Controlling Asthma: Preventing Episodes Before They Occur

1. Controlling Asthma:Preventing Episodes Before They Occur

2. Is There A Cure For Asthma? Asthma cannot be cured, but it can beControlled “We should expect nothing less”!

3. Goals Of Asthma Control • Prevent Symptoms • No coughing or wheezing • No shortness of breath or rapid breathing • No waking up at night • Maintain normal or near “normal” pulmonary function • Maintain normal activity levels (including exercise and other physical activities • Prevent exacerbations of asthma and minimize ER/UC and hospital visits • Minimal or no adverse effects from medications • Meet patients/family’s expectations and satisfaction with asthma care Exerts from NAEPP EPR2 Guidelines for Diagnosis and Management of Asthma 1997

4. Asthma ControlDo Most Students Have It?

5. UnfortunatelyNO! Many students who have asthma: • Have poor asthma control • Use “quick relief” medicine (e.g. albuterol) on a regular basis • Cough, experience chest tightness, wheezing, or shortness of breath regularly • Assume suffering from symptoms are “normal” • Remain indoors and cannot fully participate in sports, PE or recess • Miss school due to asthma

6. Examples Of Students Whose Asthma Is NOT Optimally Controlled • A 10th grader, says he feels fine except when he runs in PE class, then his chest hurts. He coughs most mornings and whenever he gets a cold or virus. He often can’t keep up with the other kids and needs to stop and rest. • A 12th grader, carries an OTC Primatine Mist inhaler & uses it a few times every day. He says he “grew out” of his asthma.

7. Examples Of Students Whose AsthmaIS Optimally Controlled • A 6th grader, doesn’t need his “reliever”(albuterol) since consistently using his controller medications twice daily. He now plays soccer without developing symptoms or having to take pre-exercise albuterol. • A kindergartener, no longer coughs or wheezes and easily keeps up with the other kids at recess. Her dad bought special dust mite proof covers for her mattresses and pillow. She now takes her controllers daily, uses her Asthma Action Plan, and sees her health care provider every 6 months for a well asthma check-up.

8. Asthma Severity Level vs Asthma Control • Asthma Severity Levels(Mild Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent) • Based on signs and symptoms before a student starts on controller medications • Levels can change over time • Asthma Control(or “Current Asthma Severity”) • Is the students current severity level- regardless if they are on medications, experiencing symptoms (episodes) and/or able to be fully active

9. Asthma Control Proactive vs Reactive • Going from a reactive to a proactive approach • Instead of thinking- “ How do I treat these symptoms?” • e.g. with albuterol after the fact • Think- “ How could have the symptoms have been prevented in the first place?” • e.g. daily controller medications, pre-exercise meds, asthma action plan, environmental control

10. Controlling Asthma Medical & Environmental Management

11. Controlling Asthma Medical Management

12. How To Achieve Good Asthma Control • Have regular asthma check-ups with a primary healthcare provider, even when feeling well • At least every 6 months (more often if having symptoms) • Monitor symptoms and peak flow readings daily • Ask for and use a personalized Asthma Action Plan • Know personal green- yellow- red zones, what each zone feels like and what to do in each zone

13. Asthma Control Continued... • Get a flu shot every fall • Avoid asthma triggers • Asthma’s not in control? Check in regularly at school health office for: • Peak flow check /symptom evaluation • Lung sounds / respiratory rate check • Pre-exercise and/or controller meds • Asthma education • Care coordination

14. Asthma Action Plan See MDH Asthma Action PlanF1

15. Written Asthma Action Plans • Developed by the health care provider for each individual child with asthma • Medications are determined by asthma severity level • Based on symptoms and peak flow rates • Lists daily & rescue medications • Symptom management and emergency plan • Copies to be shared by clinic, family and school

16. Asthma Action Plan Zones • Green Zone: All Clear/Breathing Good/Go • No asthma symptoms and/or • Peak flow 80-100% Predicted or Personal best • Yellow Zone:Caution/Slow Down • Some asthma symptoms and/or • Peak flow 50-80% Predicted or Personal best • Red Zone: Medical Alert/Stop • Severe asthma symptoms and/or • Peak flow < 50% Predicted or Personal best

