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Asthma Management Update Lisa Musso, ARNP, MN, CPNP Division of Pediatric Pulmonary Medicine Children’s Hospital and Regional Medical Center Asthma Management Update Objectives: Upon completion of this session, participants will be able to: Describe three changes that asthma causes in the airway Identify two types of medicine used to treat asthma List three typical asthma triggers and ways of minimizing their effect Asthma Management Update Overview: Airway Changes in Asthma How is Asthma Managed - Medications, Trigger Management Asthma Management Plan - Working with the Parent and Health Care Provider Triggers Trigger Management What is Asthma? Definition of Asthma: Lung disease characterized by; reversible airway obstruction airway inflammation increased airway responsiveness Pathophysiology Airway Changes: Physiologic response inflammation bronchoconstriction hypersecretion of mucus All lead to airway plugging, hyperinflation and atelectasis. Airways in Untreated Asthma Airways After Administration of a Bronchodilator Airways After Addition of an Inhaled Corticosteroid Asthma Severity Mild Intermittent days with symptoms: < 2/week nights with symptoms: < 2/month FEV1 or PEF: > 80% Asthma Severity Mild Persistent days with symptoms: >2/week nights with symptoms: 3 - 4/month FEV1 or PEF: > 80% Asthma Severity Quick review of asthma severity Moderate persistent days with symptoms: daily nights with symptoms: > 5/month FEV1 or PEF . 60% to <80% Asthma Severity Quick review of asthma severity Severe persistent days with symptoms: continual nights with symptoms: frequent FEV1 or PEF: < 60% Comparison of Asthma Severity Levels Severity Daytime Symptoms Nighttime Symptoms Lung Functions Mild Intermittent Less than or equal to 2 times per week Less than 2 times per month FEV1 or PEF of greater than or equal to 80% Variability < 20% Mild Persistent 3-6 times per week 3-4 times per month FEV1 or PEF of greater than or equal to 80% Variability of 20-30% Moderate Persistent Daily symptoms Greater than or equal to 5 times per month FEV1 or PEF 60-80% Variability > 30% Severe Persistent Continual symptoms Greater than 5 times per month FEV1 or PEF less than 60% Variability > 30% Triggers Viral infections Cigarette smoke Pets Exercise Strong emotion Strong odors Heart burn GE Reflux Seasonal allergies Dust mites Mold Cold weather Change in weather Air pollution Wood burning stoves Aspirin Sensitivity Infections Upper Respiratory infections Viral or bacterial “colds” ear aches sinus “flu” Smoke Active smoking Passive smoking Inside/outside home Inside/outside car Animals Furry, hairy Shedding Cats Dogs Birds Rabbits, hamsters, guinea pigs,rats To Run and Play Exercise How much is too much Recess Gym Team Sports To laugh or cry Laughing Crying Stress Anger Anxious Scared Things that Smell Perfume/cologne Incense Wood burning stoves Paint Cleaning products Hair products Foods Allergens dust mites animal dander molds, mildew, fungi pollens—grass, trees, weeds cockroaches Cold or Warm Air – Weather Changes Cold air versus warm air To exercise or not Weather changes Prevention Strategies Infections Prevention Good hand washing Use of tissues Cleaning of school areas Cleaning of toys Sharing of school supplies, equipment, toys Staying at home Completion of course of medication if given Tobacco Smoke Controlling environmental tobacco smoke: smoke-free child care environment smoke-free vehicle quit smoking smoke outside wearing “smoking jacket” Animal Dander Controlling animal dander: keep cats, dogs, and other furry animals out of children’s area replace w/non furred or feathered animals Molds Controlling molds, mildews and fungi: locate and remove mold growth check walls, floors, window molding, ceiling, under carpet don’t lay carpet on cement prevent growth w/ good ventilation Roaches Controlling cockroaches: restrict where food is eaten clean up after food preparation do not leave out pet food overnight cover trash bins don’t store paper products/ bottles at floor level repair cracks, holes in foundation, plumbing, walls fix leaky faucets Pollens Controlling pollen exposure: minimize outdoor activity on high pollen days close windows and doors on high pollen days run air conditioning allergy medicine as directed by parent/provider Allergy Control Controlling dust mites: cover mattresses and pillows minimize stuffed animals remove upholstered furniture vacuum frequently w/children absent maintain humidity @ about 40% filters over heating ducts washable rugs instead of carpets Air Pollution Controlling exposure to air pollution/ozone: Minimize outside activity on high pollution days avoid ozone-generating air cleaners Odors---the good and the bad Controlling exposure to fumes/sprays/strong odors: avoid aerosol sprays avoid strong “clean” smelling sprays avoid perfumes, after shave, candles, potpourri, incense clean with weak bleach solution and let air dry (see handout) Exercise Dealing with exercise-induced asthma: pre-treat as directed by parent/ provider Cover mouth and nose warm up before strenuous exercise rest periods minimize outdoor activity if high level of triggers