Transcript Title Page

Controlling
Asthma at School
Fadel Ruiz MD
Pediatric Pulmonary
Baylor College of Medicine
Texas Children’s Hospital
Pediatrics
Objectives
• Review basic facts about asthma
•Understand basics of asthma treatment
•Review how to recognize control and
uncontrolled asthma
•Review goals and policies for the
management of asthma in the school setting
•Review proper use of inhalers and spacers
•Practical (hands/on) review of use of inhalers
and spacers
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Epidemiology
•Asthma is the most common chronic health problem in
childhood. (7.1 million children ≤18 year) ,10% of children
•4.1 million had an asthma episode or attack within the
previous year in 2011
•Most common reason for school absence(12.8 million
school days and costs caretakers $726.1 million because
of work absence.)
•$ 3.2 billion per year to treat childhood asthma
http://www.cdc.gov/healthyyouth/asthma/(2009) and 2010)
ALA ; asthma & children fact sheet: October 2012
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Epidemiology
•Life- threatening disease
‐3388 deaths attributed to asthma in 2009
•3rd leading cause of hospitalizations <15 years
age
•400,000 to 1 million children with worse asthma
due to 2nd hand smoke exposure
ALA ; asthma & children fact sheet: October 2012
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% of Pediatric Asthma Patients
Approximately 46% of Pediatric Patients
Had Uncontrolled Asthma
60%
54%
46%
40%
20%
0%
Well Controlled
Uncontrolled
Results from cross-sectional epidemiological survey to patients in Pediatric Primary Care offices, regardless of
reason for visit. Data for 1739 pediatric patients with a self-reported physician diagnosis of asthma completed
the Childhood Asthma Control Test, (for children aged 4 to 11 years) or the Asthma Control Test™. Uncontrolled
asthma defined as Asthma Control Test™ ≤19. Asthma Control Test is a trademark of QualityMetric
Incorporated.
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Uncontrolled Asthma:
Negative Impact on Children
70
% of Respondents*
60
50
40
30
20
10
0
Limited Activity
Missed
School in
Past Year
Symptoms
in Past
4 Weeks
Sudden Severe
Attacks Past
Year
*Respondents (N=801) were parents of children with asthma (aged 4-15 years) and children with asthma (aged 16-18 years).
Adapted with permission from Chipps BE, Spahn JD. J Asthma. 2006;43:567-572.
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Status of Asthma Control in Pediatric Primary Care: Results from the Pediatric Asthma Control Characteristics
and Prevalence Survey Study (ACCESS), . Liu et al J ped 2010
History of exacerbations and health care utilization in the previous year by asthma control
status in patients with asthma seen for non–respiratory-related illness.
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What is Asthma?
A disease that:
‐ Is chronic
‐ Produces recurring episodes of breathing problems
• Coughing
• Wheezing
• Chest tightness
• Shortness of breath
‐ Cannot be cured, but can be controlled
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Normal
Asthma
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Pathophysiology of Asthma
BRONCHIOLE
Reduced airway
opening
Tightened
muscle
Excess
Mucus
Alveolus filled
with trapped
air
Muscle
Layer
Inflammation
Bronchoconstriction
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What Happens During an Episode of
Asthma?
•The lining of the airways becomes
swollen (inflamed)
•The airways produce a thick mucus
•The muscles around the airways tighten
and make airways narrower
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What are the Symptoms of
Asthma?
‐Shortness of breath
‐Wheezing
‐Tightness in the chest
‐Coughing at night or after physical activity;
cough that lasts more than a week
‐Waking at night with asthma symptoms (a key
marker of uncontrolled asthma)
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Evaluation in Children: History
•“Noisy symptoms”
• Symptom frequency & severity
‐ Limitation of physical activity
‐ Wheezing
• Timing and pattern
‐ Interference with sleep
• Age of onset
‐ ED visits/hospitalizations
• Acute or chronic
• Associated factors
• Course
‐ Intermittent vs chronic
‐ Cough
• “Quiet” symptoms
‐ Chest tightness
‐ Recurrent
• Past medical history
‐ β-Adrenergic responsiveness
‐ Chest pain
‐ Family history
‐ Fatigue with exertion
‐ Atopy
‐ Irritability
‐ Social/environmental history
National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Heart,
Lung, and Blood Institute, National Institutes of Health; July 1997. NIH publication 97-4051.
