AsthmaAsthma

A Presentation on Asthma Management and Prevention

What is Asthma? Chronic disease of the airways that may cause

WheezingBreathlessnessChest tightnessNighttime or early morning coughing

Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

Pathology of Asthma

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Normal Asthma

Asthma involves inflammation of the airways

Asthma Prevalence in the United States

National Center for Environmental Health Division of Environmental Hazards and Health Effects

June 2014

IntroductionAsthma:

affects 25.7 million people, including 7.0 million children under 18;

is a significant health and economic burden to patients, their families, and society:

In 2010, 1.8 million people visited an ED for asthma-related care and 439,000 people were hospitalized because of asthma

IntroductionAsthma prevalence is an estimate of the percentage of the U.S. population with asthma. Prevalence estimates help us understand the burden of asthma on the nation.

Asthma “period prevalence” is the percentage of the U.S. population that had asthma in the previous 12 months.

“Current” asthma prevalence is the percentage of the U.S. population who had been diagnosed with asthma and had asthma at the time of the survey.

Asthma “period prevalence” was the original prevalence measure (1980-1996). The survey was redesigned in 1997 and this measure was replaced by lifetime prevalence (not presented in slides) and asthma episode or attack in the past 12 months. In 2001, another measure was added to assess current asthma prevalence.

Current asthma prevalence, 2001-2010

Asthma period prevalence, 1980-1996

Asthma Period Prevalence and Current Asthma Prevalence: United States, 1980-2010

The percentage of the U.S. population with asthma increased from 3.1% in 1980 to 5.5% in 1996 and 7.3% in 2001 to 8.4% in 2010.

Total number of persons Percent

Current Asthma Prevalence: United States, 2001-2010

One in 12 people (about 26 million, or 8% of the U.S. population) had asthma in 2010, compared with 1 in 14 (about 20 million, or 7%) in 2001.

Year

Current Asthma Prevalence by Race and Ethnicity:United States, 2001-2010

Blacks are more likely to have asthma than both Whites and Hispanics.

Current Asthma Prevalence by Age Group, Sex, Race and Ethnicity, Poverty Status, Geographic Region, and Urbanicity: United States,

Average Annual 2008-2010

Children, females, Blacks, and Puerto Ricans are more likely to have asthma.

People with lower annual household income were more likely to have asthma.

Residents of the Northeast and Midwest were more likely to have asthma.

Living in or not in a city did not affect the chances of having asthma.

Child and Adult Current Asthma Prevalence by Age and Sex: United States, 2006-2010

Among children aged 0-14, boys were more likely than girls to have asthma. Boys and girls aged 15-17 years had asthma at the same rate..

Among adults women were more likely than men to have asthma.

Children aged 0-17 years

Adults aged 18 and over

Asthma Attack Prevalence among Children and Adults with Current Asthma: United States, 2001-2010

From 2001 to 2010 both children and adults had fewer asthma attacks.For children, asthma attacks declined from at least one asthma attack in the previous 12 months for 61.7% of children with asthma in

2001 to 58.3% in 2010.For adults, asthma attacks declined from at least one asthma attack in the previous 12 months for 53.8% of adults with asthma in

2001, to 49.1% in 2010.

Asthma Attack Prevalence among Persons with Current Asthma by Age Group, Sex, Race and Ethnicity, Poverty Status, and Geographic Region:

Unites States, Average Annual 2008-2010

From 2008 to 2010 asthma attacks occurred more often in children and women, among families whose income was below 100% of the federal poverty threshold, and in the South and West.

Race or ethnicity did not significantly affect asthma attack prevalence.

