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FACTORS CONTRIBUTING TO ASTHMA EXACERBATIONS Trisch Van Sciver RN MS CFNP DOM AE-C Disclosure of Potential Bias Trisch Van Sciver I have a potential bias: –Speakers Bureau for Teva Pharmaceutical Industries Ltd. –Consultant for NM Health Care Connection This presentation has been reviewed to evaluate for potential bias and the presentation will be monitored to evaluate for bias. Ranking the Evidence The NAEEP Expert Panel Report 3 uses the following criteria to specify the level of evidence to justify recommendations made: • Evidence A – Rich body of data – A lot of randomized controlled trials (RCT) • Evidence B – Limited body of data – some RCTs • Evidence C – Non-randomized trials and observational studies • Evidence D – Panel consensus judgment (for when guidance seems valuable but lacks literature backing) NAEEP Expert Panel Report – 3 It is essential to identify and reduce exposures to allergens and irritants and to control other factors that have been shown to increase asthma symptoms in your patient.*A Effective allergen avoidance requires a multifaceted, comprehensive approach; individual steps alone are generally ineffective.*A Focus on allergen-control education for cockroach, dust mite and rodent allergens for patients sensitive to these allergens as these have proven interventions.*A This session will cover… Allergens Irritants School, work and outdoor environments Other contributing factors Exerciseinduced bronchospasm Co-morbid conditions Allergens vs. Irritants Allergens • IgE mediated disease • Require sensitization • Affects only those that are sensitized to the allergen • Not usually dosedependent Irritants • Not mediated through IgE • Dose-dependent response • Will affect everyone at high enough dose (See Asthma 101 – Asthma Triggers Handout for examples.) Assess Environment • Identify and control triggers to: – Prevent symptoms – Prevent hospitalizations and ED visits – Improve quality of life and self-management skills – Reduce medications IMPORTANT: Ask, “Have you noticed anything in your home, work or school that makes your asthma worse?” Assess Home Triggers Does the patient: • Keep a pet? • Have moisture or dampness in their home environment? • Have visible mold in any part of their home? • Smoke or live with a smoker? • Have a wood burning stove or fireplace? • Have unvented stoves or heaters? SOURCE: EPA , Asthma Home Environment Checklist for Home Visitors at http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf. EPA Asthma Home Environment Checklist • Inspect Mattress & bedding. Are there carpets, other floor covering, drapes, upholstered furniture, stuffed toys? • Cockroaches, rodents in kitchen, bath, basement? • Pets? Types? • Mold in bathroom, kitchen, basement? • Smoke – tobacco second hand? • Gas cooking appliances, fireplaces, woodstoves, unvented heaters? (NO2) • Heating/Cooling system? • Cleaning products/pesticides/air fresheners/cosmetics? Common Home Triggers: Allergens Animal allergens Dust mites Cockroach allergens Indoor fungi Tobacco smoke Animal Allergens*D All warm-blooded animals produce flakes of skin (dander), feces, urine and dried saliva that can cause allergic reactions. – Best option - Keep animals out of house – If you can’t keep the pet outside, keep it out of the bedroom and keep the door shut – Wash hands and clothes after contact with the pet – Remove upholstered furniture and carpets from the home or isolate the pet in areas without these items Dust Mites*A • Require humidity and human dander to survive, thrive in most areas of the United States but usually not present in high altitudes or arid areas • High levels are found in bedding, pillows, mattress, upholstered furniture, carpets, clothes and soft toys IMPORTANT: The patient’s bed is the most important source of dust mites that need to be controlled. Dust Mites Control Measures*B • Encase the pillow and mattress in an allergen-impermeable cover. • Wash all bedding in hot (>130ºF) water weekly*. • Keep humidity below 60% (ideally 30%-50%). • Remove carpets from the bedroom. • Avoid sleeping or lying on upholstered furniture. • In children’s beds, minimize the number of stuffed toys; each week, wash the toys in hot water or freeze them. • Room air filtration devices are not recommended to control dust mite exposure – the allergens are air-borne only briefly and not removed via air filtration. (*Exposure to dry heat or freezing kills dust mites but does not remove the allergen.) Cockroach Control Measures*B • Keep counters, sinks, tables and floors clean and clear of