Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed and Provided by: Welcome to Managing Asthma.

Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed and Provided by: Welcome to Managing Asthma in MN Schools - STAFF introduction for presentation Co-written by Susan Ross RN Clinical advisor for the asthma program Stephanie Bisson Belseth NP w/Mpls Public Schools/Mpls Childrens Clinic Deb Hill Health Educator And Laura Oatman Environmental Research Scientist Wendy Brunner is our asthma epidemiologist and verified statistics. Janet Keysser is our asthma program director. This program has been created for All MN school personnel by: The Minnesota Department of Health Asthma Program.

MDH Asthma Program Staff
Presenter For Today Susan K. Ross RN, AE-C MDH Asthma Program Staff

Minnesota Department of Health www.health.state.mn.us/asthma
MN Dept of Health thanks to a grant the Centers for Disease control- we are one of 6 states initially awarded both a planning and implementation grant. We’re currently in our 2nd year of the grant (5 year).

Funding grant awarded by:
Acknowledgements Our Advisory Group consisted of participants from every region of the state! See the acknowledgements page at the beginning of the manual. Special thanks to: Denise Herrmann from SPPS Cecelia Erickson from MPS “Healthy Learners Asthma Initiative” Cheryl Smoot MDH Funding grant awarded by: Centers for Disease Control and Prevention (CDC) Please take a minute to look through the acknowledgements pages. We made every effort to create a manual that reflects the needs of schools across the state. Our advisory group consists of school staff from every region of the state. Our thanks for all the time, energy and effort these individuals contributed. Special thanks to Denise Herrmann from SPPS, Cheryl Smoot from MDH and Cecelia Erickson from MPS. This manual has been created thanks to a grant awarded by Centers for Disease Control and Prevention

Thanks To: GlaxoSmith Kline Pharmaceuticals
AstraZeneca Pharmaceuticals Starbright Foundation Hennepin County Medical Center For contributing PFM’s, Spacers, Diskus, asthma booklets and CD-Rom games for our participants Read slide

Overview of Today Controlling Asthma Asthma triggers and irritants
Asthma Basics Asthma triggers and irritants Diagnostic/ assessment process NIH/NHLBI/NAEPP asthma guideline overview Severity level workout Medication Overview Asthma “gadgets” Controlling Asthma Tools available (MDH website-Manual) Coordinated School Health There will be multiple opportunities for group interaction and case scenario breakdown. We will do a complete overview of current medications used to treat and prevent asthma episodes from occurring and cover the most commonly used equipment to evaluate and treat asthma. Controlling Asthma covers the tools available on the MDH website and how to work within and outside your school/district.

Post Tests - Evaluations C.E.U’s
Complete the post test Complete the program evaluation Complete your goals sheet Hand everything in before you leave You will receive credit for 7.2 C.E.U’s after attending today's presentation At the end of our program there is a Post test and evaluation and goals. Our contact information is on the introduction cover and on our website under asthma staff In order for you the get your CEU’s for this program- as you leave today, you must return to us all evaluations and tests.

As We Go Through This Program
Consider how you would use the tools provided today. How can you take this information and use it to establish an asthma program in your school or district? How can you promote involvement by other school personnel outside the health office? Read slide

How To Use This Manual Resource and Training document
Each Section is all-inclusive to each staff member’s role Lift out the entire section - copy it and use as a basis for teaching about asthma Supplemental forms/handouts are in the back folders and provided on CD and website Full resources section w/websites are listed Power Point presentations are also on our asthma website and CD in back of your manual The manual is intended to be used as both a resource and training document. Each section is all-inclusive and written according to the needs of the staff member's role in the school. The amount of time and type of interaction the staff member has with students directly correlates to the content of the section. The manual has been written so that you can simply life the entire section out- copy it and use it as a basis for educating school personnel. Supplemental materials/ forms and such are located at the back of the manual. A full resources section that includes website links and suggested program/educational sites are listed. A CD ROM at the back of your manual contains all text pages and forms for print in PDF/Word format. You can alter the word documents to fit your needs and add your school logo. The entire manual is also available on line at the MDH asthma website. PowerPoint presentations you may use at your discretion are also on the CD and website. Provided are: Asthma basics for school personnel Asthma basics for coaches Asthma basics for PE/HE teachers Asthma and the school environment And the PPT from this entire program broken down into 3 presentations.

You Should Know! This manual contains suggestions for action and you are strongly urged to consult your school district policies and guidelines before implementing these suggestions. The manual contains suggestions for action and you are strongly urged to read your school district policy and guidelines before implementing these suggestions. The forms provided in the back are a compilation of options from a number of sources, and you have the choice whether to use these sample documents or to create your own. Again, check with district and school policies regarding what is mandated in your area.

Staffing Models School health staffing varies greatly across the entire state The manual provides a few suggested staffing models in the “All Health Staff” section Today’s program is based on a school that has at least some LSN/PHN/RN staffing in the school on regular basis Staffing Models: Because school health staffing levels and type across the state vary depending on school size, location, policy and budget; we have provided a few different staffing models in the all health staff section. The information we are providing today is based on the assumption the school has at least some LSN/RN staffing coming into the school on a regular basis.

PRE- TEST PRE- TEST*******

Mikey’s Mom Didn’t Know Asthma Could Kill… From GlaxoSmithKline and Allergy & Asthma Network, Mothers of Asthmatics (AANMA)

Did You Know.. Asthma kills people equally regardless of severity level 1/3 of deaths are in those with mild asthma 1/3 of deaths are in those with moderate asthma 1/3 of deaths are in those with severe asthma Read slide

Asthma: Accounts for 14 million lost school days annually3
Is the most common chronic disease causing absence from school2 Is the 3rd leading cause of hospitalizations among children under 152 1 in 13 school children have asthma1 6.3 million children under 18 have asthma1 1 Asthma Prevalence, Health Care Use, and Mortality, , National Center for Health Statistics, CDC 2 Morbidity and Mortality Report, National Center for Health Statistics (NCHS), U.S. CDC, 2003 3 Surveillance for Asthma - United States, , MMWR Surveillance Summaries, CDC, March 29, 2002

Minnesota Children In a 2003 MDH survey of more than 5,000 7th & 8th graders at 15 junior highs outside the metro area- 1 in 12 reported they currently have asthma In a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN- 1 in 11 reported they currently have asthma Information provided due to surveys with information evaluated and compiled by MDH Epidemiologists Wendy Brunner and Marian Marbury (consultant to MDH) Questions were answered by students only. Survey results available on MDH asthma website: Data & Research section.

