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Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed Managing Asthma In Minnesota Schools “A Comprehensive Resource & Training for School Personnel” Developed and Provided by:

Presenters For Today Susan K. Ross RN, AE-C MDH Asthma Program Staff 651 -201 Presenters For Today Susan K. Ross RN, AE-C MDH Asthma Program Staff 651 -201 -5629 Susan. [email protected] state. mn. us & Denise Herrmann LSN, CNP, AE-C St. Paul Public Schools Denise. [email protected] org

Minnesota Department of Health www. health. state. mn. us/asthma Minnesota Department of Health www. health. state. mn. us/asthma

Acknowledgements Our Advisory Group consisted of participants from every region of the state! See Acknowledgements Our Advisory Group consisted of participants from every region of the state! See the acknowledgements page at the beginning of the manual. Special thanks to: Denise Herrmann from SPPS Minneapolis Public Schools “Healthy Learners Asthma Initiative” Cheryl Smoot MDH Funding grant awarded by: Centers for Disease Control and Prevention (CDC)

Thanks To: • • Glaxo. Smith Kline Pharmaceuticals Astra. Zeneca Pharmaceuticals Starbright Foundation Hennepin Thanks To: • • Glaxo. Smith Kline Pharmaceuticals Astra. Zeneca Pharmaceuticals Starbright Foundation Hennepin County Medical Center For contributing PFM’s, Spacers, Diskus, asthma booklets and CD-Rom games for our participants

Overview of Today Ø Asthma Basics § § Ø Asthma triggers and irritants Diagnostic/ Overview of Today Ø Asthma Basics § § Ø Asthma triggers and irritants Diagnostic/ assessment process NIH/NHLBI/NAEPP asthma guideline overview Severity level workout Medication Overview § Asthma “gadgets” Ø Controlling Asthma § Tools available (MDH website-Manual) § Coordinated School Health

Post Tests - Evaluations C. E. U’s §Complete the post test §Complete the program Post Tests - Evaluations C. E. U’s §Complete the post test §Complete the program evaluation §Complete your goals sheet §Hand everything in before you leave §You will be eligible to receive credit for 7. 2 C. E. U’s after attending today's presentation

As We Go Through This Program § Consider how you would use the tools As We Go Through This Program § Consider how you would use the tools provided today. § How can you take this information and use it to establish an asthma program in your school or district? § How can you promote involvement by other school personnel outside the health office?

How To Use This Manual § Resource and Training document § Each Section is How To Use This Manual § Resource and Training document § Each Section is all-inclusive to each staff member’s role § Lift out the entire section - copy it and use as a basis for teaching about asthma § Supplemental forms/handouts are in the back folders and provided on CD and website § Full resources section w/websites are listed § Power Point presentations are also on our asthma website and CD in back of your manual

You Should Know! This manual contains suggestions for action and you are strongly urged You Should Know! This manual contains suggestions for action and you are strongly urged to consult your school district policies and guidelines before implementing these suggestions.

Staffing Models § School health staffing varies greatly across the entire state § The Staffing Models § School health staffing varies greatly across the entire state § The manual provides a few suggested staffing models in the “All Health Staff” section § Today’s program is based on a school that has at least some LSN/PHN/RN staffing in the school on regular basis

PRE- TEST PRE- TEST

Mikey’s Mom Didn’t Know Asthma Could Kill… From Glaxo. Smith. Kline and Allergy & Mikey’s Mom Didn’t Know Asthma Could Kill… From Glaxo. Smith. Kline and Allergy & Asthma Network, Mothers of Asthmatics (AANMA)

Did You Know. . Asthma kills people equally regardless of severity level § 1/3 Did You Know. . Asthma kills people equally regardless of severity level § 1/3 of deaths are in those with mild asthma § 1/3 of deaths are in those with moderate asthma § 1/3 of deaths are in those with severe asthma

Asthma: § Accounts for 14 million lost school days annually 3 § Is the Asthma: § Accounts for 14 million lost school days annually 3 § Is the most common chronic disease causing absence from school 2 § Is the 3 rd leading cause of hospitalizations among children under 152 § 1 in 13 school children have asthma 1 § 6. 3 million children under 18 have asthma 1 1 Asthma Prevalence, Health Care Use, and Mortality, 2000 -01, 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, 1980 -99, MMWR Surveillance Summaries, CDC, March 29, 2002

