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:
2Managing 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 presentationCo-written by Susan Ross RN Clinical advisor for the asthma programStephanie Bisson Belseth NP w/Mpls Public Schools/Mpls Childrens ClinicDeb Hill Health EducatorAnd Laura Oatman Environmental Research ScientistWendy 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.
3MDH Asthma Program Staff Presenter For TodaySusan K. Ross RN, AE-CMDH Asthma Program Staff
4Minnesota 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).
5Funding grant awarded by: AcknowledgementsOur 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 SPPSCecelia Erickson from MPS“Healthy Learners Asthma Initiative”Cheryl Smoot MDHFunding 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
6Thanks To: GlaxoSmith Kline Pharmaceuticals AstraZeneca PharmaceuticalsStarbright FoundationHennepin County Medical CenterFor contributing PFM’s, Spacers, Diskus, asthma booklets and CD-Rom games for our participantsRead slide
7Overview of Today Controlling Asthma Asthma triggers and irritants Asthma BasicsAsthma triggers and irritantsDiagnostic/ assessment processNIH/NHLBI/NAEPP asthma guideline overviewSeverity level workoutMedication OverviewAsthma “gadgets”Controlling AsthmaTools available (MDH website-Manual)Coordinated School HealthThere 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.
8Post Tests - Evaluations C.E.U’s Complete the post testComplete the program evaluationComplete your goals sheetHand everything in before you leaveYou will receive credit for 7.2 C.E.U’safter attending today's presentationAt 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 staffIn order for you the get your CEU’s for this program- as you leave today, you must return to us all evaluations and tests.
9As 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
10How To Use This Manual Resource and Training document Each Section is all-inclusive to each staff member’s roleLift out the entire section - copy it and use as a basis for teaching about asthmaSupplemental forms/handouts are in the back folders and provided on CD and websiteFull resources section w/websites are listedPower Point presentations are also on our asthma website and CD in back of your manualThe 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 personnelAsthma basics for coachesAsthma basics for PE/HE teachersAsthma and the school environmentAnd the PPT from this entire program broken down into 3 presentations.
11You 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.
12Staffing ModelsSchool health staffing varies greatly across the entire stateThe manual provides a few suggested staffing models in the “All Health Staff” sectionToday’s program is based on a school that has at least some LSN/PHN/RN staffing in the school on regular basisStaffing 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.
16Did You Know..Asthma kills people equally regardless of severity level1/3 of deaths are in those with mild asthma1/3 of deaths are in those with moderate asthma1/3 of deaths are in those with severe asthmaRead slide
17Asthma: Accounts for 14 million lost school days annually3 Is the most common chronic disease causing absence from school2Is the 3rd leading cause of hospitalizations among children under 1521 in 13 school children have asthma16.3 million children under 18 have asthma11 Asthma Prevalence, Health Care Use, and Mortality, , National Center for Health Statistics, CDC2 Morbidity and Mortality Report, National Center for Health Statistics (NCHS), U.S. CDC, 20033 Surveillance for Asthma - United States, , MMWR Surveillance Summaries, CDC, March 29, 2002
18Minnesota ChildrenIn a 2003 MDH survey of more than 5,0007th & 8th graders at 15 junior highs outside the metro area-1 in 12 reported they currently have asthmaIn a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN-1 in 11 reported they currently have asthmaInformation 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.
19This means..In a class of 30 children, you can expect2 to 3 students WILL have asthmaThis number varies depending on age and geographical location
21Do School Children Have Asthma Action Plans? In MDH’s survey of 7th and 8th graders ingreater Minnesota:37% of the children who had asthma did not know if they had a written asthma action plan28% did not have an asthma action planOverall, only 34% of children who have asthma actually had asthma action plansREAD SLIDEInterestingly 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
22Asthma & Exercise Of the 7th & 8th graders with asthma: 80% reported wheezing “sometimes” or “a lot” during or after running, playing sports or exercising36% reported missing recess, sports or other physical activities due to asthma symptoms24% reported missing a day or more of school in the past year due to asthma symptoms66% reported wheezing “sometimes” or “a lot”**from the same MDH survey as the previous slide.(Wendy Brunner, Marian Marbury MDH)
23Survey ConclusionsThere is substantial uncontrolled asthma among school children in this age groupThis 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 asthmaThe survey also suggests that there may be substantial undiagnosed asthmaREAD 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.