This means.. In a class of 30 children, you can expect 2 to 3 students WILL have asthma This number varies depending on age and geographical location

“ Healthy Children Learn Better”

Do School Children Have Asthma Action Plans?
In MDH’s survey of 7th and 8th graders in greater Minnesota: 37% of the children who had asthma did not know if they had a written asthma action plan 28% did not have an asthma action plan Overall, only 34% of children who have asthma actually had asthma action plans READ SLIDE Interestingly enough, In MDH’s survey of 7th and 8th graders in greater MN, 37% of the children who had asthma did not know if they had a written AAP. 28% did NOT have have an AAP. (versus the 37% that didn’t even know IF they had them) Overall only 34% of children who have asthma HAD AAP’s. This was a survey from 15 Junior High schools located outside of the MPLS/ St. Paul Metropolitan area completed in 2003. The survey summary results will be available on the MDH website late spring of 2004 **Survey: 2003 Minnesota School Prevalence Survey- Marian Marbury & Wendy Brunner- MDH Epidemiologist

Asthma & Exercise Of the 7th & 8th graders with asthma:
80% reported wheezing “sometimes” or “a lot” during or after running, playing sports or exercising 36% reported missing recess, sports or other physical activities due to asthma symptoms 24% reported missing a day or more of school in the past year due to asthma symptoms 66% reported wheezing “sometimes” or “a lot” **from the same MDH survey as the previous slide. (Wendy Brunner, Marian Marbury MDH)

Survey Conclusions There is substantial uncontrolled asthma among school children in this age group This lack of control is manifested by the high rate of morbidity as measured by school absence and missed activities among children who have been diagnosed with asthma The survey also suggests that there may be substantial undiagnosed asthma READ SLIDE: Summary of survey results: AAP’s among children with diagnosed asthma suggests that this cornerstone of asthma care is underused and that the majority of students w/ asthma do NOT have them.

Impact Of Asthma On Students
School Performance: Poorly controlled asthma has a negative impact on school performance in both academic achievement and physical education Poorly controlled asthma affects a child’s performance. It disrupts sleep, the ability to concentrate, memorize, and, when not managed properly can prevent a child from participating in “normal” school activities.

Impact Of Asthma On Students cont...
Psychosocial: Poor self-esteem Anxiety about asthma Fear of becoming ill at school Anxiety about exercise at school Fear of being different Children with poorly controlled asthma may feel drowsy, tired or anxious about taking medications, or even embarrassed when disruption to school activities occur due to an asthma episode

YOU Can Make A Difference!
Asthma is a chronic but manageable disease and the more you know about asthma and how to manage it, the more you can help ensure the immediate safety and the long-term health of students in your school. As a member of the health care staff, you play a vital role in helping your school become an asthma- friendly school and in creating a supportive educational environment where all students can learn and thrive.

What Is Asthma? Asthma is a chronic disease that causes:
Bronchoconstriction Inflammation of the bronchioles (small airways) Hyper-responsive “twitchy” airways Excessive mucus production in the bronchioles Asthma is a multi component chronic disease. Asthma is a chronic disease that causes broncho-constriction and spasm (tightening of the muscles around the airways) Inflammation of the bronchioles/airways. Excessive mucus production in the bronchioles There may be periods when there are no symptoms but the airways are swollen and sensitive to some degree all of the time. For those of you have also been out of school for a LONG time- here’s a mini lung anatomy refresher. Oxygen moves through the trachea or Large air tube Thru the bronchi or middle sized air tubes to the bronchioles or smallest air tubes - this is where mucus can clog the airways and make exhalation difficult. The final destination is the alveoli or air sacs … Airway constriction or in the case of asthma - OBSTRUCTION affects the entire lung.

Normal Bronchiole Inflamed Bronchiole with Mucus
During an “asthma episode,” muscles around the airways tighten, linings of the airways (bronchioles) become inflamed, and mucus clogs the tiny airways, making breathing difficult. The airways become overly responsive (twitchy) to environmental changes, sometimes resulting in wheezing, coughing, breathlessness, or tightness in the chest. During an asthma episode a child may feel he/she can't inhale enough air, but actually, the child’s lungs are having trouble exhaling. Continued exposure and/or lack of treating the inflammation results in preventing O2/CO2 exchange. Untreated, the inflammation can cause recurrent episodes of wheezing, coughing, breathlessness, and chest tightness, especially at night / early morning Potentially, airway remodeling (a type of lung scarring which is permanent) can occur when asthma goes untreated.

Copyright 3M Pharmaceuticals 2004
Airway Obstruction It is not curable but is very treatable. Copyright 3M Pharmaceuticals 2004

Airway Inflammation of bronchial tissue: Allergen exposure causes irritation w/redness' and swelling which in turn causes the mucus production. Inhaled corticosteroids is the gold standard for treating (on a daily basis) persistent severity levels of asthma (levels 2-4) per NHI/NHLBI guidelines. See web page for more info /bronchiole edema

Epithelial columnar Basement membrane Celia

Before 3 months on an ICS and after 3 months on an ICS BID

A Lot Going On Beneath The Surface
Symptoms Airflow obstruction Bronchial hyperresponsiveness With asthma, what we see is the tip of the iceberg, the symptoms. At the base of the iceberg is the airway inflammation. This inflammation underlies the bronchial hyperresponsiveness of asthma, the air flow obstruction, and the culmination of the inflammatory process is the tip of the iceberg, the symptoms. *Active inflammation of the airways can be present for 6 to 8 weeks following a sever respiratory infection. *Airflow obstruction results from bronchoconstriction, bronchial edema, mucus hypersecretion, and inflammatory cell recruitment including eosinophils, a key inflammatory cell. Airway inflammation Slide courtesy of ALAMN - PACE program 2004

Immune System Response
The Immune System Response Think of falling dominoes. It's a reasonable model for what is known as the allergic cascade. Starting with the initial exposure to an allergen in the early phase, a series of reactions in the immune system—one reaction precipitating another reaction- similar to dominoes lined up- Asthma Triggers: A number of factors can trigger acute attacks of asthma: allergens such as pollen, animal dander, dust mites, or cockroaches; certain medications to which you are allergic; exposure to dust or bus diesel fume; or irritants such as strong odors, cigarette smoke, or air pollution. In some people, strenuous exercise or cold air can trigger an asthma attack.