Minnesota Children In a 2005 MDH re-surveyed 3, 500 7 th & 8 th Minnesota Children In a 2005 MDH re-surveyed 3, 500 7 th & 8 th graders at 12 junior highs outside the metro areaØ 1 in 10 reported they currently have asthma In a 2001 MDH survey of 13, 000, 9 th - 11 th graders in rural MNØ 1 in 11 reported they currently have asthma

This means. . In a class of 30 children, you can expect 2 to 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

“ Healthy Children Learn Better” “ Healthy Children Learn Better”

Do School Children Have Asthma Action Plans? In MDH’s survey of 7 th and Do School Children Have Asthma Action Plans? In MDH’s survey of 7 th and 8 th graders in greater Minnesota: § 40% of the children who had asthma did not know if they had a written asthma action plan § 24% did not have an asthma action plan § Overall, only 35% of children who have asthma actually had asthma action plans

Asthma & Exercise Of the 7 th & 8 th graders with asthma: § Asthma & Exercise Of the 7 th & 8 th graders with asthma: § 31% reported missing recess, sports or other physical activities due to asthma symptoms § 25% reported missing a day or more of school in the past year due to asthma symptoms § 70% reported wheezing “sometimes” or “a lot”

Survey Conclusions § There is substantial uncontrolled asthma among school children in this age Survey Conclusions § There is substantial uncontrolled asthma among school children in this age group § This lack of control is manifested by the high rate of morbidity as measured by school absence and missed activities among children who have been diagnosed with asthma § The survey also suggests that there may be substantial undiagnosed asthma

Impact Of Asthma On Students School Performance: § Poorly controlled asthma has a negative 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: Ø Poor self-esteem Ø Anxiety Impact Of Asthma On Students cont. . . Psychosocial: Ø Poor self-esteem Ø Anxiety about asthma Ø Fear of becoming ill at school Ø Anxiety about exercise at school Ø Fear of being different

YOU Can Make A Difference! YOU Can Make A Difference!

What Is Asthma? Asthma is a chronic disease that causes: § Bronchoconstriction (obstruction that What Is Asthma? Asthma is a chronic disease that causes: § Bronchoconstriction (obstruction that is reversible) § Inflammation of the bronchioles (small airways) § Hyper-responsive “twitchy” airways § Excessive mucus production in the bronchioles

Normal Bronchiole Inflamed Bronchiole with Mucus Normal Bronchiole Inflamed Bronchiole with Mucus

l During an asthma attack, smooth muscles located in the bronchioles of the lung l During an asthma attack, smooth muscles located in the bronchioles of the lung constrict and decrease the flow of air in the airways. Inflammation or excess mucus secretion can further decrease the amount of air flow. l

Airway Obstruction Copyright 3 M Pharmaceuticals 2004 Airway Obstruction Copyright 3 M Pharmaceuticals 2004

A Lot Going On Beneath The Surface Symptoms Airflow obstruction Bronchial hyperresponsiveness Airway inflammation A Lot Going On Beneath The Surface Symptoms Airflow obstruction Bronchial hyperresponsiveness Airway inflammation Slide courtesy of ALAMN - PACE program 2004

Immune System Response Immune System Response

The Asthma Cascade © 2003 Genentech, Inc. and Novartis Pharmaceuticals Corporation. The Asthma Cascade © 2003 Genentech, Inc. and Novartis Pharmaceuticals Corporation.

Mediator Phases Ø Early-phase reaction caused by mediator release, usually peaks within an hour Mediator Phases Ø Early-phase reaction caused by mediator release, usually peaks within an hour after initial exposure to the allergen. Ø Three to four hours after an acute asthma episode, a "late-phase reaction" may occur and may last up to 24 hours

The End Results Of The Cascade Ø Localized mucosal edema in the walls of The End Results Of The Cascade Ø Localized mucosal edema in the walls of the small bronchioles Ø Secretion of thick mucus into the bronchiolar lumens (Clogs and narrows the airways) Ø Spastic contraction of bronchiolar smooth muscle

A CHILD CAN’T BREATHE A CHILD CAN’T BREATHE

Group Straw Exercise 1. Stand up 2. Place the straw in your mouth 3. Group Straw Exercise 1. Stand up 2. Place the straw in your mouth 3. Try to breathe! This is what is may feel like when a child is having a severe asthma episode

