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Managing Asthma In Minnesota Schools A Comprehensive Resource & Training for School Personnel Developed and Provided by:

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

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2 Managing Asthma In Minnesota Schools A Comprehensive Resource & Training for School Personnel Developed and Provided by:

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

4 Minnesota Department of Health

5 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: Funding grant awarded by: Centers for Disease Control and Prevention (CDC ) Centers for Disease Control and Prevention (CDC ) Acknowledgements

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

7 Overview of Today Asthma Basics Asthma Basics Asthma triggers and irritants Asthma triggers and irritants Diagnostic/ assessment process Diagnostic/ assessment process NIH/NHLBI/NAEPP asthma guideline overview NIH/NHLBI/NAEPP asthma guideline overview Severity level workout Severity level workout Medication Overview Medication Overview Asthma gadgets Asthma gadgets Controlling Asthma Controlling Asthma Tools available (MDH website-Manual) Tools available (MDH website-Manual) Coordinated School Health Coordinated School Health

8 Post Tests - Evaluations C.E.Us Complete the post test Complete the post test Complete the program evaluation Complete the program evaluation Complete your goals sheet Complete your goals sheet Hand everything in before you leave Hand everything in before you leave You will receive credit for 7.2 C.E.Us You will receive credit for 7.2 C.E.Us after attending today's presentation after attending today's presentation

9 As We Go Through This Program Consider how you would use the tools provided today. 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 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? How can you promote involvement by other school personnel outside the health office?

10 How To Use This Manual Resource and Training document Resource and Training document Each Section is all-inclusive to each staff members role Each Section is all-inclusive to each staff members role Lift out the entire section - copy it and use as a basis for teaching about asthma 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 Supplemental forms/handouts are in the back folders and provided on CD and website Full resources section w/websites are listed Full resources section w/websites are listed Power Point presentations are also on our asthma website and CD in back of your manual Power Point presentations are also on our asthma website and CD in back of your manual

11 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. This manual contains suggestions for action and you are strongly urged to consult your school district policies and guidelines before implementing these suggestions.

12 Staffing Models School health staffing varies greatly across the entire state School health staffing varies greatly across the entire state The manual provides a few suggested staffing models in the All Health Staff section The manual provides a few suggested staffing models in the All Health Staff section Todays program is based on a school that has at least some LSN/PHN/RN staffing in the school on regular basis Todays program is based on a school that has at least some LSN/PHN/RN staffing in the school on regular basis

13 PRE- TEST

14 Mikeys Mom Didnt Know Asthma Could Kill… From GlaxoSmithKline and Allergy & Asthma Network, Mothers of Asthmatics (AANMA)

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

17 Asthma: Accounts for 14 million lost school days annually 3 Accounts for 14 million lost school days annually 3 Is the most common chronic disease causing absence from school 2 Is the most common chronic disease causing absence from school 2 Is the 3 rd leading cause of hospitalizations among children under 15 2 Is the 3 rd leading cause of hospitalizations among children under in 13 school children have asthma 1 1 in 13 school children have asthma million children under 18 have asthma million children under 18 have asthma 1 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, Surveillance for Asthma - United States, , MMWR Surveillance Summaries, CDC, March 29, 2002

18 Minnesota Children In a 2003 MDH survey of more than 5,000 In a 2003 MDH survey of more than 5,000 7th & 8th graders at 15 junior highs outside the metro area- 7th & 8th graders at 15 junior highs outside the metro area- 1 in 12 reported they currently have asthma 1 in 12 reported they currently have asthma In a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN- In a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN- 1 in 11 reported they currently have asthma 1 in 11 reported they currently have asthma

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

20 Healthy Children Learn Better Healthy Children Learn Better

21 Do School Children Have Asthma Action Plans? In MDHs survey of 7th and 8th graders in In MDHs survey of 7th and 8th graders in greater Minnesota: greater Minnesota: 37% of the children who had asthma did not know if they had a written asthma action plan 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 28% did not have an asthma action plan Overall, only 34% of children who have asthma actually had asthma action plans Overall, only 34% of children who have asthma actually had asthma action plans