The Asthma Cascade The Immune System Response -The asthma Cascade Allergens are identified as a key cause of allergic asthma. But the real culprit in causing allergic asthma is the IgE antibody. The IgE antibody is produced by the body in response to allergen exposure. The combination of the IgE antibody with allergens results in the release of potent chemicals called mediators. The mediators cause the inflammation and swelling of the airways, resulting in the symptoms of asthma. This makes the antibody IgE the root cause of allergic asthma.************ from AAAAI The first time you are exposed to an allergen, your immune system produces special antibodies that will recognize only that particular allergen. The antibody involved in allergic asthma is called immunoglobulin E (IgE). Once the IgE antibodies are produced, they attach themselves to special receptors on the mast cells. The immune system is now sensitized—"primed." But the child won't experience symptoms until he is re-exposed to the allergen. When he/she IS re-exposure, the mast cells trigger the release of histamine and other inflammatory substances, called mediators. These mediators are responsible for the symptoms of an allergic reaction. © 2003 Genentech, Inc. and Novartis Pharmaceuticals Corporation.

Mediator Phases Early-phase reaction caused by mediator release, usually peaks within an hour after initial exposure to the allergen. Three to four hours after an acute asthma episode, a "late-phase reaction" may occur and may last up to 24 hours Acute Asthma Attacks Within minutes after these mediators are released into the airway tissues, the smooth muscles surrounding the airways tighten. The airways get narrow, and breathing becomes difficult. Fluid leaks from affected blood vessels into the tissues in the airway walls, causing them to become inflamed and swollen. They become even narrower. The airways might fill with mucus. By now, breathing is difficult having trouble letting the air out. Wheezing, shortness of breath, chest tightness, and coughing may follow. This "early-phase reaction," caused by mediator release, usually peaks within an hour after initial exposure to the allergen. About three to four hours after an acute asthma attack, a "late-phase reaction" may occur. The late-phase reaction may last up to 24 hours. Breathing may also become more difficult during this time.

The End Results Of The Cascade
Localized mucosal edema in the walls of the small bronchioles Secretion of thick mucus into the bronchiolar lumens (Clogs and narrows the airways) Spastic contraction of bronchiolar smooth muscle The end results of the cascade include: 1) localized mucosal edema in the walls of the small bronchioles 2) secretion of thick mucus into the bronchiolar lumens (clogs and narrows the airways) 3) spastic contraction of bronchiolar smooth muscle Consequences of Chronic Allergic Reaction in Asthma With repeated rounds of allergen exposure and allergic response, there is bound to be some damage done to the tissues involved. Researchers are exploring the issue of airway remodeling, or scarring of the airways in the lungs of asthma patients. SO- an Asthma episode or attack- whatever the wording, the outcome is essentially the same-

A CHILD CAN’T BREATHE The child can’t breathe!

Group Straw Exercise Stand up Place the straw in your mouth Try to breathe! This is what is may feel like when a child is having a severe asthma episode Have participants stand up in place Pinch closed nose (nares) with their fingers Place the straw in mouth and without cheating, try to breathe only through the straw. This is what is feels like to suffer a severe asthma attack or episode The only difference is…YOU can remove the straw (do this for only 1 minute) but the child having an asthma episode cannot remove a straw- they must wait for the muscles to relax, for the bronchioles to open enough for air to pass through. If the airways are TOO filled with mucus- no amount of albuterol will open those airways- they’re clogged with mucus. The only way to prevent the mucus and swelling is for asthmatics to take daily medications such as inhaled corticosteroids (Controllers).

Common Symptoms Of Asthma
Frequent cough, especially at night Shortness of breath or rapid breathing Chest tightness Chest pain Wheezing Fatigue READ SLIDE: These symptoms vary greatly in severity and not ALL children have the same symptoms Symptoms are often worse at night and in the early morning hours. The severity of asthma varies from child to child and the severity may worsen or improve depending on the child’s symptom control and amount of exposure to triggers or allergens.

Early Signs Of An Asthma “Episode”
Stomachache Headache Sneezing Congestion Restlessness Dark circles under eyes Irritability Mild cough Drop in Peak Flow reading Itchy, watery or glassy eyes Itchy, scratchy or sore throat Runny nose Recognizing the EARLY Signs of an Asthma Episode Children themselves are often the best source for identifying an asthma episode. they learn to identify their own unique early warning signs-the physical changes that occur as their airways begin to close. These early warning signs may begin long before the more serious symptoms appear An asthma episode is easier to subdue if a child and school staff are aware of significant changes and the child is able to take medication quickly.

Acute Asthma Episodes

What’s An “Episode”? An asthma episode occurs when a child is exposed to a trigger or irritant and their asthma symptoms start to appear This can occur suddenly without a lot of warning, or brew for days before the symptoms emerge Episodes are preventable by avoiding exposure to triggers and taking daily controller medications (if prescribed)

Handling Acute Asthma Episodes At School
Remain calm and reassure the child Have the child sit up and breathe slowly- in through the nose slowly, out through pursed lips very slowly Have the child sip water / fluids Check peak flow (with severe symptoms: skip PF & give quick-relief or reliever medication immediately) Child should not be left alone

Handling Acute Asthma Episodes At School Cont…
Give asthma reliever (bronchodilator) per the child's Asthma Action Plan / medication orders Assess response to medication After ~5-10 minutes recheck peak flow Call parent/guardian/health care provider prn Call 911 if escalating symptoms or no improvement Read slide

Call 911 if.. Lips or nail beds are bluish
Child has difficulty talking, walking or drinking Quick relief or “rescue” meds (albuterol) is ineffective or not available Neck, throat, or chest retractions are visible Nasal flaring occurs when inhaling Obvious distress Altered level of consciousness/confusion Rapidly deteriorating condition IF any ONE of these symptoms/situations is happening, call 911 and provide care as appropriate per the child’s AAP or individualized health plan.