24Impact Of Asthma On Students School Performance:Poorly controlled asthma has a negative impact on school performance in both academic achievement and physical educationPoorly 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.
25Impact Of Asthma On Students cont... Psychosocial:Poor self-esteemAnxiety about asthmaFear of becoming ill at schoolAnxiety about exercise at schoolFear of being differentChildren 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
26YOU 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.
27What Is Asthma? Asthma is a chronic disease that causes: BronchoconstrictionInflammation of the bronchioles (small airways)Hyper-responsive “twitchy” airwaysExcessive mucus production in the bronchiolesAsthma 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 bronchiolesThere 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 tubeThru the bronchi or middle sized air tubesto 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.
28Normal 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 morningPotentially, airway remodeling (a type of lung scarring which is permanent) can occur when asthma goes untreated.
29Copyright 3M Pharmaceuticals 2004 Airway ObstructionIt is not curable but is very treatable.Copyright 3M Pharmaceuticals 2004
30Airway 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
32Before 3 months on an ICS and after 3 months on an ICS BID
33A Lot Going On Beneath The Surface SymptomsAirflowobstructionBronchialhyperresponsivenessWith 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.AirwayinflammationSlide courtesy of ALAMN - PACE program 2004
34Immune System Response The Immune System ResponseThink 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.
36Mediator PhasesEarly-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 hoursAcute Asthma AttacksWithin 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.
37The End Results Of The Cascade Localized mucosal edema in the walls of the small bronchiolesSecretion of thick mucus into the bronchiolar lumens(Clogs and narrows the airways)Spastic contraction of bronchiolar smooth muscleThe end results of the cascade include:1) localized mucosal edema in the walls of the small bronchioles2) secretion of thick mucus into the bronchiolar lumens (clogs and narrows the airways)3) spastic contraction of bronchiolar smooth muscleConsequences of Chronic Allergic Reaction in AsthmaWith 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-
39Group Straw ExerciseStand upPlace the straw in your mouthTry to breathe!This is what is may feel like when a child is having a severe asthma episodeHave participants stand up in placePinch closed nose (nares) with their fingersPlace 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 episodeThe 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).
40Common Symptoms Of Asthma Frequent cough, especially at nightShortness of breath or rapid breathingChest tightnessChest painWheezingFatigueREAD SLIDE:These symptoms vary greatly in severity and not ALL children have the same symptomsSymptoms 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.
41Early Signs Of An Asthma “Episode” StomachacheHeadacheSneezingCongestionRestlessnessDark circles under eyesIrritabilityMild coughDrop in Peak Flow readingItchy, watery or glassy eyesItchy, scratchy or sore throatRunny noseRecognizing the EARLY Signs of an Asthma EpisodeChildren 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 appearAn 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.
43What’s An “Episode”?An asthma episode occurs when a child is exposed to a trigger or irritant and their asthma symptoms start to appearThis can occur suddenly without a lot of warning, or brew for days before the symptoms emergeEpisodes are preventable by avoiding exposure to triggers and taking daily controller medications (if prescribed)
44Handling Acute Asthma Episodes At School Remain calm and reassure the childHave the child sit up and breathe slowly- in through the nose slowly, out through pursed lips very slowlyHave the child sip water / fluidsCheck peak flow (with severe symptoms: skip PF & give quick-relief or reliever medication immediately)Child should not be left alone
45Handling Acute Asthma Episodes At School Cont… Give asthma reliever (bronchodilator) per the child's Asthma Action Plan / medication ordersAssess response to medicationAfter ~5-10 minutes recheck peak flowCall parent/guardian/health care provider prnCall 911 if escalating symptoms or no improvementRead slide
46Call 911 if.. Lips or nail beds are bluish Child has difficulty talking, walking or drinkingQuick relief or “rescue” meds (albuterol) is ineffective or not availableNeck, throat, or chest retractions are visibleNasal flaring occurs when inhalingObvious distressAltered level of consciousness/confusionRapidly deteriorating conditionIF any ONE of these symptoms/situations is happening, call 911 and provide care as appropriate per the child’s AAP or individualized health plan.
47“There should not be any delay once a child notifies school staff of a possible problem or developing asthma episode”READ SLIDESchool 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.
48A little fun -This joke refers to one of many theories that exposure to some animals may prevent asthma from developing.
