Asthma Management in School A presentation in honor of World Asthma Day 2013 thru a collaboration with Children’s Healthcare of Atlanta and the Department of Education. Jodie Rodriguez, RN, MS, CPNP, AE-C Children’s Asthma Center of Excellence ? DOE Logo

Asthma in Georgia’s Children Approximately 10% have asthma, an estimated 226,000 children (approx 2-3 per class)* #1 reason for inpatient admissions and emergency room visit to Children’s Healthcare of Atlanta Higher morbidity and mortality rates among minority children from lower income households 65% do not have a written asthma management plan (Georgia Asthma Surveillance Report 2007, DHR, Georgia) Note: THERE HAVE BEEN 6 DEATHS IN METRO ATLANTA Oct 2011-Feb 2011; 2 more with severe hypoxic ischemic encephalopathy! State epidemiologists are evaluating for pattern

Impact of Uncontrolled Asthma on Student Learning 470,000 missed school days annually due to asthma Missed class time due to frequent visits to the school clinic Student fatigue due to night time symptoms

Asthma cannot be cured but it can be controlled A disease of the lungs where: Airway becomes swollen and inflamed in response to a trigger Variable among students, seasons, and a person’s lifetime Asthma episodes (attacks) can be mild, moderate or life-threatening Asthma cannot be cured but it can be controlled A chronic disease Compare how your nose feels when you come down with a cold. Itchy, running, stuffy and irritated. This compares to what is happening inside the airways. People can become less sensitive to triggers as the age but do not outgrow asthma. One explanation- airways get bigger as we age, may account for decreased sensitivity.

Asthma Triggers Allergens Irritants Dust mites, pollens, cockroaches, molds, animals Irritants Smoke Poor air quality Aerosols/fumes Upper Respiratory Infections, illness Emotion (laughing or crying) Weather or Temperature Changes Exercise

What Are the Symptoms of Asthma? (early signs) Coughing Wheezing or whistling in the chest Feeling short of breath Tightness in the chest Waking at night with symptoms* *A key indicator of uncontrolled asthma

Signs of Distress (late signs) Can’t stop coughing or wheezing Blue/gray color Increased WOB/Tachypnea Retractions Tripod breathing Difficulty completing a sentence without pausing for breath **May not hear wheeze on Auscultation in late phase due to decreased air flow through bronchioles** If in distress…. ACT QUICKLY Must act quickly and get the child’s quick-relief medication ASAP.

Reducing Triggers in School Avoid exposure to tobacco smoke and other smoke Avoid exposure to strong smells and odors Keep temperature and humidity at appropriate settings Dry up damp and wet areas immediately Consider removing furred or feathered animals from the classroom Use pest management techniques to control pests Adjust schedule for high smog, high pollen, low temps Allow student to pre-medicate before exercise, if needed Encourage good hand washing and flu shots Focus strongly on tobacco smoke. The #1 trigger for all who have asthma. Also stress 80-90% of people who have asthma have an allergy component and may be allergic to pets.

Children’s Asthma Action Plan

Components of an Asthma Action Plan Prescribed daily controller and quick-relief medicines Treatment guidelines for handling asthma episodes Guidelines for pre-treatment before activity Emergency contacts List of Triggers Should be on file with the school with copies for student’s teachers, PE teachers , and coaches and easily available for all on and off-site activities before, during, and after school Updated annually and as needed

Asthma Medication Quick Relievers ( yellow/red zone medication) Two Main types of inhalers: Quick Relievers ( yellow/red zone medication) Used to treat or relieve asthma symptoms Should ALways have it with them (ALbuterol) Open airways by relaxing the muscles that surround the airway Works very quickly, but for a short period of time (3-4 hours) Used every 4 hours during a flare up to prevent further exacerbation This medication is used to SAVE LIVES (e.g., Albuterol, ProAir, Proventil, Ventolin, Xopenex) Long-term Controllers (green zone medication) Used for daily control and prevention Reduce inflammation on the inside of the airway and helps to prevent future episodes Will NOT work for quick relief of symptoms (e.g. Flovent, Pulmicort, Qvar, Asmanex, Advair, Dulera, Symbicort) AN AEROCHAMBER IS NECESSARY WITH ALL MDI USE Focus on the fact that quick-relief will be what the school should have to relieve symptoms and to make sure that they have this on hand for field trips. Recognize that in as many as 1 in 6 Caucasians and 1 in 5 African-Americans (unknown Hispanic) can have down-regulation of B2 receptor with repeated exposure to b2 agonists.