Common Symptoms Of Asthma üFrequent cough, especially at night üShortness of breath or rapid Common Symptoms Of Asthma üFrequent cough, especially at night üShortness of breath or rapid breathing üChest tightness üChest pain üWheezing üFatigue

Early Signs Of An Asthma “Episode” ü Mild cough ü Drop in Peak Flow Early Signs Of An Asthma “Episode” ü Mild cough ü Drop in Peak Flow reading ü Itchy, watery or glassy eyes ü Itchy, scratchy or sore throat ü Runny nose ü Stomachache ü Headache ü Sneezing ü Congestion ü Restlessness ü Dark circles under eyes ü Irritability

Acute Asthma Episodes Acute Asthma Episodes

What’s An “Episode”? Ø An asthma episode occurs when a child is exposed to What’s An “Episode”? Ø An asthma episode occurs when a child is exposed to a trigger or irritant and their asthma symptoms start to appear Ø This can occur suddenly without a lot of warning, or brew for days before the symptoms emerge Ø Episodes are preventable by avoiding exposure to triggers and taking daily controller medications (if prescribed)

Handling Acute Asthma Episodes At School ü Remain calm and reassure the child ü Handling Acute Asthma Episodes At School ü Remain calm and reassure the child ü Have the child sit up and breathe slowly- in through the nose slowly, out through pursed lips very slowly ü Have the child sip water / fluids ü Check peak flow (with severe symptoms: skip PF & give quick-relief or reliever medication immediately) ü Child should not be left alone

Handling Acute Asthma Episodes At School Cont… ü Give asthma reliever (bronchodilator) per the Handling Acute Asthma Episodes At School Cont… ü Give asthma reliever (bronchodilator) per the child's Asthma Action Plan / medication orders ü Assess response to medication ü After ~5 -10 minutes recheck peak flow ü Call parent/guardian/health care provider prn ü Call 911 if escalating symptoms or no improvement

Call 911 if. . ü Lips or nail beds are bluish ü Child has Call 911 if. . ü Lips or nail beds are bluish ü Child has difficulty talking, walking or drinking ü Quick relief or “rescue” meds (albuterol) is ineffective or not available ü Neck, throat, or chest retractions are visible ü Nasal flaring occurs when inhaling ü Obvious distress ü Altered level of consciousness/confusion ü Rapidly deteriorating condition

“There should not be any delay once a child notifies school staff of a “There should not be any delay once a child notifies school staff of a possible problem or developing asthma episode”

What Causes Asthma? Ø Of the 21 million asthma sufferers in the US, 10 What Causes Asthma? Ø Of the 21 million asthma sufferers in the US, 10 Million (approx. 60%) have allergic asthma. 3 million of those are children 1 Ø Exposure to certain allergens trigger asthma symptoms to begin Ø Exposure to certain irritants can also set an asthma episode in motion 1 National Institute of Environmental Health Sciences

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

Triggers and Irritants Copyright 2004, 3 M Pharmaceuticals Triggers and Irritants Copyright 2004, 3 M Pharmaceuticals

Common Allergens (Triggers) Seasonal Pollens Ø Animal dander saliva/urine Ø Dust Mites Ø Cockroaches/Mice/Rat Common Allergens (Triggers) Seasonal Pollens Ø Animal dander saliva/urine Ø Dust Mites Ø Cockroaches/Mice/Rat droppings and urine Ø Mold Ø Some medications Ø Some Foods Ø

Common Irritants (Triggers) Ø Exercise Ø Cold Air Ø Chalk Dust Ø Viral/upper respiratory Common Irritants (Triggers) Ø Exercise Ø Cold Air Ø Chalk Dust Ø Viral/upper respiratory infections Ø Air pollution Ø Tobacco smoke or secondhand smoke Ø Chemical irritants and strong smells Ø Strong emotional feelings Ø Diesel fumes Ø Cleaning supplies

Role of Viral Respiratory Infections In Asthma Exacerbations Role of Viral Respiratory Infections In Asthma Exacerbations

VRIs And Hospitalizations For Asthma Hospital admissions for asthma correlate with virus isolation peaks VRIs And Hospitalizations For Asthma Hospital admissions for asthma correlate with virus isolation peaks and school terms URIs 20 Total pediatric and adult hospitalizations 15 School holidays 10 5 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Adapted with permission from Johnston SL et al. Am J Respir Crit Care Med. 1996; 154: 654. Official Journal of the American Thoracic Society. ©American Lung Association.

