ASTHMA BASICS Developed and Provided by: Minnesota Department of Health Asthma Program

Minnesota Department of Health www.health.state.mn.us/asthma http://www.health.state.mn.us/asthma The Minnesota Department of Health has a website containing information for school personnel as well as for the general public. The site contains links to a variety of informational websites and has a special section just for children.

As you view this presentation.. Consider how many people you know who have asthma. How will you use the information you see here today? How can you help prevent asthma symptoms from appearing? How can you help reduce asthma triggers in your home, at work or at school?

Asthma In 2008, it is estimated that 23.3 million Americans currently have asthma Is one of the most common chronic disorders in childhood, affecting an approx. 7.1 million children under 18 years (9.6%) 1 In 2007, 3,447 deaths were attributed to asthma, 152 deaths were children under the age of 15 2 Is the third leading cause of hospitalization among children under the age of 15 6 Is one of the leading causes of school absenteeism 3 In 2008 asthma accounted for approx. 14.4 million lost school days4 The annual health care costs of asthma is approx. $20.7 billion dollars 5 From ALA website 11/2010 www.Lungusa.org 1 CDC: National Center for Health Statistics, National Health Interview Survey Raw Data, 2009 2 CDC. National Center for Health Statistics. Final Vital Statistics Report. Deaths: Final Data for 2007. April 17, 2009. Vol 58 No 19. 3 CDC. National Center for Chronic Disease Prevention and Health Promotion. Healthy Youth! Health Topics: Asthma. August 14, 2009 4 CDC: National Center for Health Statistics, National Health Interview Survey Raw Data, 2008. 5 NHLBI Chartbook, U.S. Department of Health and Human Services, National Institute of Health, 2009 6 CDC: National Center for Health Statistics, National Hospital Discharge Survey, 2006.

Goal of asthma management People with asthma should live happy, healthy, physically active lives, without asthma symptoms slowing them down. The general goals of proper asthma therapy/management according to NAEPP, NIH, 2007 EPR-3 Asthma Guidelines, pp. 55-56 The Expert Panel recommends that asthma control be defined as follows (Evidence A): Asthma Control Reduce impairment 1. Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion) 2. Require infrequent use (<2 days a week) of SABA (rescue medications for quick relief of symptoms) 3. Maintain (near) “normal” pulmonary function 4. Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) 5. Meet patients’ and families’ expectations of and satisfaction with asthma care Reduce risk 6. Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations 7. Prevent progressive loss of lung function; for children, prevent reduced lung growth 8. Provide optimal pharmacotherapy with minimal or no adverse effects

What Is asthma? Airflow obstruction A chronic disorder of the airways involving: Airflow obstruction Tightening of the muscles surrounding the airways (Bronchoconstriction/spasm) Over production of sticky mucus in the airways Bronchial hyperresponsiveness An underlying inflammation (swelling) of the airways 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 bronchioles There may be periods when there are no symptoms but the airways are swollen and sensitive to some degree all of the time. For children with persistent asthma, Long-term anti-inflammatory medications are the proven treatment to control airway inflammation and eliminate or reduce symptoms.

What causes asthma? Exposure to certain allergens trigger asthma symptoms to begin Exposure to certain irritants can also set an asthma episode in motion About 70% of asthmatics also have allergies 1 Food allergies have been recently found to be a major risk factor for severe asthma and life-threatening asthma episodes 2 The prevalence of food allergy in the USA is estimated to be between 3.5 to 4.0% 3 Sources: World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach, 2007, via www.AAAAi.org 2.Liu A,Jaramillo R.,Stat M., Sicherer S.,Wood R.,Bock S.A,Burks A.W,Massing M.,Cohn R.,Zeldin D. J. National Prevalence & Risk Factors for Food Allergy & Relationship to Asthma: Results from the National Health and Nutrition Examination Survey 2005-2006; Allergy Clin Immunol. Vol. 126, Issue 4, Oct 2010 3 Sampson HA. Update on food allergy. J Allergy Clin Immunol. 2004 May;113(5):805–19. quiz 820. Review. PubMed PMID: 15131561 1. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach, 2007 via www.AAAAi.org 2. .Liu A,Jaramillo R.,Stat M., Sicherer S.,Wood R.,Bock S.A,Burks A.W,Massing M.,Cohn R.,Zeldin D. J. National Prevalence & Risk Factors for Food Allergy & Relationship to Asthma: Results from the National Health and Nutrition Examination Survey 2005-2006; Allergy Clin Immunol. Vol. 126, Issue 4, Oct 2010 3. Sampson HA. Update on food allergy. J Allergy Clin Immunol. 2004 May;113(5):805–19. quiz 820. Review. PubMed PMID: 15131561

What causes asthma? Asthma may be caused by genetic, immune and/or environmental factors, and is often associated with eczema (scaly skin patches) and allergies Researchers do not understand all of the causes of asthma or its increasing prevalence It boils down to “We just don’t really know for sure” YET!

