Teach Asthma Management (TAM)

1. Teach Asthma Management (TAM) Provided by: Generously supported by the Robert Wood Johnson Foundation Some slides adapted from Physician Asthma Care Education, developed by Noreen Clark, University of Michigan, School of Public Health

2. Part II of II

3. Hand-Held Nebulizer • Mask <5yrs., Mouthpiece >5yrs. • Assemble equipment • Sit child upright • Put mouthpiece in mouth between lips and teeth (if using mask, cover nose & mouth) • Turn machine on • Instruct to take slow deep breaths (mist should disappear on inspiration) • Done when medicine is gone, may need to tap • Rinse and air dry, Disinfect once per week • Change filter when dirty

4. MDI Technique (Break-out) • Use with spacer/holding chamber • Dry powder inhaler; close mouth tightly around the mouthpiece of the inhaler and inhale rapidly • If don’t have spacer/holding chamber • Open mouth technique with inhaler 1-2” away • In mouth (not for use with corticosteroids)

5. MDI with Spacer Technique (Break-out) • Remove cap, attach MDI to a spacer & shake • Breathe out & put spacer between lips • Press canister one time • Take deep breath in slowly & hold for 10 sec • Breathe out • Take one more deep breath without pressing canister • Wait 60 seconds before taking next puff • Rinse Mouth if using inhaled corticosteroid

6. MDI with Spacer and Mask (Break-out) • Remove cap, attach MDI to spacer & shake • Place mask tightly on child’s face (cover nose and mouth) • Press canister one time • Hold mask tightly on face for 6-10 breaths • Assure valve is opening with each breath • Take mask off & wait 60 seconds before giving next puff • Wash face & rinse Mouth if using inhaled corticosteroid

7. Maxair™ Autohaler™ (Break-out) • Remove cover & shake • Prime if needed (1st use and if not used for 48 hrs.) • Load Dose • Lips tight around mouthpiece • Take deep steady breath in and hold for 10 seconds • Remove from mouth & exhale • Lower lever and repeat if needed

8. Turbuhaler® (Break-out) • Prime if this is a new Turbuhaler (twist & click X2) • Load a dose (twist & click) • Turn head away & exhale • Place in mouth tightly, take deep, quick breath • Hold breath for 10 seconds • Repeat as needed

9. Push grip to open Diskus® Push lever away until hear & feel click Turn head away & exhale Place in mouth tightly, take deep, quick breath Hold breath for 10 seconds Diskus® (Break-out) mouthpiece grip lever

10. Foradil® Aerolizer™ (Break-out) • Remove cover and open Aerolizer™ Inhaler • Remove capsule from foil, place in capsule-chamber • Twist mouthpiece to close position • With mouthpiece upright, press buttons ONCE (hear click), this will break the capsule • Turn head away & exhale • Place in mouth tightly, take deep, quick breath (if no whirling sound, may be stuck) • Hold breath for 10 seconds • Check Aerolizer™ for left over medicine, if some left close and breathe rest of medicine

11. Asthma Triggers Laurie Smrz,RN, BSN Medical College of Wisconsin

12. Asthma Triggers Objective: Teach caregivers to control asthma triggers

13. Role of Allergy in Asthma: Clinical Evidence • Allergy is common in children(80%–90% of school-aged children with asthma) • Presence of allergy is associated with more severe and persistent asthma • Allergen exposure is associated with • Increased risk of developing asthma • Increased asthma morbidity • Allergen avoidance can reduce airway hyperreactivity (AHR) and asthma morbidity

14. Identifying Asthma Triggers • Avoiding triggers can: • Prevent asthma symptoms and exacerbations • Reduce need for medication

15. Identifying Asthma Triggers • Hypersensitivity of the immune response to allergens initiates an allergic cascade: Sensitization: Initial exposure to allergen production of allergen specific IgE antibody Early phase reaction: Subsequent exposure of IgE antibody to specific allergen release of histamine, tryptase, leukotrienes, cytokines inflammation & bronchoconstriction Late phase reaction: mediators continued inflammatory reactions Stimulation of immune cells produces inflammatory response

