make A YOU Can Make A Difference!Difference!

What Is Asthma?What Is Asthma?

Asthma is a chronic disease that causesAsthma is a chronic disease that causes::

BronchoconstrictionBronchoconstriction Inflammation of the bronchioles (small airways)Inflammation of the bronchioles (small airways) Hyper-responsive “twitchy” airwaysHyper-responsive “twitchy” airways Excessive mucus production in the bronchiolesExcessive mucus production in the bronchioles

Normal BronchioleNormal Bronchiole Inflamed Inflamed BronchioleBronchiole

with Mucus with Mucus

Airway ObstructionAirway Obstruction

Copyright 3M Pharmaceuticals 2004

A Lot Going On Beneath The A Lot Going On Beneath The SurfaceSurface

Airway inflammation

Airflow obstruction

Bronchial hyperresponsiveness

Symptoms

Slide courtesy of ALAMN - PACE program 2004

Immune System Immune System ResponseResponse

The Asthma CascadeThe Asthma Cascade

© 2003 Genentech, Inc. and Novartis Pharmaceuticals Corporation.

Mediator PhasesMediator Phases

Early-phase reaction caused by Early-phase reaction caused by mediator release, usually peaks mediator release, usually peaks within an hour after initial exposure within an hour after initial exposure to the allergen. to the allergen.

Three to four hours after an acute Three to four hours after an acute asthma episode, a "late-phase asthma episode, a "late-phase reaction" may occur and may last up reaction" may occur and may last up to 24 hoursto 24 hours

The End Results Of The The End Results Of The CascadeCascade

Localized mucosal edema in the Localized mucosal edema in the walls of the small bronchioleswalls of the small bronchioles

Secretion of thick mucus into the Secretion of thick mucus into the bronchiolar lumens bronchiolar lumens

((Clogs and narrows the airwaysClogs and narrows the airways)) Spastic contraction of bronchiolar Spastic contraction of bronchiolar

smooth muscle smooth muscle

A CHILD CAN’T BREATHEA CHILD CAN’T BREATHE

Group Straw ExerciseGroup Straw Exercise

1.1. Stand upStand up

2.2. Place the straw in your mouthPlace the straw in your mouth

3.3. Try to breathe!Try to breathe!

This is what is may feel like when a This is what is may feel like when a childchild is having a severe asthma is having a severe asthma episodeepisode

Common Symptoms Of Common Symptoms Of AsthmaAsthma

Frequent cough, especially at nightFrequent cough, especially at nightShortness of breath or rapid Shortness of breath or rapid breathing breathing

Chest tightness Chest tightness Chest pain Chest pain WheezingWheezingFatigueFatigue

EarlyEarly Signs Of An Asthma Signs Of An Asthma “Episode”“Episode”

Mild coughMild cough Drop in Peak Flow Drop in Peak Flow

readingreading Itchy, watery or Itchy, watery or

glassy eyesglassy eyes Itchy, scratchy or Itchy, scratchy or

sore throatsore throat Runny noseRunny nose

StomachacheStomachacheHeadacheHeadacheSneezingSneezingCongestionCongestionRestlessnessRestlessnessDark circles under Dark circles under

eyeseyes IrritabilityIrritability

Acute Asthma Acute Asthma EpisodesEpisodes

What’s An “Episode”?What’s An “Episode”?

An asthma episode occurs when a child is An asthma episode occurs when a child is exposed to a trigger or irritant and their exposed to a trigger or irritant and their asthma symptoms start to appearasthma symptoms start to appear

This can occur suddenly without a lot of This can occur suddenly without a lot of warning, or brew for days before the warning, or brew for days before the symptoms emergesymptoms emerge

Episodes are preventable by avoiding Episodes are preventable by avoiding exposure to triggers and taking daily exposure to triggers and taking daily controller medications (if prescribed)controller medications (if prescribed)

Handling Acute Asthma Handling Acute Asthma Episodes At SchoolEpisodes At School

Remain calm and reassure the child Remain calm and reassure the child Have the child sit up and breathe slowly- in Have the child sit up and breathe slowly- in

through the nose slowly, out through through the nose slowly, out through pursed lips very slowlypursed lips very slowly

Have the child sip water / fluidsHave the child sip water / fluids Check peak flow Check peak flow ((with severe symptoms: skip with severe symptoms: skip

PF & give quick-relief or reliever medication PF & give quick-relief or reliever medication immediatelyimmediately))

Child should not be left aloneChild should not be left alone

Handling Acute Asthma Handling Acute Asthma Episodes At School Cont…Episodes At School Cont…

Give asthma reliever (bronchodilator) per the Give asthma reliever (bronchodilator) per the child's Asthma Action Plan / medication orderschild's Asthma Action Plan / medication orders

Assess response to medicationAssess response to medication After ~5-10 minutes recheck peak flowAfter ~5-10 minutes recheck peak flow Call parent/guardian/health care provider prn Call parent/guardian/health care provider prn Call 911 if escalating symptoms or no Call 911 if escalating symptoms or no

improvementimprovement

Call 911 if..Call 911 if..

