Asthma Management Update

1
Asthma Management Update

• Lisa Musso, ARNP, MN, CPNP
• Division of Pediatric Pulmonary Medicine
• Childrens Hospital and Regional Medical Center

2
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

3
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

4
What is Asthma?

• Definition of Asthma
• Lung disease characterized by
• reversible airway obstruction
• airway inflammation
• increased airway responsiveness

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Pathophysiology

• Airway Changes
• Physiologic response
• inflammation
• bronchoconstriction
• hypersecretion of mucus
• All lead to airway plugging, hyperinflation and
  atelectasis.

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Airways in Untreated Asthma
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Airways After Administration of a Bronchodilator
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Airways After Addition of an Inhaled
Corticosteroid
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Asthma Severity

• Mild Intermittent
• days with symptoms lt 2/week
• nights with symptoms lt 2/month
• FEV1 or PEF gt 80

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Asthma Severity

• Mild Persistent
• days with symptoms gt2/week
• nights with symptoms 3 - 4/month
• FEV1 or PEF gt 80

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Asthma Severity

• Quick review of asthma severity
• Moderate persistent
• days with symptoms daily
• nights with symptoms gt 5/month
• FEV1 or PEF . 60 to lt80

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Asthma Severity

• Quick review of asthma severity
• Severe persistent
• days with symptoms continual
• nights with symptoms frequent
• FEV1 or PEF lt 60

13
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 lt 20
FEV1 or PEF of greater than or equal to 80
Variability of 20-30
3-6 times per week
Mild Persistent
3-4 times per month
Moderate Persistent
Daily symptoms
Greater than or equal to 5 times per month
FEV1 or PEF 60-80 Variability gt 30
Severe Persistent
FEV1 or PEF less than 60 Variability gt 30
Greater than 5 times per month
Continual symptoms
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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

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Infections

• Upper Respiratory infections
• Viral or bacterial
• colds
• ear aches
• sinus
• flu

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Smoke

• Active smoking
• Passive smoking
• Inside/outside home
• Inside/outside car

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Animals

• Furry, hairy
• Shedding
• Cats
• Dogs
• Birds
• Rabbits, hamsters, guinea pigs,rats

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To Run and Play

• Exercise
• How much is too much
• Recess
• Gym
• Team Sports

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To laugh or cry

• Laughing
• Crying
• Stress
• Anger
• Anxious
• Scared

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Things that Smell

• Perfume/cologne
• Incense
• Wood burning stoves
• Paint
• Cleaning products
• Hair products
• Foods

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Allergens

• dust mites
• animal dander
• molds, mildew, fungi
• pollensgrass, trees, weeds
• cockroaches

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Cold or Warm Air Weather Changes

• Cold air versus warm air
• To exercise or not
• Weather changes

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Prevention Strategies
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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

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Tobacco Smoke

• Controlling environmental tobacco smoke
• smoke-free child care environment
• smoke-free vehicle
• quit smoking
• smoke outside wearing smoking jacket

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Animal Dander

• Controlling animal dander
• keep cats, dogs, and other furry animals out
  of childrens area
• replace w/non furred or feathered animals

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Molds

• Controlling molds, mildews and fungi
• locate and remove mold growth
• check walls, floors, window molding, ceiling,
  under carpet
• dont lay carpet on cement
• prevent growth w/ good ventilation

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Roaches

• Controlling cockroaches
• restrict where food is eaten
• clean up after food preparation
• do not leave out pet food overnight
• cover trash bins
• dont store paper products/ bottles at floor
  level
• repair cracks, holes in foundation, plumbing,
  walls
• fix leaky faucets

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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

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Allergy Control

• Controlling dust mites
• cover mattresses and pillows
• minimize stuffed animals
• remove upholstered furniture
• vacuum frequently w/children absent
• maintain humidity _at_ about 40
• filters over heating ducts
• washable rugs instead of carpets

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Air Pollution

• Controlling exposure to air pollution/ozone
• Minimize outside activity on high pollution
  days
• avoid ozone-generating air cleaners

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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)

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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

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Triggers

• Drop in peak flow
• cough
• wheeze
• cold symptoms
• chest tightness
• difficulty breathing

• Fast breathing
• shortness of breath
• restlessness
• poor appetite
• headache
• dark circles

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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)

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Gadgets and Gizmos

• Nebulizers
• metered dose inhaler (MDI)
• spacer /spacer with mask
• diskhaler
• Aerolizers
• Turbohaler
• dry powder inhaler
• tablets
• liquids

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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

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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

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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 Take controller medications daily Have rescue medications handy
Yellow 50 - 80 of predicted Having some asthma symptoms Drop in peak flow Take controller medications Use rescue medications Monitor for improvement
Red Less than 50 of predicted Increased asthma symptoms Drop in peak flow Poor or no response to rescue medications Take controller medications daily Have rescue medications handy
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Asthma Management Plans

• Definition
• an written educational tool or plan which
  describes daily management and how to handle
  asthma episodes/excerbations

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ASTHMA MANAGEMENT PLAN
Known Asthma Symptoms
Name__________________________________________Drug
Allergies__________________________
Weight________
Plan A Take these preventative medicines all
the time Controller/Preventative Medicine How
delivered How much How often 15-20 minutes
before sports/exercising take
Green Zone Go
? coughing ? wheezing ? shortness of breath ?
tightness in chest ? other______________

• 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________

Known Asthma Triggers
Plan B Continue Plan A and add these quick
relief medicines Short-Acting ?2 Medicine How
delivered How much How often 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.
? respiratory infection ? animals
(specify)_______ ? foods (specify) ________ ?
cigarette smoke ? pollens/mold ? temperature
changes ? strong odors or fumes ? exercise ? wood
smoke ? dust/chalk dust ? other ________________
Yellow Zone Caution

• Increased asthma symptoms, 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__________

Plan C This is a Danger Zone! Take these
medicines immediately! Short-Acting ?2 Medicine
How delivered How much How often 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.
Red Zone DANGER

• Very short of breath, coughing and wheezing that
  wont stop
• Usual activities severely limited, cant 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
• Cant talk in complete sentences, ribs show with
  each breath
• Peak Flow less than 50 of personal best
• PFM less than ______________

Asthma Management Plan ASTHMA DISEASE MANAGEMENT
PROGRAM
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 medications ___Yes
___No He/she can reliably report asthma symptoms
___Yes ___No
PARENT SIGNATURE ________________________________
________________ Date signed___________________
______
Health Care Providers Signature_________________
__________________________Date_________________
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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

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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!

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Questions
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References

• Helpful Web Resources
• http//www.ginasthma.com
• http//www.guidelines.gov
• http//nhlbi.nih.gov
• http//lungusa.org