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Evaluation in Children:
Physical Examination
•Chest/lungs (at rest and with forced
•Physical examination may
be normal
expiration)
‐ Tachypnea
‐ Inspiratory vs expiratory
•Skin
‐ Prolonged expiratory phase
‐ Atopic dermatitis
‐ Decreased air entry
‐ Wheeze/cough
•HEENT
‐ Allergic facies
•During exacerbations only
‐ Pharyngeal cobblestoning
‐ Accessory muscle use
‐ Nasal voice
‐ Hyperexpansion of thorax
‐ Mouth breathing
‐ Cyanosis
‐ Pale/swollen nasal mucosa
‐ Clear nasal discharge
•Not associated with asthma
‐ Digit clubbing
HEENT = head, ears, eyes, nose, throat.
National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Heart,
Lung, and Blood Institute, National Institutes of Health; July 1997. NIH publication 97-4051.
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‐ Isolated “crackles”
Pediatrics
‐ Stridor without wheeze
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Asthma Imitators
‐Cystic fibrosis
‐Gastroesophageal reflux
‐Chronic lung disease of prematurity
‐Aerodigestive foreign body
‐Congenital airway anomaly
‐Immunodeficiency
‐Congenital heart disease
‐Vocal cord dysfunction
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Goals of Asthma Care
No asthma symptoms. No cough. No wheeze.
No chest tightness.
No limitation of exercise.
No asthma attacks: daytime or nighttime!
 No need for urgent or emergency care.
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3 lines of defense
•1) Manage THE ENVIRONMENT
Keep asthma triggers away.
‐Irritants
•smoke, strong chemicals, and cold viruses
‐ Allergens
•dusts, molds, pollens, furry or feathered pets,
cockroaches, and rodents
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Asthma Triggers
•Allergens
‐Warm-blooded pets (including dogs, cats, birds, and small
rodents)
‐House dust mites
‐Cockroaches
‐Pollens from grass and trees
‐Molds (indoors and outdoors)
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Control of Triggers
Mountain cedar
Mites
Oak
Timothy
Fungi
Cockroach
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Ragweed
Cat
Asthma Triggers
•Irritants
‐Cigarette smoke and wood smoke
‐Scented products such as hair spray, cosmetics, and
cleaning products
‐Strong odors from fresh paint or cooking
‐Automobile fumes and air pollution
‐Chemicals such as pesticides and lawn treatments
•Infections
‐Colds & Flu
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Asthma Triggers
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Asthma Triggers
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Asthma Triggers
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Asthma Triggers
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3 lines of defense
•2) Protect THE BREATHING TUBES
‐Long acting asthma controller medicine taken
every day.
‐Rule of 2’s for well controlled asthma
•Needs quick relief inhaler < 2x/week
•Sleep interrupted from asthma <2x/month
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ACT ( Asthma Control Test)
•Reliable, valid, and
responsive to changes in
asthma control over time
•A cutoff score of 19 or
less identifies patients
with poorly controlled
asthma.
•Useful tool to identify
patients with
uncontrolled asthma and
to follow progress with
treatment.
Schatzet al J Allergy Clin Immunol 2006;117:549-56.