Lips or nail beds are bluishLips or nail beds are bluishChild has difficulty talking, walking or Child has difficulty talking, walking or

drinkingdrinkingQuick relief or “rescue” meds (albuterol) is Quick relief or “rescue” meds (albuterol) is

ineffective or not availableineffective or not availableNeck, throat, or chest retractions are Neck, throat, or chest retractions are

visible visible Nasal flaring occurs when inhaling Nasal flaring occurs when inhaling Obvious distressObvious distressAltered level of consciousness/confusion Altered level of consciousness/confusion Rapidly deteriorating conditionRapidly deteriorating condition

““There should not be any delay There should not be any delay once a child notifies school staff of once a child notifies school staff of a possible problem or developing a possible problem or developing

asthma episode”asthma episode”

What Causes Asthma?What Causes Asthma? Of the 21 million asthma sufferers in Of the 21 million asthma sufferers in

the US, 10 Million (approx. 60%) the US, 10 Million (approx. 60%) have allergic asthma. 3 million of have allergic asthma. 3 million of those are childrenthose are children11

Exposure to certain allergens trigger Exposure to certain allergens trigger asthma symptoms to beginasthma symptoms to begin

Exposure to certain irritants can also Exposure to certain irritants can also set an asthma episode in motionset an asthma episode in motion

1National Institute of Environmental Health Sciences

What Causes Asthma?What Causes Asthma?

Asthma may be caused by genetic, Asthma may be caused by genetic, immune and/or environmental factors, immune and/or environmental factors, and is often associated with eczema and and is often associated with eczema and allergiesallergies

Researchers do not understand all of the Researchers do not understand all of the causes of asthma or its increasing causes of asthma or its increasing prevalenceprevalence

It boils down to “We just don’t really know It boils down to “We just don’t really know for sure”for sure”

Triggers and IrritantsTriggers and Irritants

Copyright 2004, 3M Pharmaceuticals

Common Allergens (Triggers)Common Allergens (Triggers)

Seasonal PollensSeasonal Pollens Animal dander Animal dander

saliva/urinesaliva/urine Dust MitesDust Mites Cockroaches/Mice/Cockroaches/Mice/

Rat droppings and Rat droppings and urineurine

MoldMold Some medicationsSome medications Some FoodsSome Foods

Common Irritants (Triggers)Common Irritants (Triggers)

Exercise Exercise Cold AirCold Air Chalk DustChalk Dust Viral/upper Viral/upper

respiratory respiratory infectionsinfections

Air pollutionAir pollution Tobacco smoke or Tobacco smoke or

secondhand smokesecondhand smoke

Chemical irritants Chemical irritants and strong smellsand strong smells

Strong emotional Strong emotional feelingsfeelings

Diesel fumesDiesel fumes Cleaning suppliesCleaning supplies

Role of Viral Role of Viral Respiratory Infections Respiratory Infections

In Asthma In Asthma ExacerbationsExacerbations

Hospital admissions for asthma correlate Hospital admissions for asthma correlate with virus isolation peaks and school termswith virus isolation peaks and school terms

Adapted with permission from Johnston SL et al. Am J Respir Crit Care Med. 1996;154:654. Official Journalof the American Thoracic Society. ©American Lung Association.

VRIs And Hospitalizations VRIs And Hospitalizations For AsthmaFor Asthma

Total pediatric andadult hospitalizations

School holidays

URIs

0

5

10

15

20

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

AirwayHyperresponsiveness

Plasmaleakage

Mucus hypersecretion

Inflammatorycell recruitmentand activation

Neural activation

Virus-infected epithelium

Adapted from Gern JE, Busse WW. J Allergy Clin Immunol. 2000;106:201.

RV-Induced Airway RV-Induced Airway InflammationInflammation

Viruses cause asthma exacerbations in Viruses cause asthma exacerbations in childrenchildren

RVs cause ~60% of virus-induced RVs cause ~60% of virus-induced exacerbations of asthmaexacerbations of asthma

RVs directly infect the bronchial airwaysRVs directly infect the bronchial airways The response to viral infection is shaped The response to viral infection is shaped

by the host’s antiviral responseby the host’s antiviral response

SummarySummary

Exercise Induced Exercise Induced AsthmaAsthma

What Is Exercise What Is Exercise InducedInduced Asthma (EIA)?Asthma (EIA)?

Tightening of the muscles around the Tightening of the muscles around the airways (bronchospasm)airways (bronchospasm)

Distinct from allergic asthma in that it does Distinct from allergic asthma in that it does NOTNOT cause swelling and mucus cause swelling and mucus production in the airwaysproduction in the airways

Can be avoided by taking pre-exercise Can be avoided by taking pre-exercise medications and by warming up/cooling medications and by warming up/cooling down down

EIA - What Happens?EIA - What Happens?

