1. Environmental Protection Agency American Association for Respiratory Care

2. Asthma Definition - 1997 National Asthma Education and Prevention Program - NAEPP A disease characterized by the following:A disease characterized by the following: –Airway inflammation mast cells,eosinophils, T lymphocytes, neutrophils and epithelial cellsmast cells,eosinophils, T lymphocytes, neutrophils and epithelial cells –Increased airway responsiveness to a variety of stimuli –Airway obstruction that is reversible (at least to a significant degree)

3. Asthma in the United States 17.3 million Americans with Asthma17.3 million Americans with Asthma 4.8 million children < 18 with Asthma4.8 million children < 18 with Asthma Asthma prevalenceAsthma prevalence –5.8% of Americans 75% increase since 198075% increase since 1980 –6.8% of preschool children 160% increase since 1980160% increase since 1980

4. National Health Interview Survey Asthma Prevalence

5. 19821983198419851986198719881989199019911992 0 1 2 3 4 5 6 7 8 Black White Prevalence (%) Year Other Prevalence of Asthma by Race Ages 5-34 United States, 1982 - 1995 Source: National Health Interview Survey Race and Prevalence

6. Asthma Morbidity Approximately 500,000 hospitalizationsApproximately 500,000 hospitalizations Approximately 1.9 million ER visitsApproximately 1.9 million ER visits 10 million missed school days per year10 million missed school days per year Loss productivity is estimated at $1 billion per yearLoss productivity is estimated at $1 billion per year

7. Hospital Discharge Rates (per 100,000 Population) for Asthma as the First Listed Diagnosis, by Race, Age and Year, Age 5-34 Years the First Listed Diagnosis, by Race, Age and Year, Age 5-34 Years A-A (Age 5 through 14) Rate Year A-A (Age 15 through 34) Cauc. (Age 5 through 14) Cauc. (Age 15 through 34) National Hospital Discharge Survey - United States, 1982 - 1992 Morbidity

8. Asthma Mortality Rate Ages 5-34, United States, 1979-1995 Asthma Mortality

9. African-American Caucasian Other Asthma Annual Mortality Rates by: Race, Ages 5-34, U.S. 1979-1995

10. Costs

11. Smith D et al. AJRCCM 156:787-93,1997 Direct Cost Estimates for Asthma 348(6.8)165(4.7)131(15.6)52(6.5) ED Visits $ (col%) 5,1473,514(100)839(100)792(100) Total Direct Cost 2,800(54.4)1,926(54.8)286(34.1)586(74.1) Admissions 1,182(23) 841(23.9)235(28)105(13.4) Ambulatory Visits 81(15.9)581(16.5)187(22.3)48(6.1) Prescribed Medicines Total> 175-170-4 Cost Component Age in Years

12. Risk Factors for Asthma Host - IntrinsicHost - Intrinsic –genetic: atopy, IgE, BHR –gender, race, pre-, perinatal EnvironmentalEnvironmental –allergens, diet, air pollution –Environmental tobacco smoke (ETS) –infections

13. Asthma Definition - 1997 National Asthma Education and Prevention Program - NAEPP A disease characterized by the following:A disease characterized by the following: –Airway inflammation mast cells,eosinophils, T lymphocytes, neutrophils and epithelial cellsmast cells,eosinophils, T lymphocytes, neutrophils and epithelial cells –Increased airway responsiveness to a variety of stimuli –Airway obstruction that is reversible (at least to a significant degree)

14. Expert Panel Report 2: Four Components of Asthma Management Measures of Assessment and MonitoringMeasures of Assessment and Monitoring Control of Factors Contributing to Asthma SeverityControl of Factors Contributing to Asthma Severity Pharmacologic TherapyPharmacologic Therapy Education for a Partnership in Asthma CareEducation for a Partnership in Asthma Care

15. All of the common asthma triggers are found indoorsAll of the common asthma triggers are found indoors Americans spend about 90% time indoorsAmericans spend about 90% time indoors Reducing exposure to indoor allergens and irritants can reduce asthma symptomsReducing exposure to indoor allergens and irritants can reduce asthma symptoms Prevention is an important asthma management toolPrevention is an important asthma management tool What does the Indoor Environment have to do with Asthma?