17. What Can A Student Do To Stay In The Green Zone? Select The IncorrectAnswer A. Take their controller (anti-inflammatory) medication every day B. Avoid cigarette smoke and other asthma triggers C. Take their pre-exercise (usually reliever) medicine before P.E. or at recess D. Wash their bathroom often with bleach to avoid mold and mildew build-up

18. What Can A Student Do To Stay In The Green one? Select The IncorrectAnswer A.Take their controller (anti-inflammatory) medication every day B. Avoid cigarette smoke and other asthma triggers C. Take their pre-exercise (usually reliever) medicine before P.E. or at recess D.Wash their bathroom often with bleach to avoidmold and mildew build-up

19. If A Student Is In The Yellow Zone, TheyShould: A.Be cautious. Breathing isn’t their best. Take action B.Eat a lot of yellow foods such as bananas, which are high in potassium C.Automatically stay home from school D.Call their doctor or nurse practitioner immediately

20. If A Student Is In The Yellow Zone, They Should: A.Be cautious. Breathing isn’t their best. Take action B. Eat a lot of yellow foods such as bananas, which are high in potassium C. Automatically stay home from school D. Call their doctor or nurse practitioner immediately (correct answer: call if they aren’t fully back into the green zone within 48-72 hours). R1

21. Which Is One Symptom/ Clinical Indicator Is NOTAssociated With The Red Zone? A. Mild coughing B. Peak Flow reading < 50% of personal best C. Significant breathing problems D. Persistent wheezing or no wheezing at all indicating severely limited aeration

22. Which Is One Symptom/ Clinical Indicator Is NotAssociated With the Red Zone? A.Mild coughing B. Peak Flow reading < 50% of personal best C. Significant breathing problems D. Persistent wheezing or no wheezing at all indicating severely limited aeration

23. ActivityGroup Case Discussion • The first month of school, you are called to an elementary school by a substitute teacher. She sent a 3rd grader to the nurse’s office alone, and told her to lay down. • When you arrive, child has neck vein distension, accessory muscle retractions, dark/dusky color. No inhaler available • Mom is 45 min. away.Grandma is in town • WHAT DO YOU DO?

24. Answer: • Provide emergency care and medication per AAP/ Management plan and • CALL 911!

25. Controlling Asthma - Environmental Management

26. Indoor Triggers Animals with fur Dust mites Mold Pests Secondhand smoke Chemicals (e.g. strong smelling cleaning supplies, perfume, air fresheners) Outdoor Triggers Ozone Particulate matter Diesel exhaust Chemicals(e.g. re-surfacing the playground or roof, etc.) Common Environmental TriggersAt Schools

27. Animals • Dander, urine & saliva are triggers • Triggers remain months after animal pet removed • Actions: • Prohibit/remove animals from schools if able • If removal is not possible: • Keep animals in cages or localized areas • Clean cages often • Keep animals away from fabric furniture, carpet & ventilation system • Locate sensitive students away from animals • Pre-notify parents if animals with fur/feathers visit • Sample Animals in School Guidelines in manual R1

28. Dust Mites • Both cause & trigger asthma; live in pillows, carpet, fabric-covered furniture, curtains • Actions: • Keep classrooms clutter-free • Make informed decision: presence of carpet • Vacuum often when people with asthma/allergies are gone (HEPA filter vacuum cleaners may help) • Pillows/mattress/box spring in dust-mite proof zipped covers • Wash bedding and stuffed toys weekly in HOT water (>130 degrees F) • Keep room humidity < 50% if possible

29. Mold • Moisture control is key • Actions: • Report leaks and wet/moist areas right away • Wash mold off hard surfaces • Replace moldy porous items such as ceiling tiles & carpet • Avoid carpet in areas with regular moisture such as drinking fountains & sinks E9

30. Pests • Droppings or body parts can trigger asthma • Actions: • Use integrated pest management (IPM) methods • Don’t leave food, water or garbage exposed • Don’t eat or drink in classroom • Seal entry points for pests • Use pesticides only as needed • Parent Right to Know Act: must notify parents & employees when using specific pesticides F32, F33, F34