22 Asthma & Exercise Of the 7th & 8th graders with asthma: 80% reported wheezing sometimes or a lot during or after running, playing sports or exercising 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 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 24% reported missing a day or more of school in the past year due to asthma symptoms 66% reported wheezing sometimes or a lot 66% reported wheezing sometimes or a lot

23 Survey Conclusions There is substantial uncontrolled asthma among school children in this age group 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 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 The survey also suggests that there may be substantial undiagnosed asthma

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

25 Impact Of Asthma On Students cont... Psychosocial: Psychosocial: Poor self-esteem Poor self-esteem Anxiety about asthma Anxiety about asthma Fear of becoming ill at school Fear of becoming ill at school Anxiety about exercise at school Anxiety about exercise at school Fear of being different Fear of being different

26 YOU Can Make A Difference!

27 What Is Asthma? Asthma is a chronic disease that causes: Asthma is a chronic disease that causes: Bronchoconstriction Bronchoconstriction Inflammation of the bronchioles (small airways) Inflammation of the bronchioles (small airways) Hyper-responsive twitchy airways Hyper-responsive twitchy airways Excessive mucus production in the bronchioles Excessive mucus production in the bronchioles

28 Normal Bronchiole Inflamed Bronchiole with Mucus

29 Airway Obstruction Copyright 3M Pharmaceuticals 2004

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33 A Lot Going On Beneath The Surface Airway inflammation Airflow obstruction Bronchial hyperresponsiveness Symptoms Slide courtesy of ALAMN - PACE program 2004

34 Immune System Response

35 The Asthma Cascade © 2003 Genentech, Inc. and Novartis Pharmaceuticals Corporation.

36 Mediator Phases Early-phase reaction caused by mediator release, usually peaks within an hour after initial exposure to the allergen. 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 Three to four hours after an acute asthma episode, a "late-phase reaction" may occur and may last up to 24 hours

37 The End Results Of The Cascade Localized mucosal edema in the walls of the small bronchioles Localized mucosal edema in the walls of the small bronchioles Secretion of thick mucus into the bronchiolar lumens Secretion of thick mucus into the bronchiolar lumens ( Clogs and narrows the airways ) Spastic contraction of bronchiolar smooth muscle Spastic contraction of bronchiolar smooth muscle

38 A CHILD CANT BREATHE

39 Group Straw Exercise Group Straw Exercise 1. Stand up 2. Place the straw in your mouth 3. Try to breathe! This is what is may feel like when a child is having a severe asthma episode This is what is may feel like when a child is having a severe asthma episode

40 Common Symptoms Of Asthma Frequent cough, especially at night Frequent cough, especially at night Shortness of breath or rapid breathing Shortness of breath or rapid breathing Chest tightness Chest tightness Chest pain Chest pain Wheezing Wheezing Fatigue Fatigue

41 Early Signs Of An Asthma Episode Mild cough Mild cough Drop in Peak Flow reading Drop in Peak Flow reading Itchy, watery or glassy eyes Itchy, watery or glassy eyes Itchy, scratchy or sore throat Itchy, scratchy or sore throat Runny nose Runny nose Stomachache Stomachache Headache Headache Sneezing Sneezing Congestion Congestion Restlessness Restlessness Dark circles under eyes Dark circles under eyes Irritability Irritability

42 Acute Asthma Episodes

43 Whats An Episode? An asthma episode occurs when a child is exposed to a trigger or irritant and their asthma symptoms start to appear 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 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) Episodes are preventable by avoiding exposure to triggers and taking daily controller medications (if prescribed)

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

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

46 Call 911 if.. Lips or nail beds are bluish Lips or nail beds are bluish Child has difficulty talking, walking or drinking Child has difficulty talking, walking or drinking Quick relief or rescue meds (albuterol) is ineffective or not available Quick relief or rescue meds (albuterol) is ineffective or not available Neck, throat, or chest retractions are visible Neck, throat, or chest retractions are visible Nasal flaring occurs when inhaling Nasal flaring occurs when inhaling Obvious distress Obvious distress Altered level of consciousness/confusion Altered level of consciousness/confusion Rapidly deteriorating condition Rapidly deteriorating condition