16. Indoor Environment in the U.S. 8 of 10 people are exposed to mites 6 of 10 people are exposed to cat or dog dander Clinical studies have demonstrated the prevalence of cockroaches in the inner city, schools and Southern U.S.

17. What is the Indoor Environment... Home EnvironmentHome Environment –Bedroom –Kitchen –Bathroom –Basement –Living Area

18. Triggers Away fron the Home Environment…... SchoolSchool WorkplaceWorkplace Public areasPublic areas Second hand smokeSecond hand smoke

19. * 5 major indoor asthma triggers Common Asthma Triggers AllergensAllergens –molds, dust mites, cockroaches, animal dander, pollens, foods IrritantsIrritants –secondhand smoke, strong odors, aerosols, volatile organic compounds, ozone, particulate matter OtherOther –Viral respiratory infections –Changes in weather (cold air, wind, humidity) –Exercise –Medication –Endocrine factors (menstrual period, pregnancy, thyroid disease)

20. Frequency of Positive Skin Tests % Positive Tests

21. Most Common Indoor Environmental Triggers Secondhand Smoke Dust Mites MoldPetsCockroaches

22. Secondhand Smoke Contains more than 4,000 substances (over 40 are carcinogenic)Contains more than 4,000 substances (over 40 are carcinogenic) Is particularly harmful to young childrenIs particularly harmful to young children Can trigger asthma attacks and cause young children to develop asthmaCan trigger asthma attacks and cause young children to develop asthma

23. Avoiding Secondhand Smoke Choose not to smoke in your home or car and do not allow others to do so either

24. Tobacco Smoke Secondhand smoke is classified by the EPA as a known cause of lung cancerSecondhand smoke is classified by the EPA as a known cause of lung cancer Is a serious asthma triggerIs a serious asthma trigger EPA estimates that between 200,000 - 1,000,000 asthmatic children are affectedEPA estimates that between 200,000 - 1,000,000 asthmatic children are affected

25. Smoking Interventions Stop smokingStop smoking Smoke outsideSmoke outside Enforce smoking bans on school propertyEnforce smoking bans on school property Enroll in a smoking cessation programEnroll in a smoking cessation program Get help from physicianGet help from physician Take the Smoke-Free PledgeTake the Smoke-Free Pledge

26. It’s Okay to Let People Know Smoking Around People with Asthma Is Not Cool

27. Remember Other Sources of Secondhand Smoke

28. Dust Mites Found in most homesFound in most homes Live in soft beddingLive in soft bedding Feed on skin flakesFeed on skin flakes Mites and mite droppings can be asthma triggersMites and mite droppings can be asthma triggers Can cause children to develop asthmaCan cause children to develop asthma

29. Dust Mites Evidence suggests that avoidance can effectively reduce allergic symptomsEvidence suggests that avoidance can effectively reduce allergic symptoms Dust mites feed on skin scales and organic materials found in homesDust mites feed on skin scales and organic materials found in homes Need RH of 55% or moreNeed RH of 55% or more

30. NCICAS - Hospitalization, Allergy, Exposure Rosenstreich et al. NEJM 1997; 336: 1556 p = 0.88 Dust Mites

31. Avoiding Dust Mite Triggers Wash sheets and blankets once a week in hot waterWash sheets and blankets once a week in hot water Cover mattresses and pillows in dust-proof (allergen-impermeable) zippered coversCover mattresses and pillows in dust-proof (allergen-impermeable) zippered covers

32. Avoiding Dust Mite Triggers Choose washable stuffed toys, wash them often in hot water, and dry thoroughly -- keep stuffed toys off bedsChoose washable stuffed toys, wash them often in hot water, and dry thoroughly -- keep stuffed toys off beds –Freezing soft toys and small items

33. Avoiding Dust Mite Triggers Vacuum often (when asthmatic is not present)Vacuum often (when asthmatic is not present) Maintain low indoor humidity, ideally between 30-50%Maintain low indoor humidity, ideally between 30-50% Replace carpets, draperies, and upholsteryReplace carpets, draperies, and upholstery