31. Secondhand Smoke • Causes asthma in young children & triggers asthma in children & adults • Contains over 4,000 substances • State law prohibits tobacco use in K-12 public schools • Actions: • Enforce smoking bans (for anyone on school property) • Include anti-smoking message in curriculum • Encourage parents/guardians to quit smoking or to not smoke inside their home

32. Outdoor Air • Ozone & fine particles are concerns in MN • Staff have little control over outdoor air • Actions: • Sign up for Air Quality Index notice • Pollution Control Agency sends e-mail alerts when they expect poor air quality (regional) • Avoid being outside at high pollen count times, especially if students are allergic to particular pollen/s

33. Sept. 14, 2000/June 28, 2001

34. The AQI

35. Average Number Of Alerts • 6-12 alerts per year in last few years • Most due to PM2.5 • Not violation of federal air quality standards thus far • Health issues still valid

36. 2003 – Air Pollution Health Alerts • Expanded AQI to Duluth, St. Cloud, Rochester • Detroit Lakes, Marshall coming soon • Expanded media coverage (Pioneer Press, TV meteorologists, health reporters, others) • Expanded web & e-mail alert signup

37. MPCA’s AQI web page 1

38. MPCA’s AQI web page 2

39. School Buses • State law requires: • Reduce unneeded idling in front of schools • Reroute bus parking zones away from air intakes, if possible • Actions: • Post “no idling” signs • Maintain bus fleet • Invest in cleaner fuels • Purchase newer, cleaner buses over long-term R2, R3, R4

40. Other Environmental Issues • Indoor Air Quality Management Plan • Cleaning & cleaning products • Flooring • Air cleaners R7

41. Home Environment Resources • US Environmental Protection Agency • Asthma Home Environment Checklist • 8 page checklist of common asthma triggers • Questions to identify triggers & action steps • Clear Your Home of Asthma Triggers fact sheet • EPA website www.epa.gov/iaq/asthma/resources.html

42. Communication &Care Coordination

43. Key Communication Triad Parent/ Guardian Child Health Care School Health Providers Office

44. Care Coordination / Communication (Health Assistant / Paraprofessional/LPN Role) • Health Assistants / Paraprofessionals / LPNs must alert LSN/PHN/RNs of students who come in frequently with asthma type symptoms • Monitor students with asthma as directed by LSN/PHN/RN • Perform delegated responsibilities once skills have been validated per district/school policies

45. Care Coordination /Communication(LSN/RN/PHN) • Examples of asthma care coordination activities • Request AAPs on students • Review AAP and/or IHP and develop/modify plan for care coordination • Determine medical insurance status and connect to appropriate provider(s) • Arrange for special transportation (in rare cases) prn • Connect to community resources

46. Care Coordination/ Communication • Communicating with Students • Educate them to: • Follow an individualized Asthma Action Plan • Avoid or control exposure to their triggers • Use medication appropriately • Long-term-control medicine • Quick-relief medicine • Monitor symptoms and response to treatment • Understand symptoms and peak flow levels • Seek a health care providers help when needed

47. Communicating w/ Students Continued.. • Get regular follow-up care • Be able to exercise/ play at optimal levels • Be responsible for carrying and using their asthma medications per school policies • Ask for help when they need it!

48. Care Coordination/ Communication • Communicating with parents/guardians • Review parent/guardian and student questionnaires • Determine current asthma severity levels • Provide education to family/student as needed • Encourage questions and give feedback • Contact parent/guardian every time a student has asthma symptoms and or if having poor asthma control • Obtain a signed consent to release/ share information F11, F14, F3, E1, F7

49. Care Coordination / Communication • Communicating with health care providers • Report status changes and re-evaluation needs • Advocate for pre-exercise and /or controller medications as appropriate • Arrange for asthma education • Complete IHP and/or ECP if needed • Document as appropriate in Pupil Health Record • Evaluate symptoms, lung sounds and peak flow regularly on poorly controlled students F17, F18

50. Communicating With School Staff • Share information with staff on a need to know basis only • Maintain student confidentiality • Provide general asthma education to staff proactively • Provide asthma first aid training to staff • Act as a resource to school staff for questions and concerns