Technical NotesAsthma Period Prevalence and Current Asthma Prevalence: Estimates of asthma prevalence indicate the percentage of the population with asthma at a given point in time and represent the burden on the U.S. population. Asthma prevalence data are self-reported by respondents to the National Health Interview Survey (NHIS). Asthma period prevalence was the original measure (1980-1996) of U.S. asthma prevalence and estimated the percentage of the population that had asthma in the previous 12 months. From 1997-2000, a redesign of the NHIS questions resulted in a break in the trend data as the new questions were not fully comparable to the previous questions. Beginning in 2001, current asthma prevalence (measured by the question, ‘‘Do you still have asthma?’’ for those with an asthma diagnosis) was introduced to identify all persons with asthma. Current asthma prevalence estimates from 2001 onward are point prevalence (previous 12 months) estimates and therefore are not directly comparable with asthma period prevalence estimates from 1980 to 1996

Behavioral Risk Factor Surveillance System (BRFSS): State asthma prevalence rates on the map come from the BRFSS. The BRFSS is a state-based, random-digit-dialed telephone survey of the noninstitutionalized civilian population 18 years of age and older. It monitors the prevalence of the major behavioral risks among adults associated with premature illness and death. Information from the survey is used to improve the health of the American people. More information about BRFSS can be found at: http://www.cdc.gov/brfss/.

Sources

Sources (continued)

What is Epidemiology?

The study of the distribution and determinants of diseases and injuries in human populations.

Source: Mausner and Kramer, Mausner and Bahn Epidemiology- An Introductory Text, 1985.

Risk Factors for Developing Asthma

Genetic characteristics Occupational exposures Environmental exposures

Risk Factors for Developing Asthma: Genetic Characteristics

AtopyThe body’s predisposition to develop an antibody

called immunoglobulin E (IgE) in response to exposure to environmental allergens

Can be measured in the bloodIncludes allergic rhinitis, asthma, hay fever, and

eczema

Risk Factors for Developing Asthma: Environmental Exposure

Clearing the Air: Asthma and Indoor Air Exposures

http://www.iom.edu (Publications)Institute of Medicine, 2000Committee on the Assessment of Asthma and Indoor Air

Review of current evidence about indoor air exposures and asthma

Clearing the Air:Categories for Associations of Various

Elements

Sufficient evidence of a causal relationshipSufficient evidence of an associationLimited or suggested evidence of an

associationInadequate or insufficient evidence to

determine whether an association existsLimited or suggestive evidence of no

association

Clearing the Air:Indoor Air Exposures & Asthma Development

Biological Agents Sufficient evidence of causal

relationship House dust mite

Sufficient evidence of association None found

Limited or suggestive evidence of association Cockroach (among pre-school aged

children) Respiratory syncytial virus (RSV)

Chemical Agents Sufficient evidence of causal

relationship None found

Sufficient evidence of association Environmental Tobacco Smoke

(among pre-school aged children)

Limited or suggestive evidence of association None found

Clearing the Air: Indoor Air Exposures & Asthma Exacerbation

Biological Agents Sufficient evidence of causal

relationship Cat Cockroach House dust mite

Sufficient evidence of an association Dog Fungus/Molds Rhinovirus

Limited or suggestive evidence of association

Domestic birds Chlamydia and Mycoplasma pneumonia RSV

Chemical Agents Sufficient evidence of causal

relationship Environmental tobacco smoke

(among pre-school aged children) Sufficient evidence of

association NO2, NOX (high levels)

Limited or suggestive evidence of association Environmental Tobacco Smoke

(among school-aged, older children, and adults)

Formaldehyde Fragrances

Reducing Exposure to House Dust Mites

Use bedding encasements

Wash bed linens weekly Avoid down fillings Limit stuffed animals to

those that can be washed Reduce humidity level

(between 30% and 50% relative humidity per EPR-3)

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Reducing Exposure to Environmental Tobacco Smoke

Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults.

Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.

Reducing Exposure to Cockroaches

Remove as many water and food sources as possible to avoid cockroaches.

Reducing Exposure to Pets

People who are allergic to pets should not have them in the house.

At a minimum, do not allow pets in the bedroom.

Reducing Exposure to Mold

Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations.

Other Asthma Triggers

Air pollution

Trees, grass, and weed pollen

Clinical Management of Asthma

Expert Panel Report 3

National Asthma Education and Prevention Program

National Heart, Lung and Blood Institute, 2007

Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

2007 NAEPP EPR-3

Treatment recommendations based on:Severity ControlResponsiveness

Provide patient self-management education at multiple points of care

Reduce exposure to inhaled indoor allergens to control asthma-multifaceted approach

Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

What is GIP?

