Asthma Management Update

1. Asthma Management Update • Lisa Musso, ARNP, MN, CPNP • Division of Pediatric Pulmonary Medicine Children’s Hospital and Regional Medical Center

2. Asthma Management Update Objectives: Upon completion of this session, participants will be able to: • Describe three changes that asthma causes in the airway • Identify two types of medicine used to treat asthma • List three typical asthma triggers and ways of minimizing their effect

3. AsthmaManagement Update Overview: Airway Changes in Asthma How is Asthma Managed - Medications, Trigger Management Asthma Management Plan - Working with the Parent and Health Care Provider Triggers Trigger Management

4. What is Asthma? Definition of Asthma: Lung disease characterized by; • reversible airway obstruction • airway inflammation • increased airway responsiveness

5. Pathophysiology Airway Changes: Physiologic response • inflammation • bronchoconstriction • hypersecretion of mucus • All lead to airway plugging, hyperinflation and atelectasis.

6. Airways in Untreated Asthma

7. Airways After Administration of a Bronchodilator

8. Airways After Addition of an Inhaled Corticosteroid

9. Asthma Severity • Mild Intermittent • days with symptoms: < 2/week • nights with symptoms: < 2/month • FEV1 or PEF: > 80%

10. Asthma Severity • Mild Persistent • days with symptoms: >2/week • nights with symptoms: 3 - 4/month • FEV1 or PEF: > 80%

11. Asthma Severity Quick review of asthma severity • Moderate persistent • days with symptoms: daily • nights with symptoms: > 5/month • FEV1 or PEF . 60% to <80%

12. Asthma Severity Quick review of asthma severity • Severe persistent • days with symptoms: continual • nights with symptoms: frequent • FEV1 or PEF: < 60%

13. Comparison of Asthma Severity Levels Mild Intermittent Less than or equal to 2 times per week Less than 2 times per month FEV1 or PEF of greater than or equal to 80% Variability < 20% FEV1 or PEF of greater than or equal to 80% Variability of 20-30% 3-6 times per week Mild Persistent 3-4 times per month Moderate Persistent Daily symptoms Greater than or equal to 5 times per month FEV1 or PEF 60-80% Variability > 30% Severe Persistent FEV1 or PEF less than 60% Variability > 30% Greater than 5 times per month Continual symptoms

14. Viral infections Cigarette smoke Pets Exercise Strong emotion Strong odors Heart burn GE Reflux Seasonal allergies Dust mites Mold Cold weather Change in weather Air pollution Wood burning stoves Aspirin Sensitivity Triggers

15. Infections Upper Respiratory infections Viral or bacterial “colds” ear aches sinus “flu”

16. Smoke • Active smoking • Passive smoking • Inside/outside home • Inside/outside car

17. Animals • Furry, hairy • Shedding • Cats • Dogs • Birds • Rabbits, hamsters, guinea pigs,rats

18. To Run and Play • Exercise • How much is too much • Recess • Gym • Team Sports

19. To laugh or cry Laughing Crying Stress Anger Anxious Scared

20. Things that Smell • Perfume/cologne • Incense • Wood burning stoves • Paint • Cleaning products • Hair products • Foods

21. Allergens dust mites animal dander molds, mildew, fungi pollens—grass, trees, weeds cockroaches

22. Cold or Warm Air – Weather Changes • Cold air versus warm air • To exercise or not • Weather changes

23. Prevention Strategies

24. Infections • Prevention • Good hand washing • Use of tissues • Cleaning of school areas • Cleaning of toys • Sharing of school supplies, equipment, toys • Staying at home • Completion of course of medication if given

25. Tobacco Smoke Controlling environmental tobacco smoke: smoke-free child care environment smoke-free vehicle quit smoking smoke outside wearing “smoking jacket”

26. Animal Dander Controlling animal dander: keep cats, dogs, and other furry animals out of children’s area replace w/non furred or feathered animals

27. Molds Controlling molds, mildews and fungi: locate and remove mold growth check walls, floors, window molding, ceiling, under carpet don’t lay carpet on cement prevent growth w/ good ventilation

28. Roaches Controlling cockroaches: restrict where food is eaten clean up after food preparation do not leave out pet food overnight cover trash bins don’t store paper products/ bottles at floor level repair cracks, holes in foundation, plumbing, walls fix leaky faucets

29. Pollens Controlling pollen exposure: minimize outdoor activity on high pollen days close windows and doors on high pollen days run air conditioning allergy medicine as directed by parent/provider

30. Allergy Control Controlling dust mites: cover mattresses and pillows minimize stuffed animals remove upholstered furniture vacuum frequently w/children absent maintain humidity @ about 40% filters over heating ducts washable rugs instead of carpets

31. Air Pollution Controlling exposure to air pollution/ozone: Minimize outside activity on high pollution days avoid ozone-generating air cleaners