RV-Induced Airway Inflammation Plasma leakage Inflammatory cell recruitment and activation Mucus hypersecretion Virus-infected epithelium RV-Induced Airway Inflammation Plasma leakage Inflammatory cell recruitment and activation Mucus hypersecretion Virus-infected epithelium Airway Hyperresponsiveness Neural activation Adapted from Gern JE, Busse WW. J Allergy Clin Immunol. 2000; 106: 201.

Summary Ø Viruses cause asthma exacerbations in children Ø RVs cause ~60% of virus-induced Summary Ø Viruses cause asthma exacerbations in children Ø RVs cause ~60% of virus-induced exacerbations of asthma Ø RVs directly infect the bronchial airways Ø The response to viral infection is shaped by the host’s antiviral response

Exercise Induced Asthma Exercise Induced Asthma

What Is Exercise Induced Asthma (EIA)? Ø Tightening of the muscles around the airways What Is Exercise Induced Asthma (EIA)? Ø Tightening of the muscles around the airways (bronchospasm) Ø Distinct from allergic asthma in that it does NOT cause swelling and mucus production in the airways Ø Can be avoided by taking pre-exercise medications and by warming up/cooling down

EIA - What Happens? Ø Symptoms include coughing, wheezing, chest tightness and shortness of EIA - What Happens? Ø Symptoms include coughing, wheezing, chest tightness and shortness of breath Ø Symptoms may begin during exercise and can be worse 5 to 10 minutes after exercise Ø EIA can spontaneously resolve 20 to 30 minutes after starting Ø Can be avoided by doing the following:

Preventing Exercise Induced Asthma (EIA) ü Become familiar with Asthma Action Plans ü Use Preventing Exercise Induced Asthma (EIA) ü Become familiar with Asthma Action Plans ü Use reliever (Albuterol) 15 -30 minutes before activity ü Do warm-up/ cool-down exercises before and after activities ü Check outdoor ozone/air quality levels www. aqi. pca. state. mn. us/hourly/ ü Never encourage a child to “tough it out” when having asthma symptoms

Exercise As A Trigger! ü Exercise can be a trigger for those who have Exercise As A Trigger! ü Exercise can be a trigger for those who have “chronic” asthma ü Their pre-exercise treatment is the same butü These children will have the underlying inflammation and require daily controller medication

Assess Need For Pre-Medication ü Take note of medication order wording “As needed” vs. Assess Need For Pre-Medication ü Take note of medication order wording “As needed” vs. “prior to exercise” ü Evaluate if activity level requires premedication ü Pre-medicate for strenuous activity only ü Contact parent/ HCP if questioning need for pre-exercise medication

Coach’s Asthma Clipboard Program “Winning With Asthma” v 100% online education for: § Coaches Coach’s Asthma Clipboard Program “Winning With Asthma” v 100% online education for: § Coaches § Referee’s § Physical Education Teachers v Coaches will receive: § Coach’s asthma clipboard § Special Coach’s asthma education booklet § Certificate of completion § The satisfaction of knowing what to do during an asthma episode! www. Winning. With. Asthma. org

Where Can Coaches See It? www. Winning. With. Asthma. org Where Can Coaches See It? www. Winning. With. Asthma. org

Myths and Truths Myths and Truths

Myths & Truths Asthma Myths § It is a psychological / § § § Myths & Truths Asthma Myths § It is a psychological / § § § Asthma Truths § Asthma is a very real, physical disease emotional illness § Asthma is a chronic It is only an acute disease, even when disease symptoms are not active It always limits normal § Taking proper asthma activities medications allow It limits a child's ability children to fully participate in any physical activities, activity, including sports especially sports

Myths & Truths Continued. . Asthma Myths § Medication is addictive Asthma Truths • Myths & Truths Continued. . Asthma Myths § Medication is addictive Asthma Truths • Asthma medications are not addictive § Medication becomes • Anti-inflammatories (controllers) are most effective when used everyday § Children do not die • Children and adults die from asthma each year ineffective if used regularly from asthma

One Last Myth • Use “reactive airway Truth • Reactive airway disease’s code is One Last Myth • Use “reactive airway Truth • Reactive airway disease’s code is the disease” instead of same code used for “asthma” for a diagnosis – that way asthma! the insurance company • Any order for will never know albuterol (or other rescue inhaler) flags the insurance company