Symptoms include coughing, wheezing, Symptoms include coughing, wheezing, chest tightness and shortness of breathchest tightness and shortness of breath

Symptoms may begin during exercise Symptoms may begin during exercise and can be worse 5 to 10 minutes after and can be worse 5 to 10 minutes after exerciseexercise

EIA can spontaneously resolve 20 to 30 EIA can spontaneously resolve 20 to 30 minutes after startingminutes after starting

Can be avoided by doing the following:Can be avoided by doing the following:

Preventing Exercise Induced Preventing Exercise Induced Asthma (EIA)Asthma (EIA)

Become familiar with Asthma Action Plans Become familiar with Asthma Action Plans Use reliever (Albuterol) 15 -30 minutes Use reliever (Albuterol) 15 -30 minutes

before activitybefore activity Do warm-up/ cool-down exercises before Do warm-up/ cool-down exercises before

and after activitiesand after activities Check outdoor ozone/air quality levelsCheck outdoor ozone/air quality levels

www.aqi.pca.state.mn.us/hourlywww.aqi.pca.state.mn.us/hourly// Never encourage a child to “tough it out” Never encourage a child to “tough it out”

when having asthma symptomswhen having asthma symptoms

Exercise As A Trigger!Exercise As A Trigger!

Exercise can be a trigger for those who Exercise can be a trigger for those who have “chronic” asthmahave “chronic” asthma

Their pre-exercise treatment is the same Their pre-exercise treatment is the same butbut--

These children will have the underlying These children will have the underlying inflammation and require daily controller inflammation and require daily controller medicationmedication

Assess Need For Pre-MedicationAssess Need For Pre-Medication

Take note of medication order wording Take note of medication order wording

““As needed” vs. “prior to exercise”As needed” vs. “prior to exercise”Evaluate if activity level requires pre- Evaluate if activity level requires pre-

medicationmedicationPre-medicate for strenuous activity onlyPre-medicate for strenuous activity onlyContact parent/ HCP if questioning need Contact parent/ HCP if questioning need

for pre-exercise medication for pre-exercise medication

Coach’s Asthma Clipboard Coach’s Asthma Clipboard ProgramProgram

“Winning With Asthma”“Winning With Asthma” 100% online education for:100% online education for:

CoachesCoaches Referee’sReferee’s Physical Education TeachersPhysical Education Teachers

Coaches will receive:Coaches will receive: Coach’s asthma clipboard Coach’s asthma clipboard Special Coach’s asthma education bookletSpecial Coach’s asthma education booklet Certificate of completionCertificate of completion The satisfaction of knowing what to do during The satisfaction of knowing what to do during

an asthma episode!an asthma episode!

www.WinningWithAsthma.orgwww.WinningWithAsthma.org

Where Can Coaches See It?Where Can Coaches See It?

www.WinningWithAsthma.orgwww.WinningWithAsthma.org

Myths and TruthsMyths and Truths

Myths & TruthsMyths & Truths

Asthma MythsAsthma Myths It is a psychological / It is a psychological /

emotional illnessemotional illness It is only an acute It is only an acute

diseasedisease It always limits It always limits

normal activitiesnormal activities It limits a child's It limits a child's

ability to fully ability to fully participate in participate in physical activities, physical activities, especially sports especially sports

Asthma TruthsAsthma Truths Asthma is a very real, Asthma is a very real,

physical diseasephysical disease Asthma is a chronic Asthma is a chronic

disease, even when disease, even when symptoms are not symptoms are not activeactive

Taking proper asthma Taking proper asthma medications allow medications allow children to fully children to fully participate in any participate in any activity, including activity, including sportssports

Myths & Truths Continued..Myths & Truths Continued..

Asthma MythsAsthma Myths

Medication is Medication is addictiveaddictive

Medication Medication becomes becomes ineffective if used ineffective if used regularlyregularly

Children do not Children do not die from asthmadie from asthma

Asthma TruthsAsthma Truths• Asthma medications Asthma medications

are not addictiveare not addictive

• Anti-inflammatories Anti-inflammatories (controllers) are (controllers) are most effective when most effective when used everydayused everyday

• Children and adults Children and adults die from asthma die from asthma each yeareach year

One Last MythOne Last MythMythMyth TruthTruth

• Use “reactive airway Use “reactive airway disease” instead of disease” instead of “asthma” for a “asthma” for a diagnosis – that way diagnosis – that way the insurance the insurance company will never company will never knowknow

• Reactive airway Reactive airway disease’s code is disease’s code is the same code the same code used for asthma!used for asthma!