32. Odors---the good and the bad Controlling exposure to fumes/sprays/strong odors: avoid aerosol sprays avoid strong “clean” smelling sprays avoid perfumes, after shave, candles, potpourri, incense clean with weak bleach solution and let air dry (see handout)

33. Exercise Dealing with exercise-induced asthma: pre-treat as directed by parent/ provider Cover mouth and nose warm up before strenuous exercise rest periods minimize outdoor activity if high level of triggers are present

34. Drop in peak flow cough wheeze cold symptoms chest tightness difficulty breathing Fast breathing shortness of breath restlessness poor appetite headache dark circles Triggers

35. Controller Cromolyn sodium Nedocromil sodium Inhaled Corticosteroids Leukotriene modifiers Long acting Beta 2 Sustained released theophylline Nebulized steroids Rescue Short acting Beta 2 Oral steroids (short burst) Medications

36. Gadgets and Gizmos Nebulizers metered dose inhaler (MDI) spacer /spacer with mask diskhaler Aerolizers Turbohaler dry powder inhaler tablets liquids

37. Peak Flow Meters • What do they really tell you? • If asthma is worsening • If asthma is better or worse • If medications is helping • Are you really having an asthma attack

38. Peak Flow Meters • Who should use one? • Moderate to severe asthmatics • Poor perceivers of severity of symptoms • Newly diagnosed • History of severe exacerbations • Exercised Induced Asthmatics

39. Peak Flow Zones

40. Asthma Management Plans • Definition: • an written educational tool or plan which describes daily management and how to handle asthma episodes/excerbations

41. ASTHMA MANAGEMENT PLAN Name__________________________________________Drug Allergies__________________________ Weight________ Known Asthma Symptoms Plan A: Take these preventative medicines all the time: Controller/Preventative Medicine How delivered How much How often 15-20 minutes before sports/exercising take: Green Zone: Go  coughing  wheezing  shortness of breath  tightness in chest  other______________ • No symptoms of an asthma episode (no coughing, no wheezing, no shortness of breath, no nighttime awakenings) • Able to do usual activities, run, play, attend school. Usual medications control asthma • Peak Flow 80% of personal best • PFM________to________ Known Asthma Triggers Plan B: Continue Plan A and add these quick relief medicines: Short-Acting 2 Medicine How delivered How much How often If you feel better after taking this medication: Go back to your Green Zone medications and recheck every4 hours for continued improvement or worsening of asthma symptoms. If you DO NOT feel better in20 to 60minutes or if you need Albuterol every 4 hours then Follow the RED ZONE Plan.  respiratory infection  animals (specify)_______  foods (specify) ________  cigarette smoke  pollens/mold  temperature changes  strong odors or fumes  exercise  wood smoke  dust/chalk dust  other ________________ Yellow Zone: Caution • Increased asthma symptoms, increased coughing, wheezing, work of breathing, shortness of breath, retractions, awakening at night • Usual activities somewhat limited, unable to run, play, attend school as can normally • Increased need for asthma medication • Peak Flow 50-80% of personal best • PFM__________to__________ Plan C: This is a Danger Zone! Take these medicines immediately! Short-Acting 2 Medicine How delivered How much How often Oral steroid dose Next, call your own physician for further instructions. BUT, see the doctor RIGHT AWAY or go to the hospital if ANY of these things are happening: •Lips or fingernails are blue or gray, or •You are struggling to breathe, or •You do not feel any better 20 to 30 minutes after taking the extra medicine. Red Zone: DANGER • Very short of breath, coughing and wheezing that won’t stop • Usual activities severely limited, can’t walk, run, play, sleep or need to sleep upright • Asthma symptoms have not gone away or return quickly (less than 4 hours) despite using asthma medications • Can’t talk in complete sentences, ribs show with each breath • Peak Flow less than 50% of personal best • PFM less than ______________ Asthma Management Plan ASTHMA DISEASE MANAGEMENT PROGRAM FOR SCHOOL AND CHILD CARE MEDICATION PERMISSION:This patient has been instructed in the proper way to take his/her medications. He/she is capable of self-administering medications: ___Yes ___No He/she can reliably report asthma symptoms: ___Yes ___No PARENT SIGNATURE ________________________________________________ Date signed_________________________ Health Care Provider’s Signature___________________________________________Date_________________

42. No coughing No difficulty breathing No waking at night Normal activities No acute episodes that require PCP visit, ER or hospitalization No absences from school or work Normal ( or near normal) lung function What does this mean in real life?

43. Summary • Asthma is a chronic disease • It is controllable, some exacerbations sometimes can be prevented • Different medications treat the different phases of asthma • Asthma Management Plans really do help • School Nurses do a great job!

44. Questions

45. References • Helpful Web Resources • http://www.ginasthma.com • http://www.guidelines.gov • http://nhlbi.nih.gov • http://lungusa.org