May 20, 2013

Definition Involves bronchial airways, not lung tissue Characterized by REVERSIBLE narrowing Peribronchial muscle spasm Mucous production, excess volume and tenacity Edema of airway lining Reverses spontaneously or in response to meds

Asthma effects on airways

Prevalence 12.7% of children under 18 with at least one episode of wheezing 9.6% of all US children with active asthma, equal to 9 million children Martinez,FD JACI 2011; 128:939-45

Acute Symptoms Coughing From tight, dry, “croupy” to very “wet” Wheezing Tachypnea Chest pain or back pain Dyspnea Speaking in incomplete sentences Poor exercise tolerance

Symptoms Cough : localized in large airways, trachea and main bronchial tubes Wheeze: localized in medium sized airways, secondary bronchial tubes Silent but dyspneic: localized in small airways, terminal bronchioles

Asthma Classification By Severity and Frequency NAEPP By types of triggers: allergic, non-allergic, both

Severity and Frequency Mild Intermittent Needing rescue medication < twice weekly OK to need pre exercise treatment No HS wheeze/cough Mild Persistent Needing single maintenance medication daily No breakthrough need for rescue or HS symptoms Moderate Persistent Needing two maintenance medications daily Severe Persistent Needing rescue medications despite three or more daily medications

Asthma Classification By Severity and Frequency NAEPP By Types of Triggers: Allergic Non-allergic Both

Classic Triggers Viral infection Exercise: alone or only if already inflamed Irritants: Cigarette smoke, Perfumes, VOCs Weather changes Allergens Dust mites Pollens Mold spores Pet danders Foods : Egg, milk, peanut, wheat, chocolate

Goals of Treatment No loss of school days No restriction on sports/activities No loss of sleep from asthma or from meds No or minimal side effects from medications Maintain lung function/prevent permanent injury

Treatment Based on Triggers Allergic Control of foods in school Control of pollen exposure Control of pet dander exposure School projects designed with allergens in mind Non Allergic Exercise modification when necessary Minimize irritants in classroom

Treatment Based on Severity and Frequency NAEPP Guidelines: Step up Step down Based on Triggers Environmental controls Allergens Irritants Infection avoidance Exercise management

Step up Step down Albuterol alone: for exercise asthma or for rescue up to twice weekly, with no night symptoms Step Up I: add Singulair or ICS if albuterol needed more than 2 times weekly or at all at night; consider allergy IT if appropriate Step Up II: add combination ICS-LABA or increase ICS dose if still not controlled

Step up Step down II Step Up III: combine Singulair and higher dose combined ICS-LABA Step Up IV: add oral corticsteroid to all of the above Step Up V: consider Xolair for appropriate candidate Step Down: to preceding level if symptoms are controlled for an appropriate amount of time

NAEPP 2007 EPR-3

Rescue Medications Albuterol Proventil, Ventolin, ProAir, albuterol HFA Xopenex (Lev albuterol) MDI vs nebulizer

Preventers Anti Leukotrienes – Singulair, Zyflo, Accolate Mast cell stabilizers – Intal Inhaled corticosteroids – Flovent, Qvar, Pulmicort, Alvesco, Asmanex Combination ICS with LABAs – Advair, Symbicort, Dulera Oral corticosteroids – prednisone, Medrol (methylprednisolone) Orapred (prednisolone)

Your Role Prevention  Assess and address risks in classroom and school  Identify students at risk – asthma control test  Consider environmental strategies: Air conditioning Timing of outdoor activities Types of class projects or field trips  Educate students and faculty

Red Flags Refilling rescue inhaler more than once per month “Sudden” or gradual loss of interest in sports/playing Needing rescue inhaler at night…even once Needing rescue inhaler more than every 4 hours Rescue inhaler doesn’t “work” May repeat every 15 minutes for 3 doses only

Your Role Treatment Assess Peak Flow O2 Sat Pulse Respiratory rate Respiratory effort Skin, mucous membrane color Ease of speaking/quality of speech Treat per asthma action plan Communicate

Preventive measures With classroom personnel With cafeteria personnel With gym department With janitors (via principal, school doctor) After an acute episode With emergency personnel With parents With individuals involved at time of episode