Treatment Myths § Gecko liquid tonic § Herbal supplements § Acupuncture/pressure, chiropractic adj. § Treatment Myths § Gecko liquid tonic § Herbal supplements § Acupuncture/pressure, chiropractic adj. § Cockroach tea § Asthma diets § Pranic healing with mantras § Owning a Chihuahua

Small Group Exercise § Report back a couple activity steps appropriate to that role Small Group Exercise § Report back a couple activity steps appropriate to that role § Each table will review a section

Assessing Asthma Assessing Asthma

Measures Of Assessment And Monitoring Two Aspects: Ø Initial assessment and diagnosis of asthma Measures Of Assessment And Monitoring Two Aspects: Ø Initial assessment and diagnosis of asthma Ø Periodic assessment and monitoring Excerts from NHLBI/NIH presentations @http: //nih. nhlbi. nih. gov/naepp_slds/menu. htm

Initial Assessment & Diagnosis of Asthma Determines That: ü Patient has a history or Initial Assessment & Diagnosis of Asthma Determines That: ü Patient has a history or presence of episodic symptoms of airflow obstruction ü Airflow obstruction is at least partially reversible ü Alternative diagnoses are excluded

Methods for Establishing Diagnosis Ø Detailed medical history Ø Physical exam Ø Spirometry to Methods for Establishing Diagnosis Ø Detailed medical history Ø Physical exam Ø Spirometry to demonstrate reversibility

History or Current Episodic Symptoms of Airflow Obstruction? ü Wheezing, shortness of breath, chest History or Current Episodic Symptoms of Airflow Obstruction? ü Wheezing, shortness of breath, chest tightness, or cough? ü Asthma symptoms vary throughout the day? ü Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma!

Asthma Lung Assessment Spirometry ü Spirometry is Gold standard to assist in asthma diagnosis Asthma Lung Assessment Spirometry ü Spirometry is Gold standard to assist in asthma diagnosis ü Assess need to start, step up, or step down asthma medications ü Should be done at least yearly in children with persistent asthma ü Spirometry is easily done at any health care providers office

Spirometry Continued… Ø Performed before and after bronchodilator dose to look for airway obstruction Spirometry Continued… Ø Performed before and after bronchodilator dose to look for airway obstruction reversibility Ø Can also be done with a cold-air or methylcholine challenge, or an exercise challenge in the case of exercise-induced asthma

l Spirometry is a painless study of air volume and flow rate within the l Spirometry is a painless study of air volume and flow rate within the lungs. Spirometry is frequently used to evaluate lung function in people with obstructive or restrictive lung diseases such as asthma or cystic fibrosis.

Is Airflow Obstruction At Least Partially Reversible? Use spirometry to establish airflow obstruction § Is Airflow Obstruction At Least Partially Reversible? Use spirometry to establish airflow obstruction § FEV 1 < 80% of predicted § FEV 1/FVC <65% or below the lower limit of normal Use spirometry to establish reversibility § FEV 1 increases >12% and at least 200 m. L after using a short-acting inhaled beta 2 -agonist

Have Alternative Diagnoses Been Excluded? Examples: Ø Vocal cord dysfunction Ø Vascular rings Ø Have Alternative Diagnoses Been Excluded? Examples: Ø Vocal cord dysfunction Ø Vascular rings Ø Foreign body aspiration Ø Other pulmonary diseases Ø Cystic Fibrosis Ø Gastroesophageal reflux

Under Diagnosis Of Asthma In Children The majority of people who have asthma experience Under Diagnosis Of Asthma In Children The majority of people who have asthma experience onset before age 5 Commonly misdiagnosed as: § Chronic or wheezy bronchitis § Bronchiolitis § Recurrent croup § Recurrent upper respiratory infection § Recurrent pneumonia

National Heart, Lung, and Blood Institute (NHLBI) NAEPP Guidelines for the Diagnosis & Management National Heart, Lung, and Blood Institute (NHLBI) NAEPP Guidelines for the Diagnosis & Management of Asthma EPR 2002 Update NAEPP, NHLBI, NIH- EPR 2 2002

NHLBI- NAEPP Asthma Severity Levels 1. Mild Intermittent 2. Mild Persistent 3. Moderate Persistent NHLBI- NAEPP Asthma Severity Levels 1. Mild Intermittent 2. Mild Persistent 3. Moderate Persistent 4. Severe Persistent

NAEPP Classification of Asthma Severity: Clinical Features Before Treatment Days With Symptoms Variability Step NAEPP Classification of Asthma Severity: Clinical Features Before Treatment Days With Symptoms Variability Step 4 Continuous Nights With Symptoms Frequent PEF or FEV 1 PEF 60% 30% Severe Persistent Step 3 Daily >1 night/week 60%-<80% 30% Moderate Persistent Step 2 >2/week, <1 x/day >2 nights/month 80% 20 -30% 80% 20% Mild Persistent Step 1 2 days/week 2/month Mild Intermittent Footnote: The patient’s step is determined by the most severe feature.

