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Asthma Basics For Para Professionals

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1 Asthma Basics For Para Professionals
Minnesota Department of Health Asthma Program

2 MDH Asthma Program Staff
Presenter Susan Ross RN, AE-C MDH Asthma Program Staff

3 Minnesota Department Of Health Asthma Website: www. health. state. mn
Minnesota Department Of Health Asthma Website: 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.

4 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 improve asthma management at your 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?

5 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 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, , National Center for Health Statistics, CDC 2 Morbidity and Mortality Report, National Center for Health Statistics (NCHS), U.S. CDC, 2003 3 Surveillance for Asthma - United States, , MMWR Surveillance Summaries, CDC, March 29, 2002

6 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.

7 This Means.. In a class of 30 children, you can expect
2 to 3 students WILL have asthma! Information per the CDC

8 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”

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

10 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

11 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.

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

13 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.

14 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”

15 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

16 Triggers And Irritants
Copyright 2004, 3M Pharmaceuticals

17 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.

18 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.

19 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)

20 Handling Asthma Episodes

21 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)

22 How Do I Handle An Asthma Episode At School?
Remain calm and reassure the child If you know what triggered their episode, move the child away from it Have the child sit up and breathe slowly- in through the nose, out through pursed lips Contact the school nurse for assistance or whomever is responsible for providing medications in the nurses absence

23 Handling An Episode cont..
If you are responsible for medications, check the child's asthma action plan, emergency care plan or medication card for actions Give “rescue or reliever” medications if ordered and available (some students carry their own asthma inhalers with them) Have the child sip room temperature water/ fluids Contact the parent or guardian as necessary AND-

24 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.

25 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.

26 Exercise Induced Asthma

27 What Is Exercise Induced Asthma (EIA)?
Tightening of the muscles around the airways (bronchospasm) Distinct from “chronic” 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.

28 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 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.

29 Preventing Exercise Induced Asthma (EIA)
Become familiar with Asthma Action Plans, pre-exercise medication orders and or health care plan Student should use reliever (Albuterol) minutes before activity Do warm-up/ cool-down exercises before and after activities Check outdoor ozone/air quality levels 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 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.

30 Medications

31 Medication: Determined By Severity Level Classification
Mild Intermittent Reliever only prn Mild Persistent Controller and reliever Moderate Persistent Controller plus long-acting bronchodilator and reliever Severe Persistent Level 1: Mild Intermittent Needs only a reliever only prn (e.g. albuterol or pirbuterol) Level 2: Mild Persistent Requires both a Controller and reliever (low dose inhaled cortico-steroid, sometimes other medicaitons) Level 3: Moderate Persistent Needs controllers (usuallly a medium dose inhaled cortico-steroid and a long-acting bronchodilator, sometimes other medications) and a reliever. Level 4 Severe Persistent Needs controllers (usually high dose inhaled corticosteriods and long-acting bronchodilator, other medications) and a reliever.

32 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)

33 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.

34 Rescue Or Reliever Medications
Are taken when asthma symptoms are appearing (asthma episode) Are taken 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.

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

36 Typical Spacers/Holding Chambers

37 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

38 How MDI Technology Works

39 How To Use Your Inhaler

40 How To Use: Metered Dose Inhalers w/Spacers
1. Stand up (or sit up straight) 2. Shake the inhaler well to mix up the medicine 3. Remove the cap and check the spacer/inhaler for foreign objects 4. Insert the inhaler into the spacer 5. Exhale all your air out fully 6. Before inhaling, put the mouthpiece of the spacer into your mouth, over your tongue and between your teeth Close your lips around it while tilting your head and the inhaler back slightly

41 Using An MDI Cont.. Press down on the inhaler canister and breathe in slowly and deeply through your mouth Hold your breath for 10 seconds, exhale normally If using a “reliever”, wait 1-2 minutes between puffs Repeat starting with #5 if a 2nd puff is ordered Rinse your mouth and spit after using a “controller” inhaler

42 Minnesota Inhaler Law

43 MN Asthma Inhaler Law Summary (2001)
Allows MN students to self-carry and administer inhalers In order for a child to carry his/her inhaler at school, authorization and signatures from the following individuals are required: Child’s health care provider Parent/guardian Assessment and approval of the school nurse (if present in district) Be sure to check and follow policies and procedures in local school district R8 MN Medication Administration statutes R9 MN Inhaler use Statute

44 Para Professionals Role
Identify students with asthma Distribute & collect communication forms In the health office the RN may delegate specific tasks such as: Documenting asthma visits by completing or initiating student asthma records Asking about symptoms & check PFM levels Providing episodic care to students with asthma symptoms including medication administration Communicating with parents regarding asthma care/episodes

45 Communicate With The NURSE
You are the eyes and ears for the nurse Be aware of students with asthma and their typical symptoms Help remind students to pre-medicate before exercise Always document clearly and neatly what you see, hear and what the student tells you Call the nurse with questions or urgent situations If you don’t know- ask! Don’t be afraid to call 911 in emergencies

46 Tools To Help Manage Asthma

47 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..

48 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.

49 How to use a Peak Flow Meter
Review the steps Stand up Place indicator at the base of the numbered scale Take a deep breath Place the meter in the mouth and close lips around the mouthpiece Blow out into the meter as hard and fast as possible Write down the achieved number Repeat the process twice more Record the highest of the three numbers achieved Read slide- Exercise-- PFM results can then be compared to the AAP for determination of what ZONE 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

50 Asthma Action Plan (AAP)

51 Asthma Action Plan Zones
Green Zone: All Clear/Breathing Good/Go No asthma symptoms and/or Peak flow % Predicted or Personal best Yellow Zone: Caution/Slow Down Some asthma symptoms and/or Peak flow 50-80% Predicted or Personal best Red Zone: Medical Alert/Stop Severe asthma symptoms and/or Peak flow < 50% Predicted or Personal best

52 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

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