Download Asthma in Schools What are the issues?

Asthma: Information for You
and Your
Student Athletes
Presented to WIAA Annual Conference
July 31, 2009
Greg L. Ledgerwood MD, AAFP, ACAAI, AE-C
Co-Chair Practitioner Support
Washington Asthma Initiative
Private Practice
Brewster, Washington
Let’s See What You Know
About Asthma!
For an athlete whose asthma is
well controlled, which is true?
A.
B.
C.
D.
E.
Only has asthma symptoms at night
Can participate in sports like other
athletes only if using albuterol 3
times/day
Still has abnormal lung function
Should never warm up before exercise
None of the above
What happens in the airway of people
whose asthma is poorly controlled?
A.
B.
C.
D.
E.
F.
Swelling of the airways
Excessive mucous production
Spasm of the airway muscles
Permanent loss of air capacity
A., B., C correct
All are correct
You should call 911 if and athlete is
having which of the following?
A.
B.
C.
D.
E.
F.
Rescue medication (albuterol) is not
relieving the breathing difficulties or is
not available
Symptoms are relieved by using “rescue”
albuterol twice
Pulse rate stays > 150 beats/minute
Peak flow is moving into the “red” zone
A., B., D. correct
All of the above are correct
What is the recommended to prevent
exercise induced asthma (EIA)?: T or F
A.
B.
C.
D.
Albuterol should be used after an athlete
has started wheezing
Warming up adequately before exercise
Take rescue medication 10-15 minutes
before activity
Avoid those sports that cause the EIA
Athletes should return to competition
only when they can breath easily and
are free of asthma symptoms
A.
B.
True
False
Some athletes need to take medication
every day to prevent asthma
symptoms. These medications are call
controller medications and should not
be used in an emergency situation
A.
B.
True
False
What item(s) is/are used to evaluate
lung function and provide information
on asthma symptoms and medications?
A.
B.
C.
D.
E.
Peak flow meter
Asthma action plan
Nebulizer
A and B only
B and C only
Parents should always inform the coach
that their child has asthma, provide
him/her with an asthma action plan, and
discuss when and under what situations
to implement it
A.
B.
True
False
What is Asthma???


Asthma is an obstruction of the
pulmonary (lung) system that is
completely reversible (most of the time).
Untreated asthma that starts in childhood
and goes untreated often cannot be
distinguished from lung obstruction seen
in a smoking individual
Who has Asthma???




How many listening to this presentation
think they have asthma?
How many had asthma and “outgrew” it
as an adult?
How many have had MD diagnosis of
asthma?
How many of you have had PFT’S
(breathing tests)?
Variability of Untreated
Asthma
Severe
Mild
Time
For purposes of illustration only.
Students Over-estimate Their
Asthma Control

Of patients who report symptoms that meet
NIH criteria for moderate-persistent asthma


61% still consider their asthma to be
“well controlled” or “completely controlled”
Of patients who report symptoms that meet
NIH criteria for severe-persistent asthma

32% still consider their asthma to be
“well controlled” or “completely controlled”
Asthma in America Survey. SRBI. December 1998.
The Goals of Asthma Therapy
Are Inadequately Realized
60
48
40
30
Patients
(%)
32
23
20
0
Sleep Disruption
 Once/Week
Missed School/Work
in Past Year
Limited
Sports/Recreation
Rickard K et al. J Allergy Clin Immunol. 1999;103:A655.
Asthma in America Survey. SRBI. December 1998.
Unscheduled ED
Visits in Past Year
Deaths in our state still primarily
in the youth!!!
Asthma Information for You
And Your Family
Early-Onset Asthma

Infants colonized by bacteria at early age
significantly more likely to wheeze at age
5 than other children*



H.influenza
M. catarrhalis
S. pneumoniae
S. aureus not associated with increased risk
*N. Engl. J. Med. 2007;357:1545
Infection Early in Life and Asthma

In male children, early life exposure to
infection is associated with lung
impairment as adults:



~60% higher of overall mortality in adulthood
2-fold increase in COPD mortality
Significant increase in MD diagnosis of asthma
in adulthood
Thorax; BMJ; November, 2007
Glasgow University 1948-1968
9544 students; 4044 f/u in 2007
Asthma, Antibiotics,
Antihistamines/Decongestants

Recent study shows:

Antihistamine/decongestants plus NSAIDS
given during severe lower respiratory track
infection in first year of life increases risk of
having asthma at age 6 by 2-fold!!! (50% vs 24%,
P= .001)
(No association with the use of antibiotics in
the first year of life and the presence of
asthma at age 6)
Roberg, KA; Presentation AAAAI Annual meeting;
Philadelphia, March 2008; Abstract #357
What about Vitamins/Nutrients?