Copyright 3M Pharmaceuticals 2004 Airway Obstruction Asthma is a multi component chronic disease. It is not curable but is very treatable. Components are: Bronchial spasm (bronchoconstriction) or narrowing of the airways due to the muscles surrounding the bronchioles (small airways) tightening and closing the lumen off. Inflammation of bronchial tissue: Allergen exposure causes irritation w/redness' and swelling which in turn causes the mucus production. Continued exposure and/or lack of treating the inflammation can (and has) resulted in the child/asthma sufferer from being able to push out used oxygen (Co2). Inhaled corticosteroids is the gold standard for treating (on a daily basis) persistent severity levels of asthma per NHI/NHLBI guidelines. Copyright 3M Pharmaceuticals 2004

Common symptoms of asthma Frequent cough, especially at night Shortness of breath or rapid breathing Chest Tightness Chest pain Wheezing Fatigue These symptoms vary greatly in severity and not ALL people have the same symptoms Symptoms are often worse at night and in the early morning hours. The severity of asthma varies from person to person and the severity may worsen or improve depending on the person’s symptom control and amount of exposure to triggers or allergens.

Every person is unique! Wheezing and coughing are the most common symptoms -but- No two people will have the exact same symptoms or the same trigger Every person who has a diagnosis of asthma should have access to a rescue inhaler! Every person who has asthma should have an asthma action plan (AAP) immediately available

Handling Asthma Episodes

What’s an “Episode”? An asthma episode (also called ‘attack’) occurs when a person is exposed to a trigger or irritant and breathing becomes difficult 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) 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 morning Potentially, airway remodeling (a type of lung scarring which is permanent) can occur when asthma goes untreated.

Normal and asthmatic bronchiole 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 morning Potentially, airway remodeling (a type of lung scarring which is permanent) can occur when asthma goes untreated.

What to do when someone is having an ‘episode’? Remain calm and reassure the person Call someone nearby for assistance if needed Check their asthma action plan if they have one Give “rescue” inhaler medications if ordered and available If identified, move the person away from the trigger Have the person sit up and breathe slowly- in through the nose - out through pursed lips slowly Do not leave the person alone until you know they are breathing okay

Call 911 if.. Lips or nail beds are bluish The person has difficulty talking, walking or drinking Quick relief or “rescue” meds (albuterol) is ineffective or not available Neck, throat, or chest muscles are pulling in (retracting) Nasal flaring occurs when inhaling Obvious distress Altered level of consciousness/confusion Rapidly deteriorating condition DO NOT HESITATE IF ANY OF THESE SYMPTOMS ARE PRESENT! ANY of these symptoms require a call to 911 after you have given the person their rescue inhaler (if available). Do not hesitate to call 911- it’s better to be safe.

You notice something's wrong! There should not be any delay once a person tells you they are having trouble breathing OR You notice something's wrong!

Triggers and Irritants Copyright 2004, 3M Pharmaceuticals

Common Allergens (Triggers) Seasonal pollens Animal dander /saliva/urine Dust mites Cockroaches/mice/rat droppings and urine Mold Some foods or food additives Seasonal pollens can mean some people suffer from asthma only during their “allergy” season. Ie tree pollen in the spring, grass in the summer etc. Aspirin is an example of a medication that some asthmatics can react to as a trigger. Only 6-8% of asthmatics have food as their asthma trigger, even though they may also have allergies that don’t cause an asthma reaction.

Common Irritants (Triggers) Exercise/sports Cold air Chalk dust Viral/upper respiratory infections Air pollution Tobacco smoke or secondhand smoke Chemical irritants and strong smells Diesel fumes Cleaning supplies Other – Strong emotions, weather changes, some medications Strong emotional feelings such as crying, laughing, or even fear and agitation can set off an asthma episode in some people. 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 people need the same treatment and care anyone else who has asthma receives.