“There should not be any delay once a child notifies school staff of a possible problem or developing asthma episode” READ SLIDE School personnel should contact the nurse (if on site) immediately and remain with the child. The school nurse should immediately evaluate the child’s breathing status and give albuteral or appropriate reliever medication per the childs AAP or Individualized Health Care Plan.

A little fun -This joke refers to one of many theories that exposure to some animals may prevent asthma from developing.

What Causes Asthma? Of the 21 million asthma sufferers in the US, 10 Million (approx. 60%) have allergic asthma. 3 million of those are children1 Exposure to certain allergens trigger asthma symptoms to begin Exposure to certain irritants can also set an asthma episode in motion 1National Institute of Environmental Health Sciences Triggers and Irritants

What Causes Asthma? Asthma may be caused by genetic, immune and/or environmental factors, and is often associated with eczema and allergies Researchers do not understand all of the causes of asthma or its increasing prevalence It boils down to “We just don’t really know for sure”

Triggers and Irritants
Copyright 2004, 3M Pharmaceuticals

Common Allergens (Triggers)
Seasonal Pollens Animal dander saliva/urine Dust Mites Cockroaches/Mice/Rat droppings and urine Mold Some medications Some Foods COMMON TRIGGERS: allergens such as pollen animal dander, saliva/urine- from furry or feathery animals including PETS in the classroom dust mites Cockroaches/Mice/Rat Droppings and their urine certain medications to which you are allergic such as Aspirin or NASAIDS exposure to dust or bus diesel fume; or irritants such as strong odors, cigarette smoke, or air pollution. In some people, strenuous exercise or cold air can trigger an asthma attack.

Common Irritants (Triggers)
Exercise Cold Air Chalk Dust Viral/upper respiratory infections Air pollution Tobacco smoke or secondhand smoke Chemical irritants and strong smells Strong emotional feelings Diesel fumes Cleaning supplies Common TRIGGERS or irritants that set off an asthma episode include: Exercise induced asthma and or exercise induced symptoms Cold air Chalk dust or now days- whiteboard marker scents Viral/upper respiratory infections such as sinusitis, bronchitis etc Air pollution- more specifically, when the ozone is high/or high particulate matter in the air Tobacco smoke or second hand smoke- there are a number of initiatives right now that are addressing secondhand smoke exposure in public places such as restaurants, work place and such. Chemical irritants and strong smells. Some children are very sensitive to perfume scents, cleaning solutions (for example: pine sol- the odor is extremely strong) or soaps. Even car exhaust or diseal fumes from buses can set off an asthma episode in sensitive children. see the bus driver section for information regarding diesel fume reduction and what your school can do. One of the simplest things is having bus drivers turn off their engines while waiting for children. Please see the school bus idling law in the resources section for more info. Strong emotional feelings such as crying, laughing, or even fear and agitation can set off an asthma episode in some children. One thing to keep in mind is just because the trigger is a psychological factor does NOT mean the asthma episode is not a physical reaction. These children need the same treatment and care any other child who has asthma receives.

Role of Viral Respiratory Infections In Asthma Exacerbations

VRIs And Hospitalizations For Asthma
Hospital admissions for asthma correlate with virus isolation peaks and school terms URIs 5 10 15 20 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total pediatric and adult hospitalizations School holidays Johnston and associates1 reported the relationship between asthma and VRIs in a time-trend analysis of hospital admissions for asthma during a 1-year period. Strong correlations were found between seasonal patterns of URIs and hospital admissions for asthma (r=0.72, P<.0001). The relationship was stronger for pediatric admissions (r=0.68, P<.0001) than for adult admissions (r=0.53, P<.01). There were clear relationships between the peaks of both respiratory infections and asthma admissions in all age groups and the start of a new school term. Upper respiratory infections and admissions for asthma were more frequent during periods of school attendance (87% of pediatric and 84% of total admissions) than during school holiday periods (P<.001). RVs were the most common pathogen isolated, as reported in the study by Johnston and others in children,2 and were associated with the four peaks identified for viral infection or asthma admissions.1 1. Johnston SL, Pattemore PK, Sanderson G, et al. The relationship between upper respiratory infections and hospital admissions for asthma: a time-trend analysis. Am J Respir Crit Care Med. 1996;154: 2. Johnston SL, Pattemore PK, Sanderson G, et al. Community study of role of viral infections in exacerbations of asthma in 9-11 year old children. BMJ. 1995;310: Adapted with permission from Johnston SL et al. Am J Respir Crit Care Med. 1996;154:654. Official Journal of the American Thoracic Society. ©American Lung Association.

RV-Induced Airway Inflammation
Hyperresponsiveness Plasma leakage Mucus hypersecretion Inflammatory cell recruitment and activation Neural activation Virus-infected epithelium The mechanism of RV-induced airway inflammation is thought to depend on viral replication within respiratory epithelial cells. This viral replication triggers intracellular signaling pathways that lead to increased secretion of multiple cytokines (tumor necrosis factor-alpha, granulocyte colony-stimulating factor, and interferon-gamma [IFN-]), and chemokines (interleukin-8 [IL-8] and RANTES), and also to increased expression of adhesion molecules.1 These chemokines and cytokines are increased in airway secretions during viral infections. Their actions are thought to involve recruitment and activation of the inflammatory cells (neutrophils, eosinophils, and activated T cells) that have been linked to asthma exacerbations.1 Neutrophils are the main cells found in nasal and lower airway secretions during acute viral infections,1 and increases in blood and nasal neutrophils correlate with cold and asthma symptom scores and cold-induced changes in airway hyperresponsiveness.2 1. Gern JE, Busse WW. The role of viral infections in the natural history of asthma. J Allergy Clin Immunol. 2000;106: 2. Grünberg K, Timmers MC, Smits HH, et al. Effect of experimental rhinovirus 16 colds on airway hyperresponsiveness to histamine and interleukin-8 in nasal lavage in asthmatic subjects in vivo. Clin Exp Allergy. 1997;27:36-45. Adapted from Gern JE, Busse WW. J Allergy Clin Immunol. 2000;106:201.

