Asthma Basics Minnesota Department of Health Asthma Program Developed and Provided by: Minnesota Department of Health Asthma Program

Minnesota Department Of Health www. health. state. mn Minnesota Department Of Health www.health.state.mn.us/divs/hpcd/cdee/asthma http://www.health.state.mn.us/divs/hpcd/cdee/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 kids.

As You View This Program.. Consider how many people you know who have asthma? How will you use the information you receive here today? How can you help students prevent their asthma symptoms from appearing? How can you help your schools health office staff reduce asthma triggers at school? While in school, caring for children who have asthma is not just he school health offices/ Nurses responsibility- it’s everyone's job to assure the safety and welfare of each child and that includes children who suffer from asthma. Do you know anyone who has asthma? What do you think you will learn from this program today? How can you help your school health office/ Nurse keep kids with asthma in school and able to participate in all aspects of school activity?

Goal Setting Think about what you would like to achieve here today Pick one goal to work toward when you go back to your classroom or work place Pick a goal that is realistic- write it down and consider what steps you can take to achieve that goal. Consider who you need to work with, what questions you will need to ask and how to phrase those questions.

Asthma: Accounts for 14 million lost school days annually3 Is the most common chronic disease causing absence from school2 Is the leading cause of hospitalizations (chronic) among children under 152 1 in 13 school children have asthma1 6.3 million children under 18 have asthma1 1 Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC 2 Asthma in Children Fact Sheet, American Lung Association, June 17, 2003 3 Surveillance for Asthma - United States, 1980-99, MMWR Surveillance Summaries, CDC, March 29, 2002

Minnesota Children In a 2003 MDH survey of more than 5,000 7th & 8th graders at 15 junior highs outside the metro area- 1 in 12 reported they currently have asthma In a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN- 1 in 11 reported they currently have asthma Information 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. http://www.health.state.mn.us/divs/hpcd/cdee/asthma/

This Means.. In a class of 30 children, you can expect 2 to 3 students WILL have asthma! This number varies depending on age and geographical location. Information per the CDC

“Healthy Children Learn Better”

The Goal Of Asthma Management “Children should live happy, healthy, physically active lives, without asthma symptoms slowing them down “ The General goals of proper asthma therapy/management according to NAEPP 1. Prevent Chronic asthma symptoms and asthma episodes during the day and night 2. No sleep disruption by asthma, 3. No missed school or work due asthma 4.No or minimal need for ER (or UC) visits or hospitalizations 5.Maintain normal activity levels- including exercise and other physical activities 6.Have normal or near-normal lung function 7. Be satisfied with the asthma care received. 8. Have no or minimal side effects while receiving optimal medications (taken from p. 7 NAEPP/ NHLBI/NIH “Practical Guide for the Diagnosis and Management of Asthma- 10/97”

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

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

What Is Asthma? Asthma is a chronic disease that causes: Tightening of the muscles surrounding the airways (Bronchoconstriction/spasm) Swelling of the small airways (bronchioles) Over production of sticky mucus in 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.

Group Exercise Straw Exercise Stand up Place the straw in your mouth Try to breathe! This is what is may feel like when a child is having a severe asthma episode Have participants stand up in place Pinch closed their nose (nares) with their fingers Place the straw in their mouth and without cheating try to breathe only through the straw. This is what it feels like to suffer a severe asthma attack or episode. The only difference is…..you can remove the straw (do this for only 1 minute) but the child having an asthma episdoe 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- their clogged with mucus. The only way to prevent the mucus and swelling is for asthmatics to take daily medications such as inhaled corticosteroids (controllers).

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 (levels 2-4) per NHI/NHLBI guidelines. See web page for more info http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf 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 Behavior changes These symptoms vary greatly in severity and not ALL children have the same symptoms Symptoms 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.

Every Child Is Unique! Wheezing and coughing are the most common symptoms -but- 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 asthma should have an asthma action plan at school (AAP)

Handling Asthma Episodes

What’s An “Episode”? 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 Episodes are preventable by avoiding exposure to triggers and taking daily controller medications (if prescribed)

How Do I Handle An Asthma Episode At School? Remain calm and reassure the child Contact the school health office for assistance Check the child's asthma action plan or individualized health plan for actions Give “rescue or reliever” medications if ordered and available (some students carry their own asthma inhalers with them)

Handling An Episode cont.. 5. If identified, get the child away from the trigger 6. Have the child sit up and breathe slowly- in through the nose, out through pursed lips slowly 7. Have the child sip room temperature water/ fluids 8. Contact the parent or guardian as necessary - AND-

Do NOT Leave The Child Alone! Every asthmatic reacts differently to their asthma- what you perceive as “okay” may in fact be a child is severe distress. Do NOT send a child to the health office by his/herself, either accompany the child, call the school nurse to come to him/her or find another adult (immediately) to assist the child.

