1. Asthma Basics For Para Professionals
Minnesota Department of Health
Asthma Program

2. MDH Asthma Program Staff
Presenter
Susan Ross RN, AE-C
MDH Asthma Program Staff

3. Minnesota Department Of Health Asthma Website: www. health. state. mn
Minnesota Department Of Health Asthma Website:
The Minnesota Department of Health has a website containing information for school personnel as well as for the general public. The site contains links to a variety of informational websites and has a special section just for kids.

4. As You View This Program..
Consider how many people you know who have asthma?
How will you use the information you receive here today?
How can you help students prevent their asthma symptoms from appearing?
How can you help improve asthma management at your school?
While in school, caring for children who have asthma is not just he school health offices/ Nurses responsibility- it’s everyone's job to assure the safety and welfare of each child and that includes children who suffer from asthma.
Do you know anyone who has asthma?
What do you think you will learn from this program today?
How can you help your school health office/ Nurse keep kids with asthma in school and able to participate in all aspects of school activity?

5. Asthma: Accounts for 14 million lost school days annually3
Is the most common chronic disease causing absence from school2
Is the 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

6. 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.

7. This Means.. In a class of 30 children, you can expect
2 to 3 students WILL have asthma!
Information per the CDC

8. The Goal Of Asthma Management
“Children should live happy, healthy, physically active lives, without asthma symptoms slowing them down “
The General goals of proper asthma therapy/management according to NAEPP 1. Prevent Chronic asthma symptoms and asthma episodes during the day and night
2. No sleep disruption by asthma,
3. No missed school or work due asthma
4.No or minimal need for ER (or UC) visits or hospitalizations
5.Maintain normal activity levels- including exercise and other physical activities
6.Have normal or near-normal lung function
7. Be satisfied with the asthma care received.
8. Have no or minimal side effects while receiving optimal medications
(taken from p. 7 NAEPP/ NHLBI/NIH “Practical Guide for the Diagnosis and Management of Asthma- 10/97”

9. Impact Of Asthma On Students
School Performance:
Poorly controlled asthma has a negative impact on school performance in both academic achievement and physical education

10. 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

11. What Is Asthma? Asthma is a chronic disease that causes:
Tightening of the muscles surrounding the airways (Bronchoconstriction/spasm)
Swelling of the small airways (bronchioles)
Over production of sticky mucus in the airways
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 children with persistent asthma, Long-term anti-inflammatory medications are the proven treatment to control airway inflammation and eliminate or reduce symptoms.

12. 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.
Asthma is a multi component chronic disease. It is not curable but is very treatable.
Components are: Bronchial spasm (bronchoconstriction) or narrowing of the airways due to the muscles surrounding the bronchioles (small airways) tightening and closing the lumen off.
Inflammation of bronchial tissue: Allergen exposure causes irritation w/redness' and swelling which in turn causes the mucus production. Continued exposure and/or lack of treating the inflammation can (and has) resulted in the child/asthma sufferer from being able to push out used oxygen (Co2). 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

13. Common Symptoms Of Asthma
Frequent cough, especially at night
Shortness of breath or rapid breathing
Chest Tightness
Chest pain
Wheezing
Fatigue
Behavior changes
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.

14. What Causes Asthma?
Asthma may be caused by genetic, immune and/or environmental factors, and is often associated with eczema (scaly skin patches) 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”

15. What Causes Asthma cont..
Of the 17 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

16. Triggers And Irritants
Copyright 2004, 3M Pharmaceuticals

17. Common Allergens (Triggers)
Seasonal pollens
Animal dander /saliva/urine
Dust mites
Cockroaches/mice/rat droppings and urine
Mold
Some medications
Some foods
Strong emotional feelings
Seasonal pollens can mean some children suffer from asthma only during their “allergy” season. Ie tree pollen in the spring, grass in the summer etc.
Aspirin is an example of a medication that some asthmatics can react to as a trigger.
Only 6-8% of asthmatics have food as their asthma trigger, even though they may also have allergies that don’t cause an asthma reaction.

18. 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
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.