Dust Mites Live in pillows and mattresses, carpet, fabric-covered furniture, curtains, stuffed toys - Avoid buying fabric covered furniture Remove carpeting from bedrooms Wash bedding in hot water (130o) Vacuum often when people with asthma/allergies are not in the area (HEPA filter vacuum cleaners) Wet dust book cases and furniture frequently Keep room humidity < 50% if possible

Mold Moisture control is key - Repair leaks and dry wet/moist areas right away Wash mold off surfaces using plain soap and water Replace moldy porous items such as ceiling tiles & carpet Avoid installing carpet in areas exposed to regular moisture such as drinking fountains, sinks, bathrooms, kitchens

Pests Droppings or body parts from cockroach, can trigger asthma symptoms- Use integrated pest management (IPM) methods: Don’t leave food, water or garbage exposed Vacuum or sweep areas prone to cockroach every 2-3 days Seal entry points for pests Use pesticides only as needed; try roach traps or gels See the MDH Asthma website environmental page for more information www.health.state.mn.us/asthma

PETS Fury and feathery pets can cause asthma symptoms Fur is not the trigger; the animals dander, saliva and urine are the culprits - Keep pets outside or at least out of the bedroom Keeps pets off the furniture Bath pets weekly Vacuum frequently or damp mop hard floor surfaces at least weekly

Tobacco and secondhand smoke Is an irritant triggering asthma in children and adults State law prohibits tobacco use in K-12 public schools Maintain a clean indoor air environment – do not permit anyone to smoke inside the home or in the car Use a smoking jacket if you do smoke and leave it outside when finished Ask your health care provider for a referral to a quit smoking program, or call the US Network of Quitlines: 800-QUIT-NOW (800-784-8669)

Outdoor Air High seasonal pollen counts aggravate allergies Ozone and fine particles are biggest concern caused by industrial emissions and car exhaust Sign up for Air Quality Index e-mail notices Pollution Control Agency sends e-mail alerts when they expect poor air quality (regional) Avoid being outside at high pollen count times, especially if allergic to particular seasonal pollens Keep windows closed during pollen season (e.g. Tree pollen March - June, Weed pollen July-Oct., ragweed pollen Aug. - Oct (counts are highest late morning), grass pollen May-Aug. (highest in the afternoon ), Alternaria mold common in fall in MN) Pollution caused by industrial emissions and automobile exhaust can cause an asthma attack. Pay attention to air quality forecasts on radio, television, and Internet and plan your activities for when air pollution levels will be low if air pollution aggravates your asthma

Exercise Induced Asthma

What is exercise induced asthma (EIA)? Symptoms begin due to aerobic activity that increases the heart and respiratory rate A narrowing of the airways caused by acute tightening of the muscles around the airways (bronchospasm) Distinct from allergic asthma in that it does not produce long-term increase in airway activity Can be avoided by taking pre-exercise medications and by warming up/cooling down Exercise Induced Asthma Exercise-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 albuteral. Information from NHI/NHLBI guidelines: see webpage for more info. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

EIA - What happens? Symptoms include coughing, wheezing, chest tightness, shortness of breath and fatigue Symptoms may begin during exercise and or up to 30 minutes after exercise EIA can spontaneously resolve 20 to 30 minutes after starting Symptoms can range from mild impairment to severe bronchospasm The symptoms of EIA may begin during exercise and be worse 5 to 10 minutes after stopping exercise or during the normal cool down period Symptoms range from mild to severe and often resolve in 20-30 min. Occasionally, some people 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.

Preventing exercise induced asthma (EIA) Have an Asthma Action Plan (AAP) that provides details on pre-exercise medication regimen Athletes should use their reliever medication (Albuterol) 10-15 minutes before activity Do warm-up/ cool-down exercises before and after activities Check outdoor ozone/air quality levels http://aqi.pca.state.mn.us/ Never encourage an athlete to “tough it out” when having asthma symptoms People 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.