16. Identifying Asthma Triggers • "Atopy“ - The genetic tendency to develop the "classical" allergic diseases: Allergic rhinitis, asthma and atopic dermatitis. Associated with the capacity to have an IgE response to common, generally inhaled, allergens • "Allergen" - Substances that can induce IgE antibody responses • "Allergy" - IgE antibody responses to allergens • “Irritant" - Cold air, laughing, crying, yelling, weather change, air pollution

17. Irritants • “Irritate already inflammed sensitive airways” • Air pollutants: ETS, wood smoke, ozone, chemicals in the air • Strong odors/sprays: perfumes, household cleaners, paints, and varnishes • Airborne particles: chalk dust, talcum powder • Changing weather conditions • Viral infections • Exercise • Strong emotional response: crying/laughing

18. Allergens • “Any substance that triggers an allergy” • Pollen • Molds • Animal Dander • House dust mites • Cockroaches

19. Identifying Asthma Triggers • Allergens Confirm: • RAST Blood Test (Radioallergosorbent Test) • Skin prick (most accurate) • Irritants Observation: • Ask child or caregiver: What do you think makes your asthma worse?

20. Most Common Triggers • Tobacco Smoke • Avoid it! • Ask smoker to “Take it outside” • Even odor of smoke residue is a trigger • Colds and Infections (most common childhood trigger) • Wash hands before meals and bedtime • Encourage yearly flu shot • Exercise • Plan warm up activities • Allow time for pre-medication

21. Indoor Triggers

22. Dust Mites (Der p, Der f) • Eight legged arachnids (related to spiders, chiggers and ticks) • Thrive in warm moist micro-environments (inside pillows, cushions, mattresses) • Feed on human and animal dander (dead skin flakes) • Focus on the bedroom • Pillow and mattress covers • Wash bedding in hot water • Damp dust • Cost effective tips • (cheese cloth) The weight of a paper clip 1gram of dust = 100-19,000 dust mites

23. Cockroaches (Bla g1, Bla g2) • American and German cockroach • Integrated Pest Management (IPM) • Minimal use of pesticides • Eliminate food, water & entry points • Use baits: keep away from children • Children's Health Education Center 1997

25. Animal Allergy - Why So Important • 5%–10% of general population • 20%–70% of people with allergies/asthma • >50% of US homes have at least one cat or dog • Homes and public buildings without pets may have significant allergen levels • Other furred animals also are commonly encountered

26. Furry and Feathered Friends (Can d1, Fel d1, Mus m) • Dander: proteins in dead skin, urine and saliva • Cats (most common) • Dogs • Birds • Rodents

27. Cat Dander (Fel d I) • Unlike dust mite allergen, stays airborne • Unlike dust mite allergen, it is sticky • Bind to walls and other surfaces in buildings • Detected in homes and buildings without cats • Munir AK, et al. JACI 1993:91:1067-74 • May take months for all allergen to decompose

28. Animal Control Measures • The ideal solution: • Remove pets from house • If not possible: • Keep pet out of bedroom • Use HEPA air filtering system • Remove carpet and other reservoirs for allergens in the bedroom • Encasing on mattress, box springs, and pillow • Wash pet weekly

29. Outdoor Triggers Pollens: particles released from trees, weeds and grasses Highest levels at midday (10-2pm) Use air conditioning, not fans Visit an air-conditioned mall or movie theater Not many options (avoidance)

30. Molds (indoors and out) • Damp soil and leaves • Outdoor plastic toys and equipment • Poor kitchen/bathroom ventilation • Leaky faucets • Clean mold with a mild bleach solution • Air Pollution • Small particulate matter: ozone, diesel exhaust • and coal combustion byproduct • Stay indoors on Ozone Action Days Mold and Air Pollution • Children's Health Education Center 1997