Summary Viruses cause asthma exacerbations in children
RVs cause ~60% of virus-induced exacerbations of asthma RVs directly infect the bronchial airways The response to viral infection is shaped by the host’s antiviral response VRIs cause asthma exacerbations in adults and children. RVs cause approximately 60% of virus-induced exacerbations. It has been demonstrated that RVs directly infect the bronchial airways. Therefore, it seems reasonable to assume that if baseline lung function is decreased, as in chronic asthma, virally induced enhancement of preexisting airway inflammation may lead to exacerbation of wheezing and other symptoms of asthma. However, another consideration is the effectiveness of the host antiviral response, as indicated by PBMC responses. Asthmatic individuals who have impaired lower-airway antiviral responses could have enhanced RV replication in the lower airway, leading to inflammation, airway obstruction, and exacerbation of asthma. 1. Gern JE, Busse WW. The role of viral infections in the natural history of asthma. J Allergy Clin Immunol. 2000;106: 2. Grünberg K, Timmers MC, Smits HH, et al. Effect of experimental rhinovirus 16 colds on airway hyperresponsiveness to histamine and interleukin-8 in nasal lavage in asthmatic subjects in vivo. Clin Exp Allergy. 1997;27:36-45.

Exercise Induced Asthma
Exercise Induced Asthma or exercise induced symptoms

What Is Exercise Induced Asthma (EIA)?
Tightening of the muscles around the airways (bronchospasm) Distinct from allergic asthma in that it does NOT cause swelling and mucus production in the airways Can be avoided by taking pre-exercise medications and by warming up/cooling down Exercise Induced Asthma Exercise-induced asthma is distinct from allergic asthma in that it does not produce long-term increase in airway activity. I.e.- bronchial inflammation w/mucus and these children wouldn’t necessarily require ICS’s (Inhaled Corticosteroids).. Exercise induced SYMPTOMS are different because those children most likely either already have asthma and their asthma is triggered by exercise- yet they always have some inflammation going on in the lungs. These children should most likely be on ICS’s in addition to using reliever/rescue inhalers such as albuterol. Information from NHI/NHLBI guidelines: see webpage for more info.

EIA - What Happens? Symptoms include coughing, wheezing, chest tightness and shortness of breath Symptoms may begin during exercise and can be worse 5 to 10 minutes after exercise EIA can spontaneously resolve 20 to 30 minutes after starting Can be avoided by doing the following: The symptoms of EIA may begin during exercise and be worse 5 to 10 minutes after stopping exercise or during the normal cool down period Symptoms range from mild to severe and often resolve in min. Occasionally, some children will experience “late phase” symptoms four to 12 hours after stopping exercise. These late phase symptoms are frequently less severe and can take up to 24 hours to go away.

Preventing Exercise Induced Asthma (EIA)
Become familiar with Asthma Action Plans Use reliever (Albuterol) minutes before activity Do warm-up/ cool-down exercises before and after activities Check outdoor ozone/air quality levels Never encourage a child to “tough it out” when having asthma symptoms Children who only experience asthma when they exercise may be able to control their symptoms with preventive measures such as warm-up and cool-down exercises. To prevent EIA: Become familiar w/the child’s AAP- school personnel who are w/children who’s asthma occurs w/exercise should also be familiar w/that child’s aap and what actions to take. This is outlined in each section of our manual. Check ozone/air quality levels for outdoor activity prior to exercise. In addition to warm ups. Most children who have EIA can prevent symptoms by using their inhaler minutes before they begin strenuous exercise.

Exercise As A Trigger! Exercise can be a trigger for those who have “chronic” asthma Their pre-exercise treatment is the same but- These children will have the underlying inflammation and require daily controller medication

Assess Need For Pre-Medication
Take note of medication order wording “As needed” vs. “prior to exercise” Evaluate if activity level requires pre- medication Pre-medicate for strenuous activity only Contact parent/ HCP if questioning need for pre-exercise medication It’s important for school nurses to assess each child’s need for their inhaler because each child has a different exercise tolerance level before their asthma kicks in. One child may need their inhaler at lower levels of physical activity- another may need it only when they are running or participating in very aggressive physical activity Working collaboratively with the PE teacher or coach can help reduce unneeded treatment with albuterol.

Coach’s Asthma Clipboard Program “Winning With Asthma”
100% online education for: Coaches Referee’s Physical Education Teachers Coaches will receive: Coach’s asthma clipboard Special Coach’s asthma education booklet Certificate of completion The satisfaction of knowing what to do during an asthma episode!

Where Can Coaches See It?

Myths and Truths Myths and Truths

Cartoon - Answer? You didn’t ..you probably had it as a child but it went undiagnosed and probably untreated. Many respiratory illnesses probably were asthma episodes were written off as Bronchitis or “reactive airway disease”- a popular term to avoid labeling a child w/”asthma” You don’t outgrow asthma- this topic is constantly debated even amongst “experts”. “Asthma is a chronic lung disease characterized by inflammation of the airways. There may be periods when there are no symptoms, but the airways are swollen and sensitive to some degree all of the time. Long term anti-inflammatory medications are important to control airway inflammation” from the PRACTICAL guide for the diagnosis and management of Asthma/ NHLBI EPR2 But heh- it doesn’t help that she’s smoking either!