• Any order for Any order for albuterol (or other albuterol (or other rescue inhaler) rescue inhaler) flags the flags the insurance insurance companycompany

Treatment MythsTreatment Myths

Gecko liquid tonic Gecko liquid tonic Herbal supplementsHerbal supplements Acupuncture/pressure, chiropractic Acupuncture/pressure, chiropractic

adj.adj. Cockroach teaCockroach tea Asthma dietsAsthma diets Pranic healing with mantras Pranic healing with mantras Owning a ChihuahuaOwning a Chihuahua

Small Group Small Group ExerciseExercise

Report back a couple activity Report back a couple activity steps appropriate to that rolesteps appropriate to that role

Each table will review a Each table will review a sectionsection

Assessing AsthmaAssessing Asthma

Measures Of Assessment Measures Of Assessment

And MonitoringAnd Monitoring

Two AspectsTwo Aspects:: Initial assessment and diagnosis of Initial assessment and diagnosis of

asthmaasthma Periodic assessment and monitoringPeriodic assessment and monitoring

Excerts from NHLBI/NIH presentations @http://nih.nhlbi.nih.gov/naepp_slds/menu.htmExcerts from NHLBI/NIH presentations @http://nih.nhlbi.nih.gov/naepp_slds/menu.htm

Initial Assessment &Initial Assessment & Diagnosis of Asthma Diagnosis of Asthma

Determines That:Determines That: Patient has a history or presence of Patient has a history or presence of

episodic symptoms of airflow obstructionepisodic symptoms of airflow obstruction

Airflow obstruction is at least partially Airflow obstruction is at least partially

reversiblereversible

Alternative diagnoses are excludedAlternative diagnoses are excluded

Methods for Establishing Methods for Establishing DiagnosisDiagnosis

Detailed medical historyDetailed medical history Physical examPhysical exam Spirometry to demonstrate Spirometry to demonstrate

reversibilityreversibility

History or Current History or Current Episodic Symptoms of Episodic Symptoms of Airflow Obstruction?Airflow Obstruction?

Wheezing, shortness of breath, chest Wheezing, shortness of breath, chest tightness, or cough?tightness, or cough?

Asthma symptoms vary throughout the Asthma symptoms vary throughout the day?day?

Absence of symptoms at the time of the Absence of symptoms at the time of the examination does not exclude the examination does not exclude the diagnosisdiagnosisof asthma!of asthma!

Asthma Lung AssessmentAsthma Lung Assessment SpirometrySpirometry

Spirometry is Spirometry is GoldGold standard to assist in standard to assist in asthma diagnosisasthma diagnosis

Assess need to start, step up, or step down Assess need to start, step up, or step down asthma medicationsasthma medications

Should be done at least yearly in children Should be done at least yearly in children with persistent asthmawith persistent asthma

Spirometry is easily done at any health Spirometry is easily done at any health care providers officecare providers office

Spirometry Spirometry ContinuedContinued……

Performed before and after Performed before and after bronchodilator dose to look for airway bronchodilator dose to look for airway obstructionobstruction reversibilityreversibility

Can also be done with a cold-air or Can also be done with a cold-air or methylcholine challenge, or an exercise methylcholine challenge, or an exercise challenge in the case of exercise-challenge in the case of exercise-induced asthmainduced asthma

Is Airflow Obstruction At Is Airflow Obstruction At Least Partially Reversible?Least Partially Reversible?

UseUse spirometry to establish airflow spirometry to establish airflow obstructionobstruction FEVFEV11 < 80% of predicted < 80% of predicted

FEVFEV11/FVC <65% or below the lower limit of /FVC <65% or below the lower limit of normalnormal

Use spirometry to establish reversibilityUse spirometry to establish reversibility FEVFEV11 increases increases >>12%12% and at least 200 mL and at least 200 mL

after using a short-acting inhaled betaafter using a short-acting inhaled beta22-agonist-agonist

Have Alternative Have Alternative Diagnoses Been Diagnoses Been

ExcludedExcluded??Examples:Examples: Vocal cord dysfunctionVocal cord dysfunction Vascular ringsVascular rings Foreign body aspirationForeign body aspiration Other pulmonary diseasesOther pulmonary diseases Cystic FibrosisCystic Fibrosis Gastroesophageal refluxGastroesophageal reflux

Under Diagnosis Of AsthmaUnder Diagnosis Of Asthma In Children In Children

The majority of people who have The majority of people who have asthma experience onset before age asthma experience onset before age 55

Commonly misdiagnosed as:Commonly misdiagnosed as: Chronic or wheezy bronchitisChronic or wheezy bronchitis BronchiolitisBronchiolitis Recurrent croupRecurrent croup Recurrent upper respiratory infectionRecurrent upper respiratory infection Recurrent pneumoniaRecurrent pneumonia

Guidelines for the Diagnosis & Guidelines for the Diagnosis & Management of Management of

Asthma Asthma EPR 2002 EPR 2002 UpdateUpdate

NAEPP, NHLBI, NIH- EPR2 2002NAEPP, NHLBI, NIH- EPR2 2002

National Heart, Lung, and National Heart, Lung, and Blood Institute (NHLBI)Blood Institute (NHLBI)