49What Causes Asthma?Of the 21 million asthma sufferers in the US, 10 Million (approx. 60%) have allergic asthma. 3 million of those are children1Exposure to certain allergens trigger asthma symptoms to beginExposure to certain irritants can also set an asthma episode in motion1National Institute of Environmental Health SciencesTriggers and Irritants
50What Causes Asthma?Asthma may be caused by genetic, immune and/or environmental factors, and is often associated with eczema and allergiesResearchers do not understand all of the causes of asthma or its increasing prevalenceIt boils down to “We just don’t really know for sure”
51Triggers and Irritants Copyright 2004, 3M Pharmaceuticals
52Common Allergens (Triggers) Seasonal PollensAnimal dander saliva/urineDust MitesCockroaches/Mice/Rat droppings and urineMoldSome medicationsSome FoodsCOMMON TRIGGERS:allergens such as pollenanimal dander, saliva/urine- from furry or feathery animals including PETS in the classroomdust mitesCockroaches/Mice/Rat Droppings and their urinecertain 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.
53Common Irritants (Triggers) ExerciseCold AirChalk DustViral/upper respiratory infectionsAir pollutionTobacco smoke or secondhand smokeChemical irritants and strong smellsStrong emotional feelingsDiesel fumesCleaning suppliesCommon TRIGGERS or irritants that set off an asthma episode include:Exercise induced asthma and or exercise induced symptomsCold airChalk dust or now days- whiteboard marker scentsViral/upper respiratory infections such as sinusitis, bronchitis etcAir pollution- more specifically, when the ozone is high/or high particulate matter in the airTobacco 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.
54Role of Viral Respiratory Infections In Asthma Exacerbations
56RV-Induced Airway Inflammation HyperresponsivenessPlasmaleakageMucushypersecretionInflammatorycell recruitmentand activationNeural activationVirus-infectedepitheliumThe 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.1These 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.21. 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.
57Summary Viruses cause asthma exacerbations in children RVs cause ~60% of virus-induced exacerbations of asthmaRVs directly infect the bronchial airwaysThe response to viral infection is shaped by the host’s antiviral responseVRIs 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.
58Exercise Induced Asthma Exercise Induced Asthma or exercise induced symptoms
59What 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 airwaysCan be avoided by taking pre-exercise medications and by warming up/cooling downExercise Induced AsthmaExercise-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.
60EIA - What Happens?Symptoms include coughing, wheezing, chest tightness and shortness of breathSymptoms may begin during exercise and can be worse 5 to 10 minutes after exerciseEIA can spontaneously resolve 20 to 30 minutes after startingCan 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 periodSymptoms 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.
61Preventing Exercise Induced Asthma (EIA) Become familiar with Asthma Action PlansUse reliever (Albuterol) minutes before activityDo warm-up/ cool-down exercises before and after activitiesCheck outdoor ozone/air quality levelsNever encourage a child to “tough it out” when having asthma symptomsChildren 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.
62Exercise As A Trigger!Exercise can be a trigger for those who have “chronic” asthmaTheir pre-exercise treatment is the same but-These children will have the underlying inflammation and require daily controller medication
63Assess Need For Pre-Medication Take note of medication order wording“As needed” vs. “prior to exercise”Evaluate if activity level requires pre- medicationPre-medicate for strenuous activity onlyContact parent/ HCP if questioning need for pre-exercise medicationIt’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 activityWorking collaboratively with the PE teacher or coach can help reduce unneeded treatment with albuterol.
64Coach’s Asthma Clipboard Program “Winning With Asthma” 100% online education for:CoachesReferee’sPhysical Education TeachersCoaches will receive:Coach’s asthma clipboardSpecial Coach’s asthma education bookletCertificate of completionThe satisfaction of knowing what to do during an asthma episode!
67Cartoon -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 asBronchitis 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 thePRACTICAL guide for the diagnosis and management of Asthma/ NHLBI EPR2But heh- it doesn’t help that she’s smoking either!