19. 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 who has asthma should have an asthma action plan at school (AAP)

20. Handling Asthma Episodes

21. 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)

22. How Do I Handle An Asthma Episode At School?
Remain calm and reassure the child
If you know what triggered their episode, move the child away from it
Have the child sit up and breathe slowly- in through the nose, out through pursed lips
Contact the school nurse for assistance or whomever is responsible for providing medications in the nurses absence

23. Handling An Episode cont..
If you are responsible for medications, check the child's asthma action plan, emergency care plan or medication card for actions
Give “rescue or reliever” medications if ordered and available (some students carry their own asthma inhalers with them)
Have the child sip room temperature water/ fluids
Contact the parent or guardian as necessary AND-

24. Do NOT Leave The Child Alone!
Every asthmatic reacts differently to their asthma- what you perceive as “okay” may in fact be a child is severe distress. Do NOT send a child to the health office by his/herself, either accompany the child, call the school nurse to come to him/her or find another adult (immediately) to assist the child.

25. 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 muscles are pulling in (retracting)
Nasal flaring occurs when inhaling
Obvious distress
Altered level of consciousness/confusion
Rapidly deteriorating condition
ANY of these symptoms require a call to 911 after you have given the child their rescue inhaler (if available and ordered or the child is carrying their inhaler). Do not hesitate to call 911- it’s better to be safe.

26. Exercise Induced Asthma

27. What Is Exercise Induced Asthma (EIA)?
Tightening of the muscles around the airways (bronchospasm)
Distinct from “chronic” 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 albuteral.
Information from NHI/NHLBI guidelines: see webpage for more info.

28. 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.

29. Preventing Exercise Induced Asthma (EIA)
Become familiar with Asthma Action Plans, pre-exercise medication orders and or health care plan
Student should 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.
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 albuteral.

30. Medications

31. Medication: Determined By Severity Level Classification
Mild Intermittent
Reliever only prn
Mild Persistent
Controller and reliever
Moderate Persistent
Controller plus long-acting bronchodilator and reliever
Severe Persistent
Level 1:
Mild Intermittent
Needs only a reliever only prn (e.g. albuterol or pirbuterol)
Level 2:
Mild Persistent
Requires both a Controller and reliever (low dose inhaled cortico-steroid, sometimes other medicaitons)
Level 3:
Moderate Persistent
Needs controllers (usuallly a medium dose inhaled cortico-steroid and a long-acting bronchodilator, sometimes other medications) and a reliever.
Level 4
Severe Persistent
Needs controllers (usually high dose inhaled corticosteriods and long-acting bronchodilator, other medications) and a reliever.

32. Two Categories Of Medications
Controller Medications
Taken every day to prevent swelling in the lungs
Reliever or Rescue Medications
Taken only when needed to relieve symptoms
Or to prevent exercise induced asthma from developing (taken before strenuous exercise)

33. Controller Medications
Keep swelling and mucus from developing in the lungs
Must be taken EVERY day even when the child is not having symptoms
Inhaled corticosteroids (ICS’s) are the most common and effective way to control asthma
Help prevent asthma exacerbations from developing!
An example of typical “controller” medications may be Inhaled Corticosteroids such as Azmacort, Pulmicort, Flovent, Advair
These medications must be taken every day, regardless if there are symptoms or not. Typically, it can take up to 3 weeks before the inflammation in the lungs is reduced- a asthmatic may or maynot even notice in the short term but long term- the frequency of their episodes is reduced greatly.

34. Rescue Or Reliever Medications
Are taken when asthma symptoms are appearing (asthma episode)
Are taken minutes before strenuous exercise/activity by children with EIA
Do NOT reduce or prevent swelling from developing in the lungs
May be carried in school by a student only IF approved by the doctor, school nurse and parent!
Rescue medications- which school personnel most likely have already come in contact with are Albuterol, Proventil, Ventolin, Maxair. These medications should always be used WITH a spacer and used to prevent exercise induced asthma or to treat an emerging asthma episode (attack).
A child may carry their own inhaler ONLY with the signed permission of their doctor or medical care provider, their parent or guardian and in most districts (depending on school board policy) with the evaluation and approval of the school nurse.
Check your school board policy for specifics but Minnesota does have an inhaler law.