NAEPPNAEPP

NHLBI- NAEPP Asthma NHLBI- NAEPP Asthma Severity LevelsSeverity Levels

1.1.Mild IntermittentMild Intermittent

2.2.Mild PersistentMild Persistent

3.3.Moderate PersistentModerate Persistent

4.4.Severe PersistentSevere Persistent

NAEPP Classification of Asthma NAEPP Classification of Asthma Severity: Clinical Features Before Severity: Clinical Features Before

TreatmentTreatmentDays With Nights With PEF or PEFDays With Nights With PEF or PEFSymptoms SymptomsSymptoms Symptoms FEV FEV11 Variability Variability

Step 4Step 4 Continuous Frequent Continuous Frequent 60% 60% 30%30%SevereSeverePersistentPersistentStep 3Step 3 Daily Daily >>1night/week 1night/week 60%-<80% 60%-<80% 30%30%ModerateModeratePersistentPersistentStep 2Step 2 >2/week, <1x/day >2 nights/month >2/week, <1x/day >2 nights/month 80% 20-30%80% 20-30%MildMildPersistentPersistentStep 1Step 1 2 days/week 2 days/week 2/month 2/month 80% 80% 20%20%MildMildIntermittentIntermittent

Footnote: The patient’s step is determined by the most severe feature. Footnote: The patient’s step is determined by the most severe feature.

Peak Flow VariabilityPeak Flow Variability

Is the difference between the Is the difference between the child’s morning and evening PFM child’s morning and evening PFM readingsreadings

Peak flow readings tend to be Peak flow readings tend to be higher in the evening than in the higher in the evening than in the morningmorning

NAEPP Stepwise Approach To NAEPP Stepwise Approach To Asthma TherapyAsthma Therapy

Reliever:Reliever: Inhaled beta Inhaled beta

agonist prnagonist prn

Reliever: Inhaled beta

agonist prn

Reliever:Reliever: Inhaled beta Inhaled beta

agonist prnagonist prn

Reliever:Reliever: Inhaled beta Inhaled beta

agonist prnagonist prn

Controller:Controller: One daily medicationOne daily medication Possibly add long Possibly add long

acting bacting brronchodilatoronchodilator Anti-leukotrienesAnti-leukotrienes

Controller:Controller: Daily inhaled Daily inhaled

corticosteroidcorticosteroid Daily long acting Daily long acting

bronchodilatorbronchodilator Anti-leukotrieneAnti-leukotriene

Controller:Controller: Daily inhaled Daily inhaled

corticosteroidcorticosteroid Daily long acting Daily long acting

bronchodilatorbronchodilator Daily/alternate day Daily/alternate day

oral corticosteroidoral corticosteroid

When controlled, When controlled, reduce therapyreduce therapy

MonitorMonitor

PEF: ≥80% PEF: ≥80% PEF: <60%

STEP 1:STEP 1:IntermittentIntermittent

STEP 2:STEP 2:Mild PersistentMild Persistent

STEP 3:STEP 3:Moderate PersistentModerate Persistent

STEP 4:STEP 4:Severe PersistentSevere Persistent StepdownStepdown

Outcome:Outcome:Control of AsthmaControl of Asthma

Outcome:Outcome:Best Possible ResultsBest Possible Results

PEF: 60-80%

Mild IntermittentMild Intermittent

Symptoms Symptoms 2 days/week with nighttime 2 days/week with nighttime symptoms symptoms 2 nights/month2 nights/month

Asymptomatic with normal peak flows Asymptomatic with normal peak flows between exacerbations between exacerbations

Exacerbations are brief (hours to a few Exacerbations are brief (hours to a few days)days)

Peak Flows Peak Flows 80% predicted with variability 80% predicted with variability 20% 20%

Mild PersistentMild Persistent

Symptoms > 2 days /week but < 1x/day Symptoms > 2 days /week but < 1x/day with nighttime symptoms greater than 2 with nighttime symptoms greater than 2 nights/monthnights/month

Exacerbations may affect activityExacerbations may affect activity Peak flow 80% of predicted with variability Peak flow 80% of predicted with variability

ofof

< 20-30%< 20-30%

Moderate PersistentModerate Persistent

Child is likely to have daily symptoms and Child is likely to have daily symptoms and use reliever dailyuse reliever daily

Child is waking up at least once a week due Child is waking up at least once a week due to asthma symptomsto asthma symptoms

Peak flows 60-80% of predicted with Peak flows 60-80% of predicted with variability of >30%variability of >30%

Activity is affected and exacerbations may Activity is affected and exacerbations may last dayslast days

Severe PersistentSevere Persistent

Continual daytime symptoms with frequent Continual daytime symptoms with frequent nighttime symptomsnighttime symptoms

Very limited physical activityVery limited physical activity Frequent exacerbationsFrequent exacerbations Peak flows Peak flows 60% of predicted and variability 60% of predicted and variability

of more than 30%of more than 30% Treatment involves a combination of many Treatment involves a combination of many

drug therapiesdrug therapies

Rules Of “Two”Rules Of “Two”