68Myths & Truths Asthma Truths Asthma Myths Asthma is a very real, physical diseaseAsthma is a chronic disease, even when symptoms are not activeTaking proper asthma medications allow children to fully participate in any activity, including sportsAsthma MythsIt is a psychological / emotional illnessIt is only an acute diseaseIt always limits normal activitiesIt limits a child's ability to fully participate in physical activities, especially sportsREAD SLIDEMultitude of false cures : Gecko liquid tonic (from the backs and tails of gecko’s), herbal supplements, accupuncture/pressure, asthma diets, cockroach tea, chiropractic adjustmentsPranic healing w/mantras -apparently breathing certain words or mantras help healOwning 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.
69Myths & Truths Continued.. Asthma TruthsAsthma medications are not addictiveAnti-inflammatories (controllers) are most effective when used everydayChildren and adults die from asthma each yearAsthma MythsMedication is addictiveMedication becomes ineffective if used regularlyChildren do not die from asthmaRead slideUltimately, 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.
70One 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 companyUse “reactive airway disease” instead of “asthma” for a diagnosis – that way the insurance company will never knowWe’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!
71Treatment Myths Gecko liquid tonic Herbal supplements Acupuncture/pressure, chiropractic adj.Cockroach teaAsthma dietsPranic healing with mantrasOwning 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 asthmaChihuahua are born w/the tendency to develop respiratory difficulties and the childrens improvement was merely coincidental.
72Small Group ExerciseReport back a couple activity steps appropriate to that roleEach table will review a sectionRead slide
73Assessing 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.
74Measures Of Assessment And Monitoring Two Aspects:Initial assessment and diagnosis of asthmaPeriodic assessment and monitoringExcerts from NHLBI/NIHREAD SLIDE:Measures of Assessment and Monitoring:Information in this section in part are taken from NHLBI/NIH PPT presentationsTheir web address is
75Initial Assessment & Diagnosis of Asthma Determines That:Patient has a history or presence of episodic symptoms of airflow obstructionAirflow obstruction is at least partially reversibleAlternative diagnoses are excludedRead Slide
76Methods for Establishing Diagnosis Detailed medical historyPhysical examSpirometry to demonstrate reversibilityREAD SLIDE
77History 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 airflowObstruction?Is there Wheezing, SOB, Chest Tightness or coughingDo the asthma symptoms vary throughout the day andThe 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 tobronchia constriction/spasm and inflammation will come and go depending oncircumstances.
78Asthma Lung Assessment Spirometry Spirometry is Gold standard to assist in asthma diagnosisAssess need to start, step up, or step down asthma medicationsShould be done at least yearly in children with persistent asthmaSpirometry is easily done at any health care providers officeRead slide:PFT or pulmonary function testing is also done but at an appropriate facility and generally is ordered by specialist such as allergists, Pulmonologists.
79Spirometry Continued… Performed before and after bronchodilator dose to look for airway obstruction reversibilityCan also be done with a cold-air or methylcholine challenge, or an exercise challenge in the case of exercise-induced asthmaRead slidesSpirometry 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 yearlyAnd to evaluate the resonse to a change in therapy (step up, step down)
80This 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.
81Is Airflow Obstruction At Least Partially Reversible? Use spirometry to establish airflow obstructionFEV1 < 80% of predictedFEV1/FVC <65% or below the lower limit of normalUse spirometry to establish reversibilityFEV1 increases >12% and at least 200 mL after using a short-acting inhaled beta2-agonistRead SlideMany 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.
82Have Alternative Diagnoses Been Excluded? Examples:Vocal cord dysfunctionVascular ringsForeign body aspirationOther pulmonary diseasesCystic FibrosisGastroesophageal refluxREAD SLIDE
83Under Diagnosis Of Asthma In Children The majority of people who have asthma experience onset before age 5Commonly misdiagnosed as:Chronic or wheezy bronchitisBronchiolitisRecurrent croupRecurrent upper respiratory infectionRecurrent pneumoniaThe 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
84National Heart, Lung, and Blood Institute (NHLBI) NAEPP Guidelines for the Diagnosis & Management of Asthma EPR 2002 UpdateNAEPP, NHLBI, NIH- EPR2 2002Read slide:Show update card from NHLBI
85NHLBI- NAEPP Asthma Severity Levels Mild IntermittentMild PersistentModerate PersistentSevere PersistentRead Slide: there are 4 severity levels
86Footnote: The patient’s step is determined by the most severe feature. NAEPP Classification of Asthma Severity: Clinical Features Before TreatmentDays With Nights With PEF or PEFSymptoms Symptoms FEV VariabilityStep Continuous Frequent 60% 30%SeverePersistentStep Daily >1night/week 60%-<80% 30%ModerateStep >2/week, <1x/day >2 nights/month 80% %MildStep 1 2 days/week 2/month 80% 20%IntermittentFootnote: The patient’s step is determined by the most severe feature.
