2. Breathing problems at school: Pulse Oximetry, Asthma, and the Return to Control Harold J. Farber, MD, MSPH Associate Professor Baylor College of Medicine Section of Pediatric Pulmonology Associate Medical Director for Chronic Conditions Texas Children’s Health Plan hjfarber@texaschildrens.org

3. How to assess severity breathing problems: It is more than the Oxygen Saturation It is more than the Oxygen Saturation A child can have severe difficulty breathing but a normal oxygen saturation!

4. Severe Respiratory Distress: Symptoms – Anxiety – Agitation – Persistent cough – Trouble speaking more than a word or two – Grunting Signs – Tachypnea – Retractions – Wheezing – Stridor – Flaring – Use of accessory muscles – Lack of wheezing.

5. Pulse Oximeters

6. Oxygen Saturation

7. Measuring the Oxygen Saturation Pulse oximetry depends on the pulse. – If you don’t have a good pulse wave you have garbage

8. Oxygen Saturation Error: Pulse oximeters only calibrated from 75% to 100% saturation (unethical to take healthy adult to <75% SpO2) May be inaccurate under 75% SpO2 Sources of error: – Ambient light – Motion Artifact – Nail Polish – Carbon monoxide – Hypoperfusion Shock Cold finger

9. Oxygen Saturation: With PaO2 above 60, SpO2 is > 90%. Oxygen content does not change much When PaO2 drops <60, SpO2 rapidly decreases. Oxygen content of the blood rapidly decreases.

10. Processes Leading to Desaturation V-Q mismatch – Example: Asthma Bronchiolitis Atelectasis Pneumonia – Treatment: Supplemental O 2 Hypoventilation – Examples Guillaine Barre Syndrome Botulism Neuromuscular diseases – Treatment: Supplemental VENTILATION! Tracheal Obstruction – Severe Croup – Aspirated foreign body – Tracheostomy plug – Treatment: Open the airway

11. Peak Flow Meters Provides a number that measures how hard the child blows out. Peak expiratory flow is effected by – Effort – Lung size / child size – How open or closed breathing tubes are

12. How to interpret peak flow readings Is it a maximal effort using correct technique, or is it garbage? If maneuver is done correctly with maximal effort interpret in relation to personal best or predicted based on age, ethnicity, and height.

13. How to interpret peak flow readings Peak flow over 80% of predicted or personal best: Green zone. All is well Peak flow 50-80% of predicted or personal best: Yellow zone. Mild asthma flare. Peak flow below 50% of predicted or personal best: Red zone: Urgent medical attention is needed.

14. Assessing Asthma Severity

15. Recognizing Symptoms

19. Handling an asthma flare at school Anything I tell you takes a back seat to school policy.

20. Handling an asthma flare at school First: Do not leave child alone Second: Assess severity – is it mild, moderate or severe? Third: Look at the child’s asthma plan – If appropriate consider giving a quick relief medicine – Albuterol (Ventolin, Proventil, ProAir) – Levalbuterol (Xopenex)

21. If severe asthma flare Breathing fast Hardly able to speak a few words between breaths Nasal flaring Retractions

22. If severe asthma flare Breathing fast Hardly able to speak a few words between breaths Nasal flaring Retractions Give quick relief medicine (if available) Call 911 Notify parents Allow to rest in position of comfort Do NOT leave child alone

23. Preventing the flare ups: Asthma is not controlled if: – If frequent asthma symptoms at school – If severe asthma flares needing urgent treatment at school – If asthma interferes with exercise – If asthma interferes with sleep.

24. Preventing the flare ups: If asthma is not controlled: Communicate with child’s parents and health care providers. Advocate for the child. Asthma can be controlled.

25. When asthma is well controlled There are no asthma symptoms. No cough. No wheeze. No chest tightness. Need for quick relief medication for asthma symptoms is less than twice a week. A child’s sports participation is not limited by his/her asthma. – Sometimes quick relief medicine is needed before exercise There are NO asthma attacks: daytime or nighttime. There are no Emergency Room visits for asthma

26. Asthma Control: Reduce Impairment – No chronic or troublesome symptoms – Day to day activities are not limited by asthma – Normal or near normal lung function Reduce Risk – Prevent flare ups/ED visits/hospitalizations/death – Prevent progressive loss of lung function – Minimize medication side effects.