are present Triggers Drop in peak flow cough wheeze cold symptoms chest tightness difficulty breathing Fast breathing shortness of breath restlessness poor appetite headache dark circles Medications Controller Cromolyn sodium Nedocromil sodium Inhaled Corticosteroids Leukotriene modifiers Long acting Beta 2 Sustained released theophylline Nebulized steroids Rescue Short acting Beta 2 Oral steroids (short burst) Gadgets and Gizmos Nebulizers metered dose inhaler (MDI) spacer /spacer with mask diskhaler Aerolizers Turbohaler dry powder inhaler tablets liquids Peak Flow Meters What do they really tell you? If asthma is worsening If asthma is better or worse If medications is helping Are you really having an asthma attack Peak Flow Meters Who should use one? Moderate to severe asthmatics Poor perceivers of severity of symptoms Newly diagnosed History of severe exacerbations Exercised Induced Asthmatics Peak Flow Zones Zones Signs and Symptoms Plan Green 80% of predicted No asthma symptoms No night time cough Normal activities No need for rescue medications Having some asthma symptoms Drop in peak flow Take controller medications daily Have rescue medications handy Yellow 50 - 80% of predicted Red Increased asthma symptoms Less than 50% of Drop in peak flow predicted Poor or no response to rescue medications Take controller medications Use rescue medications Monitor for Take controller improvement medications daily Have rescue medications handy Asthma Management Plans Definition: an written educational tool or plan which describes daily management and how to handle asthma episodes/excerbations ASTHMA MANAGEMENT PLANName__________________________________________Drug Allergies__________________________ Weight________ Green Zone: Go No symptoms of an asthma episode (no coughing, no wheezing, no shortness of breath, no nighttime awakenings) Able to do usual activities, run, play, attend school. Usual medications control asthma Peak Flow 80% of personal best PFM________to________ Yellow Zone: Caution Increased asthma symptoms, Plan A: Take these preventative medicines all the time: Controller/Preventative Medicine How delivered How much How often coughing wheezing shortness of breath tightness in chest other______________ Known Asthma Triggers 15-20 minutes before sports/exercising take: Plan B: Continue Plan A and add these quick relief medicines: Short-Acting 2 Medicine How delivered How much How often increased coughing, wheezing, work of breathing, shortness of breath, retractions, awakening at night Usual activities somewhat limited, unable to run, play, attend school as can normally Increased need for asthma medication Peak Flow 50-80% of personal best PFM__________to__________ Red Zone: Very short of breath, coughing and DANGER wheezing that won’t stop Usual activities severely limited, can’t walk, run, play, sleep or need to sleep upright Asthma symptoms have not gone away or return quickly (less than 4 hours) despite using asthma medications Can’t talk in complete sentences, ribs show with each breath Peak Flow less than 50% of personal best PFM less than ______________ Known Asthma Symptoms respiratory infection animals (specify)_______ foods (specify) ________ cigarette smoke pollens/mold If you feel better after taking this medication: Go back to your Green Zone medications and recheck every 4 hours for continued improvement or worsening of asthma symptoms. If you DO NOT feel better in 20 to 60 minutes or if you need Albuterol every 4 hours then Follow the RED ZONE Plan. Plan C: This is a Danger Zone! Take these medicines immediately! Short-Acting 2 Medicine How delivered How much How often temperature changes strong odors or fumes exercise wood smoke dust/chalk dust other ________________ Asthma Management Plan Oral steroid dose Next, call your own physician for further instructions. BUT, see the doctor RIGHT AWAY or go to the hospital if ANY of these things are happening: • Lips or fingernails are blue or gray, or • You are struggling to breathe, or • You do not feel any better 20 to 30 minutes after taking the extra medicine. FOR SCHOOL AND CHILD CARE MEDICATION PERMISSION: This patient has been instructed in the proper way to take his/her medications. He/she is capable of self-administering PARENT medications: ___Yes ___No SIGNATURE ________________________________________________ He/she can reliably report asthma symptoms: ___Yes ___No Health Care Provider’s Signature___________________________________________Date_________________ Date signed_________________________ ASTHMA DISEASE MANAGEMENT PROGRAM What does this mean in real life? No coughing No difficulty breathing No waking at night Normal activities No acute episodes that require PCP visit, ER or hospitalization No absences from school or work Normal ( or near normal) lung function Summary Asthma is a chronic disease It is controllable, some exacerbations sometimes can be prevented Different medications treat the different phases of asthma Asthma Management Plans really do help School Nurses do a great job! Questions References Helpful Web Resources http://www.ginasthma.com http://www.guidelines.gov http://nhlbi.nih.gov http://lungusa.org