Recent evidence suggest that young
students that are “relative” vitamin D
deficient are twice as likely to develop
asthma.
ASTHMA and it’s natural history
is evolving; what do we know
about asthma in our state?
The Burden of Asthma in
Washington State 2008

Prevalence of lifetime asthma by
grade:
6th---15%
8th---17%
10th--19%
12th---21%
The Burden of Asthma in
Washington State 2008
Prevalence of lifetime asthma by grade
and sex:
6th----16% male, 13% female
8th----18% male, 16% female
10th---18% male, 20% female
12th---20% male, 22% female
The Burden of Asthma in
Washington State 2008

Prevalence of CURRENT asthma by grade:
6th---7%: 8% male, 7% female
8th---8%: 8% male, 8% female
10th--9%: 7% male, 11% female
12th--9%: 7% male, 11% female
African American youth 30% more
Likely to have asthma than white youth
The Burden of Asthma in
Washington State 2008


Prevalence highest in Whitman, Cowlitz,
Grays Harbor and San Juan counties
Lowest in Adams, Grant, Chelan and
Skamania counties
WHY?????????
Patients with asthma, %
Asthma Incidence by
Age*
45
40
35
30
37%
10% 15-19
30%
21%
25
20
15
19% 6-14
12%
10
5
8%
0-5
0
0-19
*National Data
20-39
40-59
60+
In Washington State in 2003,
Asthmatic Students are:



2 ½ times more likely to
require emergency care
2 times as likely to need
specialty care
Almost 5 times more likely
to require daily medications!
Asthma Diagnosis and Treatment:
Achieving Control

There needs to be a concerted effort by all
persons involved with the patient
diagnosed with asthma:





Primary Care Providers
Nursing staff
Pharmacists
School contacts: teachers,
coaches, etc.
Parents, care givers
Assessment & Monitoring
Remember:
Students with asthma and normal daily
function are still be at risk for
frequent acute asthma attacks if their
asthma is not controlled!!!
What can Teachers do?






Know which students have asthma
Have general idea of the different types of
asthma
Understand what triggers affect asthma
Understand asthma “action” plans
Recognize how the classroom may
contribute to asthma flares
When to be concerned
Asthma occurs in all age
groups




Myth: You do not “out grow” asthma in
most cases
Male children more apt to have asthma
until puberty
Obesity in females increases asthma risk
Highest percentage of asthma occurs in
the school-aged population
Asthma Myths




Exercise should be avoided!
People with asthma should
not participate in sports
Use of medications before/during
exercise/games should be prohibited
If athletes just run more, they will “outcondition” their asthma
Asthma types



Intermittent: often mild or occurring with
infections
Persistent: mild, moderate, severe
Exercise induced (EIA)
Asthma triggers






Infection
Environmental irritants/allergens
Cold air
Exercise: particularly
running, swimming, biking
Smoking
Any strong odor
“School Irritants”






Animals in classroom
Dust or mold in the classroom
Overuse of perfumes/hairsprays
Smoke or other noxious fumes
Physical activity
Others?
Exercise-induced Asthma (EIA)




All coaching and training staff need to be
able to recognize symptoms of asthma.
Desiccation (rapid drying) of the airway
principle cause.
Ignorance/lack of recognition can result in
a life-threatening event with a student.
Understanding of the disease creates a
win/win environment.
EIA (continued)

Symptoms seen with EIA


Coughing after running, both early in
“season” and after “adequate” conditioning
Frequent muscle cramping: so-called “sideaches”


Poor performance during practice and games



Lactic acid build-up
Oxygen debt
“Dogging it”
Increase in sx during cold weather
participation (Sport specific)
Asthma Medications

Inhalers



Quick-acting: albuterol
Controller type: salmeterol, steroids, cromolyn
Oral medications



Singulair®
Steroids
Theophylline
When to be concerned In
Students with Asthma






Repetitive coughing
Fever
During infectious disease seasons
Rapid heart rate/breathing rate
Complaints of air hunger
“Color” changes particularly with lips or
finger tips
Action Plans


All asthma students
should have one.
Are steps that a person
will initiate with asthma
flare or in anticipation of
asthma symptoms.
Action Plan (cont)

Steps:






STAY CALM!!!
Repeat medication (inhaler) as frequently as
needed
If respiratory distress not improving quickly (5
minutes, or so) consider calling EMT services
Use oxygen if available
Continue monitoring vital signs: pulse rate,
breathing rate, color of digits
Contact appropriate “emergency services”
Coaching/Trainer Action Plan




Know which of your athletes have asthma
Recognize when is an athlete “in trouble”!
Know what medications are available
Steps to consider when concerned:




Stop activity
Check vital signs
Let student/athlete administer own meds—
remember they should also know what to do
Have someone else call for assistance
Influenza 2009, 2010
School Year