27. 3 Lines of Defense Manage the Environment – Reduce triggers Manage the Breathing Tubes – Medication to make airways less sensitive Manage the Flare ups – Recognize attacks early and head them off at the pass

28. Types of asthma triggers Irritants – Smoke – Air pollution – Strong Chemicals – Air “fresheners Allergens – Furry or feathered animals – Dust and mold – Pollens

29. Reducing Asthma Triggers at School (see EPA IAQ Tools for Schools) – No air fresheners or sprays in classroom – No furry or feathered animals in classroom – No smoking in or around school – Building maintenance – to reduce dust and mold problems. – Use integrated pest management to reduce chemicals – Don’t cut grass, etc. when children are present – Don’t idle motor vehicles (cars, buses, etc.) near school, when children are waiting.

32. Smoke and asthma When a child is smoke exposed – Asthma medications don’t work as well – Viral infections are more severe Parents are the most important source of a child’s smoke exposure FREE help is available – National Cancer Institute/American Cancer Society QUITLINE: 1 800 QUIT NOW

33. Graphic from Farber HJ, Boyette M. Control Your Child’s Asthma: A Breakthrough Program for the Treatment and Management of Childhood Asthma. Owl Books, 2001. Used with Permission.

34. Guide to asthma medicines Quick Relivers – Short Acting Beta Agonists Albuterol (inhaled) – Impairment: Symptom relief within minutes, lasts about 4 hours Useful to prevent exercise induced asthma – Risk: Overuse associated with increased risk hospitalization, ED visit, mortality Warning: Be stingy with SABA refills!

35. Guide to asthma medicines Long Acting Beta Agonists – Salmeterol: Onset in ½ hour, lasts about 12 hrs – Formoterol: Onset in minutes, lasts about 12 hrs IMPAIRMENT: – When used with an inhaled corticosteroid day to day asthma control is improved. RISK: – When used without an inhaled corticosteroid, risk of hospitalization, ED visit, mortality is increased. – LABA + ICS combo reduces impairment, has minimal impact on risk.

36. Guide to asthma medicines Inhaled corticosteroids – Regular use: Impairment: – Reduces asthma symptoms – Onset 1-2 weeks, max effect ~ 4-6 weeks Risk: – Reduces risk of flare ups – Reduces risk for hospitalization/ED visit/mortality – Most of benefit achieved at low to moderate doses – Adherence to regular use is major challenge.

37. Guide to asthma medicines Leukotriene modifiers – Impairment: Equivalent to low dose ICS – Risk: Inferior to low dose ICS – Gives additional symptom reduction when combined with low to moderate dose ICS. – Possible benefit in Viral triggered asthma Smoke triggered asthma

38. Guide to asthma medicines Oral corticosteroids (Prednisone, Prednisolone) – Speeds resolution and attenuates severity of moderate to severe asthma flare up – Steroid toxicity minimized by occasional use and short bursts – Poorly controlled moderate to severe asthma may need longer steroid taper to reverse long- standing airways inflammation

39. Teaching Role of Medication

40. Albuterol/ Xopenex

41. Teaching Role of Medication Albuterol/ Xopenex Inhaled corticosteroid

42. Teaching Role of Medication Albuterol/ Xopenex Prednisone/ Prednisolone

43. Teaching Role of Medication Albuterol/ Xopenex Prednisone/ Prednisolone

44. Teaching Role of Medication Albuterol/ Xopenex Prednisone/ Prednisolone Inhaled corticosteroid

45. Asthma Action Plans are Important!

46. In summary Appropriately assess severity of an asthma flare. – If in doubt, believe the child Asthma flares can be prevented by good asthma control Written asthma action plans are essential If a child’s asthma is not in control – Talk to their parents, physician, or care manager – Texas Children’s Health Plan care management (if child is TCHP member): 832 828 1430

47. Asthma Research at TCH Gene-Environments and Admixture in Latino Asthmatics (GALA-2) study – NIH funded multi-center case-control study – Objective: Determine genetic factors and gene- environment interactions associate with asthma in Latinos

48. GALA-2 Study Eligibility: – Age 8-21 years – Latino parents and grandparents – CASES: Has physician diagnosed asthma Has been symptomatic within past 2 years – CONTROLS Does not have asthma or allergies

49. GALA-2 Study Study Procedures – All subjects: FREE Allergy skin testing for common inhalant allergens FREE Lung function testing Questionnaire Blood Draw

50. GALA-2 Study Locations – Texas Children’s Hospital – Ben Taub General Hospital Compensation – $40 per visit completed – Parking Validation – Small gift provided for children All study materials and personnel are bilingual (English/Spanish)

51. GALA-2 Study Call 832 – 822 – GALA (832 822 4252) for information or to enroll

52. Summary GALA – 8-21 years – Latino Ancestry – Asthma cases and healthy controls – Free allergy skin testing and lung function testing – To refer: Call 832 822 GALA We can send you recruitment flyers. – $40 per visit compensation for patients