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Pharmacotherapy
Long-Term Control
•Corticosteroids
•Leukotriene modifiers
Quick Relief
•Short-acting inhaled
beta2-agonists
•Anticholinergics
•Long-acting beta2agonists
•Systemic corticosteroids
•Methylxanthines
•Cromolyn/nedocromil
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2007 NIH Guidelines for Children
Intermittent
Asthma
Persistent Asthma: Daily Medication for Ages 5–11
Step up if needed
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
(first, check
adherence,
inhaler technique,
environmental
control, and
comorbid
conditions)
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred:
Step 1
Low-dose ICS
Preferred:
Alternative:
SABA PRN
LTRA,
cromolyn,
nedocromil, or
theophylline
Preferred:
Either
Low-dose ICS
+ either LABA,
LTRA, or
theophylline
OR
Medium-dose
ICS
Preferred:
Medium-dose
ICS + LABA
Alternative:M
edium-dose ICS
+ either LTRA
or theophylline
Preferred:
Preferred:
High-dose
ICS + LABA +
oral systemic
corticosteroid
High-dose
ICS + LABA
Alternative:
High-dose ICS
+ either
LTRA or
theophylline
Alternative:
High-dose ICS
+ either LTRA
or theophylline
+ oral systemic
corticosteroid
Assess
control
Step down if
possible
(and asthma is
well controlled at
least
3 months)
Each step: Patient education, environmental control, and management of comorbidities.
Steps 2–4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma.
Quick-relief medication for all patients:
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute
intervals as needed. Short course of systemic oral corticosteroids may be needed.
National Institutes of Health, National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3
2007). NIH Item No. 08-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthgdlin.htm. Accessed September 10, 2007.
Daily Albuterol Users Not on a Controller
Experience More Frequent Activity Limitation
% of Subjects Limiting
Physical Activity
60
40
36%
20
12%
0
Daily Albuterol
Not Daily Albuterol
Q3c: How much do exercise – or exertion-related asthma symptoms limit your participation in sports or other
vigorous activities – some or a lot?
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1 in 4 Daily Albuterol Users Not on a Controller
Said “Asthma Controls Me and My Life”
% of Subjects
40
25
%
20
6
%
0
Daily Albuterol
Not Daily Albuterol
Q20: Please indicate how strongly you agree or disagree with the following statement:
Asthma controls me and my life.
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Inhaled Steroids Reduce Asthma
Mortality
Suissa et al. New Engl J Med 2000; 343:332-336
Pediatrics
Page
Suissa et
al.33New Engl J Med 2000; 343:332-336.
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Relative Risk of Asthma Hospitalization
in the United States
2-agonists
8
Total
Age 0-17
Age 18-44
Age 45+
7
6
Relative 5
Risk
4
ICS
3
Total
Age 0-17
Age 18-44
Age 45+
2
1
0
None 0-1
1-2
2-3
3-5
5-8
8+
Prescriptions per person-year
Donahue et al. JAMA. 1997;277:887-891.
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Effects of Inhaled Corticosteroids
on Inflammation
Before
After
Epithelium
Epithelium
Basement
Membrane
Basement
Membrane
Eosinophil
Lymphocytes
Mast Cells
Before and After 3 Months of
Treatment With an ICS
Reprinted with permission from Laitinen LA et al. J Allergy Clin Immunol. 1992;90:32-42. Copyright (1992), with permission from the American Academy
of Allergy, Asthma and Immunology.
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•
•
•
•
•
•
Benefits of ICS
Reduces symptom severity
Improves pulmonary function
Reduces bronchial hyperreactivity and
airway inflammation
Reduces rescue inhaler use
Reduces exacerbations, hospitalizations and
asthma-related mortality
The safety of these agents when used
correctly is well-established in all age
groups.
Guidelines for the Diagnosis and Management of Asthma. 1997. NIH
Publication No. 97-4051
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Guidelines for the Diagnosis and Management of Asthma.
1997. NIH Publication No. 97-4051.
Pediatrics
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3 lines of defense
•3) Anticipate THE FLARE UPS
‐Know the early signs of asthma.
‐Doctors should provide a written asthma action
plan (also called a green, yellow, red zone plan)
for each child with asthma.
