Transcript Environmental Management - American Lung Association

FACTORS CONTRIBUTING TO
ASTHMA EXACERBATIONS
Trisch Van Sciver RN MS
CFNP DOM AE-C
Disclosure of Potential Bias
Trisch Van Sciver
I have a potential bias:
–Speakers Bureau for Teva Pharmaceutical Industries Ltd.
–Consultant for NM Health Care Connection
This presentation has been reviewed to evaluate for potential bias
and the presentation will be monitored to evaluate for bias.
Ranking the Evidence
The NAEEP Expert
Panel Report 3
uses the following
criteria to specify
the level of
evidence to justify
recommendations
made:
• Evidence A – Rich body of data – A lot
of randomized controlled trials (RCT)
• Evidence B – Limited body of data –
some RCTs
• Evidence C – Non-randomized trials
and observational studies
• Evidence D – Panel consensus
judgment (for when guidance seems
valuable but lacks literature backing)
NAEEP Expert Panel Report – 3
It is essential to identify and reduce exposures to allergens and irritants
and to control other factors that have been shown to increase asthma
symptoms in your patient.*A
Effective allergen avoidance requires a multifaceted, comprehensive
approach; individual steps alone are generally ineffective.*A
Focus on allergen-control education for cockroach, dust mite and rodent
allergens for patients sensitive to these allergens as these have proven
interventions.*A
This session will cover…
Allergens
Irritants
School, work
and outdoor
environments
Other
contributing
factors
Exerciseinduced
bronchospasm
Co-morbid
conditions
Allergens vs. Irritants
Allergens
• IgE mediated disease
• Require sensitization
• Affects only those that
are sensitized to the
allergen
• Not usually dosedependent
Irritants
• Not mediated through
IgE
• Dose-dependent
response
• Will affect everyone at
high enough dose
(See Asthma 101 – Asthma Triggers Handout for examples.)
Assess Environment
• Identify and control triggers to:
– Prevent symptoms
– Prevent hospitalizations and ED visits
– Improve quality of life and self-management skills
– Reduce medications
IMPORTANT: Ask, “Have you noticed anything in
your home, work or school that makes your asthma
worse?”
Assess Home Triggers
Does the patient:
• Keep a pet?
• Have moisture or dampness in their home environment?
• Have visible mold in any part of their home?
• Smoke or live with a smoker?
• Have a wood burning stove or fireplace?
• Have unvented stoves or heaters?
SOURCE: EPA , Asthma Home Environment Checklist for Home Visitors at
http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf.
EPA Asthma Home Environment Checklist
• Inspect Mattress & bedding. Are there carpets, other floor
covering, drapes, upholstered furniture, stuffed toys?
• Cockroaches, rodents in kitchen, bath, basement?
• Pets? Types?
• Mold in bathroom, kitchen, basement?
• Smoke – tobacco second hand?
• Gas cooking appliances, fireplaces, woodstoves, unvented
heaters? (NO2)
• Heating/Cooling system?
• Cleaning products/pesticides/air fresheners/cosmetics?
Common Home Triggers: Allergens
Animal allergens
Dust mites
Cockroach allergens
Indoor fungi
Tobacco smoke
Animal Allergens*D
All warm-blooded animals produce flakes of
skin (dander), feces, urine and dried saliva
that can cause allergic reactions.
– Best option - Keep animals out of house
– If you can’t keep the pet outside, keep it out of
the bedroom and keep the door shut
– Wash hands and clothes after contact with the
pet
– Remove upholstered furniture and carpets from
the home or isolate the pet in areas without
these items
Dust Mites*A
• Require humidity and human
dander to survive, thrive in most
areas of the United States but
usually not present in high
altitudes or arid areas
• High levels are found in bedding,
pillows, mattress, upholstered
furniture, carpets, clothes and soft
toys
IMPORTANT: The patient’s bed is
the most important source of dust
mites that need to be controlled.
Dust Mites Control Measures*B
• Encase the pillow and mattress in an allergen-impermeable
cover.
• Wash all bedding in hot (>130ºF) water weekly*.
• Keep humidity below 60% (ideally 30%-50%).
• Remove carpets from the bedroom.
• Avoid sleeping or lying on upholstered furniture.
• In children’s beds, minimize the number of stuffed toys; each
week, wash the toys in hot water or freeze them.
• Room air filtration devices are not recommended to control
dust mite exposure – the allergens are air-borne only briefly
and not removed via air filtration.
(*Exposure to dry heat or freezing kills dust mites but does not remove the allergen.)