clutter. • Fix plumbing leaks and other moisture problems. • Remove piles of boxes, newspapers and other items where cockroaches may hide. • Seal all entry points. • Make sure trash in your home is properly stored in containers with lids that close securely; remove trash daily • Try using poison baits, boric acid or traps first before using pesticide sprays. Common Home Triggers: Irritants Molds Basements Bathrooms Smoke & Gases Kerosene heaters Wood stoves/Firep laces VOCs Hairspray, Cooking spray & odors Furniture polish New carpets Perfumes Tobacco smoke Mold Control Measures*C • Moisture control = mold control, so ACT QUICKLY. – If wet or damp materials or areas are dried 24-48 hours after a leak or spill, in most cases mold will not grow. • Scrub mold off hard surfaces with detergent and water; dry completely. • Absorbent or porous materials, such as moldy ceiling tiles and carpet, may have to be thrown away. • Dehumidify basements if possible. (SOURCE: A Brief Guide to Mold and Moisture in Your Home, EPA Publication #402-K-02-003.) Smoke and Gas Control Measures • Minimize exposure to strong odors and sprays (perfume, talcum powder, hair spray, paints, new carpets, particle board). • Minimize production of nitrogen dioxide*C – – – – – – – Inspect the heating system annually. Inspect and keep clear the chimney clean-out opening. Do not use unvented space heaters. Do not use stoves for heating. Do not use wood burning fireplaces . Use kitchen exhaust fans. Do not let the car idle in the garage. Tobacco Smoke Control Measures • If you smoke, ask for ways to help you quit. Ask family members to quit too.*C • Do not allow smoking in your home or car. • Be sure no one smokes at your child’s daycare or school. • Advocate for smoke free workplaces. IMPORTANT: An estimated 46.5 million adults in the United States smoke cigarettes = 23.25 million deaths. Secondhand Smoke • Exposure is linked to increased asthma symptoms, decreased lung function and greater use of health services among those who have asthma. • Message to person with asthma or caregiver – Quit or at least smoke outside (may not adequately reduce exposure). • Provide smoking cessation support if possible.*B ACTIVE SMOKING & ASTHMA • More frequent exacerbations, hospitalizations, ER visits • Therapeutic response to corticosteroids impaired • Increased theophylline clearance • Higher risk of developing worsening fixed airway obstruction COPD- asthmatics smoking 15 or > cigarettes /day have an 18% decline in FEV1 over 10 yrs compared with a 10% decline in nonsmokers with asthma* • Increased risk of cancer, heart disease, gerd, chronic sinusitis *Apostol et al “Early life factors contribute to the decrease in lung function between ages 18 and 40” AJRespCritCM 2002;166:166-172 5/25/2017 20 PASSIVE TOBACCO SMOKING (SHS*) & ASTHMA – Children exposed to passive smoke have increased risk of developing asthma of between 21% and 37% ** and of having increased respiratory infections – Implicated in some cases of new onset adult asthma particularly women (60% in one study, no increase in men -Toren et al Int J Tuberc Lung Dis 1999;3(3): 192-197 – Non smoking asthmatics have increased risk for asthma symptoms and episodes – Frequent exposure to passive smoke can increase risk of development of COPD and other smoking related diseases- lung cancer and cardiovascular disease 5/25/2017 *SHS =second hand smoke **California Environmental Protection Agency: Health effects assessment for environmental tobacco smoke. Office of Environmental Health Hazard Assessment Sacramento, CA 2005 21 Techniques That May Modify Indoor Air • Vacuum 1-2 times per week – Get someone else to do this if possible or wear a dust mask • Damp mop • Air conditioning during warm weather recommended for asthma patients*C • Dehumidifiers to reduce house-dust mite levels in highhumidity areas • HEPA filters to reduce airborne cat dander, mold spores and particulate tobacco smoke. – Not a substitute for more effective measures! Techniques Not Recommended • Humidifiers not recommended for use in homes with dust-mite sensitive patients*c • Insufficient evidence to recommend cleaning air ducts in HVAC systems*D • Insufficient evidence to recommend using indoor air cleaning devices Immunotherapy It is recommended that allergen immunotherapy be considered for patients with persistent asthma if evidence is clear of a relationship between symptoms and exposure to an allergen to which the patient is sensitive.