Medications

Two categories of medications Controller medications Taken every day to prevent swelling in the airways Reliever / rescue medications Taken only when needed to relieve symptoms To prevent exercise induced asthma from developing (taken before strenuous exercise)

Controller medications Keeps swelling and mucus from developing in the airways Must be taken EVERY day even when not having symptoms Inhaled corticosteroids (ICS’s) are the most common and effective way to control asthma Help prevent asthma exacerbations from developing! An example of typical “controller” medications may be Inhaled Corticosteroids such as Pulmicort, Flovent, Advair, Qvar, Symbicort, Singulair etc. Controller medications are NOT used when having an asthma attack – These medications must be taken every day, regardless if there are symptoms or not. Typically, it can take up to 3 weeks before the inflammation in the lungs is reduced- a asthmatic may or may not notice in the short term but long term- the frequency of their episodes is reduced greatly. Oral corticosteroids (pills) can be taken by people with severe and difficult to control asthma on a daily basis. These are NOT the same steroids used by athletes to bulk up muscle.

Rescue / reliever medications Rescue inhalers are typically Albuterol and Xopenex (levalbuterol) products Are taken when asthma symptoms are appearing (asthma episode) Work by relaxing the muscles surrounding the airways Are taken 10-15 minutes before strenuous exercise/activity by people with EIA Do NOT reduce or prevent swelling from developing in the lungs May be carried in school by a student only if approved by the doctor, school nurse and parent Rescue medications- examples are Albuterol & Xopenex which are beta2-agonists. These medications should always be used WITH a spacer and used to prevent exercise induced asthma or to treat an emerging asthma episode (attack). These medication work by relaxing the contracting muscles of the airways. A child may carry their own inhaler ONLY with the signed permission of their doctor or medical care provider, their parent or guardian and in most districts (depending on school board policy) with the evaluation and approval of the school nurse. Check your school board policy for specifics but Minnesota does have an inhaler law. Oral corticosteroids (pills) can be used as a rescue medication but generally not as a replacement for a rescue inhaler since onset isn’t immediate.

Delivery methods Both control and rescue medications come in MDI (metered dose inhalers) and nebulized forms Control medications are also available in dry powder discs, breath actuated inhalers and pill form

Yep, this horse needed an inhaler treatment after a race-! Picture courtesy of American Lung Association of the Inland Counties CA 2004

Spacers or holding chambers Most MDI’s (metered dose inhalers) should be used with a spacer or holding chamber This device attaches to the MDI and allows the user to breathe in more medication effectively The clinician must write an order for a chamber when prescribing your MDI medication Both controller and reliever medications are in MDI dispensers Dry powder inhalers do NOT require spacers

Typical Spacers/Holding Chambers

Tools to Help Manage Asthma

Peak Flow Meters (PFM) Peak flow rates can be evaluated by anyone - as long as you receive training and are confident you can do it properly..

Peak flow meters Measures how well the student’s lungs are doing at that moment Associated with the Green-Yellow-Red system of managing asthma symptoms Congruent with asthma action plans Helps students and families self-manage asthma by providing an objective measure to compare to symptoms Use of a PFM (Peak Flow Meter) in conjunction with an AAP (Asthma Action Plan) can many times track the downward spiral of an individuals peak flow rate. For asthmatics who have persistent asthma (those on daily medications), taking a peak flow rate every morning when you wake up BEFORE you take medications- this should be a daily routine. Write down the peak flow rate in your ASTHMA DIARY. Take your PFR (Peak Flow rate) when you are having asthma symptoms or an episode and after taking medicine for the episode. This can tell you hw bad your asthma episode is and whether your medicine is working or not. Your PFR corresponds to the green/yellow/red zones on an asthma action plan.

Symptoms and PFM diary Peak Flow and Asthma Diary

Asthma Action Plan (AAP)

Asthma Action Plan Zones Green Zone: All Clear/Breathing Good/Go No asthma symptoms and/or Peak flow 80-100% Yellow Zone: Caution/Slow Down Some asthma symptoms and/or Peak flow 50-80% Red Zone: Medical Alert/Stop Severe asthma symptoms and/or Peak flow < 50% Peak flow rates are either determined as personal bests (which is the most accurate) or as predicted values based on the persons height and age. The zones indicate how well that persons lungs are functioning at that moment in time. Action Plans are simply an educational tool with specific care instructions for that patient. Every child (or adult) who has persistent asthma should have one in school, at home and w/every sports coach.

Resources Minnesota Department of Health Asthma Website www.health.state.mn.us/asthma Centers for Disease Control (CDC) http://www.cdc.gov/asthma/ National Heart Lung & Blood Institute (NHLBI), EPR-3 Asthma Guidelines http://www.nhlbi.nih.gov/guidelines/asthma/ Environmental Protection Agency http://www.epa.gov/asthma/programs.html Asthma Community Network http://www.asthmacommunitynetwork.org/