Myths & Truths Asthma Truths Asthma Myths
Asthma is a very real, physical disease Asthma is a chronic disease, even when symptoms are not active Taking proper asthma medications allow children to fully participate in any activity, including sports Asthma Myths It is a psychological / emotional illness It is only an acute disease It always limits normal activities It limits a child's ability to fully participate in physical activities, especially sports READ SLIDE Multitude of false cures : Gecko liquid tonic (from the backs and tails of gecko’s), herbal supplements, accupuncture/pressure, asthma diets, cockroach tea, chiropractic adjustments Pranic healing w/mantras -apparently breathing certain words or mantras help heal Owning a chihuahua: this myth got started south of the border, where some children with asthma began to improve at the same time as their pet Chihuahuas developed asthma. Chihuahuas are born with the tendency to develop respiratory difficulties, and the children's improvement was merely coincidental.

Myths & Truths Continued..
Asthma Truths Asthma medications are not addictive Anti-inflammatories (controllers) are most effective when used everyday Children and adults die from asthma each year Asthma Myths Medication is addictive Medication becomes ineffective if used regularly Children do not die from asthma Read slide Ultimately, the best way to avoid asthma episodes is proper medical management ie. taking controller meds for persistent asthma and seeing a health care provider on a regular basis for re-evaluation and proper care.

One Last Myth Myth Truth
Reactive airway disease’s code is the same code used for asthma! Any order for albuterol (or other rescue inhaler) flags the insurance company Use “reactive airway disease” instead of “asthma” for a diagnosis – that way the insurance company will never know We’re not fooling anybody by trying to using diagnostic coding or wording when referring to asthma. It’s important to diagnose, treat and educate people who have asthma otherwise we risk perpetuating the myths that still dominate the medical field when it comes to asthma and it’s proper treatment. Be a part of the solution and not the problem!

Treatment Myths Gecko liquid tonic Herbal supplements
Acupuncture/pressure, chiropractic adj. Cockroach tea Asthma diets Pranic healing with mantras Owning a Chihuahua *Gecko Liquid tonic (from the backs and tails of Gecko’s *Pranic healing w/ mantras- breathing certain words or mantras help heal *Chihuahua: this myth got started south of the border, where some children w/asthma began to improve at the same time as their pet chihuahua developed asthma Chihuahua are born w/the tendency to develop respiratory difficulties and the childrens improvement was merely coincidental.

Small Group Exercise Report back a couple activity steps appropriate to that role Each table will review a section Read slide

Assessing Asthma Assessing Asthma
The following information is provided today in order for the school nurse to understand the diagnostic process and workup a physician or NP should use in order to verify a diagnosis of asthma or rule out other potential disease’s.

Measures Of Assessment And Monitoring
Two Aspects: Initial assessment and diagnosis of asthma Periodic assessment and monitoring Excerts from NHLBI/NIH READ SLIDE: Measures of Assessment and Monitoring: Information in this section in part are taken from NHLBI/NIH PPT presentations Their web address is

Initial Assessment & Diagnosis of Asthma
Determines That: Patient has a history or presence of episodic symptoms of airflow obstruction Airflow obstruction is at least partially reversible Alternative diagnoses are excluded Read Slide

Methods for Establishing Diagnosis
Detailed medical history Physical exam Spirometry to demonstrate reversibility READ SLIDE

History or Current Episodic Symptoms of Airflow Obstruction?
Wheezing, shortness of breath, chest tightness, or cough? Asthma symptoms vary throughout the day? Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma! Does the child have a HISTORY or CURRENT episodic symptoms of airflow Obstruction? Is there Wheezing, SOB, Chest Tightness or coughing Do the asthma symptoms vary throughout the day and The fact that there may be an absence of symptoms at the time of the examination does NOT exclude the diagnosis of asthma. Asthma is a REVERSABLE OBSTRUCTIVE disease, of which the obstruction due to bronchia constriction/spasm and inflammation will come and go depending on circumstances.

Asthma Lung Assessment Spirometry
Spirometry is Gold standard to assist in asthma diagnosis Assess need to start, step up, or step down asthma medications Should be done at least yearly in children with persistent asthma Spirometry is easily done at any health care providers office Read slide: PFT or pulmonary function testing is also done but at an appropriate facility and generally is ordered by specialist such as allergists, Pulmonologists.

Spirometry Continued…
Performed before and after bronchodilator dose to look for airway obstruction reversibility Can also be done with a cold-air or methylcholine challenge, or an exercise challenge in the case of exercise-induced asthma Read slides Spirometry is recommended to establish a diagnosis of asthma but may not be feasible in young children (under at 5). It should be performed at the intial visit- after treatment is initiated and symptoms and PEF have been established to document attainment of near normal function. Done at least once yearly And to evaluate the resonse to a change in therapy (step up, step down)

This is a before and after picture of bronchi following methylcholine challenge. Notice the edema and closing off w/edema of the lumens. One lumen is not even visible any longer.

Is Airflow Obstruction At Least Partially Reversible?
Use spirometry to establish airflow obstruction FEV1 < 80% of predicted FEV1/FVC <65% or below the lower limit of normal Use spirometry to establish reversibility FEV1 increases >12% and at least 200 mL after using a short-acting inhaled beta2-agonist Read Slide Many providers will skip this step and attempt to establish a diagnosis only on symptoms or a “hunch” or they’ll use a PFM which is not an appropriate to verify asthma. The reversibility of at least 12% of obstruction is the standard.