IF a child has: IF a child has: Daytime symptoms greater than two times Daytime symptoms greater than two times

per per weekweek -or- -or- Nighttime symptoms greater than two times Nighttime symptoms greater than two times

per per monthmonth -or- -or- Albuterol (reliever) refills of canisters more Albuterol (reliever) refills of canisters more

than two times per than two times per yearyear

**The child needs to be assessed if he/she The child needs to be assessed if he/she requires controller medication or a step requires controller medication or a step up in therapyup in therapy

MDH Interactive Asthma MDH Interactive Asthma Action Plan (IAAP)Action Plan (IAAP)

Available at MDH website:Available at MDH website:www.health.state.mn.us/asthmawww.health.state.mn.us/asthma

Click on “Asthma Action Plan”Click on “Asthma Action Plan” Click on “Medical Professionals”Click on “Medical Professionals” Choose to download desktop version Choose to download desktop version

oror use online versionuse online version

Which of These Does Which of These Does NotNot Fit Fit With With SevereSevere Persistent Persistent

Asthma?Asthma?

A.A. Continual coughing, wheezing or Continual coughing, wheezing or shortness of breath during shortness of breath during

day, frequent nighttime symptomsday, frequent nighttime symptomsB.B. Limited physical activityLimited physical activityC.C. Near normal Pulmonary Function Near normal Pulmonary Function

Test (Spirometry)Test (Spirometry)D.D. Frequent asthma exacerbationsFrequent asthma exacerbations

Which Of These Does Which Of These Does NotNot Fit Fit With With SevereSevere Persistent Persistent

Asthma?Asthma?

A.A. Continual coughing, wheezing or Continual coughing, wheezing or shortness of breath during day, frequent shortness of breath during day, frequent nighttime symptomsnighttime symptoms

B.B. Limited physical activityLimited physical activityC.C. Near normal Pulmonary Function Test Near normal Pulmonary Function Test

(Spirometry(Spirometry))D.D. Frequent asthma exacerbationsFrequent asthma exacerbations

Which Of These Does Which Of These Does NotNot Fit Fit With With ModerateModerate Persistent Persistent

Asthma?Asthma?

A.A. Daily daytime symptoms, nighttime Daily daytime symptoms, nighttime symptoms > 1 night per weeksymptoms > 1 night per week

B.B. Nighttime Symptoms Nighttime Symptoms << 2 times a 2 times a weekweek

C.C. Daily use of albuterol/bronchodilatorsDaily use of albuterol/bronchodilators

D.D. Asthma exacerbations can last for Asthma exacerbations can last for daysdays

Which Of These Does Which Of These Does NotNot Fit Fit With With ModerateModerate Persistent Persistent

Asthma?Asthma?

A.A. Daily daytime symptoms, nighttime Daily daytime symptoms, nighttime symptoms > 1 night per weeksymptoms > 1 night per week

B.B. Night time Symptoms < 2 times a Night time Symptoms < 2 times a weekweek

C.C. Daily use of albuterol/bronchodilatorsDaily use of albuterol/bronchodilators

D.D. Asthma exacerbations can last for Asthma exacerbations can last for daysdays

Which Of These Does Which Of These Does NotNot Fit Fit With With MildMild Persistent Asthma?Persistent Asthma?

A.A. Daytime symptoms > 2 times a week, Daytime symptoms > 2 times a week, but < 1 time a day but < 1 time a day

B.B. Symptoms may affect activitySymptoms may affect activity

C.C. Need for albuterol 3 times a week, Need for albuterol 3 times a week, sometimes twice a day (not related to sometimes twice a day (not related to EIA)EIA)

D.D. Nighttime symptoms > 2 times a monthNighttime symptoms > 2 times a month

Which Of These Does NWhich Of These Does Notot Fit Fit With With MildMild Persistent Asthma?Persistent Asthma?

A.A. Daytime symptoms > 2 times a week, Daytime symptoms > 2 times a week, but < 1 time a day but < 1 time a day

B.B. Symptoms may affect activitySymptoms may affect activity

C.C. Need for albuterol 3 times a week, Need for albuterol 3 times a week, sometimes twice a day (not related to sometimes twice a day (not related to EIAEIA))

D.D. Nighttime symptoms > 2 times a Nighttime symptoms > 2 times a monthmonth

Which Of These Does Which Of These Does NotNot Fit Fit With With MildMild Intermittent Intermittent

AsthmaAsthma??

A.A. Daytime symptoms Daytime symptoms << 2 times a week 2 times a week

B.B. Nighttime symptoms Nighttime symptoms >> 2 times a 2 times a monthmonth

C.C. No symptoms and normal Peak Flow No symptoms and normal Peak Flow between exacerbationsbetween exacerbations

D.D. Exacerbations are brief and may last Exacerbations are brief and may last from a few hours to a few daysfrom a few hours to a few days

Which Of These Does Which Of These Does NotNot Fit Fit With With MildMild Intermittent Intermittent

AsthmaAsthma??