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Good asthma care providers give
Written Asthma Action Plans
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Recognizing Symptoms
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Recognizing Symptoms
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Recognizing Symptoms
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Recognizing Symptoms
Danger signs:
IMMEDIATE medical attention is needed – call 911!!
Difficulty speaking more than 1 or 2 words between
breaths
Hard to walk more than a few steps due to difficulty
breathing
Chest or belly sucking in with each breath
Nostrils flaring out with each breath
Breathing very fast (more than 40 breaths in a minute)
Lips or fingers turning blue
Peak flow significantly below 50% of personal best
NEVER send a student of any age ALONE to the office/nurse’s
office during an asthma flare!
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FIRST AID FOR ASTHMA
Symptoms May Include:
•
•
•
Wheezing
Coughing
Breathing difficulty
•
•
•
Chest tightness
Shortness of breath
Low peak flow readings
1
STAY CALM, SPEAK
REASSURINGLY.
DO NOT LEAVE CHILD ALONE.
2
HAVE STUDENT SIT UPRIGHT
AND RELAX.
DO NOT LET STUDENT LIE
DOWN.
3
4
ALLOW CHILD TO USE RESCUE
INHALER IF THEY HAVE ONE.
IF NO IMPROVEMENT, NOTIFY SCHOOL
OFFICE/SCHOOL NURSE.
IF THERE IS:
• very fast or hard breathing,
• sucking in the stomach or ribs to breathe,
• breathing so hard they cannot walk or speak,
• lips or fingers turn blue.
CALL 911 USING
SCHOOL PROTOCOL
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Control of Environmental Factors
•House-dust mites
‐Encase mattress and pillow in impermeable
cover
‐Wash bedding weekly in hot water
‐Reduce indoor humidity < 50 %
‐Remove dust “collectors” from room
•Animal Dander
‐Remove animal from house
‐Keep out of patient’s bedroom and off fabric
furniture
‐Filter on bedroom air duct
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Control of Environmental Factors
‐Indoor Mold
• Fix leaky faucets and pipes
• Avoid humidifiers
• Reduce humidity < 50 %
‐Cockroaches
• Traps
• Preventative measures
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Precipitating / Sustaining Factors
for Asthma
‐Allergen exposure
‐Allergic Rhinitis
‐Exercise
‐Viral URI’s
‐Rhinosinusitis
‐GERD
‐Cigarette smoke
‐Environmental exposures (eg, pollution, fumes)
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Levels of Asthma Control
(on controller therapy)
Components of Control
Impairment
Well controlled
Not well controlled
Very poorly controlled
Symptoms
≤ 2 days/week but
not more than once
on each day
>2 days/week or multiple
times on ≤ 2 days/week
Throughout the day
Nighttime awakenings
≤ 1x/month
≥ 2x/month
≥ 2x/week
Interference with normal activity
None
Some limitation
Extremely limited
Short-acting beta2-agonist use for
symptom control (not prevention of
EIB)
≤ 2 days/week
> 2 days/week
Several times per day
> 80% predicted or
personal best
> 80% predicted
60%–80% predicted or
personal best
75%–80% predicted
< 60% predicted or personal
best
< 75% predicted
Lung function:
• FEV1 or peak flow
• FEV1/FVC
Exacerbations requiring oral
systemic corticosteroids
Risk
Classification of Asthma Control: 5–11 Years of Age
0–1 per year
≥ 2/year (see note)
Consider severity and interval since last exacerbation
Reduction in lung growth
Evaluation requires long-term follow-up
Treatment-related adverse effects
Medication side effects can vary in intensity from “none” to “very troublesome and
worrisome.” The level of intensity does not correlate to specific levels of control but
should be considered in the overall assessment of risk
National Institutes of Health, National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). NIH
Item No. 08-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthgdlin.htm. Accessed September 10, 2007.
What are the main reasons for poor
control of asthma?