Have Alternative Diagnoses Been Excluded?
Examples: Vocal cord dysfunction Vascular rings Foreign body aspiration Other pulmonary diseases Cystic Fibrosis Gastroesophageal reflux READ SLIDE

Under Diagnosis Of Asthma In Children
The majority of people who have asthma experience onset before age 5 Commonly misdiagnosed as: Chronic or wheezy bronchitis Bronchiolitis Recurrent croup Recurrent upper respiratory infection Recurrent pneumonia The majority of people who have asthma experience the initial onset before the age of 5. Infants and young children under age 6 often wheeze with URI’s and may benefit from asthma treatment yet not actually have asthma! Underdiagnosis of asthma is very common. Some common misdiagnoses are: READ SLIDE LIST

National Heart, Lung, and Blood Institute (NHLBI) NAEPP
Guidelines for the Diagnosis & Management of Asthma EPR 2002 Update NAEPP, NHLBI, NIH- EPR2 2002 Read slide: Show update card from NHLBI

NHLBI- NAEPP Asthma Severity Levels
Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent Read Slide: there are 4 severity levels

Footnote: The patient’s step is determined by the most severe feature.
NAEPP Classification of Asthma Severity: Clinical Features Before Treatment Days With Nights With PEF or PEF Symptoms Symptoms FEV Variability Step Continuous Frequent 60% 30% Severe Persistent Step Daily >1night/week 60%-<80% 30% Moderate Step >2/week, <1x/day >2 nights/month 80% % Mild Step 1 2 days/week 2/month 80% 20% Intermittent Footnote: The patient’s step is determined by the most severe feature.

Peak Flow Variability Is the difference between the child’s morning and evening PFM readings Peak flow readings tend to be higher in the evening than in the morning

NAEPP Stepwise Approach To
Asthma Therapy Outcome: Control of Asthma Outcome: Best Possible Results Controller: Daily inhaled corticosteroid Daily long acting bronchodilator Daily/alternate day oral corticosteroid When controlled, reduce therapy Monitor Controller: Daily inhaled corticosteroid Daily long acting bronchodilator Anti-leukotriene Controller: One daily medication Possibly add long acting bronchodilator Anti-leukotrienes Reliever: Inhaled beta agonist prn Reliever: Inhaled beta agonist prn Reliever: Inhaled beta agonist prn Reliever: Inhaled beta agonist prn Slide courtesy of ALAMN- PACE program 2004 PEF: ≥80% PEF: ≥80% PEF: 60-80% PEF: <60% STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent Stepdown

Mild Intermittent Symptoms £ 2 days/week with nighttime symptoms £ 2 nights/month Asymptomatic with normal peak flows between exacerbations Exacerbations are brief (hours to a few days) Peak Flows ³ 80% predicted with variability < 20% Read Slide

Mild Persistent Symptoms > 2 days /week but < 1x/day with nighttime symptoms greater than 2 nights/month Exacerbations may affect activity Peak flow 80% of predicted with variability of < 20-30% Read Slide

Moderate Persistent Child is likely to have daily symptoms and use reliever daily Child is waking up at least once a week due to asthma symptoms Peak flows 60-80% of predicted with variability of >30% Activity is affected and exacerbations may last days READ SLIDE

Severe Persistent Continual daytime symptoms with frequent nighttime symptoms Very limited physical activity Frequent exacerbations Peak flows £ 60% of predicted and variability of more than 30% Treatment involves a combination of many drug therapies

Rules Of “Two” IF a child has:
Daytime symptoms greater than two times per week -or- Nighttime symptoms greater than two times per month -or- Albuterol (reliever) refills of canisters more than two times per year *The child needs to be assessed if he/she requires controller medication or a step up in therapy

MDH Interactive Asthma Action Plan (IAAP)
Available at MDH website: Click on “Asthma Action Plan” Click on “Medical Professionals” Choose to download desktop version or use online version

Which of These Does Not Fit With Severe Persistent Asthma?
Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptoms Limited physical activity Near normal Pulmonary Function Test (Spirometry) Frequent asthma exacerbations Read Slide:

Which Of These Does Not Fit With Severe Persistent Asthma?
Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptoms Limited physical activity Near normal Pulmonary Function Test (Spirometry) Frequent asthma exacerbations Read Slide: Answer = C Pulmonary function tests in an asthmatic w/severe persistent asthma levels (when not controlled) are not in the normal range

Which Of These Does Not Fit With Moderate Persistent Asthma?
Daily daytime symptoms, nighttime symptoms > 1 night per week Nighttime Symptoms < 2 times a week Daily use of albuterol/bronchodilators Asthma exacerbations can last for days Read Slide:

Which Of These Does Not Fit With Moderate Persistent Asthma?
Daily daytime symptoms, nighttime symptoms > 1 night per week Night time Symptoms < 2 times a week Daily use of albuterol/bronchodilators Asthma exacerbations can last for days Answer = B. In Moderate persistent, symptoms are daily

Which Of These Does Not Fit With Mild Persistent Asthma?
Daytime symptoms > 2 times a week, but < 1 time a day Symptoms may affect activity Need for albuterol 3 times a week, sometimes twice a day (not related to EIA) Nighttime symptoms > 2 times a month Read slide

Which Of These Does Not Fit With Mild Persistent Asthma?
Daytime symptoms > 2 times a week, but < 1 time a day Symptoms may affect activity Need for albuterol 3 times a week, sometimes twice a day (not related to EIA) Nighttime symptoms > 2 times a month Answer: C. If a child is requiring albuterol which is a reliever or rescue inhaler 3 times a week and sometimes twice a day, they are in a moderate persistent level

Which Of These Does Not Fit With Mild Intermittent Asthma?
Daytime symptoms < 2 times a week Nighttime symptoms > 2 times a month No symptoms and normal Peak Flow between exacerbations Exacerbations are brief and may last from a few hours to a few days Read Slide:

Which Of These Does Not Fit With Mild Intermittent Asthma?
Daytime symptoms < 2 times a week Nighttime symptoms > 2 times a month No symptoms and normal Peak Flow between exacerbations Exacerbations are brief and may last from a few hours to a few days Read Slide: Answer: B. Mild intermittent children should not have night time symptoms more often than two nights per month. This child would be in the Mild Persistent level and And most likely require controller medication.

Which Level Does Not Need Daily Controller Medication?
Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent Read Slide:

Which Level Does Not Need Daily Controller Medication?
Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent Read Slide: Answer: A Mild Intermittent. BUT, these children should have an albuterol or rescue type inhaler available to them.

Severity Level Workout
Case Scenario Group Interactive Format Read slide and give instructions to work in small groups and come up w/an answer to each case scenario. The have…..? Minutes.