The use of a spacer is “best practices” and that without the spacer an individual only gets about 23-30% of the inhaled medicine. Although small particle inhalers do better without a spacer (may be up to 50%) still use spacer!!! As soon as child is able encourage single breath technique with controller medications

Questions

Managing an Exacerbation – Yellow Zone Early recognition of symptoms and/or triggers critical Pre-treatment before exercise/exposure to known trigger Don’t have to hear a wheeze to be asthma (cough, early signs URI, increased allergic symptoms) Proper use of Albuterol; one vial nebulized or FOUR puffs every 3-4 hours for 24-48 hours or until 24 hours after symptoms subside Student may come to school in yellow zone; every four hour Albuterol is crucial to managing exacerbation and/or decreasing severity even if symptoms not present.

Managing an Attack – Red Zone Evaluate breathing: increased breathing rate, short of breath, color, signs of distress Immediately administer 4-6 Puffs MDI Albuterol or Albuterol nebulizer. Evaluate response. Implement your school’s emergency protocol (EMS, parents, administrator) if needed Continue 4-6 Puffs MDI Albuterol or Albuterol nebulizer every 20 minutes x3 if needed

Exercise Induced Asthma (EIA) 10-15% of General Population 90% of all Asthmatics have some component Watch for: Cough after exercise Shortness of Breath Wheezing/ Chest tightness “Out of shape” Tend to avoid play/Cannot keep up May need pre-treatment before exercise or strenuous activity Beware of dizziness- reflects cardiac issue

Signs of Poor Control A persistent cough Coughing, wheezing, chest tightness, or shortness of breath after vigorous physical activity on a recurring basis Low level of stamina during physical activity or reluctance to participate Frequent use of quick relief medication *may be using an empty inhaler (Source: Asthma & physical activity in the school, NHLBI, 2006) The school has a role in recognizing and reporting signs of uncontrolled asthma to the school nurse. The school nurse can then contact the family to follow-up with the PCP.

Senate Bill 472 (SB 472) Self-administration of Asthma Medication by Minor Children at School Effective on July 1, 2002 Also known as the “Kellen Bolden Act” Any student who is authorized for self-administration of asthma medication: 1. while in school 2. at a school sponsored activity 3. while under supervision of school personnel 4. while in before-school or after-school care on school property

School Asthma Management Key components: Identify students with asthma Obtain asthma management/emergency plans Educate staff and students on asthma Implement policies to promote asthma control Teamwork is essential to create a healthy school environment

Resources Asthma Awareness Month: Event Planning Kit http://www.epa.gov/asthma/pdfs/awm/event_planning_kit.pdf Georgia School Health Resource Manual 2013 http://www.choa.org/Health-Professionals/Nurse-Resources/School-Nurses/~/media/CHOA/Documents/Health-Professionals/2013-School-Health-Manual/Manual-Chapters/Ch-5-Chronic-Health-Conditions.pdf

References The American Academy of Allergy, Asthma & Immunology (2007). Pediatric Asthma: Promoting Best Practice, Guide for Managing Asthma in Children. The National Institutes of Health, National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. The National Institutes of Health, (2007). Practical Guide for the Diagnosis and Management of Asthma. Plaut, T. (2005). One Minute Asthma: What You Need to Know, Seventh Edition. Amherst: Pediapress, Inc. Fanta C.H., Carter, E.L., Stieb, E.S., Haver, K.E. (2007). The Asthma Educator’s Handbook, McGraw - Hill. Centers for Disease Control (CDC), 2008. CDC, EPA: (2009). Help Your Child Gain Control Over Asthma. Georgia Asthma Surveillance Report 2007