Peak Flow Variability Ø Is the difference between the child’s morning and evening PFM Peak Flow Variability Ø Is the difference between the child’s morning and evening PFM readings Ø Peak flow readings tend to be higher in the evening than in the morning

NAEPP Stepwise Approach To Asthma Therapy Outcome: Control of Asthma Outcome: Best Possible Results NAEPP Stepwise Approach To Asthma Therapy Outcome: Control of Asthma Outcome: Best Possible Results Controller: n n Reliever: n Inhaled beta agonist prn PEF: ≥ 80% STEP 1: Intermittent n One daily medication Possibly add long acting bronchodilator Anti-leukotrienes Reliever: n Inhaled beta agonist prn PEF: ≥ 80% STEP 2: Mild Persistent n n Daily inhaled corticosteroid Daily long acting bronchodilator Anti-leukotriene Reliever: n Inhaled beta agonist prn n n Daily inhaled corticosteroid Daily long acting bronchodilator Daily/alternate day oral corticosteroid n n When controlled, reduce therapy Monitor Reliever: n Inhaled beta agonist prn PEF: 60 -80% PEF: <60% STEP 3: Moderate Persistent STEP 4: Severe Persistent Step-down

Mild Intermittent § Symptoms £ 2 days/week with nighttime § § § symptoms £ Mild Intermittent § Symptoms £ 2 days/week with nighttime § § § symptoms £ 2 nights/month Asymptomatic with normal peak flows between exacerbations Exacerbations are brief (hours to a few days) Peak Flows ³ 80% predicted with variability 20%

Mild Persistent § Symptoms > 2 days /week but < 1 x/day with nighttime Mild Persistent § Symptoms > 2 days /week but < 1 x/day with nighttime symptoms greater than 2 nights/month § Exacerbations may affect activity § Peak flow 80% of predicted with variability of < 20 -30%

Moderate Persistent § Child is likely to have daily symptoms and use reliever daily Moderate Persistent § Child is likely to have daily symptoms and use reliever daily § Child is waking up at least once a week due to asthma symptoms § Peak flows 60 -80% of predicted with variability of >30% § Activity is affected and exacerbations may last days

Severe Persistent § Continual daytime symptoms with frequent § § nighttime symptoms Very limited Severe Persistent § Continual daytime symptoms with frequent § § nighttime symptoms Very limited physical activity Frequent exacerbations Peak flows £ 60% of predicted and variability of more than 30% Treatment involves a combination of many drug therapies

Rules Of “Two” IF a child has: ü Daytime symptoms greater than two times Rules Of “Two” IF a child has: ü Daytime symptoms greater than two times per week -orü Nighttime symptoms greater than two times per month -orü Albuterol (reliever) refills of canisters more than two times per year *The child needs to be assessed if he/she requires controller medication or a step up in therapy

MDH Interactive Asthma Action Plan (IAAP) Available at MDH website: www. health. state. mn. MDH Interactive Asthma Action Plan (IAAP) Available at MDH website: www. health. state. mn. us/asthma v Click on “Asthma Action Plan” v Click on “Medical Professionals” v Choose to download desktop version or use online version

Which of These Does Not Fit With Severe Persistent Asthma? A. Continual coughing, wheezing Which of These Does Not Fit With Severe Persistent Asthma? A. Continual coughing, wheezing or B. C. D. shortness of breath during day, frequent nighttime symptoms Limited physical activity Near normal Pulmonary Function Test (Spirometry) Frequent asthma exacerbations

Which Of These Does Not Fit With Severe Persistent Asthma? A. Continual coughing, wheezing Which Of These Does Not Fit With Severe Persistent Asthma? A. Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptoms B. Limited physical activity C. Near normal Pulmonary Function Test (Spirometry) D. Frequent asthma exacerbations