Cockroach Control Measures*B
• Keep counters, sinks, tables and floors
clean and clear of clutter.
• Fix plumbing leaks and other moisture
problems.
• Remove piles of boxes, newspapers and
other items where cockroaches may hide.
• Seal all entry points.
• Make sure trash in your home is properly
stored in containers with lids that close
securely; remove trash daily
• Try using poison baits, boric acid or traps
first before using pesticide sprays.
Common Home Triggers: Irritants
Molds
Basements
Bathrooms
Smoke
& Gases
Kerosene
heaters
Wood
stoves/Firep
laces
VOCs
Hairspray,
Cooking spray
& odors
Furniture
polish
New carpets
Perfumes
Tobacco
smoke
Mold Control Measures*C
• Moisture control = mold control, so ACT QUICKLY.
– If wet or damp materials or areas are
dried 24-48 hours after a leak or spill,
in most cases mold will not grow.
• Scrub mold off hard surfaces with
detergent and water; dry completely.
• Absorbent or porous materials, such
as moldy ceiling tiles and carpet, may
have to be thrown away.
• Dehumidify basements if possible.
(SOURCE: A Brief Guide to Mold and Moisture in Your
Home, EPA Publication #402-K-02-003.)
Smoke and Gas Control Measures
• Minimize exposure to strong odors and sprays (perfume,
talcum powder, hair spray, paints, new carpets, particle
board).
• Minimize production of nitrogen dioxide*C
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Inspect the heating system annually.
Inspect and keep clear the chimney clean-out opening.
Do not use unvented space heaters.
Do not use stoves for heating.
Do not use wood burning fireplaces .
Use kitchen exhaust fans.
Do not let the car idle in the garage.
Tobacco Smoke Control Measures
• If you smoke, ask for ways to help you quit.
Ask family members to quit too.*C
• Do not allow smoking in your home or car.
• Be sure no one smokes at your child’s
daycare or school.
• Advocate for smoke free workplaces.
IMPORTANT: An estimated 46.5 million adults
in the United States smoke cigarettes = 23.25
million deaths.
Secondhand Smoke
• Exposure is linked to increased asthma
symptoms, decreased lung function and
greater use of health services among
those who have asthma.
• Message to person with asthma or
caregiver – Quit or at least smoke
outside (may not adequately reduce
exposure).
• Provide smoking cessation support if
possible.*B
ACTIVE SMOKING & ASTHMA
•
More frequent exacerbations, hospitalizations, ER visits
• Therapeutic response to corticosteroids impaired
• Increased theophylline clearance
• Higher risk of developing worsening fixed airway obstruction COPD- asthmatics smoking 15 or > cigarettes /day have an 18%
decline in FEV1 over 10 yrs compared with a 10% decline in
nonsmokers with asthma*
• Increased risk of cancer, heart disease, gerd, chronic sinusitis
*Apostol et al “Early life factors contribute to the decrease in lung function between
ages 18 and 40” AJRespCritCM 2002;166:166-172
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PASSIVE TOBACCO SMOKING
(SHS*) & ASTHMA
– Children exposed to passive smoke have increased risk of developing
asthma of between 21% and 37% ** and of having increased
respiratory infections
– Implicated in some cases of new onset adult asthma particularly
women (60% in one study, no increase in men -Toren et al Int J Tuberc
Lung Dis 1999;3(3): 192-197
– Non smoking asthmatics have increased risk for asthma symptoms and
episodes
– Frequent exposure to passive smoke can increase risk of development
of COPD and other smoking related diseases- lung cancer and
cardiovascular disease
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*SHS =second hand smoke
**California Environmental Protection Agency: Health effects assessment for environmental
tobacco smoke. Office of Environmental Health Hazard Assessment Sacramento, CA 2005
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Techniques That May Modify Indoor Air
• Vacuum 1-2 times per week
– Get someone else to do this if possible or wear a dust mask
• Damp mop
• Air conditioning during warm weather recommended for
asthma patients*C
• Dehumidifiers to reduce house-dust mite levels in highhumidity areas
• HEPA filters to reduce airborne cat dander, mold spores
and particulate tobacco smoke.
– Not a substitute for more effective measures!
