1. Asthma in School-Aged Children: A Community Issue

2. Table of Contents Chapter 1. The Prevalence and Burden of Asthma in School-Aged Children Chapter 2. What Is Asthma? Chapter 3. Asthma Control Chapter 4. Current Gaps in Managing Asthma in the School Setting Chapter 5. What Can I Do?

3. Chapter 1. The Prevalence and Burden of Asthma in School-Aged Children

4. Objectives Questions we’ll address in this section: Which children have asthma? What is the burden of asthma on: – The student? – The parent? – Society?

5. Asthma in School-Aged Children 1. Centers for Disease Control and Prevention. cdc.gov/nchs/products/pubs/pubd/hestats/ashtma03-05/asthma03-05.htm. Accessed February 25, 2009. 2. Asthma and Allergy Foundation of America. aafa.org/display.cfm?id=8&sub=42. Accessed February 25, 2009. Asthma Over 6 million US children with asthma (2005) 1 Most common chronic illness in children 2 63,000 people miss school or work due to asthma One of the leading causes of hospitalizations of children 2 – 198,000 hospitalizations in 2004 1 One of the leading causes of school absenteeism 2 – 12.8 million lost school days in 2003 1

6. Asthma in MS 1 in every 14 adults have asthma –More women than men (8% v. 5%). 1 in every 10 children have asthma –About 2 per classroom. –More African American children than other children (13% v. 8%). –More boys than girls (12% v. 8%).

7. Specific Populations With Asthma Any child can have asthma. It is more common in boys throughout childhood. 1 It is more commonly diagnosed in Puerto Rican and African American children. 1 Lower-income and inner-city children appear to be at increased risk of hospitalizations, emergency department visits, and deaths due to asthma. 2,3 1. Akinbami LJ. cdc.gov/nchs/data/ad/ad381.pdf. Accessed February 25, 2009. 2. Eisner MD et al. Respir Res. 2001;2:53–60. 3. Centers for Disease Control and Prevention dc.gov/healthyyouth/asthma/pdf/asthma.pdf. Accessed February 25, 2009.

8. Burden on Children Children with asthma: – May not be able to participate fully in extracurricular activities – May avoid sports or play – May not be able to sleep through the night without coughing – May not feel comfortable visiting certain friends or relatives – May miss school days O’Connell EJ. Allergy. 2004;59:7 – 11.

9. Burden on Parents Parents of a child with asthma: – May have to leave work to pick up a child who’s having severe symptoms – Fear their child may have an attack while not with them – May feel overwhelmed trying to understand the role of different medications and the schedule for taking each one – May experience reduced productivity during the day after caring for their child at night

10. Burden on Society and the Community Health care use due to childhood asthma 1 – Doctor visits have doubled since 1980. – Health care use is highest among the youngest children. Estimated cost of treating asthma in children, according to Weiss, is $3.2 billion per year. 2 Nearly half of all families with an asthmatic child report that they do not have enough money to pay for their health care. 3 There are indirect costs due to lost work days. 4 1. Akinbami LJ. cdc.gov/nchs/data/ad/ad381.pdf. Accessed February 25, 2009. 2. Weiss KB. J Allergy Clin Immunol. 2000;106:493–499. 3. McRea D. Ecos: The Environmental Communiqué of the States. Spring 2006. 4. O’Connell EJ. Allergy. 2004;59(suppl 78):7 – 11.

11. Chapter 2. What Is Asthma?

12. Objectives Questions we’ll address in this section What is asthma? What are the symptoms of asthma? What causes symptoms to get worse?

13. What Is Asthma? A chronic disease 1 Characterized by swollen airways and increased mucus 1 Makes it hard for air to move in and out of the lungs 1 Produces recurring episodes of breathing problems 1 Cannot be cured but can be controlled 2 1. American Academy of Allergy Asthma & Immunology. Pediatric Asthma: Promoting Best Practice, Guide for Managing Asthma in Children. 1999;1–106. 2. American Lung Association. www.lungusa.org/site/apps/nl/content3.asp?c=dvLUK9O0E&b=34851&ct=785189. Accessed February 25, 2009. Healthy Airway Asthmatic Airway

14. What Are the Symptoms of Asthma? Chest tightness 1 Wheezing 1 Coughing 1 Fast breathing 1 Fatigue 3 Fast heartbeat 2 Waking at night with symptoms 1 Coughing at night 1 Feeling “out of breath” 3 1. American Academy of Allergy Asthma & Immunology. Pediatric Asthma: Promoting Best Practice, Guide for Managing Asthma in Children. 1999. 1–106. 2. Wrong Diagnosis. wrongdiagnosis.com/a/asthma/symptoms.htm. Accessed February 25, 2009. 3. National Jewish Medical and Research Center. njc.org/disease-info/diseases/asthma/about/symptoms/index.aspx. Accessed February 25, 2009.