Which Of These Does Not Fit With Moderate Persistent Asthma? A. Daily daytime symptoms, Which Of These Does Not Fit With Moderate Persistent Asthma? A. Daily daytime symptoms, nighttime symptoms > 1 night per week B. Nighttime Symptoms < 2 times a week C. Daily use of albuterol/bronchodilators D. Asthma exacerbations can last for days

Which Of These Does Not Fit With Moderate Persistent Asthma? A. Daily daytime symptoms, Which Of These Does Not Fit With Moderate Persistent Asthma? A. Daily daytime symptoms, nighttime symptoms > 1 night per week B. Night time Symptoms < 2 times a week C. Daily use of albuterol/bronchodilators D. Asthma exacerbations can last for days

Which Of These Does Not Fit With Mild Persistent Asthma? A. Daytime symptoms > Which Of These Does Not Fit With Mild Persistent Asthma? A. Daytime symptoms > 2 times a week, but < 1 time a day B. Symptoms may affect activity C. Need for albuterol 3 times a week, sometimes twice a day (not related to EIA) D. Nighttime symptoms > 2 times a month

Which Of These Does Not Fit With Mild Persistent Asthma? A. Daytime symptoms > Which Of These Does Not Fit With Mild Persistent Asthma? A. Daytime symptoms > 2 times a week, but < 1 time a day B. Symptoms may affect activity C. Need for albuterol 3 times a week, sometimes twice a day (not related to EIA) D. Nighttime symptoms > 2 times a month

Which Of These Does Not Fit With Mild Intermittent Asthma? A. Daytime symptoms < Which Of These Does Not Fit With Mild Intermittent Asthma? A. Daytime symptoms < 2 times a week B. Nighttime symptoms > 2 times a month C. No symptoms and normal Peak Flow between exacerbations D. Exacerbations are brief and may last from a few hours to a few days

Which Of These Does Not Fit With Mild Intermittent Asthma? A. Daytime symptoms < Which Of These Does Not Fit With Mild Intermittent Asthma? A. Daytime symptoms < 2 times a week B. Nighttime symptoms > 2 times a month C. No symptoms and normal Peak Flow between exacerbations D. Exacerbations are brief and may last from a few hours to a few days

Which Level Does Not Need Daily Controller Medication? A. Mild Intermittent B. C. D. Which Level Does Not Need Daily Controller Medication? A. Mild Intermittent B. C. D. Mild Persistent Moderate Persistent Severe Persistent

Which Level Does Not Need Daily Controller Medication? A. Mild Intermittent B. C. D. Which Level Does Not Need Daily Controller Medication? A. Mild Intermittent B. C. D. Mild Persistent Moderate Persistent Severe Persistent

Severity Level Workout Case Scenario Group Interactive Format Severity Level Workout Case Scenario Group Interactive Format

Assessing Asthma Assessing Asthma

When Assessing Asthma Ask. . ü Whether or not the child is taking his/her When Assessing Asthma Ask. . ü Whether or not the child is taking his/her controller medication at home (are they prescribed for him/her) ü Is he/she taking it everyday and how often ü How often is he/she using reliever inhalers ü About his/her home environment § § § Pets Adults smoking in the home Moist basements or obvious mold Mattress and pillow covers Cockroaches, mice, rats etc. E 2, E 3

Physical Assessment Of Asthma In The School Health Office Symptoms (daytime, nighttime and exerciserelated) Physical Assessment Of Asthma In The School Health Office Symptoms (daytime, nighttime and exerciserelated) Ø Peak Flow Meter readings Ø Respiratory assessment (breath Sounds / lung auscultation, respiratory rate, physical assessment) Ø

Symptoms Ask about: ü ü Coughing / wheezing / tight chest Frequency of daytime Symptoms Ask about: ü ü Coughing / wheezing / tight chest Frequency of daytime symptoms Frequency of nighttime symptoms Symptoms with activity or exercise

Respiratory Assessment Respiratory Assessment

Respiratory Assessment in the School Health Office v. Physical inspection (including respiratory rate) v. Respiratory Assessment in the School Health Office v. Physical inspection (including respiratory rate) v. Auscultation of the lung fields

Normal Respiratory Rates For Children Age Newborn 1 -11 mo. 2 years 4 years Normal Respiratory Rates For Children Age Newborn 1 -11 mo. 2 years 4 years 6 years 8 years Rate 35 30 25 23 21 20 (rate=breaths/minute) Age 10 years 12 years 14 years 16 years 18 years Whaley & Wong, 1991 Rate 19 19 19 17 16 -18