Techniques Not Recommended
• Humidifiers not recommended for use in homes with
dust-mite sensitive patients*c
• Insufficient evidence to recommend cleaning air ducts in
HVAC systems*D
• Insufficient evidence to recommend using indoor air
cleaning devices
Immunotherapy
It is recommended that allergen immunotherapy be
considered for patients with persistent asthma if evidence
is clear of a relationship between symptoms and exposure
to an allergen to which the patient is sensitive.*B
Immunotherapy
Immunotherapy is usually reserved for patients whose
symptoms occur all year or during a major portion of the
year, and in whom controlling symptoms with
pharmacologic management is difficult because the
medication is ineffective, multiple medications are
required, or the patient is not accepting the use of
medication.
(EPR – 3, pg. 173)
Schools: Potential Concerns
• Poor indoor air quality
• Leaky roofs/wet carpeting =
Molds
• New carpeting/chemicals =
Toxic fumes
• Building repairs/renovations =
Dust
• Idling school busses =
Diesel fumes
• Unventilated portable
classrooms
• Fragrances (Magic Markers,
air fresheners, art supplies)
• Animals in classroom
• Cleaning supplies
• Classroom environment (old
carpeting, furniture)
• Insecticides, herbicides,
fungicides
• Chalk dust, foods
• Access to medications
• Access to a school nurse
Asthma Friendly School Resources
It is recommended that a clinician prepare a written asthma action plan for
the school setting. In addition to medications and emergency response,
this plan should identify factors that make students’ asthma worse so that
the school may help avoid exposure.
Activity: How Asthma Friendly Is Your School?
Role-play: School Employee & Asthma Educator
Gabriel is a five-year-old boy with
asthma who will begin kindergarten in
the fall. His moderate-persistent
asthma has been well managed at
home and the family wants to inquire
about the environment of the school
setting prior to enrollment.
(SOURCE: CDC. How Asthma Friendly Are Your Schools?)
How Asthma-Friendly is your School?
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Tobacco free campus? Good indoor air quality?
Policy on inhalers?
Written asthma emergency plan for teachers & staff ?
Updated asthma action plans for students with asthma
on file at school?
• School nurse?
• Education for school staff/teachers about asthma?
• Degree of participation asthma student has in PE,
sports, recess, field trips?
Assess Work Triggers - Occupational
Ask employed patients about possible occupational
exposures, particularly upon new-onset of disease.
• Occupational asthma is suggested when there is a
correlation between asthma symptoms and work, as well as
an improvement when away from work for several days.
• Patient may miss the correlation as symptoms typically
present several hours after exposure.
• Serial peak-flow records at work and home can help confirm
the association.
Possible Occupational Exposures
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Isocyanates
Metal working fluids
Coolants
Chromium salts
Cleaning agents
Pesticides
Welding fumes
Direct
Irritants
• Plicatic acid – red cedar wood
dust
• Colophony – soldering fluxes
• Diisocyanates – urethane foam
• Phthallic/trimellitic anhydride
– adhesives, paints, varnishes
• Latex, formaldehyde, drugs
Allergic
Triggers
Occupations associated
with Asthma
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Bird breeders
Seafood & food processors
Beekeepers, farmers, granary workers silk processors, dockworkers
Pharmaceutical industry, health care workers
Mushroom workers, Bakers
Beauticians
Miners, cement, electroplating and tanning workers, metal workers and
diamond polishers, alloy makers
Plastics and printing industry
Shellac/lacquer industry workers
Foresters, woodworkers and furniture makers
Polyurethane, foam coatings, adhesives production, spray painters
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Causes of
Irritant-induced OA
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Chlorine gas
Hydrogen sulfide
Fumigating fog
Heated acids
•
1984 Bhopal, India - toxic cloud of methyl isocyanate gas released from
chemical plant killed thousands and caused thousands to develop persistent
respiratory disease (some with reversible airway obstruction)
•
2001 WTS, NYC- complex mixture of airborne dusts and pollutants associated
with RADS (and other respiratory disorders) in exposed rescue and recovery
workers and residents of the surrounding area
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Hydrochloric acid
Anhydrous ammonia
Smoke Inhalation
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Material Safety Data Sheets (MSDS)
• US Occupational Safety & Health Administration
requires that suppliers include a MSDS with each
shipment of an industrial material or chemical and
workers are entitled to receive copies of these
• Helpful in identifying respiratory hazards in the
workplace
• May omit information, but can focus subsequent
literature review to obtain additional info. (materials present in
concentrations <1% need not be reported)
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Outdoor Environment
• Ask the patient – “Is
your asthma
consistently worse in
spring, summer, fall or
parts of the growing
season?”
• Avoid areas of high
pollution; stay indoors
on ozone alert days
when possible.*C
• Do not use air cleaners
that create ozone.*D
Pollen and
Molds
Ozone
Other Contributing Factors
Viral respiratory infections
• Respiratory infections can exacerbate asthma symptoms,
particularly in children under age 10. Rhinovirus, an upper
airway pathogen, has been demonstrated in the lower
airways in patients with asthma.