A.A. Daytime symptoms Daytime symptoms << 2 times a week 2 times a week

B.B. Nighttime symptoms > 2 times a Nighttime symptoms > 2 times a monthmonth

C.C. No symptoms and normal Peak Flow No symptoms and normal Peak Flow between exacerbationsbetween exacerbations

D.D. Exacerbations are brief and may last Exacerbations are brief and may last from a few hours to a few daysfrom a few hours to a few days

Which Level Does Which Level Does NotNot Need Need Daily Controller Medication?Daily Controller Medication?

A.A. Mild Intermittent Mild Intermittent

B.B. Mild PersistentMild Persistent

C.C. Moderate PersistentModerate Persistent

D.D. Severe PersistentSevere Persistent

Which Level Does Which Level Does NotNot Need Need Daily Controller Medication?Daily Controller Medication?

A.A. Mild IntermittentMild Intermittent

B.B. Mild PersistentMild Persistent

C.C. Moderate PersistentModerate Persistent

D.D. Severe PersistentSevere Persistent

Severity Level WorkoutSeverity Level Workout

Case Scenario Group Case Scenario Group Interactive FormatInteractive Format

Assessing AsthmaAssessing Asthma

When Assessing Asthma When Assessing Asthma Ask..Ask..

Whether or not the child is taking his/her Whether or not the child is taking his/her controller medication at home controller medication at home (are they (are they prescribed for him/her)prescribed for him/her)

Is he/she taking it everyday and how Is he/she taking it everyday and how oftenoften

How often is he/she using reliever How often is he/she using reliever inhalersinhalers

About his/her home environmentAbout his/her home environment PetsPets Adults smoking in the homeAdults smoking in the home Moist basements or obvious moldMoist basements or obvious mold Mattress and pillow coversMattress and pillow covers Cockroaches, mice, rats etc.Cockroaches, mice, rats etc. E2, E3E2, E3

Physical Assessment Of Physical Assessment Of Asthma In The School Health Asthma In The School Health

OfficeOffice

Symptoms (daytime, nighttime and Symptoms (daytime, nighttime and exercise-related)exercise-related)

Peak Flow Meter readingsPeak Flow Meter readings Respiratory assessment (breath Respiratory assessment (breath

Sounds / lung auscultation, respiratory Sounds / lung auscultation, respiratory rate, physical assessment)rate, physical assessment)

SymptomsSymptoms

Ask about:Ask about: Coughing / wheezing / tight chestCoughing / wheezing / tight chest Frequency of daytime symptomsFrequency of daytime symptoms Frequency of nighttime symptomsFrequency of nighttime symptoms Symptoms with activity or Symptoms with activity or

exerciseexercise

Respiratory AssessmentRespiratory Assessment

Respiratory Assessment in Respiratory Assessment in the School Health Officethe School Health Office

Physical inspection Physical inspection (including respiratory rate)(including respiratory rate)

Auscultation of the lung fieldsAuscultation of the lung fields

Normal Respiratory Normal Respiratory Rates For ChildrenRates For Children

AgeAge RateRate AgeAge RateRateNewbornNewborn 35 35 10 years10 years 19191-11 mo.1-11 mo. 30 30 12 years12 years 19192 years2 years 25 25 14 years14 years 19194 years4 years 23 23 16 years16 years 17176 years6 years 21 21 18 years18 years 16-1816-188 years8 years 20 20

(rate=breaths/minute)(rate=breaths/minute) Whaley & Wong, 1991Whaley & Wong, 1991

Why Lung Assessment Is Why Lung Assessment Is ImportantImportant

It provides additional clinical informationIt provides additional clinical information Provides a good baseline for comparison Provides a good baseline for comparison

in future assessmentsin future assessments Gives a better picture of the child’s Gives a better picture of the child’s

perception of symptoms vs. what is perception of symptoms vs. what is actually assessedactually assessed

When consulting w/the HCP, they will ask When consulting w/the HCP, they will ask for lung soundsfor lung sounds

Form F26Form F26

Physical Respiratory Physical Respiratory InspectionInspection

Respiratory rateRespiratory rate RhythmRhythm (regular, irregular or periodic)(regular, irregular or periodic) DepthDepth (deep or shallow, presence of (deep or shallow, presence of

retractions)retractions) QualityQuality (effortless, automatic, difficult, or (effortless, automatic, difficult, or

labored)labored) CharacterCharacter (noisy, grunting, snoring, or (noisy, grunting, snoring, or

heavy)heavy)

AuscultationAuscultation

Breath sounds best heard in a quiet Breath sounds best heard in a quiet environment environment

Wheezing and crackles are best heard as Wheezing and crackles are best heard as the student takes deep breathsthe student takes deep breaths