32. Non-Specific Triggers - Irritants • Strong Odors • Self-care products • Cleaning products • Scented candles & aerosol spray room • deodorizers • Purchase scent-free products • Weather • Sudden changes in temperature • Cold weather • Cover nose and mouth • Children's Health Education Center 1997

33. Help families focus on their specific triggers • Keep it simple • Focus on the patient’s triggers • Encourage caregiver to select 1 intervention to begin • Teach simple intervention for a specific trigger

34. Key Messages • Triggers CAN be avoided or controlled • Use quick-relief medicine before exercise or an unavoidable exposure • Establish a daily – weekly - monthly cleaning routine: break it down into simple steps! • Advise smoking treatment if smokers in the home • Provide family with resources to reduce triggers

35. Where to Get Allergy Products • Local Department Stores • National Allergy Supply Company 1-800-522-1448 • Allergy Supply Company 1-800-323-6744 • American Allergy Supply 1-800-321-1096

36. Tobacco Interventions Mary Balistreri (Cywinski), MS UW Center for Tobacco Research and Intervention Education & Outreach (414) 219-4014 mc3@ctri.medicine.wisc.edu

37. Objectives: • Know what works best to help adults quit • Learn about available resources • Know why you should be an anti-smoking advocate

38. Risks to Children • Asthma • Respiratory infections - bronchitis, pneumonia • Otitis media (ear infections) • Low birth weight • Poorer school achievement • Sudden Infant Death (SIDS) • Half of parents likely to die prematurely

39. Treating Tobacco Dependence • Quitting smoking is one of the best things parents can do for themselves and their children. • Intervention from health care providers is • clinically effective and cost effective. • Nicotine is addictive, relapse is prevalent. • AAAAI Guide

40. A Systematic Approach to Every Patient at Every Visit is Most Effective • Ask smoking status and readiness to quit • Advise to quit • Assess willingness to quit • Assist plans to quit • Arrange follow-up

41. What Works Best to Help Smokers: Counseling and Medications • Practical counseling, even brief, along with FDA approved medications can triple success. • Counseling messages should be clear, strong, and personal. • Medicaid covers cessation treatments.

42. Wisconsin Tobacco Quit Line 1-877-270-STOP toll free • Counseling by trained professionals • Individualized for each patient • Highly effective • 7 days/week, 7am to 11pm • Connection to clinicians and local program To order Quit Line materials: Email: quitline@ctri.medicine.wisc.edu or Fax: 608-265-3102

43. First-line pharmacotherapies • Bupropion SR • Nicotine gum • Nicotine inhaler • Nicotine nasal spray • Nicotine patch • Nicotine lozenge

44. Resources • UW Center for Tobacco Research & Intervention • www.ctri.wisc.edu • - Resources for health care providers, smokers, family members • US PHS Clinical Practice Guideline: • Treating Tobacco Use and Dependence • - Current research and support materials • www.surgeongeneral.gov/tobacco/

45. Asthma Care Plans Erin Lee, FAM Allies Coordinator Children’s Health Education Center

46. Objective • Teach caregivers to recognize symptoms, adjust medications, and seek help according to the written action plan

47. What are the Symptoms of Asthma? • Cough • Shortness of breath • Wheezing • Tightness in the chest • Coughing at night or after physical activity; cough that lasts more than a week • Waking at night with asthma symptoms (a key marker of uncontrolled asthma)

48. Asthma Diary A record that helps patients track: • Asthma symptoms • Medication use • Peak flow numbers • Trigger contact Diaries can help • Improve communication with healthcare team • Doctors evaluate and establish asthma control

49. Asthma Care Plan • Problem solving tool, tailored to individual patients • Based on information from both parent and provider • Mutually developed between parent, patient, and provider

50. Care Plan Checklist • Patient name • Provider name and phone number • Medications, dosages, and frequency of use for Green, Yellow, and Red zones • List symptoms for each zone • Peak flow zones (when appropriate) • List who to call with questions or in an emergency