Bacterial infections
Infections such as Mycoplasma and Chlamydia
may contribute to asthma exacerbations.
Other Contributing Factors
Influenza
• Consider inactivated influenza vaccination for patients with asthma.
• Vaccinate due to increased risk of complications from influenza. Do not
expect reduced frequency or severity of asthma exacerbations during
influenza season.*B
• 2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare
Settings
• http://www.cdc.gov/hicpac/2007ip/2007ip_part3.html
•
Female hormones and dietary constituents
• There is insufficient evidence to make specific recommendations on
these topics.
Other Contributing Factors
• Aspirin sensitivity – Avoid aspirin and other NSAIDs as
these drugs could precipitate severe and fatal
exacerbations.*C
• Other medications – Recommend avoidance of nonselective β–blockers (eye drops used for glaucoma)
and HTNB & ACE inhibiters –used for HTN.
• Sulfite sensitivity – Avoid processed potatoes, shrimp,
dried fruit, or drinking beer and wine to avoid sulfite
exposure.*C
ASPIRIN INDUCED ASTHMA
SAMPTER’S SYNDROME
ASTHMA TRIAD
- Aspirin / NSAID induced respiratory reactions Asthma and
Nasal Polyps - these 3 things make up the Asthma Triad
- occurs in 4.3-21% asthmatic
– Develop persistent rhinitis in 3rd or 4th decade associated with viral
URI
– Usually asthma is severe and poorly responsive to corticosteroids
– Women affected 2.5X > men
– Mechanism: “shunting”of arachidonic acid metabolism away from
prostanoid production, leading to increased leukotriene production
and resultant bronchoconstriction
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DRUG TRIGGERS
• Non Selective Beta2 Blocker - Inderal /Propanolol - the beta 2
receptors in the lungs are responsible for relaxation of the
bronchial muscle when you take a beta 2 blocker it does the
opposite it constricts airways. Used to rx migraines, heart
disease
- Selective Beta Blockers -Metoprolol, Labetalol, Carvedilol,
etc - primary affect Beta 1 receptors in the heart
-Eye drops for Glaucoma
• ACE Inhibitors - can induce cough
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CHEMICAL/MEDICATION ASTHMA
TRIGGERS (con’t)
• Sulfites -sulfur dioxide is a gas that can irritate
airways and provoke asthma symptoms
– Some preservatives- widely used n wine, beer, & cider,
may contain additives in fresh sausages, previously used
in salad bars
– Most dried fruits (especially dried apricots) are treated with
sulfur dioxide
– If sensitive, read labels- sodium sulphite, sodium hydrogen
sulphite, sodium metabisulphite, potassium metabisulphite,
calcium sulphite
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Exercise-Induced Bronchospasm (EIB)
• EIB should be anticipated in all asthma patients. A
history of cough, shortness of breath, chest pain or
tightness, wheezing and/or endurance problems during
exercise suggests EIB.
Co-morbid Conditions
• If a patient’s asthma cannot be well controlled, evaluate
for the presence of co-morbid conditions.
• Evidence suggests that appropriately treated co-morbid
conditions can improve asthma control.
Co-morbid Conditions
Allergic broncopulmonary Aspergillosis*A
• Suspect this condition in patients with asthma and a
history of pulmonary infiltrates or evidence of IgE
sensitization.
Gastroesophageal reflux disease*B
• Suspect this condition in patients with poorly controlled
asthma, particularly at night, even without other
suggestive symptoms.
GASTROESOPHAGEAL
REFLUX DISEASE (GERD)
• Present in 50-70% of chronic asthma patients
• Proposed trigger mechanisms: microaspiration & vagally
mediated bronchospasm
• An asthma episode may be the trigger for GERD - change in
pleural pressure gradients, thoracic distension and air trapping
• Other triggers for GERD: abdominal obesity, obstructive sleep
apnea, asthma meds, exercise, cough
• Silent reflux - especially in diabetes
• Symptoms: cough, wheezing, sob, water brash, heartburn, chest
tightness
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Co-morbid Conditions
Obesity*B
• Suggest to asthma patients who are overweight or
obese that weight loss may improve asthma control, in
addition to improving overall health.
Obstructive sleep apnea*D
• Suggest to asthma patients who are overweight or
obese that weight loss may improve asthma control, in
addition to improving overall health.