35. Yep, this horse needed an inhaler treatment after a race-!
Picture courtesy of American Lung Association of the Inland Counties CA 2004

36. Typical Spacers/Holding Chambers

37. Spacers Or Holding Chambers
Most MDI’s (metered dose inhalers) must be used with a spacer or holding chamber
This device attaches to the MDI and allows the user to breathe in more medication effectively
The physician must write an order for it when prescribing your reliever medication
Dry powder inhalers do NOT require spacers

38. How MDI Technology Works

39. How To Use Your Inhaler

40. How To Use: Metered Dose Inhalers w/Spacers
1. Stand up (or sit up straight)
2. Shake the inhaler well to mix up the medicine
3. Remove the cap and check the spacer/inhaler for foreign objects
4. Insert the inhaler into the spacer
5. Exhale all your air out fully
6. Before inhaling, put the mouthpiece of the spacer into your mouth, over your tongue and between your teeth Close your lips around it while tilting your head and the inhaler back slightly

41. Using An MDI Cont..
Press down on the inhaler canister and breathe in slowly and deeply through your mouth
Hold your breath for 10 seconds, exhale normally
If using a “reliever”, wait 1-2 minutes between puffs
Repeat starting with #5 if a 2nd puff is ordered
Rinse your mouth and spit after using a “controller” inhaler

42. Minnesota Inhaler Law

43. MN Asthma Inhaler Law Summary (2001)
Allows MN students to self-carry and administer inhalers
In order for a child to carry his/her inhaler at school, authorization and signatures from the following individuals are required:
Child’s health care provider
Parent/guardian
Assessment and approval of the school nurse (if present in district)
Be sure to check and follow policies and procedures in local school district
R8 MN Medication Administration statutes
R9 MN Inhaler use Statute

44. Para Professionals Role
Identify students with asthma
Distribute & collect communication forms
In the health office the RN may delegate specific tasks such as:
Documenting asthma visits by completing or initiating student asthma records
Asking about symptoms & check PFM levels
Providing episodic care to students with asthma symptoms including medication administration
Communicating with parents regarding asthma care/episodes

45. Communicate With The NURSE
You are the eyes and ears for the nurse
Be aware of students with asthma and their typical symptoms
Help remind students to pre-medicate before exercise
Always document clearly and neatly what you see, hear and what the student tells you
Call the nurse with questions or urgent situations
If you don’t know- ask!
Don’t be afraid to call 911 in emergencies

46. Tools To Help Manage Asthma

47. Peak Flow Meters (PFM)
Peak flow rates can be evaluated by anyone - as long as you receive training and are confident you can do it properly..

48. 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
Use of a PFM (Peak Flow Meter) in conjunction with an AAP (Asthma Action Plan) can many times track the downward spiral of an individuals peak flow rate. For asthmatics who have persistent asthma (those on daily medications), taking a peak flow rate every morning when you wake up BEFORE you take medications- this should be a daily routine.
Write down the peak flow rate in your ASTHMA DIARY.
Take your PFR (Peak Flow rate) when you are having asthma symptoms or an episode and after taking medicine for the episode. This can tell you hw bad your asthma episdoe is and whether your medicine is working or not.
Your PFR corresponds to the green/yellow/red zones on an asthma action plan.

49. How to use a Peak Flow Meter
Review the steps
Stand up
Place indicator at the base of the numbered scale
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

50. Asthma Action Plan (AAP)

51. Asthma Action Plan Zones
Green Zone: All Clear/Breathing Good/Go
No asthma symptoms and/or
Peak flow % Predicted or Personal best
Yellow Zone: Caution/Slow Down
Some asthma symptoms and/or
Peak flow 50-80% Predicted or Personal best
Red Zone: Medical Alert/Stop
Severe asthma symptoms and/or
Peak flow < 50% Predicted or Personal best

52. Successful Asthma Management Requires Everyone's Cooperation
Teachers
Parents
Students
Medical Providers
Coaches
All School Personnel
Talk with your school Nurse to find out what YOU can do to help manage asthma in your school