Asthma and the School Aged Child

1. Asthma and the School Aged Child Michelle Harkins, MD University of New Mexico Project Echo

4. Asthma and School Absences • Asthma is one of the leading causes of school absenteeism. • In 2003, an estimated 12.8 million school days were missed due to asthma among the more than 4 million children who reported at least one asthma attack in the preceding year. • 39% reported receiving an asthma management plan Akinbami LJ. The State of Childhood Asthma (pdf 365K), United States, 1980-2005. Advance data from Vital and Health Statistics: no 381, Revised December 29, 2006. Hyattsville, MD: National Center for Health Statistics, 2006

5. Asthma in New Mexico • 204,292 adults have had an asthma dx • 68.8K under age 17 • # of days missed by NM School children for asthma? • Estimated cost of treating asthma in those under 18 is $3.2 billion per year (Weiss KB, Sullivan SD, Lytle SD) • 30-40 deaths/year from asthma • Mortality decreased from 3.1/100,000 in 1993 to 1.5/100,000 in 2004 • >65 years at greatest risk • Dept. of Health Statistics, 2007, BRFSS

8. 14.9* 23.3 33.1 16.8* 46.7 46.7 41.5 41.5 13.6* 13.6* 7.6* 25.5 14.2 13.2 49.2 49.2 28.7* 28.7* 26.8 23.4 42.9* 42.9* 27.7 27.7 9.0* 10.1* 15.5* 7.9* 0.0* 0.0* 0.0* 0.0* 56.5 38.2 9.5 10.3 22.5 22.5 35.1 35.1 39.2 39.2 11.1 13.7 12.0 15.3 41.8 41.8 16.5 14.9 19.0* 17.8* 135.6 135.6 17.7* 14.9 14.9 19.4 62.2 62.2 8.0* 8.0* 4.5* 4.5* 9.1* 6.6* 21.8 21.8 18.2 13.3 22.2 22.2 63.3 64.7 103.2 103.2 20.6* 22.7* 17.7* 17.7* 14.8* 6.2* 13.9* 5.8* 50.9 42.9 104.2 104.2 144.0 144.0 0.0 – 10.1 14.8* 14.8* 9.2* 13.7* 37.0 37.0 10.2 – 14.2 15.1 35.4 63.9 63.9 14.3 – 23.3 69.1 69.1 6.3* 10.5* 11.3* 11.6 77.9 23.4 – 77.9 60.4 60.4 118.2 76.3 76.3 10.9 11.4 80.1 80.1 23.7 46.5 11.5 11.7 37.9 37.9 95.3 95.3 75.4 75.4 24.5 26.1 15.6* 26.2* 24.0* 24.0* Asthma Hospitalization Rates (Age<15), New Mexico 2006-2008 STATE RATE: 20.1 Rates per 10,000 population. * Rates based of fewer than 20 cases should be interpreted with caution. SOURCE: NMHPC.

9. What is Asthma? • A chronic inflammatory disease of the airways • The majority of asthma diagnosed in childhood • Common Symptoms: • Cough-may be only at night • Wheezing • Chest Tightness • Shortness of breath • Mucus (phlegm production)

10. Features of Asthma • Intermittent wheezing, chest tightness, cough—times when there are no symptoms • Bronchial hyperresponsiveness-”twitchy” airways • Airway inflammation • Airway obstruction - initially reversible • gradual decline in lung function • Peak Flow variability

11. All that wheezes is not asthma... • Bronchiolitis: RSV • Aspiration (micro versus foreign body) • Vocal cord dysfunction, laryngeal dysfunction • Competitive athletes • 35% of “severe asthma” referred to specialty clinics • CF • Tracheal malacia

12. Pathophysiology of Asthma

13. Epithelial Damage in Asthma Normal Asthmatic Jeffery P. In: Asthma, Academic Press 1998.

14. Asthma Pathophysiology Smooth Muscle Dysfunction Airway Inflammation • Inflammatory cell infiltration/activation • Mucosal edema • Cellular proliferation • Epithelial damage • Basement membrane thickening • Bronchoconstriction • Bronchial hyperreactivity • Hypertrophy/hyperplasia • Inflammatory mediator release Symptoms/Exacerbations