It will be VERY important that all
teachers/coaches and student athletes get
annual influenza vaccine this year.
Also this year we WILL be adding the H1N1
vaccine with a separate injection.
Federal Regulations

In 2004, The Asthmatic/School Children’s
Treatment and Health Management Act of
2004 was enacted into law



Prior to federal legislation only 18 states had
laws protecting student access to asthma
meds
Brought WA State into compliance
Without Passing, Washington State could
have lost federal funding in schools
Washington State Asthma
Initiative

As of 2006/2007, students are allowed to
carry their own inhalers and epinephrine


They may use when they feel it is needed
School personnel need to become familiar
with the medications and side effects
Albuterol: rapid heart rate, shakiness
 Epinephrine: rapid heart rate, shakiness, nausea,
vomiting, increase BP

Asthma Registry




Will be “mandated” for ALL schools in
Washington State beginning 2010 school year
Several “pilot” school districts have begun their
registry
Will require continuous updating
Will eventually improved asthma care and
hopefully decrease the number of “emergencies”
for all students
Are Our Students With Asthma
Achieving Good Control?
NIH Goals of Asthma Therapy

Minimal or no symptoms day or night [Minimal use
of inhaled rescue (albuterol):<2 uses per week]


Minimal or no exacerbations (flares)
No limitations on activities; no missed
school/work

Maintain (near) normal breathing tests

Minimal or no adverse effects from medications
Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. NIH, NHLBI.
May 2007 (reprint). NIH publication 02-5075.
Evidence/Poor Control: Uncontrolled
Asthma in Children Age 4-11*


In US during 2007, ~70% of asthmatics
had asthma exacerbation in the past year.
Of These:
>50% required ER visit
>50% required oral steroids
~10% were hospitalized
*Asthma USA Summary---Summer 2007
Are There Tools That Teachers/
School Nurses Can Use to Help
Assess Asthma Control?
Asthma Control Test
Asthma Control Test™ (ACT)
1.
In the past 4 weeks, ho much of the time did your asthma keep you
from getting as much done at work, school or at home?
2.
During the past 4 weeks, how often have you had shortness
of breath?
3.
During the past 4 weeks, how often did your asthma symptoms
(wheezing, coughing, shortness of breath, chest tightness or pain)
wake you up at night, or earlier than usual in the morning?
4.
During the past 4 weeks, how often have you used your rescue
inhaler or nebulizer medication (such as albuterol)?
5.
How would you rate your asthma control during the past
4 weeks?
Copyright 2002, QualityMetric Incorporated.
Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Patient Total Score
Score
Childhood Asthma Control Test
Questions Completed by Child age 4-11 yrs
1. How is your asthma today?
0
Very bad
SCORE
1
Bad
2
Good
3
Very Good
2. How much of a problem is your asthma when you run, exercise or play sports?
0
It’s a big problem, I can’t do what I want to do.
1
2
It’s a problem and I don’t like it. It’s a little problem but it’s okay.
3
It’s not a problem
3. Do you cough because of your asthma?
0
Yes, all of the time.
1
Yes, most of the time.
2
Yes, some of the time.
3
No, none of the time
4. Do you wake up during the night because of your asthma?
0
Yes, all of the time.
1
Yes, most of the time.
2
Yes, some of the time.
3
No, none of the time
Childhood Asthma Control Test
Questions Completed by Parent/Caregiver
5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms?
5
4
3
2
1
0
Not at all
1-3 days/mo
4-10 days/mo
11-18 days/mo
19-24 days/mo
Everyday
6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?
5
4
3
2
1
0
Not at all
1-3 days/mo
4-10 days/mo
11-18 days/mo
19-24 days/mo
Everyday
7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?
5
4
3
2
1
0
Not at all
1-3 days/mo
4-10 days/mo
11-18 days/mo
19-24 days/mo
Everyday
TOTAL
Benefits of ACT
•
•
•
•
•
Reflects the multidimensional nature
of asthma control
May raise coach and patient
expectations
Encourages patient communication with
coaching staff
Simple 5-question quiz
Score of ≤19 suggests asthma may not
be controlled as well as it could be
Nathan RA, et al. J Allergy Clin Immunol. 2004;113:59-65.
Washington State Asthma Plan
-Developed by the WAI
-Released November 2005
-Contains chapter on Asthma in
educational settings
Washington State Asthma Plan



By 2010, increase the number of schools
reporting policies in place that implement
emergency care plans for all identified
students with asthma
By 2007, expand asthma-related school-based
data collection systems in Washington State
By 2010, increase the number of schools using
an evidence-based school environmental
assessment program
More Information about State
Asthma Plan



WAI web page:
www.alaw.org/asthmawashington asthma
initiative
DOH Asthma Program webpage:
www.doh.wa.gov/cfh/asthma/
THANK YOU! Questions??