34. Pets Skin flakes, urine, and saliva of warm blooded animals can be asthma triggersSkin flakes, urine, and saliva of warm blooded animals can be asthma triggers Triggers can remain in the home for several months after a pet is removed, even with cleaningTriggers can remain in the home for several months after a pet is removed, even with cleaning

35. Warm Blooded Animals Includes…. DogsDogs CatsCats BirdsBirds CowsCows HorsesHorses RodentsRodents

36. Pet Interventions Consider keeping pets outdoors or even finding a new home for your pets, if necessaryConsider keeping pets outdoors or even finding a new home for your pets, if necessary Wash weeklyWash weekly

37. Pet Interventions Keep out of bedroomKeep out of bedroom Restrict to one areaRestrict to one area

38. Pet Interventions Remove carpetingRemove carpeting Vacuum carpetingVacuum carpeting Use high-efficiency air cleanersUse high-efficiency air cleaners

39. Avoiding Pet Triggers Keep pets away from fabric-covered furniture, carpets, and stuffed toysKeep pets away from fabric-covered furniture, carpets, and stuffed toys If you remove an animal from the home, clean the home thoroughlyIf you remove an animal from the home, clean the home thoroughly

40. Molds Molds grow on damp materialsMolds grow on damp materials Found in basements, bathrooms, kitchens, outdoorsFound in basements, bathrooms, kitchens, outdoors

41. Molds Can be found almost anywhere and can grow on virtually any damp substanceCan be found almost anywhere and can grow on virtually any damp substance Key to mold control is moisture controlKey to mold control is moisture control Clean up the mold and get rid of excess water or moistureClean up the mold and get rid of excess water or moisture Reducing moisture also helps reduce other triggers, such as dust mites and cockroachesReducing moisture also helps reduce other triggers, such as dust mites and cockroaches

42. Mold Intervention Use dehumidifiersUse dehumidifiers Provide adequate ventilationProvide adequate ventilation Use exhaust fans when cookingUse exhaust fans when cooking No carpeting over cement flooringNo carpeting over cement flooring

43. Mold Intervention Vent showersVent showers Do allow standing waterDo allow standing water Frequent inspections for moldFrequent inspections for mold

44. Avoiding Mold Triggers Wash mold off hard surfaces and dry completelyWash mold off hard surfaces and dry completely Absorbent materials (ceiling tiles and carpet) may need to be replacedAbsorbent materials (ceiling tiles and carpet) may need to be replaced Fix leaky plumbing or other sources of waterFix leaky plumbing or other sources of water Keep drip pans in your air conditioner, refrigerator, and dehumidifier clean and dryKeep drip pans in your air conditioner, refrigerator, and dehumidifier clean and dry Use exhaust fans or open windows in kitchens and bathrooms when showering, cooking, or using the dishwasherUse exhaust fans or open windows in kitchens and bathrooms when showering, cooking, or using the dishwasher Vent clothes dryers to the outsideVent clothes dryers to the outside Maintain low indoor humidity (between 30-50% relative humidity)Maintain low indoor humidity (between 30-50% relative humidity)

45. Cockroaches Require a water/food sourceRequire a water/food source Over 3500 different speciesOver 3500 different species An inner city problem (85% of homes with children)An inner city problem (85% of homes with children) Inner city schools also a concern (Baltimore 69% of dust samples)Inner city schools also a concern (Baltimore 69% of dust samples) Become airborne (similar to dust mites)Become airborne (similar to dust mites)

46. Cockroaches Droppings or body parts of cockroaches can be asthma triggersDroppings or body parts of cockroaches can be asthma triggers Cockroaches likely contribute significantly to asthma problems in inner city areaCockroaches likely contribute significantly to asthma problems in inner city area Free your home of places for pests to hide and sources of food and waterFree your home of places for pests to hide and sources of food and water

47. NCICAS - Asthma Morbidity - ED Visits p < 0.001 Cockroach Rosenstreich et al. NEJM 1997; 336: 1556

48. NCICAS - Hospitalization, Allergy, Exposure Rosenstreich et al. NEJM 1997; 336: 1556 p = 0.001 Cockroach

49. Relations Among Skin Test and Morbidity Children with sensitization and high exposure to cockroach have:Children with sensitization and high exposure to cockroach have: –More symptomatic days –More nights of lost sleep –More school days missed –More days of caregiver change in plans