Guidelines Implementation Panel Report for Expert Panel Report 3

Recommendations and strategies to implement EPR-3

Six key messages

Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf

GIP’s Six Key Messages

Inhaled Corticosteroids

Asthma Action Plan

Asthma Severity

Asthma Control

Follow-up Visits

Allergen and Irritant Exposure Control

Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf

Diagnosing Asthma: Medical History

SymptomsCoughingWheezingShortness of breathChest tightness

Symptom Patterns SeverityFamily History

Diagnosing Asthma

Troublesome cough, particularly at nightAwakened by coughingCoughing or wheezing after physical

activityBreathing problems during particular

seasonsCoughing, wheezing, or chest tightness

after allergen exposure Colds that last more than 10 daysRelief when medication is used

Diagnosing Asthma

Wheezing sounds during normal breathing

Hyperexpansion of the thorax

Increased nasal secretions or nasal polyps

Atopic dermatitis, eczema, or other allergic skin conditions

Diagnosing Asthma:Spirometry

Test lung function when diagnosing asthma

Medications to Treat Asthma

Medications come in several forms.

Two major categories of medications are:Long-term controlQuick relief

Medications to Treat Asthma:Long-Term Control

Taken daily over a long period of time

Used to reduce inflammation, relax airway muscles, and improve symptoms and lung functionInhaled corticosteroidsLong-acting beta2-agonists

Leukotriene modifiers

Medications to Treat Asthma: Quick-Relief

Used in acute episodes

Generally short-acting beta2agonists

Medications to Treat Asthma: How to Use a Spray Inhaler

The health-care provider should evaluate inhaler technique at each visit.

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative for Asthma Created and funded by NIH/NHLBI

Medications to Treat Asthma: Inhalers and Spacers

Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication.

Medications to Treat Asthma:Nebulizer

Machine produces a mist of the medication

Used for small children or for severe asthma episodes

No evidence that it is more effective than an inhaler used with a spacer

Managing Asthma: Asthma Management Goals

Achieve and maintain control of symptomsMaintain normal activity levels, including

exerciseMaintain pulmonary function as close to

normal levels as possiblePrevent asthma exacerbationsAvoid adverse effects from asthma

medicationsPrevent asthma mortality

Managing Asthma: Asthma Action Plan

Develop with a physician

Tailor to meet individual needs

Educate patients and families about all aspects of planRecognizing symptomsMedication benefits and side effectsProper use of inhalers and Peak Expiratory Flow

(PEF) meters

Managing Asthma: Sample Asthma Action Plan

Describes medicines to use and actions to take

National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.

Managing Asthma: Peak Expiratory Flow (PEF) Meters

Allows patient to assess status of his/her asthma

Persons who use peak flow meters should do so frequently

Many physicians require for all severe patients

Managing Asthma: Peak Flow Chart

People with moderate or severe asthma should take readings:Every morningEvery eveningAfter an

exacerbationBefore inhaling

certain medications

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI

Managing Asthma:Indications of a Severe Attack

Breathless at restHunched forwardSpeaks in words rather than complete sentences AgitatedPeak flow rate less than 60% of normal

Managing Asthma:Things People with Asthma Can Do

Have an individual management plan containingYour medications (controller and quick-relief)Your asthma triggersWhat to do when you are having an asthma attack

Educate yourself and others aboutAsthma Action Plans Environmental interventions

Seek help from asthma resources Join an asthma support group

A Public Health Response to Asthma

A call to action for organizations and people with an interest in asthma management to work as partners in reducing the burden of asthma within our nation’s communities.

A Public Health Response to Asthma: Surveillance

Over time…How much asthma does the population have? How severe is asthma across the population? How well controlled is asthma in the population?What is the cost of asthma?

A Public Health Response to Asthma: Uses of Surveillance Data

Basis for planning and targeting intervention activities

Evaluating intervention activities

A Public Health Response to Asthma Education

Education programs can be targeted to:People with asthmaParents of children with asthmaMedical care providersSchool staff Public

A Public Health Response to Asthma: Coalition

Successful asthma campaigns need the cooperation of committed partners.