15. Common Asthma Triggers Secondhand smoke Mold Dust mites Respiratory illness Pollen Pets Air pollution Cockroaches and other pests Weather (exposure to cold air) Exercise Strong emotion Asthma and Allergy Foundation of America. aafa.org/display.cfm?id=8&cont=6. AccessedFebruary 25, 2007.

16. Healthy Airway vs Asthmatic Airway Cross-sectional view of airways Healthy Asthmatic

17. Chapter 3. Asthma Control

18. Objectives Questions we’ll address in this section What does well-controlled asthma look like? What does uncontrolled asthma look like? How is control measured? How do rescue (fast-acting) medications differ from controller medications?

19. What Does Well-Controlled Asthma Look Like? Adapted from NAEPP, NHLBI, NIH. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed February 25, 2008. Symptoms – Less than 2 days a week and no more than once a day Sleep disruptions – Less than once a month Full participation in a variety of activities, including sports and play Use of inhaler for symptom control – Less than 2 days a week Lung function – Greater than 80% of predicted or personal best

20. What Does Not-Well-Controlled Asthma Look Like? Symptoms –More than twice a day Sleep disruptions –More than twice a month Limited participation in activities, including sports and play Use of inhaler for symptom control –More than 2 days a week Lung function –60% to 80% of predicted or personal best Adapted from NAEPP, NHLBI, NIH. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed February 25, 2008.

21. What Does Very Poorly Controlled Asthma Look Like? Symptoms –Throughout the day Sleep disruptions –More than twice a week Limited participation in a variety of activities, including sports and play Use of inhaler for symptom control –Several times a day Lung function –Less than 60% of predicted or personal best Adapted from NAEPP, NHLBI, NIH. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed February 25, 2008.

22. How Is Control Assessed? Objective measures – Peak flow meter: measures how “fast” you can breathe out – Spirometer: measures how well the respiratory system can move air in and out of the lungs Subjective measures – Use of fast-acting drugs – Number of daytime symptoms – Number of nighttime symptoms – Limitation of activities Adapted from NAEPP, NHLBI, NIH. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed February 25, 2008.

23. Rescue (Fast-Acting) vs Controller Asthma Medicines Rescue (fast-acting) medications – Are for emergency situations 1 – Act immediately (within a few minutes) 1 – Reduce or eliminate coughing, wheezing, and shortness of breath during an attack 1 – Are delivered with an inhaler 2 Controller medications – Are taken daily 1 – Are delivered as tablets or syrups, or via inhalers 2 – Do not eliminate the need for rescue therapy 1 1. American Academy of Allergy Asthma & Immunology. Pediatric Asthma: Promoting Best Practice, Guide for Managing Asthma in Children. 1999.1–106. 2. Asthma and Allergy Foundation of America. aafa.org/display.cfm?id=8&cont=8. Accessed February 25, 2009.

24. Inhalant Medication Delivery Devices Not typically seen in school

25. Nebulizer and Prescribed Solutions

26. Chapter 4. Current Gaps in Managing Asthma in the School Setting

27. Objectives Items we’ll discuss in this section Communication and awareness gap Resource utilization gap Who has the roles and responsibilities?

28. Communication and Awareness Gap Student With Asthma PrincipalCoaches School Nurse Doctor ParentsTeachers

29. Resource Utilization Gap Many schools do not use the tools available to them. Only 41% of schools have full-time nurses (2002). Only a little more than half of schools educate staff about asthma (2002). Identification or tracker tools are not available. Most schools do not have asthma management tools. Many schools do not use an asthma action plan for their students with asthma. Centers for Disease Control and Prevention. cdc.gov/healthyyouth/asthma/pdf/asthma.pdf. Accessed February 25, 2009.