*B Immunotherapy Immunotherapy is usually reserved for patients whose symptoms occur all year or during a major portion of the year, and in whom controlling symptoms with pharmacologic management is difficult because the medication is ineffective, multiple medications are required, or the patient is not accepting the use of medication. (EPR – 3, pg. 173) Schools: Potential Concerns • Poor indoor air quality • Leaky roofs/wet carpeting = Molds • New carpeting/chemicals = Toxic fumes • Building repairs/renovations = Dust • Idling school busses = Diesel fumes • Unventilated portable classrooms • Fragrances (Magic Markers, air fresheners, art supplies) • Animals in classroom • Cleaning supplies • Classroom environment (old carpeting, furniture) • Insecticides, herbicides, fungicides • Chalk dust, foods • Access to medications • Access to a school nurse Asthma Friendly School Resources It is recommended that a clinician prepare a written asthma action plan for the school setting. In addition to medications and emergency response, this plan should identify factors that make students’ asthma worse so that the school may help avoid exposure. Activity: How Asthma Friendly Is Your School? Role-play: School Employee & Asthma Educator Gabriel is a five-year-old boy with asthma who will begin kindergarten in the fall. His moderate-persistent asthma has been well managed at home and the family wants to inquire about the environment of the school setting prior to enrollment. (SOURCE: CDC. How Asthma Friendly Are Your Schools?) How Asthma-Friendly is your School? • • • • Tobacco free campus? Good indoor air quality? Policy on inhalers? Written asthma emergency plan for teachers & staff ? Updated asthma action plans for students with asthma on file at school? • School nurse? • Education for school staff/teachers about asthma? • Degree of participation asthma student has in PE, sports, recess, field trips? Assess Work Triggers - Occupational Ask employed patients about possible occupational exposures, particularly upon new-onset of disease. • Occupational asthma is suggested when there is a correlation between asthma symptoms and work, as well as an improvement when away from work for several days. • Patient may miss the correlation as symptoms typically present several hours after exposure. • Serial peak-flow records at work and home can help confirm the association. Possible Occupational Exposures • • • • • • • Isocyanates Metal working fluids Coolants Chromium salts Cleaning agents Pesticides Welding fumes Direct Irritants • Plicatic acid – red cedar wood dust • Colophony – soldering fluxes • Diisocyanates – urethane foam • Phthallic/trimellitic anhydride – adhesives, paints, varnishes • Latex, formaldehyde, drugs Allergic Triggers Occupations associated with Asthma • • • • • • • • • • • Bird breeders Seafood & food processors Beekeepers, farmers, granary workers silk processors, dockworkers Pharmaceutical industry, health care workers Mushroom workers, Bakers Beauticians Miners, cement, electroplating and tanning workers, metal workers and diamond polishers, alloy makers Plastics and printing industry Shellac/lacquer industry workers Foresters, woodworkers and furniture makers Polyurethane, foam coatings, adhesives production, spray painters 5/25/2017 32 Causes of Irritant-induced OA • • • • Chlorine gas Hydrogen sulfide Fumigating fog Heated acids • 1984 Bhopal, India - toxic cloud of methyl isocyanate gas released from chemical plant killed thousands and caused thousands to develop persistent respiratory disease (some with reversible airway obstruction) • 2001 WTS, NYC- complex mixture of airborne dusts and pollutants associated with RADS (and other respiratory disorders) in exposed rescue and recovery workers and residents of the surrounding area 5/25/2017 Hydrochloric acid Anhydrous ammonia Smoke Inhalation 33 Material Safety Data Sheets (MSDS) • US Occupational Safety & Health Administration requires that suppliers include a MSDS with each shipment of an industrial material or chemical and workers are entitled to receive copies of these • Helpful in identifying respiratory hazards in the workplace • May omit information, but can focus subsequent literature review to obtain additional info. (materials present in concentrations <1% need not be reported) 5/25/2017 34 Outdoor Environment • Ask the patient – “Is your asthma consistently worse in spring, summer, fall or parts of the growing season?” • Avoid areas of high pollution; stay indoors on ozone alert days when possible.*C • Do not use air cleaners that create ozone.