47 There should not be any delay once a child notifies school staff of a possible problem or developing asthma episode

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

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

51 Triggers and Irritants Copyright 2004, 3M Pharmaceuticals

52 Common Allergens (Triggers) Seasonal Pollens Seasonal Pollens Animal dander saliva/urine Animal dander saliva/urine Dust Mites Dust Mites Cockroaches/Mice/Rat droppings and urine Cockroaches/Mice/Rat droppings and urine Mold Mold Some medications Some medications Some Foods Some Foods

53 Common Irritants (Triggers) Exercise Exercise Cold Air Cold Air Chalk Dust Chalk Dust Viral/upper respiratory infections Viral/upper respiratory infections Air pollution Air pollution Tobacco smoke or secondhand smoke Tobacco smoke or secondhand smoke Chemical irritants and strong smells Chemical irritants and strong smells Strong emotional feelings Strong emotional feelings Diesel fumes Diesel fumes Cleaning supplies Cleaning supplies

54 Role of Viral Respiratory Infections In Asthma Exacerbations

55 Hospital admissions for asthma correlate with virus isolation peaks and school terms 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. VRIs And Hospitalizations For Asthma Total pediatric and adult hospitalizations School holidays URIs

56 Adapted from Gern JE, Busse WW. J Allergy Clin Immunol. 2000;106:201. RV-Induced Airway Inflammation

57 Viruses cause asthma exacerbations in children Viruses cause asthma exacerbations in children RVs cause ~60% of virus-induced exacerbations of asthma RVs cause ~60% of virus-induced exacerbations of asthma RVs directly infect the bronchial airways RVs directly infect the bronchial airways The response to viral infection is shaped by the hosts antiviral response The response to viral infection is shaped by the hosts antiviral response Summary

58 Exercise Induced Asthma

59 What Is Exercise Induced Asthma (EIA)? Tightening of the muscles around the airways (bronchospasm) 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 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 Can be avoided by taking pre-exercise medications and by warming up/cooling down

60 EIA - What Happens? Symptoms include coughing, wheezing, chest tightness and shortness of breath 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 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 EIA can spontaneously resolve 20 to 30 minutes after starting Can be avoided by doing the following: Can be avoided by doing the following:

61 Preventing Exercise Induced Asthma (EIA) Become familiar with Asthma Action Plans Become familiar with Asthma Action Plans Use reliever (Albuterol) minutes before activity Use reliever (Albuterol) minutes before activity Do warm-up/ cool-down exercises before and after activities Do warm-up/ cool-down exercises before and after activities Check outdoor ozone/air quality levels Check outdoor ozone/air quality levels Never encourage a child to tough it out when having asthma symptoms Never encourage a child to tough it out when having asthma symptoms

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

63 Assess Need For Pre-Medication Take note of medication order wording Take note of medication order wording As needed vs. prior to exercise Evaluate if activity level requires pre- medication Evaluate if activity level requires pre- medication Pre-medicate for strenuous activity only Pre-medicate for strenuous activity only Contact parent/ HCP if questioning need for pre-exercise medication Contact parent/ HCP if questioning need for pre-exercise medication

64 Coachs Asthma Clipboard Program Winning With Asthma 100% online education for: 100% online education for: Coaches Coaches Referees Referees Physical Education Teachers Physical Education Teachers Coaches will receive: Coaches will receive: Coachs asthma clipboard Coachs asthma clipboard Special Coachs asthma education booklet Special Coachs asthma education booklet Certificate of completion Certificate of completion The satisfaction of knowing what to do during an asthma episode! The satisfaction of knowing what to do during an asthma episode!

65 Where Can Coaches See It?

66 Myths and Truths

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68 Myths & Truths Myths & Truths Asthma Myths It is a psychological / emotional illness It is a psychological / emotional illness It is only an acute disease It is only an acute disease It always limits normal activities It always limits normal activities It limits a child's ability to fully participate in physical activities, especially sports It limits a child's ability to fully participate in physical activities, especially sports Asthma Truths Asthma Truths Asthma is a very real, physical disease Asthma is a very real, physical disease Asthma is a chronic disease, even when symptoms are not active 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 Taking proper asthma medications allow children to fully participate in any activity, including sports

