1. Recommend Measures to Control Asthma Triggers Determine exposures and sensitivities, including environmental and occupational triggers. Review ways to reduce exposure to allergens and irritants that provoke asthma symptoms. Discuss smoking avoidance with every patient who smokes or who is exposed to ETS. Assess for Exercise Induced Bronchospasm if symptoms occur during exercise and provide medication and advice to enable physical activity.

2. Major Indoor Triggers Tobacco smoke Dust mites Animal dander Cockroach allergens Indoor mold Wood smoke

3. How to Identify Allergens Observe what triggers an attack Skin prick testing –Prick allergen into skin and measure wheal Intradermal testing –More sensitive: use if negative prick test RAST (radioallergosorbent) Testing –Determine serum level of allergen specific IgE –ELISA method also available

4. What Allergens to Assess INDOOR Mite (Der p) Mite (Der f) Cat (Fel d) Dog (Can d) Roach (mix) Mouse Mold –Altenaria –Cladosporium –Penicillium –Aspergillus OUTDOOR Trees –Red Alder –Cedar Grasses –Bermuda –Timothy Weeds –Ragweed –Plantain

5. Approximate Particle Sizes and Time to Settle 1 Meter

6. Associated both with asthma incidence and exacerbation Most common indoor allergen High levels of exposure and sensitization in NW Dust Mites Perennial with seasonal increases in the summer/fall Grow best >60% relative humidity, moderate temperature, source of food (skin scales) Major allergen in exoskeleton & fecal pellets Live in fabrics  Mattresses  Stuffed animals  Upholstered furniture  Carpets  Bedding

7. What Happens if Mites Are Eliminated? Moving patients to mite-free environment: –decreased total and mite specific IgE –decreased T cell activation –improved airflow: improvement in BHR, PEFR, FEV1 –reduced steroid use in severe asthmatics –did not change underlying sensitivity Elimination of mites can greatly improve asthma

8. Controlling Mites First Line Measures Control humidity to <50% by ventilation, heating or air conditioning Use mattress and pillow encasements Wash bed linens every 1–2 weeks, in hot (>130°F) water and/or dry in hot dryer for 10-20 minutes Avoid lying on upholstered furniture Remove stuffed toys (or freeze for 24h, then wash) Regularly vacuum carpeted surfaces and upholstered furniture with HEPA or double bags. Regularly dust hard surfaces.

9. Controlling Mites Second Line Measures Steam cleaning of upholstered furniture Expose rugs to sun or cold for 24 hours Remove wall-to-wall carpeting (especially in bedroom) Remove upholstered furniture Remove drapes and curtains

10. Acaricides Tannic acid Air cleaners Controlling Mites Unproven Measures

11. Controversies Bedding Encasements –Decrease allergen exposure –Clinical benefit inconsistent may decrease BHR may decrease inhaled steroid use –Recent studies show encasements alone may not be clinically effective Pillow type –Polyester rather than feather or foam pillows

12. Controlling Mites Vacuuming Allergen load decreases with regular vacuuming Steam/wet vacuuming – kills mites and decreases allergen load – doesn’t generally penetrate to bottom of carpet – residual water may promote subsequent growth, so effective for short periods only Standard dry vacuuming – Decreases allergen load – Live mite population doesn’t decline – two-layer bags OR HEPA-like filter on exhaust air

13. Controlling Mites Acaricides Benzyl benzoate best studied –Limited if any effect on decreasing allergen load: inconsistent findings across 9 studies, any observed decline is slow –Kills some but not all mites –No evidence of clinical improvement –No added benefit to bedding covers alone

14. Controlling Mites Acaricides Benzyl benzoate (continued) –Most effective when used on carpets rather than bedding –Effect short-lived –Skin sensitization occurs, other serious health risks not observed among research personnel applying Others include: –Benzene hexachloride –Borate –Paragerm –Essential plant oils

15. Ubiquitous in low levels but much higher in homes with pets Sensitization common: 20%–70% of people with allergies/asthma Contained in sebaceous secretions, saliva, perianal glands and urine (rodents) Dry on fur, bedding, carpeting, furniture, etc, and become airborne with disturbance Can exposure to dogs or cats early in life PROTECT against asthma? Animal Allergens

16. Cat Dander (Fel d I) Unlike dust mite allergen, stays airborne –High percent carried on particles <10 microns Unlike dust mite allergen, it is sticky –Binds to walls and other surfaces in buildings –Sticks to clothing Detected in homes and buildings without cats –In Sweden, classrooms showed levels of allergen which could induced sensitization May take months for all allergen to decompose

17. Eliminating Pet Allergens Effectiveness Uncertain Try to find a new home for a furry or feathered pet and replace it with fish, turtles or lizards Keep it out of the house or at least out of the child's bedroom Vacuum often to get rid of shed dander Use allergy control covers HEPA air filter may help Remove carpet, upholstered furniture, drapes Wash the pet weekly?!?

18. Pet washing Cat washing –can remove allergen –must be done weekly since effect lasts <7 days –generally impractical –inconsistent clinical impact Combination approach –cat washing, removing reservoirs (carpets, furniture), and HEPA air filter –clinically effective –limited feasibility

19. Molds Strong association between damp housing and asthma & other respiratory symptoms Less clear if mold is causal or a marker Experimental exposure causes allergic and respiratory symptoms Common indoor molds (source often outdoors) –Penicillium –Aspergillus –Cladosporium –Alternaria

20. Reducing Moisture Clinical Effectiveness Uncertain Repair leaky plumbing Increase ventilation –Exhaust fans in bathroom and kitchen –Open windows when showering and cooking Air conditioning (and dehumidifier?) Repair defects in building envelope Remove carpet from bare concrete floors Install vapor barrier in crawl spaces Heat adequately and avoid moisture traps

21. Eliminating Molds Clinical Effectiveness Uncertain Remove water-damaged materials Reduce or eliminate house plants, especially in bedrooms Clean moldy surfaces with detergent

22. Cockroaches More common in East –Prevalence in Seattle 10-20% vs. 60+% in NY Common in urban, low income households Associated with both incidence and exacerbation Allergen in digestive secretions and body parts Highest levels in kitchen and bath, near sources of food and water –Can live without food or water for 2-3 weeks

23. Eliminating Cockroaches Integrated Pest Management Keep food and water away from roaches: –fix leaks –store food in sealed containers –clean up spilled food promptly –clean dishes before bed –store garbage in sealed container and take out daily Eliminate hiding places (e.g. piles of paper, empty boxes) Keep roaches out of the house: seal cracks in the walls, floors and ceiling Use safe, odorless gel insecticides Cleaning to remove residual allergen critical Effective reducing exposure but clinical benefit needs study

24. Eliminating Mice and Rats Effectiveness Uncertain Keep food away from rodents Eliminate hiding places Keep them out of the house: fill holes around pipes or in walls with steel wool/foam/mesh, install door sweeps, screen vents, etc. Trap them if needed

25. Eliminating Tobacco Stop all smoking in the home and car If someone smokes outside the home change clothes so the smoke isn't brought home Clinician intervention to help smokers quit is clinically effective and cost effective

26. Eliminating Wood Smoke Avoid using wood stoves and fireplaces If used them, flues, chimneys and stove pipes should be well-sealed and working well

27. Eliminating Strong Odors and Fumes Eliminate or use alternatives to strong smelling products –air fresheners –cleaning products –hobby products –other VOCs When using an irritating product, provide good air circulation and have person with asthma out of the house