Call 911 if.. Lips or nail beds are bluish Child 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 ANY of these symptoms require a call to 911 after you have given the child their rescue inhaler (if available and ordered or the child is carrying their inhaler). Do not hesitate to call 911- it’s better to be safe.

You notice something's happening! There should not be any delay once a child tells you they are having trouble breathing OR You notice something's happening! School 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.

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”

What Causes Asthma cont.. Of the 17 million asthma sufferers in the US, 10 Million (approx. 60%) have allergic asthma. 3 million of those are children1 Exposure to certain allergens trigger asthma symptoms to begin Exposure to certain irritants can also set an asthma episode in motion 1National Institute of Environmental Health Sciences

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 medications Some foods Strong emotional feelings Seasonal pollens can mean some children 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 Cold air Chalk dust Viral/upper respiratory infections Air pollution Tobacco smoke or secondhand smoke Chemical irritants and strong smells Strong emotional feelings Diesel fumes Cleaning supplies 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.

Dust Mites Live in pillows, carpet, fabric-covered furniture, curtains What to do: Avoid bringing in fabric covered furniture from home Vacuum often when people with asthma/allergies are not in the area (HEPA filter vacuum cleaners) Dust book cases and furniture frequently Keep room humidity < 50% if possible

Mold Moisture control is key What to do: Report leaks and wet/moist areas right away for school custodian 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 R7 R7 MN IAQ Management Plan

Animals In The Classroom Dander, urine & saliva are triggers Triggers can remain after pet is removed What to do: Prohibit/remove animals from schools If removal is not possible: Keep animals in cages Clean cages often Keep animals away from fabric furniture, carpet & ventilation system Locate sensitive students away from animals Pre-notify parents if animals with fur/feathers visit R1 R1 Animals in schools guideline suggestions

Pests Droppings or body parts can trigger asthma What to do: Use integrated pest management (IPM) methods Don’t leave food, water or garbage exposed Don’t eat or drink in classroom Seal entry points for pests Custodians should use pesticides only as needed R7 R7 MN IAQ Management plan

Secondhand Smoke Is an irritant trigger causing asthma in children State law prohibits tobacco use in K-12 public schools What to do: Enforce smoking bans (for students, parents and teachers) Include anti-smoking message in curriculum

Outdoor Air Ozone & fine particles are biggest concern Actions: Sign up for Air Quality Index notice Pollution Control Agency sends e-mail alerts when they expect poor air quality (regional) Avoid being outside at high pollen count times, especially if students are allergic to particular pollens (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)

School Buses Diesel fuel emissions are an irritant and can set off an asthma episode in many children State law requires: Reduce unneeded idling in front of schools Reroute bus parking zones away from air intakes, if possible What to do: Post “no idling” signs Maintain bus fleet Invest in cleaner fuels Replace old buses with cleaner running ones R3, R4

Exercise Induced Asthma

What 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 airways 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 and shortness of breath 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 Can 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 period Symptoms range from mild to severe and often resolve in 20-30 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.

Preventing Exercise Induced Asthma (EIA) Become familiar with Asthma Action Plans Student should use reliever (Albuterol) 15 -30 minutes before activity Do warm-up/ cool-down exercises before and after activities Check outdoor ozone/air quality levels www.aqi.pca.state.mn.us/hourly/ Never encourage a child to “tough it out” when having asthma symptoms Children 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 15-30 minutes before they begin strenuous exercise. It’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 activity Working collaboratively with the PE teacher or coach can help reduce unneeded treatment with albuteral.

Medications

Two Categories Of Medications Controller Medications Taken every day to prevent swelling in the lungs Reliever or Rescue Medications Taken only when needed to relieve symptoms Or to prevent exercise induced asthma from developing (taken before strenuous exercise)

Controller Medications Keep swelling and mucus from developing in the lungs Must be taken EVERY day even when the child is 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 Azmacort, Pulmicort, Flovent, Advair 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 maynot even notice in the short term but long term- the frequency of their episodes is reduced greatly.

Rescue Or Reliever Medications Are taken when asthma symptoms are appearing (asthma episode) Are taken 15-30 minutes before strenuous exercise/activity by children 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- which school personnel most likely have already come in contact with are Albuterol, Proventil, Ventolin, Maxair. These medications should always be used WITH a spacer and used to prevent exercise induced asthma or to treat an emerging asthma episode (attack). 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.

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) must 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 physician must write an order for it when prescribing your reliever medication 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 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 episdoe 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 child's height and age. The zones indicate how well that child's 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.

Working Together

Successful Asthma Management Requires Everyone's Cooperation Teachers Parents Students Medical Providers Coaches All School Personnel Talk with your school Nurse to find out what you can do to help manage asthma in your school

YOU Can Make A Difference! 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.