1. ASTHMA IN CHILDREN: NEW APPROACHES TO IMPROVING OUTCOMES Cindy Capen MSN, RN Pediatric Pulmonary Center University of Florida capencl@peds.ufl.edu

2. What I plan to discuss: Pathophysiology Medications EPR Guidelines Florida initiatives Ways to get involved/Help needed

4. Goals of Asthma Management Minimizing daily symptoms Minimizing nighttime symptoms Eliminating ER and hospital visits Rare use of rescue inhalers Normal activities No school/work absences

5. What happens during an asthma episode? The insides of the airways get irritated and inflamed The linings of the airways get swollen Irritated airways make more mucus The muscles around the airways spasm and get tight

6. inflammation and bronchoconstriction prevent air from reaching the alveoli

7. When do you suspect it’s asthma? CoughWheeze Short of Breath

8. What can precipitate an asthma episode? Things called asthma TRIGGERS Everyone has their own “recipe”…SO Identify triggers problem solve ways to avoid triggers

9. National Heart, Lung and Blood Institute

10. Expert Panel Report 1991 EPR-1 1997 EPR-2 2002 EPR-2 update 2007 EPR-3 493 pages

11. Components of Asthma Management 1. Assessment/identify severity 2. Education/partnership w family 3. Control of environment/other conditions 4. Medications 0-4 years5-11 years> 12 yoa Guidelines for the diagnosis and management of asthma Expert Panel Report 3

12. Symptoms Nighttime awakenings Use of beta agonists for symptoms Interference with normal activity Lung function Consider use of oral steroids Determining severity

13. Educate & have a plan Pathophysiology Action Plan Assessment of symptoms Appropriate response to symptoms Early and aggressive treatment Plan for stepping up medications Plan for getting help

14. Lack of Adherence Check refills Reeducate Cultural issues? Multiple caregivers? Poor technique in use of delivery device Teach, return demonstrate, recheck technique Prescribe according to ability Mishandling of meds Not cleaning delivery device Damage to product (heat, moisture) Funding for meds Why would a plan fail?

15. Reeducating the care community Primary care providers Emergency responders Pharmacists Respiratory care practitioners School health team Third party payors A new way of thinking for families Daily treatment no matter what Getting past the “steroid” word Rapid response The place for specialists Rolling out the plan…

17. Preventer medicines Are for children who have frequent asthma symptoms (at least weekly) Are taken daily PREVENT most asthma episodes Help children live normal lives Parents OFTEN do not give these medicines reliably.

18. Preventer Medicines Singulair Flovent Serevent Pulmicort Advair Symbicort Qvar Dulera

19. Combination Therapies Symbicort: combined Pulmicort and formoterol; MDI Advair: combined Flovent and Serevent; MDI or DPI Dulera: combined Asmanex and formoterol; MDI All come in different dosages and dose counters

20. Rescue Medicines Albuterol Prednisone XopenexAlupent Maxair Duo-Neb

21. Only 12 pages!

24. The numbers are climbing…

25. Data from the Florida Asthma Program

28. Educate/Asthma Plan Pathophysiology Action Plan Assessment of symptoms Appropriate response to symptoms Early and aggressive treatment Plan for stepping up medications Plan for getting help

29. In Gainesville: In 2011, the largest number of ED visits among children occurred in the zip codes 32609, 32607, 32641, 32608, and 32605

30. Requested data for seven counties…

31. In the plus column? We know how to identify asthma We have medications that work We have asthma specialists We have a step by step plan for any provider to follow We have health care coverage for kids We have great programs like CMS! We know who is at risk We know where they live! …and we know where they go to school

32. Minus column? No change in outcomes!

33. Florida Asthma Program: 2009 100% federally funded by the CDC Goals increase the number of individuals with asthma who receive self- management education reduce the number of deaths, hospitalizations, emergency department visits, school or work days missed, and limitations on activity due to asthma. Facilitates the Florida Asthma Coalition conducts asthma surveillance program evaluation works to increase the number of childcare centers, schools, and hospitals that implement asthma management programs.

34. Targets Childcare CentersSchoolsEmergency Departments

35. 35 CREATING ASTHMA-FRIENDLY SCHOOLS & EARNING THE ASTHMA-FRIENDLY SCHOOL AWARD

36. 36 Asthma’s Impact on Students Absenteeism Academic Performance Physical Activity

37. 37 Asthma Prevalence is on the Rise In 2012, 1 out of 5 Florida middle and high school students (20.6%) had ever been told by a doctor or nurse that they had asthma. Source: Florida Youth Tobacco Survey, 2012

38. 38 More than 441,000 instructional hours were lost in Florida due to asthma-related absences in 2011-2012 Source: 2011 Florida Youth Tobacco Survey and 2010 Florida Child Health Survey

39. 39 Asthma-Friendly Schools Award Criteria Bronze 1. School-Based an Asthma Leadership Team (or existing health or wellness team). 2. Professional development for school nurses, faculty and staff (ALA’s Asthma 101). 3. School ensures immediate access to asthma medications per Florida statute. 4. School provides student centered asthma management support. 1. identifying children with asthma at the beginning of the school year, having asthma action plans on file for students with known asthma, and coordinating between parents and health care providers 5. School posts asthma posters in high-traffic areas. 6. Physical education and activity opportunities meet needs of children with asthma. Silver (All Bronze and Criterion 7 and 8) 7. School provides self management education to students with asthma (ALA’s Open Airways for Schools Program). 8. School provides education to parents about asthma management (ALA’s Asthma 101). Gold (All Bronze, Silver and criterion 9) 9. School implements an indoor air quality program. Platinum (All Bronze, Silver, and Criterion 10) 10. School implements comprehensive asthma procedures or a policy which includes the activities listed in criterion 1-9 and a comprehensive tobacco free campus policy.

44. What’s our role? Be part of the Florida Asthma Coalition Because asthma is an overwhelming problem Because in 2014 they will be seeking more funding The costs affect everyone Spread the word School Health Guidelines School recognition program Childcare recognition program Teach parents Early and aggressive treatment Use of medications Primary care not Emergency care

45. The basics Diagnose Manage triggers Use medications to prevent episodes Call early for exacerbations Treat aggressively and early