69 Myths & Truths Continued.. Asthma Myths Asthma Myths Medication is addictive Medication is addictive Medication becomes ineffective if used regularly Medication becomes ineffective if used regularly Children do not die from asthma Children do not die from asthma Asthma Truths Asthma medications are not addictive Anti-inflammatories (controllers) are most effective when used everyday Children and adults die from asthma each year

70 One Last Myth Myth Truth Use reactive airway disease instead of asthma for a diagnosis – that way the insurance company will never know Use reactive airway disease instead of asthma for a diagnosis – that way the insurance company will never know Reactive airway diseases code is the same code used for asthma! Reactive airway diseases code is the same code used for asthma! Any order for albuterol (or other rescue inhaler) flags the insurance company Any order for albuterol (or other rescue inhaler) flags the insurance company

71 Treatment Myths Gecko liquid tonic Gecko liquid tonic Herbal supplements Herbal supplements Acupuncture/pressure, chiropractic adj. Acupuncture/pressure, chiropractic adj. Cockroach tea Cockroach tea Asthma diets Asthma diets Pranic healing with mantras Pranic healing with mantras Owning a Chihuahua Owning a Chihuahua

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

73 Assessing Asthma

74 Measures Of Assessment And Monitoring Two Aspects: Initial assessment and diagnosis of asthma Initial assessment and diagnosis of asthma Periodic assessment and monitoring Periodic assessment and monitoring Excerts from NHLBI/NIH

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

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

77 History or Current Episodic Symptoms of Airflow Obstruction? Wheezing, shortness of breath, chest tightness, or cough? Wheezing, shortness of breath, chest tightness, or cough? Asthma symptoms vary throughout the day? Asthma symptoms vary throughout the day? Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma! Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma!

78 Asthma Lung Assessment Spirometry Asthma Lung Assessment Spirometry Spirometry is Gold standard to assist in asthma diagnosis Spirometry is Gold standard to assist in asthma diagnosis Assess need to start, step up, or step down asthma medications Assess need to start, step up, or step down asthma medications Should be done at least yearly in children with persistent asthma Should be done at least yearly in children with persistent asthma Spirometry is easily done at any health care providers office Spirometry is easily done at any health care providers office

79 Spirometry Continued … Performed before and after bronchodilator dose to look for airway obstruction reversibility 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 Can also be done with a cold-air or methylcholine challenge, or an exercise challenge in the case of exercise-induced asthma

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81 Is Airflow Obstruction At Least Partially Reversible? Is Airflow Obstruction At Least Partially Reversible? Use spirometry to establish airflow obstruction FEV 1 < 80% of predicted FEV 1 < 80% of predicted FEV 1 /FVC <65% or below the lower limit of normal FEV 1 /FVC <65% or below the lower limit of normal Use spirometry to establish reversibility FEV 1 increases >12% and at least 200 mL after using a short-acting inhaled beta 2 -agonist FEV 1 increases >12% and at least 200 mL after using a short-acting inhaled beta 2 -agonist

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

83 Under Diagnosis Of Asthma In Children The majority of people who have asthma experience onset before age 5 The majority of people who have asthma experience onset before age 5 Commonly misdiagnosed as: Chronic or wheezy bronchitis Chronic or wheezy bronchitis Bronchiolitis Bronchiolitis Recurrent croup Recurrent croup Recurrent upper respiratory infection Recurrent upper respiratory infection Recurrent pneumonia Recurrent pneumonia

84 Guidelines for the Diagnosis & Management of Asthma EPR 2002 Update Guidelines for the Diagnosis & Management of Asthma EPR 2002 Update NAEPP, NHLBI, NIH- EPR National Heart, Lung, and Blood Institute (NHLBI) NAEPP

85 NHLBI- NAEPP Asthma Severity Levels 1. Mild Intermittent 2. Mild Persistent 3. Moderate Persistent 4. Severe Persistent

86 NAEPP Classification of Asthma Severity: Clinical Features Before Treatment Days With Nights With PEF or PEF Symptoms Symptoms FEV 1 Variability Step 4 Continuous Frequent 60% 30% SeverePersistent Step 3 Daily >1night/week 60%- 1night/week 60%-<80% 30%ModeratePersistent Step 2 >2/week, 2 nights/month 80% 20-30% MildPersistent Step 1 2 days/week 2/month 80% 20% MildIntermittent Footnote: The patients step is determined by the most severe feature. Footnote: The patients step is determined by the most severe feature.