*D Pollen and Molds Ozone Other Contributing Factors Viral respiratory infections • Respiratory infections can exacerbate asthma symptoms, particularly in children under age 10. Rhinovirus, an upper airway pathogen, has been demonstrated in the lower airways in patients with asthma. Bacterial infections Infections such as Mycoplasma and Chlamydia may contribute to asthma exacerbations. Other Contributing Factors Influenza • Consider inactivated influenza vaccination for patients with asthma. • Vaccinate due to increased risk of complications from influenza. Do not expect reduced frequency or severity of asthma exacerbations during influenza season.*B • 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings • http://www.cdc.gov/hicpac/2007ip/2007ip_part3.html • Female hormones and dietary constituents • There is insufficient evidence to make specific recommendations on these topics. Other Contributing Factors • Aspirin sensitivity – Avoid aspirin and other NSAIDs as these drugs could precipitate severe and fatal exacerbations.*C • Other medications – Recommend avoidance of nonselective β–blockers (eye drops used for glaucoma) and HTNB & ACE inhibiters –used for HTN. • Sulfite sensitivity – Avoid processed potatoes, shrimp, dried fruit, or drinking beer and wine to avoid sulfite exposure.*C ASPIRIN INDUCED ASTHMA SAMPTER’S SYNDROME ASTHMA TRIAD - Aspirin / NSAID induced respiratory reactions Asthma and Nasal Polyps - these 3 things make up the Asthma Triad - occurs in 4.3-21% asthmatic – Develop persistent rhinitis in 3rd or 4th decade associated with viral URI – Usually asthma is severe and poorly responsive to corticosteroids – Women affected 2.5X > men – Mechanism: “shunting”of arachidonic acid metabolism away from prostanoid production, leading to increased leukotriene production and resultant bronchoconstriction 5/25/2017 39 DRUG TRIGGERS • Non Selective Beta2 Blocker - Inderal /Propanolol - the beta 2 receptors in the lungs are responsible for relaxation of the bronchial muscle when you take a beta 2 blocker it does the opposite it constricts airways. Used to rx migraines, heart disease - Selective Beta Blockers -Metoprolol, Labetalol, Carvedilol, etc - primary affect Beta 1 receptors in the heart -Eye drops for Glaucoma • ACE Inhibitors - can induce cough 5/25/2017 40 CHEMICAL/MEDICATION ASTHMA TRIGGERS (con’t) • Sulfites -sulfur dioxide is a gas that can irritate airways and provoke asthma symptoms – Some preservatives- widely used n wine, beer, & cider, may contain additives in fresh sausages, previously used in salad bars – Most dried fruits (especially dried apricots) are treated with sulfur dioxide – If sensitive, read labels- sodium sulphite, sodium hydrogen sulphite, sodium metabisulphite, potassium metabisulphite, calcium sulphite 5/25/2017 41 Exercise-Induced Bronchospasm (EIB) • EIB should be anticipated in all asthma patients. A history of cough, shortness of breath, chest pain or tightness, wheezing and/or endurance problems during exercise suggests EIB. Co-morbid Conditions • If a patient’s asthma cannot be well controlled, evaluate for the presence of co-morbid conditions. • Evidence suggests that appropriately treated co-morbid conditions can improve asthma control. Co-morbid Conditions Allergic broncopulmonary Aspergillosis*A • Suspect this condition in patients with asthma and a history of pulmonary infiltrates or evidence of IgE sensitization. Gastroesophageal reflux disease*B • Suspect this condition in patients with poorly controlled asthma, particularly at night, even without other suggestive symptoms. GASTROESOPHAGEAL REFLUX DISEASE (GERD) • Present in 50-70% of chronic asthma patients • Proposed trigger mechanisms: microaspiration & vagally mediated bronchospasm • An asthma episode may be the trigger for GERD - change in pleural pressure gradients, thoracic distension and air trapping • Other triggers for GERD: abdominal obesity, obstructive sleep apnea, asthma meds, exercise, cough • Silent reflux - especially in diabetes • Symptoms: cough, wheezing, sob, water brash, heartburn, chest tightness 5/25/2017 45 Co-morbid Conditions Obesity*B • Suggest to asthma patients who are overweight or obese that weight loss may improve asthma control, in addition to improving overall health. Obstructive sleep apnea*D • Suggest to asthma patients who are overweight or obese that weight loss may improve asthma control, in addition to improving overall health. OBESITY IN ASTHMA • Asthma mimic and risk factor for asthma • Lung effects: decreased functional residual capacity (FRC) and expiratory reserve volume (ERV) - decreased airway caliber, increased airway resistance, possible increased airway hyperresponsiveness - overall effect is dyspnea • Pro-inflammatory state that may contribute