•Misdiagnosis
•Under treatment with anti inflammatory meds
•Over reliance on short acting B-agonist
•Presence of other coexisting conditions
‐GERD (gastroesophageal reflux)
‐Sinusitis
‐Allergic rhinitis
‐Vocal cord dysfunction
•Wrong diagnosis
•Continuous exposure to allergens
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Achieving the Goal
The Components of Good Asthma Care
Assessment and monitoring
‐ Assess asthma severity to initiate
treatment
‐ Assess asthma control frequently,
measure lung function annually,
and adjust therapy as needed
Asthma education
‐ Disease process, medication use,
environmental avoidance, and
symptom monitoring
‐ Provide written asthma action
plans
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When Asthma Control is Elusive
‐Do I have the correct diagnosis?
‐Have I prescribed the proper medication?
‐What do I know about the patient’s adherence?
‐Are there concerns about aerosol delivery?
‐Do undiagnosed co-morbidities exist?
‐Are there persistent environmental allergens /
irritants?
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Fort Bend ISD
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Promoting asthma Health in Schools
•Asthma is #1 cause for absence from school.
•School nurses identify asthma as the most common disease
they must address.
•Asthma in school affects teachers, administrators, nurses
,coaches, and maintenance personnel
Adapted from CDC
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Challenges in the Schools
•To recognize and appropriately intervene with a
child having an asthma flare-up.
•To reduce asthma triggers in the school
•To recognize and refer children with poorly
controlled asthma.
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Asthma Resources For Schools
• Control Your Child’s Asthma: A Breakthrough Program
for the Treatment and Management of Childhood
Asthma. By Harold J. Farber, MD (Henry Holt, 2001)
• National Asthma Education and Prevention Program
(NAEPP) Website and Materials
• Start at www.nhlbi.nih.gov
• Check out health information for lung
diseases
• Indoor Air Quality: Tools for Schools
• http://www.epa.gov/iaq/schools/index.html
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Asthma Goals For School
Health
•Healthy school environment
•Health services in school
•Asthma education
•Supportive policies
•Sound communication
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Goal: Healthy School
Environment
‐ Enforce no-smoking policies
‐ Reduce exposures to triggers: tobacco
smoke, chemical vapors, furry or feathered
animals, mites, cockroaches, chalk dust,
mold
‐ Keep temperature and humidity at
appropriate settings
‐ Maintain HVAC systems
‐ Dry up damp and wet areas within 1-2 days
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Goal: Health Services in School
•Provide full-time nursing services
•Include nursing assessments, care plans in student
records
•Teach and monitor correct inhaler techniques,
peak flow meter use
•Train, supervise and delegate to health assistants
and education staff, as appropriate
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Goal: Asthma Education
•Provide asthma awareness for all students
•Teach asthma management to students with
asthma
•Provide asthma education for faculty and staff
•Teach parents how to manage asthma
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Goal: Supportive Policies
‐ Identify students with asthma
‐ Provide quick, reliable access to medications
‐ Establish individualized student asthma
management plan
‐ Establish individualized student emergency
plan for asthma episodes
‐ Promote safe and full participation in all school
activities
‐ Monitor students’ asthma
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Supportive Policies
Identify Students
•Review student health records
•Interview parents
•Interview school health staff
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Supportive Policies
Provide Access to Medication
•Ensure reliable access to medication for all school
activities
•Allow self-administration as appropriate
•Provide for nebulizer treatment as needed
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Supportive Policies
Establish Student Asthma Management Plan
‐ Address triggers
‐ Record personal best peak flow
‐ Specify routine medications
‐ Outline signs and symptoms of worsening asthma
‐ Specify medications required for emergencies and how
to monitor response to them.
‐ Indicate emergency contacts
‐ Place plan in student’s health record
• Make copies for off-campus activities
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Supportive Polices
Establish Plan for Asthma Episodes
• Develop school wide emergency
plans/procedures
‐ Include respiratory distress treatment protocols
‐ Include plan for someone without an individualized plan
• Include an emergency plan for asthma episodes
in the individualized student asthma management
plan.