15. Major Triggers • Tobacco smoke • Dust mites • Animal dander • Cockroach allergens • Indoor mold • Wood smoke • Formaldehyde • Volatile organic compounds • Air pollution • Cold, damp, windy, stormy weather • Sudden temperature changes • Weeds, trees, grass • Strenuous exercise • Respiratory infections • Common food allergies

16. Bronchospasm caused by activity Distinct from environmental induced asthma Does not cause swelling, inflammation or mucus production Can be avoided by giving medication prior to activity and by warming up and cooling down Exercise Induced Asthma

17. Bronchospasm caused by activity Some activity more likely than others to trigger it Cold environment: skiing, ice hockey Heavy exertion: Soccer, long distance running Exercising when you have a viral cold Exercise Induced Asthma

18. Symptoms include Coughing Wheezing Chest tightness Symptoms may begin during activity and peak in severity 10-20 minutes after stopping Can spontaneously resolve 20-30 minutes after its onset Exercise Induced Asthma

19. Epidemiology • Prevalence 7-20% of the general population • 80% of patients with asthma have some degree of EIB • Exercise is not a risk factor for asthma, rather a trigger • ?Exercise may help prevent onset of asthma in children • Decrease in physical activity may play a role in increased in asthma prevalence • JACI 2005 Lucas SR, Platts-Mills TA

20. Schools • Teachers and coaches should be notified of children with asthma • Students are encouraged to be active • May need to take medications prior to activity

21. Use bronchodilator 10-15 minutes before onset of activity Do warm-up/cool down exercises Check ozone/allergy warnings Never encourage a child to “tough it out” Prevention of Exercise InducedAsthma

22. Benchmarks of Good Asthma Control • No coughing or wheezing • No shortness of breath or rapid breathing • No waking up at night • Normal physical activities • No school absences due to asthma • No missed time from work for parent or caregiver

23. The Four Components of Asthma Management • Measures of assessment and monitoring • Objective tests, physical exam, history • Severity and control of asthma • Education for a partnership in asthma care • Control of environmental factors and comorbid conditions that affect asthma • Pharmacologic therapy

24. Asthma Goals for School Health 1. Infrastructure & Supportive Policies 2. Health & Mental Health Services 6. Family & Community Involvement 5. Physical Education & Activity 3. Asthma Education 4. Healthy School Environment

25. Goal 1: Infrastructure & Supportive Policies Establish emergency plan for asthma episodes at school Ensure adequate student health records Encourage policies to allow students to carry and self-administer medications Ensure immediate access to medications during all school activities

26. Goal 1: Infrastructure & Supportive Policies Establish Emergency Plan for Asthma Episodes at School Develop school-wide emergency plans/procedures. Include: • Respiratory distress treatment protocols • Procedures to access students’ individualized asthma action plans • Plan for students without an individualized plan

27. Goal 1: Infrastructure & Supportive Policies Ensure immediate access to medications at all times • Allow students to carry and self- administer their asthma medications (NM state law) • Designated secure storage location for medications that are not being self-carried

28. Goal 2: Health & Mental Health Services • Identify students with asthma • Monitor students’ asthma • Obtain and use a written asthma action plan for all students with asthma • Provide full-time nursing services • Train, supervise and delegate to health assistants and education staff, as appropriate

29. Goal 2: Health & Mental Health Services Identify Students with Asthma • Obtain information about asthma diagnosis from school health forms • Review student health records • Focus particularly on students with poorly controlled asthma. • Screening large groups of students for asthma is not recommended.

30. Goal 2: Health & Mental Health Services Monitor Students’ Asthma All school staff should: • Watch for symptoms of very poorly controlled asthma • Use attendance records to monitor absenteeism of students with asthma • Use health room records to monitor: • Medication logs • Asthma-related sick visits to the health room • Number of days sent home from school due to asthma

31. Goal 2: Health & Mental Health Services Obtain and use an asthma action plan for each student with asthma An action plan includes: • Prescribed daily and quick-relief medicines • Treatment guidelines for handling asthma episodes • Emergency contacts • List of things that make the student’s asthma worse The plan should be: • Placed in student’s health record • Shared with appropriate staff • Updated annually and as needed

32. Goal 2: Health & Mental Health Services • Consider providing individual case management for students with poorly controlled asthma • Use 504 plans or IEPs for students with asthma, as appropriate • Facilitate links to child health insurance programs and providers • Establish strong links to asthma care clinicians (Project Echo) • Communication between the student’s asthma care clinician, parent, and school staff is vital.