to lung inflammation and asthma • Necessary to evaluate symptoms with complete PFT, bronchoprovocation studies, IgE levels, etc • Obese patients with asthma require more drugs, are more symptomatic, have an increased risk of ER visits 5/25/2017 47 RHINOSINUSITIS IN ASTHMA • Most common comorbidity associated with asthma -occurs in 78% asthma patients compared to 20% general population • Allergic rhinitis (AR) is a risk factor for asthma, it’s presence before 7 yrs old predicts asthma onset • “The allergic march” progression of allergic disease from nose/sinuses to lung airways • Complications: nasal polyps, sleep apnea, recurrent rhinosinusitis, anosomia, more severe asthma 5/25/2017 48 Co-morbid Conditions Rhinitis/sinusitis*B • Suspect these conditions in patients with asthma; evaluate the possible presence of symptoms. Stress, depression and psychosocial factors*D • Suspect these conditions in patients with asthma that is not well controlled. Ask about the potential role of chronic stress or depression in complicating their asthma management . Pregnancy PREGNANCY IN ASTHMA • Rule of 1/3’s • Uncontrolled asthma during pregnancy can cause preeclampsia, cesarean delivery, placenta previa, preterm labor, vaginal hemorrhage .Fetus increased risk of low birth weight, intrauterine growth retardation and death • Other pregnancy issues - obesity, gerd, rhinitis • Aggressive Rx of asthma during pregnancy is important • Medications - Category B Budesonide, Singulair, Cromolyn, Xolair – Category C - Albuterol, other inhaled CTS, Theophylline, combination products 5/25/2017 50 Vocal Cord Disorder • Presents as acute upper airway obstruction with dyspnea, throat tightness, anxiety, wheezing, inspiratory stridor, dysphonia, hoarseness, respiratory distress (retractions may be present), +/or choking • Mimics asthma, but does not respond to asthma meds • May coexist with asthma • Occurs in up to 40% of patients being evaluated for asthma, more freq in females, can occur in conjunction with asthma 5/25/2017 51 SUMMARY OF TRIGGERS • Inhalant Allergies - pollens, molds • Irritants - chemical exposures, cold air, stomach acid with GERD • School /Occupational Triggers • Respiratory Infections - viral • Food - mostly in children peanuts, sulfites • Drugs - nonselective beta blockers, ACE inhibitors, ASA, NSAIDS • Strong Emotions • Hormones - premenstrual, pregnancy??? • Strenuous Exercise 5/25/2017 52 CO-MORBID CONDITION SUMMARY • • • • • • OBESITY GASTROESOPHAGEAL REFLUX DISEASE (GERD) OBSTRUCTIVE SLEEP APNEA VOCAL CORD DYSFUNCTION (VCD) CHRONIC RHINITIS/SINUSITIS STRESS, DEPRESSION, PSYCHOSOCIAL CONDITIONS • PREGNANCY • ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA) Case Study • 25 yr old Yongcha has been recently seen in the ER for an asthma exacerbation. She has since been diagnosed with moderate persistent asthma and is on appropriate medications for her severity level. She is still experiencing poor asthma control and her provider has referred her to you, the asthma educator to discuss trigger reduction. • Yongcha works at a childcare center in downtown Albuquerque and commutes via bus. She recently moved in with her boyfriend. Recently diagnosed, she has a poor understanding of trigger exposure. She is not taking prescription meds for allergies or other comorbid conditions. Case Study Directions Yongcha • Divide into 2 groups. • Discuss as a group what information a first meeting would entail. • Role play the meetin with one person being the asthma eduucator and the other being Yongcha. • Practice describing factors in simple English and determining priorities for intervention. Acknowledgements • Beverly Stewart American Lung Association in Oregon We will breathe easier when the air in every American community is clean and healthy. We will breathe easier when people are free from the addictive grip of cigarettes and the debilitating effects of lung disease. We will breathe easier when the air in our public spaces and workplaces is clear of secondhand smoke. We will breathe easier when children no longer battle airborne poisons or fear an asthma attack. Until then, we are fighting for air. We will breathe easier when the air in every American community is clean and healthy. We will breathe easier when people are free from the addictive grip of cigarettes and the debilitating effects of lung disease. We will breathe easier when the air in our public spaces and workplaces is clear of secondhand smoke. We will breathe easier when children no longer battle airborne poisons or fear an asthma attack. Until then, we are fighting for air. 5/25/2017 58