50. Cockroach Intervention Education that emphasizes:Education that emphasizes: –Do not leave food or garbage out Place trash outsidePlace trash outside –Store food in airtight containers –Clean all food crumbs or spilled liquids right away –Washing dishes daily –Seal off ports of entry –Remove standing water

51. Cockroaches Eradication Try using poison baits, boric acid, or traps first before using pesticide sprays If sprays are used: Limit the spray to infested area Carefully follow instructions on the label Make sure there is plenty of fresh air when you spray, and keep the person with asthma out of the room

55. Allergen Exposure Sources SchoolsSchools –Cockroach allergen detectable in 69% of samples from 4 urban schools (Sarpong, et al. JACI 1997; 99:486)detectable in 69% of samples from 4 urban schools (Sarpong, et al. JACI 1997; 99:486) elevated in mostelevated in most –Cat –Dust mite ?? Infestation/TransportedInfestation/Transported

56. Targeting the Indoor Environment... Home EnvironmentHome Environment –Bedroom –Kitchen –Bathroom –Basement –Living Area

57. Bedroom Access to animalsAccess to animals Pillow and beddingPillow and bedding Stuffed animalsStuffed animals DustDust

58. Bathroom / Kitchen Moldy surfacesMoldy surfaces Standing garbageStanding garbage Food containers left unopenedFood containers left unopened Venting of cooking fumes/vaporVenting of cooking fumes/vapor

59. Living Area Sofa and upholstered chairsSofa and upholstered chairs CarpetingCarpeting FireplaceFireplace

60. Basement Moldy surfacesMoldy surfaces Carpeting over cement floorCarpeting over cement floor Filtering at furnaceFiltering at furnace

61. Outdoor Environment GrassesGrasses PollensPollens PollutionPollution Time of dayTime of day TemperatureTemperature

62. Respiratory Therapist Interventions Symptom assessmentSymptom assessment Asthma historyAsthma history Scoring of symptoms and triggersScoring of symptoms and triggers Environmental assessmentEnvironmental assessment Skill/knowledge assessmentSkill/knowledge assessment Patient focused educationPatient focused education Action planAction plan

63. Resources and Information Environmental Protection Agency Asthma Website www.epa.gov/iaq/asthma EPA Indoor Air Quality Information Clearinghouse (800) 438-4318 Allergy and Asthma Network/Mothers of Asthmatics (800) 878-4403 www.aanma.org American Academy of Allergy, Asthma and Immunology (800) 822-2762 www.aaaai.org American Lung Association (800) LUNG-USA www.lungusa.org Asthma and Allergy Foundation of America (800) 7-ASTHMA www.aafa.org American Association for Respiratory Care (972) 243-2272 www.aarc.org REPORTS Clearing the Air: Asthma and Indoor Air Exposures, National Academy of Sciences http://books.nap.edu/books/0309064961/html Guidelines for the Diagnosis and Management of Asthma, 1997, National Asthma Education and Prevention Program (301) 592-8573

64. Getting Others To Take Action Take the recommended actions, and encourage others to do so tooTake the recommended actions, and encourage others to do so too Smoke-Free Home Pledge (800) 513-1157Smoke-Free Home Pledge (800) 513-1157 Indoor Air Quality Tools For Schools (800) 438-4318Indoor Air Quality Tools For Schools (800) 438-4318 Secondhand Smoke Community Action Kit (800) 438-4318Secondhand Smoke Community Action Kit (800) 438-4318 ALA Open Airways for schools (800) LUNG-USAALA Open Airways for schools (800) LUNG-USA ALA A is for Asthma in local Headstart or daycare centerALA A is for Asthma in local Headstart or daycare center AAFA Childcare trainingAAFA Childcare training

65. US Environmental Protection Agency Indoor Air Quality Clearinghouse www.epa.gov/asthma 800-438-4318

66. American Association For Respiratory Care www.aarc.org 972 243-2272