33. Goal 3: Asthma Education For students with asthma, the school nurse should: • Teach and monitor correct inhaler techniques • Teach how students can monitor their asthma • Teach when and how to get help • Offer asthma education programs

34. Goal 3: Asthma Education For all students, teach them: • about lung health • what asthma is • how to support classmates with asthma • what to do if a classmate has an asthma episode

35. Goal 3: Asthma Education For parents and guardians of students with asthma: • Provide education and resources to help their children better manage their asthma at school and home. • Communicate any problems/changes you see at school.

36. Goal 3: Asthma Education For faculty and staff, provide annual professional development on: • Asthma basics & emergency response • What different staff can do to make their school asthma-friendly

37. Goal 4: Healthy School Environment Adopt and enforce tobacco-free policy that prohibits tobacco use at all times, on all school property, by all people, and for all school activities

38. Goal 4: Healthy School Environment Eliminate or reduce exposure to things that make asthma worse by using good housekeeping and maintenance practices • Use integrated pest management techniques to control pests • Use least toxic products available • Keep temperature and humidity at appropriate settings • Maintain HVAC systems • Dry up damp and wet areas immediately • Consider removing furred and feathered animals

39. Goal 5: Physical Education & Activity • Encourage full participation when student is well • Allow pretreatment and/or warm-up before physical activity (if needed) • Ensure student access to quick-relief medication during activity • Provide modified activities as needed

40. Why is asthma such a problem? • Patients and families are not recognizing the symptoms of asthma. • Clinicians are not making the diagnosis. • Clinicians are either not providing state of the art care, or, if they are, patients are not adhering to the recommended programs.

41. Barriers to Achieving Optimal Care • Patients treat asthma as an acute episodic illness rather than as a chronic disease. • Providers assume that patients will put aside their own beliefs, concerns, and goals to follow the treatment plan.

42. Factors associated with ED visits • Family treat it as episodic, not a chronic disease (believe crises expected) • Younger age, greater number of days with symptoms, higher number of asthma meds • Not having criteria for treating at home • Not seeing it as unusual, “superior care” • Didn’t lack confidence they could treat at home • “Meds don’t work” or weren’t given time to work • Wasilewski et al. Am J of Public Health 86:1410-1415 1996

43. Impact of ED visits • -Sleep and family living patterns disrupted • -School attendance and performance can be impacted • May impact physical activity at home and school • -Parents report stressful feelings; • Panic, fright, nervousness, frustration, depression, sadness, or even anger • Wasilewski et al. Am J of Public Health 86:1410-1415 1996

44. Background • Excellence in medical treatment is worthless if the patient doesn’t take the medicine. • Compliance is closely linked to provider communication and patient education. • Most clinicians believe they are good communicators, but most patients feel clinician communication and education is inadequate.

45. Implications • Studies consistently show that less than 50% of patients adhere to daily medication regimens. • Clinicians cannot predict better than chance which patients will be compliant. • Therefore, all patients need to be educated to ensure adherence to the medical regimen. • Communicating well and providing education are as important as prescribing the right medicine.

46. Health Belief Model These beliefs influence willingness to follow preventive or therapeutic recommendations: • I am susceptible to this health problem. • The threat to my health is serious. • The benefits of the recommended action outweigh the costs. • I am confident that I can carry out the recommended actions successfully.

47. Beliefs About Susceptibility Some families resist accepting the diagnosis because they believe that: • Because an older relative was “crippled” by asthma, their child will also be “crippled.” • Asthma is psychologically caused or feigned by the child. Resisting the diagnosis reduces the likelihood that the family will follow the treatment plan.

48. Beliefs About Seriousness • If the family thinks asthma is not serious, they are less likely to follow the treatment plan. • If the family overestimates the seriousness of asthma, they may follow the plan, but prevent the child from taking part in normal physical activities.

49. Beliefs About Benefits and Costs • The benefits of therapy, obvious to the clinician, are often unclear to patients or irrelevant to their personal goals. • Perceived costs of therapy include: • Financial burden of care • Fear that medicines will harm the child • Regimen seen as time-consuming and hard to carry out

50. Fears About Asthma Medicines 39% believe medicines are addictive. 36% believe medicines are not safe to take over a long period. 58% believe regular use will reduce effectiveness.