OBESITY IN ASTHMA
• Asthma mimic and risk factor for asthma
• Lung effects: decreased functional residual capacity (FRC) and
expiratory reserve volume (ERV) - decreased airway caliber,
increased airway resistance, possible increased airway
hyperresponsiveness - overall effect is dyspnea
• Pro-inflammatory state that may contribute to lung inflammation
and asthma
• Necessary to evaluate symptoms with complete PFT,
bronchoprovocation studies, IgE levels, etc
• Obese patients with asthma require more drugs, are more
symptomatic, have an increased risk of ER visits
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RHINOSINUSITIS
IN ASTHMA
• Most common comorbidity associated with asthma -occurs in
78% asthma patients compared to 20% general population
• Allergic rhinitis (AR) is a risk factor for asthma, it’s presence
before 7 yrs old predicts asthma onset
• “The allergic march” progression of allergic disease from
nose/sinuses to lung airways
• Complications: nasal polyps, sleep apnea, recurrent
rhinosinusitis, anosomia, more severe asthma
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Co-morbid Conditions
Rhinitis/sinusitis*B
• Suspect these conditions in patients with asthma;
evaluate the possible presence of symptoms.
Stress, depression and psychosocial factors*D
• Suspect these conditions in patients with asthma that is
not well controlled. Ask about the potential role of
chronic stress or depression in complicating their
asthma management .
Pregnancy
PREGNANCY
IN ASTHMA
• Rule of 1/3’s
• Uncontrolled asthma during pregnancy can cause preeclampsia, cesarean
delivery, placenta previa, preterm labor, vaginal hemorrhage .Fetus
increased risk of low birth weight, intrauterine growth retardation and death
• Other pregnancy issues - obesity, gerd, rhinitis
• Aggressive Rx of asthma during pregnancy is important
• Medications - Category B Budesonide, Singulair, Cromolyn, Xolair
– Category C - Albuterol, other inhaled CTS, Theophylline, combination
products
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Vocal Cord Disorder
• Presents as acute upper airway obstruction with dyspnea,
throat tightness, anxiety, wheezing, inspiratory stridor,
dysphonia, hoarseness, respiratory distress (retractions may
be present), +/or choking
• Mimics asthma, but does not respond to asthma meds
• May coexist with asthma
• Occurs in up to 40% of patients being evaluated for asthma,
more freq in females, can occur in conjunction with asthma
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SUMMARY OF TRIGGERS
• Inhalant Allergies - pollens, molds
• Irritants - chemical exposures, cold air, stomach acid
with GERD
• School /Occupational Triggers
• Respiratory Infections - viral
• Food - mostly in children peanuts, sulfites
• Drugs - nonselective beta blockers, ACE inhibitors, ASA,
NSAIDS
• Strong Emotions
• Hormones - premenstrual, pregnancy???
• Strenuous Exercise
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CO-MORBID CONDITION SUMMARY
•
•
•
•
•
•
OBESITY
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
OBSTRUCTIVE SLEEP APNEA
VOCAL CORD DYSFUNCTION (VCD)
CHRONIC RHINITIS/SINUSITIS
STRESS, DEPRESSION, PSYCHOSOCIAL
CONDITIONS
• PREGNANCY
• ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
(ABPA)
Case Study
• 25 yr old Yongcha has been recently seen in the ER for
an asthma exacerbation. She has since been
diagnosed with moderate persistent asthma and is on
appropriate medications for her severity level. She is
still experiencing poor asthma control and her provider
has referred her to you, the asthma educator to discuss
trigger reduction.
• Yongcha works at a childcare center in downtown
Albuquerque and commutes via bus. She recently
moved in with her boyfriend. Recently diagnosed, she
has a poor understanding of trigger exposure. She is
not taking prescription meds for allergies or other
comorbid conditions.
Case Study Directions Yongcha
• Divide into 2 groups.
• Discuss as a group what information a first meeting
would entail.
• Role play the meetin with one person being the asthma
eduucator and the other being Yongcha.
• Practice describing factors in simple English and
determining priorities for intervention.
Acknowledgements
• Beverly Stewart
American Lung Association in Oregon
We will breathe easier when the air in every
American community is clean and healthy.
We will breathe easier when people are free from the addictive
grip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces and
workplaces is clear of secondhand smoke.
We will breathe easier when children no longer
battle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.
We will breathe easier when the air in every
American community is clean and healthy.
We will breathe easier when people are free from the addictive
grip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces and
workplaces is clear of secondhand smoke.
We will breathe easier when children no longer
battle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.
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