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Supportive Policies
Promote Participation in All Activities,
including Physical Activities
‐ Encourage student participation
‐ Allow pretreatment and or warm-up before
physical activity
‐ Allow access to quick relief medication
‐ Modify activity or substitute with less strenuous
option
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Supportive Policies
Monitor Students’ Asthma
•Watch for symptoms of uncontrolled asthma
•Monitor absenteeism due to asthma
•Refer for home teaching as needed
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Pediatrics
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Goal: Sound Communication
‐ Form linkages among school, home and health
care providers
‐ Observe and report symptoms, medication use
‐ Review difficulties student may have with daily
school management plan
‐ Resolve problems with school performance
related to asthma
‐ Encourage active student participation in school
activities
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Using Inhalers
Properly
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Scope of Problem
•28 – 63% of patients do not use their pMDI or DPI
well enough to get benefit
‐More than 500 million pMDIs or DPIs are produced each year
‐At an average retail cost of $50/inhaler total retail of $25 Billion
•$7 – 15.7 Billion wasted
•Increased ER visits and hospital admissions
•Increased morbidity and mortality
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Pediatrics
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pMDI +Valved Holding Chamber
‐Most studies report equal or better efficacy and
less side effects
‐Improved patient adherence to therapy
‐Immediate use with little preparation
‐Can be used in many settings
‐Treatment effect can be titrated
‐Significant cost benefit
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Pediatrics
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Valved Holding Chambers vs Nebulizers for
B2-Agonist Treatment of Acute Asthma?
•2001 analyzed 1076 children and 444 adults
who were included in 22 trials
•MDI’s with holding chambers produced
outcomes that were at least equivalent to
those of nebulizer delivery
•In children with acute asthma, holding
chambers have advantages compared with
nebulizers
Osmond M, Diner B. Ann Emerg Med 2004;43:413-415
Cates CJ, Rowe B, Bara A. 2003 Cochrane ReviewPage 71
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Poor Inhalation Technique Even After
Instruction in Children with Asthma
‐66 newly referred children with asthma
•60 / 66 had received instruction from PCP
•58% performed all steps correctly
•97% thought they had proper technique
‐29 control patients followed in asthma clinic
•93% performed all steps correctly
‐Major difference was extent of training
•PCP relied on verbal instruction for 5 mins
•Asthma clinic used demonstration til correct (30
mins)
Kamps AWA, et al. Pediatr Pulmonol 2000;29:39-42.
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Instruction of Hospitalized Patients by
Respiratory Therapists on MDI/VHC use Leads
to Decrease in Patient Errors
‐58 patients was observed by a physician while
performing 2 actuations of their MDI and the number
of errors they committed
‐After a program of MDI instruction (which included
encouragement to use a VHC) by an RT was
performed, group of hospitalized patients was again
observed
‐This improvement in proper use went from 27.6% to
91.7%
‐Instruction of hospitalized patients with obstructive
lung disease by an RT improves their correct use of
MDI and VHC
Song WS, et al. Respir Care. 2005 Aug;50(8):1040-5.
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Delivered Dose – Facemask (in vitro)
Increasing Distance From “Face”
Distance of mask from filter ‘face’4 ml of 1% cromolyn; flow = 8 l/min, VT = 50
ml
1.4
3.1%
Dose inhaled, mg
1.2
1
0.8
1.4%
0.6
0.4
0.5%
0.2
0
0 cm
1 cm
Everard ML, et al. Arch Dis Child 1992;67:586-91
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2 cm
Conclusions
‐Asthma is a leading cause of morbidity in
childhood.
‐Asthma control can be achieved with proper
evaluation and treatment
‐Proper policies, education and involvement of
key personnel in the school system help
decreased the impact of asthma.
‐Using inhalers and spacer correctly is a key
aspect in the management of asthma
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