Assessing Asthma

cartoon

When Assessing Asthma Ask..
Whether or not the child is taking his/her controller medication at home (are they prescribed for him/her) Is he/she taking it everyday and how often How often is he/she using reliever inhalers About his/her home environment Pets Adults smoking in the home Moist basements or obvious mold Mattress and pillow covers Cockroaches, mice, rats etc E2, E3 Read slide E2 Components of Asthma Care in the School Health Office (MPPS) E3 “ “ SPPS

Physical Assessment Of Asthma In The School Health Office
Symptoms (daytime, nighttime and exercise-related) Peak Flow Meter readings Respiratory assessment (breath Sounds / lung auscultation, respiratory rate, physical assessment) Physical assessment of students who have asthma is paramount to achieving optimal control of asthma and participating in the asthma management process. There are assessments an RN in the school health office should perform on a regular basis. Stephanie will outline the process of proper asthma management as it relates to the school health office. I’ll just go over the assessment pieces you would need to consider for children who visit the health office for their asthma. READ SLIDE

Symptoms Ask about: Coughing / wheezing / tight chest
Frequency of daytime symptoms Frequency of nighttime symptoms Symptoms with activity or exercise Read Slide

Respiratory Assessment

Respiratory Assessment in the School Health Office
Physical inspection (including respiratory rate) Auscultation of the lung fields Read slide

Normal Respiratory Rates For Children
Age Rate Age Rate Newborn years 19 1-11 mo years 19 2 years years 19 4 years years 17 6 years years 16-18 8 years 20 (rate=breaths/minute) Whaley & Wong, 1991 These are the normal respiratory rates for children in breaths per minute

Why Lung Assessment Is Important
It provides additional clinical information Provides a good baseline for comparison in future assessments Gives a better picture of the child’s perception of symptoms vs. what is actually assessed When consulting w/the HCP, they will ask for lung sounds Form F26 READ SLIDE- AND We won’t go into detail w/these next slides but they are here for your information But focus on WHEEZING especially for kids w/asthma. Wheezing is usually heard on expiration but can be heard on inspiration as well… Form F26- Skill Validations Lung assessment- Use this form to evaluate other health office staff abilities

Physical Respiratory Inspection
Respiratory rate Rhythm (regular, irregular or periodic) Depth (deep or shallow, presence of retractions) Quality (effortless, automatic, difficult, or labored) Character (noisy, grunting, snoring, or heavy) Read slide

Auscultation Breath sounds best heard in a quiet environment
Wheezing and crackles are best heard as the student takes deep breaths Absent / diminished breath sounds are abnormal and should be investigated Absence of wheezing does not necessarily mean absence of asthma Read slide

Breath Sounds: Crackles
Coarse Crackle: Intermittent, interrupted explosive sounds, loud, low in pitch (heard when airs passes through larger airways containing liquid) Crackles of a 9 yo boy with pneumonia Fine Crackle: Intermittent, interrupted explosive sounds, less loud and of shorter duration; higher in pitch than coarse crackles (heard when airs passes through smaller airways containing liquid) This wheezing and coarse crackles were recorded over the right posterior lower lung of an 8 month old boy with viral bronchiolitis. Read Slide- Sound=Inspiratory crackles, exp. wheezing

Breath Sounds: Wheeze And Rhonchus (Rhonchi)
Wheeze: continuous sounds, high pitched; a hissing sound (e.g. with airway narrowed by 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 Rhonchus: continuous sounds, low-pitched; a snoring sound (caused by large upper airway partially obstructed by thick secretions) Read Slide: Sounds from The R.A.L.E.

Peak Flow Meters Peak flow rates can be evaluated by anyone - as long as you receive training and are confident you can do it properly. There are skill validations listed in the manual and on the CD ROM.

Peak Flow Meters Measures how well the student’s lungs are doing at that moment Associated with the Green-Yellow-Red system of managing asthma symptoms Congruent with asthma action plans Helps students and families self-manage asthma Form F31 Read slide FORM F31- Peak Flow Meter Skill Validation for the RN to evaluate the knowledge and abilities of other health office staff.

How to use a Peak Flow Meter
Review the steps Place indicator at the base of the numbered scale Stand up Take a deep breath Place the meter in the mouth and close lips around the mouthpiece Blow out into the meter as hard and fast as possible Write down the achieved number Repeat the process twice more Record the highest of the three numbers achieved Read slide- Exercise-- PFM results can then be compared to the AAP for determination of what ZONE the child is in and guide you toward what action to take based on that information. *See MDH asthma website or CD Rom for “Peak Flow Instructions” step by step document

Group Peak Flow Exercise

Personal Best Peak Flow Values
Determined by twice daily Determined when healthy and not experiencing symptoms PFM measurements over the course of two weeks Is the BEST reading obtained during those two weeks Is used to calculate percentages for AAP’s Read slide. Personal best is the BEST way to treat a child who has asthma. It is individualized to their abilities. Everyone’s lung capacity is different and children who have asthma are no different. In the absence of a personal best peak flow rate- you can use a predicted peak flow

Predicted Peak Flow Values
Are based on a child's height Are not individualized Do not take into account other personal factors Can be identified immediately Are used when it is impossible or difficult to obtain personal best peak flow levels Form F6 Read Slide: SEE Predicted PF chart included in the forms and educational section. Whenever possible, it is best to use a personal best measurement but a predicted Peak flow is a good alternative when dealing w/children who can’t or won’t Perform personal best evaluations. Form F6

Peak Flow and Asthma Diary

Every Child Is Unique! Wheezing and coughing are the most common symptoms -but- No two children will have the exact same symptoms or the same trigger Every child who has a diagnosis of asthma should have access to a rescue inhaler! Every child with persistent asthma should have an asthma action plan at school (AAP)

Together- We Can Make A Difference!

Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed and Provided by: Welcome to Managing Asthma.

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Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed and Provided by: Welcome to Managing Asthma.

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Presentation on theme: "Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed and Provided by: Welcome to Managing Asthma."— Presentation transcript:

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