87 Peak Flow Variability Is the difference between the childs morning and evening PFM readings Is the difference between the childs morning and evening PFM readings Peak flow readings tend to be higher in the evening than in the morning Peak flow readings tend to be higher in the evening than in the morning

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

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

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

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

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

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

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

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

96 Which Of These Does Not Fit With Severe Persistent Asthma? A. Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptoms B. Limited physical activity C. Near normal Pulmonary Function Test (Spirometry) D. Frequent asthma exacerbations

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

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

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

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

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

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

103 Which Level Does Not Need Daily Controller Medication? A. Mild Intermittent B. Mild Persistent C. Moderate Persistent D. Severe Persistent

104 Which Level Does Not Need Daily Controller Medication? A. Mild Intermittent B. Mild Persistent C. Moderate Persistent D. Severe Persistent

105 Severity Level Workout Severity Level Workout Case Scenario Group Interactive Format

106 Assessing Asthma

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

109 Physical Assessment Of Asthma In The School Health Office Symptoms (daytime, nighttime and exercise- related) Symptoms (daytime, nighttime and exercise- related) Peak Flow Meter readings Peak Flow Meter readings Respiratory assessment (breath Sounds / lung auscultation, respiratory rate, physical assessment) Respiratory assessment (breath Sounds / lung auscultation, respiratory rate, physical assessment)

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

111 Respiratory Assessment

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

113 Normal Respiratory Rates For Children AgeRateAgeRate Newborn35 10 years mo years19 2 years25 14 years19 4 years23 16 years17 6 years21 18 years years20 (rate=breaths/minute) Whaley & Wong, 1991

114 Why Lung Assessment Is Important It provides additional clinical information It provides additional clinical information Provides a good baseline for comparison in future assessments Provides a good baseline for comparison in future assessments Gives a better picture of the childs perception of symptoms vs. what is actually assessed Gives a better picture of the childs perception of symptoms vs. what is actually assessed When consulting w/the HCP, they will ask for lung sounds When consulting w/the HCP, they will ask for lung sounds Form F26

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

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

117 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 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) 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.

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

119 Peak Flow Meters

120 Measures how well the students lungs are doing at that moment Measures how well the students lungs are doing at that moment Associated with the Green-Yellow-Red system of managing asthma symptoms Associated with the Green-Yellow-Red system of managing asthma symptoms Congruent with asthma action plans Congruent with asthma action plans Helps students and families self-manage asthma Helps students and families self-manage asthma Form F31 Form F31

121 How to use a Peak Flow Meter Review the steps Review the steps Place indicator at the base of the numbered scale Place indicator at the base of the numbered scale Stand up Stand up Take a deep breath Take a deep breath Place the meter in the mouth and close lips around the mouthpiece Place the meter in the mouth and close lips around the mouthpiece Blow out into the meter as hard and fast as possible Blow out into the meter as hard and fast as possible Write down the achieved number Write down the achieved number Repeat the process twice more Repeat the process twice more Record the highest of the three numbers achieved Record the highest of the three numbers achieved

122 Group Peak Flow Exercise

123 Personal Best Peak Flow Values Determined by twice daily Determined when healthy and not experiencing symptoms Determined by twice daily Determined when healthy and not experiencing symptoms PFM measurements over the course of two weeks PFM measurements over the course of two weeks Is the BEST reading obtained during those two weeks Is the BEST reading obtained during those two weeks Is used to calculate percentages for AAPs Is used to calculate percentages for AAPs

124 Predicted Peak Flow Values Are based on a child's height Are based on a child's height Are not individualized Are not individualized Do not take into account other personal factors Do not take into account other personal factors Can be identified immediately Can be identified immediately Are used when it is impossible or difficult to obtain personal best peak flow levels Are used when it is impossible or difficult to obtain personal best peak flow levels Form F6

125

126 Every Child Is Unique! Wheezing and coughing are the most common symptoms -but- Wheezing and coughing are the most common symptoms -but- No two children will have the exact same symptoms or the same trigger 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 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) Every child with persistent asthma should have an asthma action plan at school (AAP)

127 Together- We Can Make A Difference!


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