A Public Health Response to Asthma: Advocacy

Asthma needs to be addressed comprehensively by multiple government and non-government agencies.

A Public Health Response to Asthma: Interventions

Medical managementEducationEnvironment Schools

A Public Health Response to Asthma: Medical Management Interventions

Ensure people with asthma know about their disease and are empowered to demand appropriate management

A Public Health Response to Asthma: Environmental Interventions

Help people create and maintain healthy home, school, and work environments.

Environmental interventions may consist of: Assessments to identify

asthma triggers Education on how to remove

asthma triggers Remediation to remove

asthma triggers

A Public Health Response to Asthma: School Intervention Science-Based Guidance

Management and support systems

Health and mental health services

Asthma education for students, staff, and parents

Healthy school environment

Physical education and activity

School, family, and community efforts

Source: www.cdc.gov/HealthyYouth/asthma/strategies

Key Aspects

Require team effortCoordinate health, including mental and physical

health, education, environment, family, and community efforts

Assess needs of school and prioritize (every action step is not feasible to every school or district)

Focus on students with frequent asthma symptoms, health room visits, and absenteeism

1. Management & Support Systems

Family/CommunityInvolvement

Physical Education

NutritionServices

Healthy SchoolEnvironment

Health Promotion For Staff

Health Education

Health Services

Counseling, Psychological, and

Social Services

4. Healthy School Environment

2. Health & Mental Health

Services

3. Asthma Education

6. School, Family, & Community

Efforts

5. Physical Education &

Activity

A Public Health Response to Asthma: School

A leading chronic disease cause of school absence

Common disease addressed by school nurses

Affects teachers, administrators, nurses, coaches, students, bus drivers, after school program staff, maintenance personnel

are likely to have asthma.*

On average, 3 children in a classroom of 30

*Epidemiology and Statistics Unit. Trends in Asthma Morbidity and Mortality. NYC: ALA, July 2006.

A Public Health Response to Asthma:

What can make asthma worse in the school?

Mold and mildew Animals in classroom Carpeted classrooms Cockroaches

Poor air quality

Asthma-Friendly School DVD and Toolkit

Objectives Personal stories to relate to viewer Aspects of an asthma-friendly schoolSix strategies for addressing asthma in a coordinated school health programPotential impact of asthma-friendly schools

A Public Health Response to Asthma: School Actions

Establish policies and procedures to support children with asthma.

Keep students’ asthma action plans at the school. Make medications available

During school hours Before physical activity and sports During before- and after-school programs On field trips or when away from campus

Train school staff to recognize signs of an asthma attack and to use appropriate medications.

A Public Health Response to Asthma: Evaluation

The systematic investigation of the structure, activities, or outcomes of asthma control programs.

Are we doing the right thing?

Are we doing things right?

Benefits of Program Evaluation

Evaluations help asthma programs Manage resources and services effectively Understand reasons for current performance Build capacity Plan and implement new activities Demonstrate the value of their efforts Ensure accountability

Using Evaluation to Improve Programs

Highlight effective program componentsRecognize achievementsReplicate successes

Assess and prioritize needs

Target program improvements

Advocate for the program

Framework for Program Evaluation

A Public Health Response to Asthma: Summary

Asthma is a complex disease that is not yet preventable or curable.

Asthma can be managed with medication, environmental changes, and behavior modifications.

By working together, we can ensure that people with asthma enjoy a high quality of life.

Resources

National Asthma Education and Prevention Program http://www.nhlbi.nih.gov/about/naepp/

Asthma and Allergy Foundation of America http://www.aafa.org

American Lung Association http://www.lungusa.org

American Academy of Allergy, Asthma, and Immunology http://www.aaaai.org

Allergy and Asthma Network/Mothers of Asthmatics, Inc. http://www.aanma.org

Resources

American College of Allergy, Asthma, and Immunology http://www.acaai.org

American College of Chest Physicians http://www.chestnet.org

American Thoracic Society http://www.thoracic.org

The Centers for Disease Control and Prevention http://www.cdc.gov/asthma