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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??