Jodie Rodriguez, RN, MS, CPNP, AE-C Children’s Asthma Center of Excellence

1. Asthma Management in SchoolA presentation in honor of World Asthma Day 2013 thru a collaboration with Children’s Healthcare of Atlanta and the Department of Education. Jodie Rodriguez, RN, MS, CPNP, AE-C Children’s Asthma Center of Excellence

2. Asthma in Georgia’s Children • Approximately 10% have asthma, an estimated 226,000 children (approx 2-3 per class)* • #1 reason for inpatient admissions and emergency room visit to Children’s Healthcare of Atlanta • Higher morbidity and mortality rates among minority children from lower income households • 65% do not have a written asthma management plan (Georgia Asthma Surveillance Report 2007, DHR, Georgia)

3. Impact of Uncontrolled Asthma on Student Learning • 470,000 missed school days annually due to asthma • Missed class time due to frequent visits to the school clinic • Student fatigue due to night time symptoms

4. Asthma • A disease of the lungs where: • Airway becomes swollen and inflamed in response to a trigger • Variable among students, seasons, and a person’s lifetime • Asthma episodes (attacks) can be mild, moderate or life-threatening • Asthma cannot be cured but it can be controlled • A chronic disease

5. Asthma Triggers • Allergens • Dust mites, pollens, cockroaches, molds, animals • Irritants • Smoke • Poor air quality • Aerosols/fumes • Upper Respiratory Infections, illness • Emotion (laughing or crying) • Weather or Temperature Changes • Exercise

6. What Are the Symptoms of Asthma?(early signs) • Coughing • Wheezing or whistling in the chest • Feeling short of breath • Tightness in the chest • Waking at night with symptoms* *A key indicator of uncontrolled asthma

7. Can’t stop coughing or wheezing Blue/gray color Increased WOB/Tachypnea Retractions Tripod breathing Difficulty completing a sentence without pausing for breath **May not hear wheeze on Auscultation in late phase due to decreased air flow through bronchioles** If in distress…. ACT QUICKLY Signs of Distress(late signs)

8. Reducing Triggers in School • Avoid exposure to tobacco smoke and other smoke • Avoid exposure to strong smells and odors • Keep temperature and humidity at appropriate settings • Dry up damp and wet areas immediately • Consider removing furred or feathered animals from the classroom • Use pest management techniques to control pests • Adjust schedule for high smog, high pollen, low temps • Allow student to pre-medicate before exercise, if needed • Encourage good hand washing and flu shots

9. Children’s Asthma Action Plan

10. Components of an Asthma Action Plan • Prescribed daily controller and quick-relief medicines • Treatment guidelines for handling asthma episodes • Guidelines for pre-treatment before activity • Emergency contacts • List of Triggers • Should be on file with the school with copies for student’s teachers, PE teachers , and coaches and easily available for all on and off-site activities before, during, and after school • Updated annually and as needed

11. Asthma Medication Two Main types of inhalers: Quick Relievers ( yellow/red zone medication) • Used to treat or relieve asthma symptoms • Should ALways have it with them (ALbuterol) • Open airways by relaxing the muscles that surround the airway • Works very quickly, but for a short period of time (3-4 hours) • Used every 4 hours during a flare up to prevent further exacerbation • This medication is used to SAVE LIVES (e.g., Albuterol, ProAir, Proventil, Ventolin, Xopenex) Long-term Controllers(green zone medication) • Used for daily control and prevention • Reduce inflammation on the inside of the airway and helps to prevent future episodes • Will NOT work for quick relief of symptoms (e.g. Flovent, Pulmicort, Qvar, Asmanex, Advair, Dulera, Symbicort) AN AEROCHAMBER IS NECESSARY WITH ALL MDI USE

13. Questions

14. Managing an Exacerbation – Yellow Zone • Early recognition of symptoms and/or triggers critical • Pre-treatment before exercise/exposure to known trigger • Don’t have to hear a wheeze to be asthma (cough, early signs URI, increased allergic symptoms) • Proper use of Albuterol; one vial nebulized or FOUR puffs every 3-4 hours for 24-48 hours or until 24 hours after symptoms subside • Student may come to school in yellow zone; every four hour Albuterol is crucial to managing exacerbation and/or decreasing severity even if symptoms not present.

15. Managing an Attack – Red Zone • Evaluate breathing: increased breathing rate, short of breath, color, signs of distress • Immediately administer 4-6 Puffs MDI Albuterol or Albuterol nebulizer. Evaluate response. • Implement your school’s emergency protocol (EMS, parents, administrator) if needed • Continue 4-6 Puffs MDI Albuterol or Albuterol nebulizer every 20 minutes x3 if needed

16. Exercise Induced Asthma (EIA) • 10-15% of General Population • 90% of all Asthmatics have some component Watch for: • Cough after exercise • Shortness of Breath • Wheezing/ Chest tightness • “Out of shape” • Tend to avoid play/Cannot keep up • May need pre-treatment before exercise or strenuous activity • Beware of dizziness- reflects cardiac issue

17. Signs of Poor Control • A persistent cough • Coughing, wheezing, chest tightness, or shortness of breath after vigorous physical activity on a recurring basis • Low level of stamina during physical activity or reluctance to participate • Frequent use of quick relief medication *may be using an empty inhaler (Source: Asthma & physical activity in the school, NHLBI, 2006)

18. Senate Bill 472 (SB 472) Self-administration of Asthma Medication by Minor Children at School • Effective on July 1, 2002 • Also known as the “Kellen Bolden Act” Any student who is authorized for self-administration of asthma medication: 1. while in school 2. at a school sponsored activity 3. while under supervision of school personnel 4. while in before-school or after-school care on school property

19. School Asthma Management Key components: • Identify students with asthma • Obtain asthma management/emergency plans • Educate staff and students on asthma • Implement policies to promote asthma control • Teamwork is essential to create a healthy school environment

20. Resources • Asthma Awareness Month: Event Planning Kit • http://www.epa.gov/asthma/pdfs/awm/event_planning_kit.pdf • Georgia School Health Resource Manual 2013 • http://www.choa.org/Health-Professionals/Nurse-Resources/School-Nurses/~/media/CHOA/Documents/Health-Professionals/2013-School-Health-Manual/Manual-Chapters/Ch-5-Chronic-Health-Conditions.pdf

21. References • The American Academy of Allergy, Asthma & Immunology (2007). Pediatric Asthma: Promoting Best Practice, Guide for Managing Asthma in Children. • The National Institutes of Health, National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. • The National Institutes of Health, (2007). Practical Guide for the Diagnosis and Management of Asthma. • Plaut, T. (2005). One Minute Asthma: What You Need to Know, Seventh Edition. Amherst: Pediapress, Inc. • Fanta C.H., Carter, E.L., Stieb, E.S., Haver, K.E. (2007). The Asthma Educator’s Handbook, McGraw - Hill. • Centers for Disease Control (CDC), 2008. • CDC, EPA: (2009). Help Your Child Gain Control Over Asthma. • Georgia Asthma Surveillance Report 2007