Asthma Management Update

Lisa Musso, ARNP, MN, CPNP Division of Pediatric Pulmonary Medicine

Children’s Hospital and Regional Medical Center

Objectives:Upon completion of this session, participants

will be able to:Describe three changes that asthma causes in the airwayIdentify two types of medicine used to treat asthmaList 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

Asthma Management Update

What is Asthma?

Definition of Asthma:

Lung disease characterized by; reversible airway obstructionairway inflammation increased airway responsiveness

Airway Changes:

Physiologic response inflammationbronchoconstrictionhypersecretion of mucusAll lead to airway plugging, hyperinflation

and atelectasis.

Pathophysiology

                                                                                                                                                                                       

                 

Airways in Untreated Asthma

                                                                                                                                                                                         

                         

Airways After Administration of a Bronchodilator

                                                                                                                                                           

Airways After Addition of an Inhaled Corticosteroid

Mild Intermittentdays with symptoms: < 2/weeknights with symptoms: < 2/monthFEV1 or PEF: > 80%

Asthma Severity

Mild Persistentdays with symptoms: >2/weeknights with symptoms: 3 - 4/monthFEV1 or PEF: > 80%

Asthma Severity

Quick review of asthma severity

Moderate persistentdays with symptoms: dailynights with symptoms: > 5/monthFEV1 or PEF . 60% to <80%

Asthma Severity

Quick review of asthma severity

Severe persistentdays with symptoms: continualnights with symptoms: frequentFEV1 or PEF: < 60%

Asthma Severity

Severity Daytime Symptoms

Nighttime Symptoms

Lung Functions

Comparison of Asthma Severity Levels

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 allergiesDust mitesMoldCold weatherChange in weatherAir pollutionWood burning stovesAspirin Sensitivity

Upper Respiratory infections

Viral or bacterial

“colds”

ear aches

sinus

“flu”

Infections

Smoke

Active smoking

Passive smoking

Inside/outside home

Inside/outside car

Animals

Furry, hairyShedding

CatsDogsBirdsRabbits, hamsters, guinea pigs,rats

To Run and Play

ExerciseHow much is too muchRecessGymTeam Sports

Laughing

Crying

Stress

Anger

Anxious

Scared

To laugh or cry

Things that Smell

Perfume/cologne

Incense

Wood burning stoves

Paint

Cleaning products

Hair products

Foods

dust mites

animal dander

molds, mildew, fungi

pollens—grass, trees, weeds

cockroaches

Allergens

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

Controlling environmental tobacco smoke:

smoke-free child care environment

smoke-free vehicle

quit smoking

smoke outside wearing “smoking jacket”

Tobacco Smoke

Controlling animal dander:

keep cats, dogs, and other furry animals out of children’s area

replace w/non furred or feathered animals

Animal Dander

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

Molds

Controlling cockroaches:restrict where food is eatenclean up after food preparationdo not leave out pet food overnightcover trash binsdon’t store paper products/ bottles at floor levelrepair cracks, holes in foundation, plumbing, wallsfix leaky faucets

Roaches

Controlling pollen exposure:minimize outdoor activity on high pollen

daysclose windows and doors on high pollen daysrun air conditioningallergy medicine as directed by

parent/provider

Pollens

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

Allergy Control

Controlling exposure to air pollution/ozone:

Minimize outside activity on high pollution days

avoid ozone-generating air cleaners

Air Pollution

Controlling exposure to fumes/sprays/strong odors:avoid aerosol spraysavoid strong “clean” smelling spraysavoid perfumes, after shave, candles,

potpourri, incenseclean with weak bleach solution and let air dry (see handout)

Odors---the good and the bad

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

Exercise

Drop in peak flowcoughwheezecold symptomschest tightnessdifficulty breathing

Fast breathing

shortness of breath

restlessness

poor appetite

headache

dark circles

Triggers

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)

Medications

Nebulizersmetered dose inhaler (MDI)

spacer /spacer with maskdiskhaler

AerolizersTurbohaler

dry powder inhalertabletsliquids

Gadgets and Gizmos

Peak Flow Meters

What do they really tell you? If asthma is worsening If asthma is better or worse If medications is helpingAre you really having an asthma attack

Peak Flow Meters

Who should use one?Moderate to severe asthmaticsPoor perceivers of severity of symptomsNewly diagnosedHistory of severe exacerbationsExercised Induced Asthmatics

Peak Flow Zones

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 improvementRed

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

Zones Signs and Symptoms Plan

Definition:an written educational tool or plan which

describes daily management and how to handle asthma episodes/excerbations

Asthma Management Plans

Known Asthma

Symptoms

ASTHMA MANAGEMENT PLAN Name__________________________________________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________

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:

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 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.

Red Zone: DANGER Very short of breath, coughing and

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 ______________

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.

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 ___NoHe/she can reliably report asthma symptoms: ___Yes ___NoHealth Care Provider’s Signature___________________________________________Date_________________

PARENT SIGNATURE ________________________________________________

Date signed_________________________

Known Asthma Triggers

Asthma Management

Plan

ASTHMA DISEASE

MANAGEMENT PROGRAM

respiratory infection

animals (specify)_______

foods (specify) ________

cigarette smoke

pollens/mold

temperature changes

strong odors or fumes

exercise

wood smoke

dust/chalk dust

other ________________

coughing

wheezing

shortness of breath

tightness in chest

other______________

No coughing

No difficulty breathing

No waking at night

Normal activities

No acute episodes that require PCP visit, ER or hospitalizationNo absences from school or workNormal ( or near normal) lung function

What does this mean in real life?

Summary

Asthma is a chronic diseaseIt is controllable, some exacerbations sometimes can be preventedDifferent medications treat the different phases of asthmaAsthma Management Plans really do helpSchool Nurses do a great job!

Questions

References

Helpful Web Resourceshttp://www.ginasthma.comhttp://www.guidelines.govhttp://nhlbi.nih.govhttp://lungusa.org