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Asthma

Asthma . May 20, 2013. Definition. Involves bronchial airways, not lung tissue Characterized by REVERSIBLE narrowing Peribronchial muscle spasm Mucous production, excess volume and tenacity Edema of airway lining Reverses spontaneously or in response to meds. Asthma effects on airways.

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Asthma

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  1. Asthma May 20, 2013

  2. Definition • Involves bronchial airways, not lung tissue • Characterized by REVERSIBLE narrowing • Peribronchial muscle spasm • Mucous production, excess volume and tenacity • Edema of airway lining • Reverses spontaneously or in response to meds

  3. Asthma effects on airways

  4. Prevalence • 12.7% of children under 18 with at least one episode of wheezing • 9.6% of all US children with active asthma, equal to 9 million children Martinez,FD JACI 2011; 128:939-45

  5. Acute Symptoms • Coughing • From tight, dry, “croupy” to very “wet” • Wheezing • Tachypnea • Chest pain or back pain • Dyspnea • Speaking in incomplete sentences • Poor exercise tolerance

  6. Symptoms • Cough : localized in large airways, trachea and main bronchial tubes • Wheeze: localized in medium sized airways, secondary bronchial tubes • Silent but dyspneic: localized in small airways, terminal bronchioles

  7. Asthma Classification • By Severity and Frequency NAEPP • By types of triggers: allergic, non-allergic, both

  8. Severity and Frequency • Mild Intermittent • Needing rescue medication < twice weekly • OK to need pre exercise treatment • No HS wheeze/cough • Mild Persistent • Needing single maintenance medication daily • No breakthrough need for rescue or HS symptoms • Moderate Persistent • Needing two maintenance medications daily • Severe Persistent • Needing rescue medications despite three or more daily medications

  9. Asthma Classification • By Severity and Frequency • NAEPP • By Types of Triggers: • Allergic • Non-allergic • Both

  10. Classic Triggers • Viral infection • Exercise: alone or only if already inflamed • Irritants: Cigarette smoke, Perfumes, VOCs • Weather changes • Allergens • Dust mites • Pollens • Mold spores • Pet danders • Foods : Egg, milk, peanut, wheat, chocolate

  11. Goals of Treatment • No loss of school days • No restriction on sports/activities • No loss of sleep from asthma or from meds • No or minimal side effects from medications • Maintain lung function/prevent permanent injury

  12. Treatment • Based on Triggers • Allergic • Control of foods in school • Control of pollen exposure • Control of pet dander exposure • School projects designed with allergens in mind • Non Allergic • Exercise modification when necessary • Minimize irritants in classroom

  13. Treatment • Based on Severity and Frequency • NAEPP Guidelines: Step up Step down • Based on Triggers • Environmental controls • Allergens • Irritants • Infection avoidance • Exercise management

  14. Step up Step down • Albuterol alone: for exercise asthma or for rescue up to twice weekly, with no night symptoms • Step Up I: add Singulair or ICS if albuterol needed more than 2 times weekly or at all at night; consider allergy IT if appropriate • Step Up II: add combination ICS-LABA or increase ICS dose if still not controlled

  15. Step up Step down II • Step Up III: combine Singulair and higher dose combined ICS-LABA • Step Up IV: add oral corticsteroid to all of the above • Step Up V: consider Xolair for appropriate candidate • Step Down: to preceding level if symptoms are controlled for an appropriate amount of time

  16. NAEPP 2007 EPR-3

  17. Rescue Medications • Albuterol • Proventil, Ventolin, ProAir, albuterol HFA • Xopenex (Lev albuterol) • MDI vs nebulizer

  18. Preventers • Anti Leukotrienes– Singulair, Zyflo, Accolate • Mast cell stabilizers – Intal • Inhaled corticosteroids – Flovent, Qvar, Pulmicort, Alvesco, Asmanex • Combination ICS with LABAs – Advair, Symbicort, Dulera • Oral corticosteroids – prednisone, Medrol (methylprednisolone) Orapred (prednisolone)

  19. Your RolePrevention • Assess and address risks in classroom and school • Identify students at risk – asthma control test • Consider environmental strategies: Air conditioning Timing of outdoor activities Types of class projects or field trips • Educate students and faculty

  20. Red Flags • Refilling rescue inhaler more than once per month • “Sudden” or gradual loss of interest in sports/playing • Needing rescue inhaler at night…even once • Needing rescue inhaler more than every 4 hours • Rescue inhaler doesn’t “work” • May repeat every 15 minutes for 3 doses only

  21. Your Role Treatment • Assess • Peak Flow • O2 Sat • Pulse • Respiratory rate • Respiratory effort • Skin, mucous membrane color • Ease of speaking/quality of speech • Treat per asthma action plan • Communicate

  22. Communicate • Preventive measures • With classroom personnel • With cafeteria personnel • With gym department • With janitors (via principal, school doctor) • After an acute episode • With emergency personnel • With parents • With individuals involved at time of episode

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