Absent / diminished breath sounds are Absent / diminished breath sounds are abnormal and should be investigatedabnormal and should be investigated

Absence of wheezing does not necessarily Absence of wheezing does not necessarily mean absence of asthmamean absence of asthma

Breath Sounds: CracklesBreath Sounds: Crackles

Coarse CrackleCoarse Crackle: Intermittent, interrupted : Intermittent, interrupted explosive sounds, loud, low in pitch (heard explosive sounds, loud, low in pitch (heard when airs passes through when airs passes through largerlarger airways airways containing liquid) containing liquid) Crackles of a 9 yo boy with pneumonia Crackles of a 9 yo boy with pneumonia

Fine CrackleFine Crackle: Intermittent, interrupted : Intermittent, interrupted explosive sounds, less loud and of shorter explosive sounds, less loud and of shorter duration; higher in pitch than coarse duration; higher in pitch than coarse crackles (heard when airs passes through crackles (heard when airs passes through smallersmaller airways containing liquid) airways containing liquid)

This This wheezing and coarse crackleswheezing and coarse crackles were recorded over the right posterior lower lung of an 8 month old were recorded over the right posterior lower lung of an 8 month old boy with viral bronchiolitis.boy with viral bronchiolitis.

Breath Sounds: Wheeze And Breath Sounds: Wheeze And Rhonchus (Rhonchi)Rhonchus (Rhonchi)

WheezeWheeze: continuous sounds, : continuous sounds, highhigh pitched; pitched; a hissing sound (e.g. with airway narrowed a hissing sound (e.g. with airway narrowed by asthma)by asthma)

Expiratory wheezing was recorded over the right anterior upper chest of an 8 yo boy with asthma Expiratory wheezing was recorded over the right anterior upper chest of an 8 yo boy with asthma

Wheezing over trachea and right lower lung of 11 yo girl with asthma Wheezing over trachea and right lower lung of 11 yo girl with asthma

RhonchusRhonchus: continuous sounds, : continuous sounds, lowlow-pitched; -pitched; a snoring sound (caused by large upper a snoring sound (caused by large upper airway partially obstructed by thick airway partially obstructed by thick secretions)secretions)

Sounds from The R.A.L.E. Repository @http://www.rale.ca/Recordings.htm

Peak Flow MetersPeak Flow Meters

Peak Flow MetersPeak Flow Meters

Measures how well the student’s lungs are Measures how well the student’s lungs are doing at that momentdoing at that moment

Associated with the Green-Yellow-Red Associated with the Green-Yellow-Red system of managing asthma symptomssystem of managing asthma symptoms

Congruent with asthma action plansCongruent with asthma action plans Helps students and families self-manage Helps students and families self-manage

asthma asthma

Form F31Form F31

How to use a Peak Flow How to use a Peak Flow MeterMeter

Review the stepsReview the steps Place indicator at Place indicator at

the base of the the base of the numbered scalenumbered scale

Stand upStand up Take a deep Take a deep

breathbreath Place the meter in Place the meter in

the mouth and the mouth and close lips around close lips around the mouthpiecethe mouthpiece

Blow out into the Blow out into the meter as hard and meter as hard and fast as possiblefast as possible

Write down the Write down the achieved numberachieved number

Repeat the process Repeat the process twice moretwice more

Record the highest Record the highest of the three of the three numbers achievednumbers achieved

Group Peak Flow Group Peak Flow ExerciseExercise

Personal Best Peak Flow Personal Best Peak Flow ValuesValues

Determined by twice daily Determined Determined by twice daily Determined when healthy and not experiencing when healthy and not experiencing symptomssymptoms

PFM measurements over the course of PFM measurements over the course of two weekstwo weeks

Is the Is the BESTBEST reading obtained during reading obtained during those two weeksthose two weeks

Is used to calculate percentages for Is used to calculate percentages for AAP’sAAP’s

Predicted Peak Flow ValuesPredicted Peak Flow Values

Are based on a child's heightAre based on a child's height Are not individualized Are not individualized Do not take into account other personal Do not take into account other personal

factorsfactors Can be identified immediatelyCan be identified immediately Are used when it is impossible or difficult Are used when it is impossible or difficult

to obtain personal best peak flow levelsto obtain personal best peak flow levels

Form F6Form F6

Every Child Is Unique!Every Child Is Unique!

Wheezing and coughing are the most Wheezing and coughing are the most common symptoms common symptoms -but--but-

No two children will have the exact same No two children will have the exact same symptoms or the same triggersymptoms or the same trigger

Every child who has a diagnosis of asthma Every child who has a diagnosis of asthma should have access to a rescue inhaler!should have access to a rescue inhaler!

Every child with persistent asthma should Every child with persistent asthma should have an asthma action plan at school have an asthma action plan at school (AAP)(AAP)

Together- We Can Make A Together- We Can Make A Difference!Difference!