87Peak Flow VariabilityIs the difference between the child’s morning and evening PFM readingsPeak flow readings tend to be higher in the evening than in the morning
88NAEPP Stepwise Approach To Asthma TherapyOutcome:Control of AsthmaOutcome:Best Possible ResultsController:Daily inhaled corticosteroidDaily long acting bronchodilatorDaily/alternate day oral corticosteroidWhen controlled, reduce therapyMonitorController:Daily inhaled corticosteroidDaily long acting bronchodilatorAnti-leukotrieneController:One daily medicationPossibly add long acting bronchodilatorAnti-leukotrienesReliever:Inhaled beta agonist prnReliever:Inhaled beta agonist prnReliever:Inhaled beta agonist prnReliever:Inhaled beta agonist prnSlide courtesy of ALAMN- PACE program 2004PEF: ≥80%PEF: ≥80%PEF: 60-80%PEF: <60%STEP 1:IntermittentSTEP 2:Mild PersistentSTEP 3:Moderate PersistentSTEP 4:Severe PersistentStepdown
89Mild IntermittentSymptoms £ 2 days/week with nighttime symptoms £ 2 nights/monthAsymptomatic with normal peak flows between exacerbationsExacerbations are brief (hours to a few days)Peak Flows ³ 80% predicted with variability < 20%Read Slide
90Mild PersistentSymptoms > 2 days /week but < 1x/day with nighttime symptoms greater than 2 nights/monthExacerbations may affect activityPeak flow 80% of predicted with variability of< 20-30%Read Slide
91Moderate PersistentChild is likely to have daily symptoms and use reliever dailyChild is waking up at least once a week due to asthma symptomsPeak flows 60-80% of predicted with variability of >30%Activity is affected and exacerbations may last daysREAD SLIDE
92Severe PersistentContinual daytime symptoms with frequent nighttime symptomsVery limited physical activityFrequent exacerbationsPeak flows £ 60% of predicted and variability of more than 30%Treatment involves a combination of many drug therapies
93Rules 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
94MDH Interactive Asthma Action Plan (IAAP) Available at MDH website:Click on “Asthma Action Plan”Click on “Medical Professionals”Choose to download desktop version oruse online version
95Which of These Does Not Fit With Severe Persistent Asthma? Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptomsLimited physical activityNear normal Pulmonary Function Test (Spirometry)Frequent asthma exacerbationsRead Slide:
96Which Of These Does Not Fit With Severe Persistent Asthma? Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptomsLimited physical activityNear normal Pulmonary Function Test (Spirometry)Frequent asthma exacerbationsRead Slide: Answer = CPulmonary function tests in an asthmatic w/severe persistent asthma levels (when not controlled) are not in the normal range
97Which Of These Does Not Fit With Moderate Persistent Asthma? Daily daytime symptoms, nighttime symptoms > 1 night per weekNighttime Symptoms < 2 times a weekDaily use of albuterol/bronchodilatorsAsthma exacerbations can last for daysRead Slide:
98Which Of These Does Not Fit With Moderate Persistent Asthma? Daily daytime symptoms, nighttime symptoms > 1 night per weekNight time Symptoms < 2 times a weekDaily use of albuterol/bronchodilatorsAsthma exacerbations can last for daysAnswer = B. In Moderate persistent, symptoms are daily
99Which Of These Does Not Fit With Mild Persistent Asthma? Daytime symptoms > 2 times a week, but < 1 time a daySymptoms may affect activityNeed for albuterol 3 times a week, sometimes twice a day (not related to EIA)Nighttime symptoms > 2 times a monthRead slide
100Which Of These Does Not Fit With Mild Persistent Asthma? Daytime symptoms > 2 times a week, but < 1 time a daySymptoms may affect activityNeed for albuterol 3 times a week, sometimes twice a day (not related to EIA)Nighttime symptoms > 2 times a monthAnswer: 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
101Which Of These Does Not Fit With Mild Intermittent Asthma? Daytime symptoms < 2 times a weekNighttime symptoms > 2 times a monthNo symptoms and normal Peak Flow between exacerbationsExacerbations are brief and may last from a few hours to a few daysRead Slide:
102Which Of These Does Not Fit With Mild Intermittent Asthma? Daytime symptoms < 2 times a weekNighttime symptoms > 2 times a monthNo symptoms and normal Peak Flow between exacerbationsExacerbations are brief and may last from a few hours to a few daysRead 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 andAnd most likely require controller medication.