Why Lung Assessment Is Important Ø It provides additional clinical information Ø Provides a Why Lung Assessment Is Important Ø It provides additional clinical information Ø Provides a good baseline for comparison in future assessments Ø Gives a better picture of the child’s perception of symptoms vs. what is actually assessed Ø When consulting w/the HCP, they will ask for lung sounds Form F 26

Physical Respiratory Inspection Ø Respiratory rate Ø Rhythm (regular, irregular or periodic) Ø Depth Physical Respiratory Inspection Ø Respiratory rate Ø Rhythm (regular, irregular or periodic) Ø Depth (deep or shallow, presence of retractions) Ø Quality (effortless, automatic, difficult, or labored) Ø Character (noisy, grunting, snoring, or heavy)

Auscultation Breath sounds best heard in a quiet environment Ø Wheezing and crackles are Auscultation Breath sounds best heard in a quiet environment Ø Wheezing and crackles are best heard as the student takes deep breaths Ø Absent / diminished breath sounds are abnormal and should be investigated Ø Absence of wheezing does not necessarily mean absence of asthma Ø

Breath Sounds: Crackles § Coarse Crackle: Intermittent, interrupted explosive sounds, loud, low in pitch Breath Sounds: Crackles § Coarse Crackle: Intermittent, interrupted explosive sounds, loud, low in pitch (heard when airs passes through larger airways containing liquid) Crackles of a 9 yo boy with pneumonia § Fine Crackle: Intermittent, interrupted explosive sounds, less loud and of shorter duration; higher in pitch than coarse crackles (heard when airs passes through smaller airways containing liquid) This wheezing and coarse crackles were recorded over the right posterior lower lung of an 8 month old boy with viral bronchiolitis.

Breath Sounds: Wheeze And Rhonchus (Rhonchi) Ø Wheeze: continuous sounds, high pitched; a hissing Breath Sounds: Wheeze And Rhonchus (Rhonchi) Ø Wheeze: continuous sounds, high pitched; a hissing sound (e. g. with airway narrowed by asthma) Expiratory wheezing was recorded over the right anterior upper chest of an 8 yo boy with asthma Wheezing over trachea and right lower lung of 11 yo girl with asthma Ø Rhonchus: continuous sounds, low-pitched; a snoring sound (caused by large upper airway partially obstructed by thick secretions) Sounds from The R. A. L. E. Repository @http: //www. rale. ca/Recordings. htm

Peak Flow Meters Peak Flow Meters

Peak Flow Meters Ø Measures how well the student’s lungs are doing at that Peak Flow Meters Ø Measures how well the student’s lungs are doing at that moment Ø Associated with the Green-Yellow-Red system of managing asthma symptoms Ø Congruent with asthma action plans Ø Helps students and families self-manage asthma Form F 31

How to use a Peak Flow Meter ü Review the steps ü Place indicator How to use a Peak Flow Meter ü Review the steps ü Place indicator at the base of the numbered scale ü Stand up ü Take a deep breath ü Place the meter in the mouth and close lips around the mouthpiece ü Blow out into the meter as hard and fast as possible ü Write down the achieved number ü Repeat the process twice more ü Record the highest of the three numbers achieved

Group Peak Flow Exercise Group Peak Flow Exercise

Personal Best Peak Flow Values Determined by twice daily Determined when healthy and not Personal Best Peak Flow Values Determined by twice daily Determined when healthy and not experiencing symptoms Ø PFM measurements over the course of two weeks Ø Is the BEST reading obtained during those two weeks Ø Is used to calculate percentages for AAP’s Ø

Predicted Peak Flow Values Ø Are based on a child's height Ø Are not Predicted Peak Flow Values Ø Are based on a child's height Ø Are not individualized Ø Do not take into account other personal factors Ø Can be identified immediately Ø Are used when it is impossible or difficult to obtain personal best peak flow levels Form F 6

Every Child Is Unique! Ø Wheezing and coughing are the most common symptoms -butØ Every Child Is Unique! Ø Wheezing and coughing are the most common symptoms -butØ No two children will have the exact same symptoms or the same trigger Ø Every child who has a diagnosis of asthma should have access to a rescue inhaler! Ø Every child with persistent asthma should have an asthma action plan at school (AAP)

Together- We Can Make A Difference! Together- We Can Make A Difference!