30. Who Has a Role? Parents PrincipalCoaches School Nurse Doctor Teachers Student With Asthma

31. Chapter 5. What Can I Do?

32. Objectives Items we’ll discuss in this section Potential steps that can be pursued to improve asthma management in schools Integration and coordination of education for the school administration, nurse, teachers, parents, coaches, the doctor, and the student

33. Coordinating Asthma Control in Schools Adapted from: Centers for Disease Control and Prevention. cdc.gov/healthyyouth/asthma/pdf/strategies.pdf. Accessed February 25, 2009. Family and Community Involvement Physical Education Nutrition Services Healthy School Environment Health Promotion for Staff Health Education Counseling, Psychological and Social Services Management and Support Systems Health and Mental Health Services Asthma Education Healthy School Environment Physical Education and Activity School, Family, and Community Efforts Students With Asthma Health Services

34. Challenges Within the School Environmental triggers can make asthma worse. 1 One-third of US schools (housing 14 million students) have buildings needing extensive repair. 2 In a 1999 survey, 43% of US schools rated at least 1 environmental factor as unsatisfactory. 3 – 26% said ventilation was unsatisfactory. – 8% rated indoor air quality as poor. 1. American Academy of Allergy Asthma & Immunology. Pediatric Asthma: Promoting Best Practice, Guide for Managing Asthma in Children. 1999.1–106. 2. United States Environmental Protection Agency. epa.gov/iaq/schools/environmental.html. Accessed February 25, 2009. 3. National Center for Education Statistics. nces.ed.gov/surveys/frss/publications/2000032. Accessed February 25, 2009.

35. What Can I Do? School Administration Reduce environmental triggers. – Ensure air ducts are clean and functional. – Enforce a no-smoking policy – Seek ways to cut chalk dust and other irritants Provide asthma training to staff. Work with the school nurse to adopt a uniform asthma action plan for students. Help identify students with poorly controlled asthma and refer students to the school nurse for follow-up. A primary objective is to provide a healthy environment.

36. What Can I Do? Teachers Know which students in your classes have asthma. Know the symptoms of asthma. Know what poorly controlled asthma looks like. Know the asthma action plan for your students with asthma. Know whether asthma may be holding a student back from normal activity. Refer students to the school nurse for follow-up.

37. What Can I Do? Parents Ask your doctor to fill out an asthma action plan. Know and understand your child’s asthma action plan. Meet with the school staff (eg, teachers, school nurses, coaches) to discuss your child’s asthma, including triggers and medication. Provide the school with rescue medication to have on hand. Update the school on your child’s condition as necessary.

38. What Can I Do? Coaches Be aware of students with asthma. Know the asthma action plan. Allow pretreatment and warm up before strenuous physical activity. Know the signs and symptoms of an attack. Know that exercise can trigger a child’s asthma. Be an active member of the team with the parents and the school nurse. Know when it’s appropriate to refer the student to the nurse for follow-up.

39. What Can I Do? School Nurse Know which students have asthma. – What medications each student with asthma takes and where the medications are kept – How to use various asthma medications and devices – Who can administer the medications – When to contact the student’s parents or doctor Insist on obtaining and follow the asthma action plan. Use asthma management and identification tools. Provide and support asthma education in the school.

40. How Schools Can Close the Loop Identify students who seem to be at risk of developing asthma. Know which students have asthma and when they may be poorly controlled. Connect students with a doctor and caregiver as necessary. Follow up frequently! Doctor School Parents Student With Asthma

41. What Are the Goals of Asthma Management in Schools? To educate and increase awareness and improve overall managementof asthma in school- aged children May lead to: Fewer trips to the school nurse Fewer symptoms during the school day Healthy school environment Remember: A student whose asthma is well controlled should be able to take part in school activities.

42. MDE-Office of Healthy Schools Asthma lesson plans www.healthyschoolsms.org Estelle Watts School Nurse Consultant ewatts@mde.k12.ms.us

43. Resources National Asthma Education and Prevention Program National Heart, Lung, and Blood Institute 301-592-8573 nhlbi.nih.gov/about/naepp American School Health Association 330-678-1601 ashaweb.org American Lung Association 800-LUNG-USA (800-586-4872) lungusa.org American Academy of Allergy Asthma & Immunology 800-822-ASMA (800-822-2762) aaaai.org Allergy & Asthma Network Mothers of Asthmatics 800-878-4403 aanma.org Asthma and Allergy Foundation of America 800-7-ASTHMA (800-727-8462) aafa.org Copyright © 2009 Merck & Co., Inc. All rights reserved. 20903041(1)-04/09-SGR merck.com