103Which Level Does Not Need Daily Controller Medication? Mild IntermittentMild PersistentModerate PersistentSevere PersistentRead Slide:
104Which Level Does Not Need Daily Controller Medication? Mild IntermittentMild PersistentModerate PersistentSevere PersistentRead Slide: Answer: A Mild Intermittent. BUT, these children should have an albuterol or rescue type inhaler available to them.
105Severity Level Workout Case Scenario Group Interactive FormatRead slide and give instructions to work in small groups and come up w/an answer to each case scenario. The have…..? Minutes.
108When 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 oftenHow often is he/she using reliever inhalersAbout his/her home environmentPetsAdults smoking in the homeMoist basements or obvious moldMattress and pillow coversCockroaches, mice, rats etc E2, E3Read slideE2 Components of Asthma Care in the School Health Office (MPPS)E3 “ “ SPPS
109Physical Assessment Of Asthma In The School Health Office Symptoms (daytime, nighttime and exercise-related)Peak Flow Meter readingsRespiratory 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
110Symptoms Ask about: Coughing / wheezing / tight chest Frequency of daytime symptomsFrequency of nighttime symptomsSymptoms with activity or exerciseRead Slide
112Respiratory Assessment in the School Health Office Physical inspection (including respiratory rate)Auscultation of the lung fieldsRead slide
113Normal Respiratory Rates For Children Age Rate Age RateNewborn years 191-11 mo years 192 years years 194 years years 176 years years 16-188 years 20(rate=breaths/minute) Whaley & Wong, 1991These are the normal respiratory rates for children in breaths per minute
114Why Lung Assessment Is Important It provides additional clinical informationProvides a good baseline for comparison in future assessmentsGives a better picture of the child’s perception of symptoms vs. what is actually assessedWhen consulting w/the HCP, they will ask for lung soundsForm F26READ SLIDE- ANDWe won’t go into detail w/these next slides but they are here for your informationBut 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
115Physical Respiratory Inspection Respiratory rateRhythm (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
116Auscultation Breath sounds best heard in a quiet environment Wheezing and crackles are best heard as the student takes deep breathsAbsent / diminished breath sounds are abnormal and should be investigatedAbsence of wheezing does not necessarily mean absence of asthmaRead slide
117Breath 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 pneumoniaFine 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
118Breath 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 asthmaWheezing over trachea and right lower lung of 11 yo girl with asthmaRhonchus: 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.
119Peak Flow MetersPeak 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.
120Peak Flow MetersMeasures how well the student’s lungs are doing at that momentAssociated with the Green-Yellow-Red system of managing asthma symptomsCongruent with asthma action plansHelps students and families self-manage asthmaForm F31Read slideFORM F31- Peak Flow Meter Skill Validation for the RN to evaluate the knowledge and abilities of other health office staff.
121How to use a Peak Flow Meter Review the stepsPlace indicator at the base of the numbered scaleStand upTake a deep breathPlace the meter in the mouth and close lips around the mouthpieceBlow out into the meter as hard and fast as possibleWrite down the achieved numberRepeat the process twice moreRecord the highest of the three numbers achievedRead slide- Exercise--PFM results can then be compared to the AAP for determination of whatZONE 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
123Personal Best Peak Flow Values Determined by twice daily Determined when healthy and not experiencing symptomsPFM measurements over the course of two weeksIs the BEST reading obtained during those two weeksIs used to calculate percentages for AAP’sRead 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
124Predicted Peak Flow Values Are based on a child's heightAre not individualizedDo not take into account other personal factorsCan be identified immediatelyAre used when it is impossible or difficult to obtain personal best peak flow levelsForm F6Read 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 predictedPeak flow is a good alternative when dealing w/children who can’t or won’tPerform personal best evaluations.Form F6
126Every Child Is Unique!Wheezing and coughing are the most common symptoms -but-No two children will have the exact same symptoms or the same triggerEvery 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)