Asthma in Children: New Approaches to Improving Outcomes

1. Asthma in Children:New Approaches to Improving Outcomes Cindy Capen MSN, RN Pediatric Pulmonary Center University of Florida capencl@peds.ufl.edu

2. What I plan to discuss: • Pathophysiology • Medications • EPR Guidelines • Florida initiatives • Ways to get involved/Help needed

3. History Lesson

4. Goals of Asthma Management • Minimizing daily symptoms • Minimizing nighttime symptoms • Eliminating ER and hospital visits • Rare use of rescue inhalers • Normal activities • No school/work absences

5. What happens during an asthma episode? The insides of the airways get irritated and inflamed The linings of the airways get swollen Irritated airways make more mucus The muscles around the airwaysspasm and get tight

6. inflammation and bronchoconstriction prevent air from reaching the alveoli

7. Short of Breath Cough Wheeze When do you suspect it’s asthma?

8. What can precipitate an asthma episode? • Things called asthma TRIGGERS • Everyone has their own “recipe”…SO • Identify triggers • problem solve ways to avoid triggers

9. National Heart, Lung and Blood Institute Expert Panel Guidelines for the diagnosis and management of Asthma

10. Expert Panel Report 1991 EPR-1 1997 EPR-2 2002 EPR-2 update 2007 EPR-3 493 pages

11. Guidelines for the diagnosis and management of asthma Expert Panel Report 3 Components of Asthma Management • Assessment/identify severity • Education/partnership w family • Control of environment/other conditions • Medications 0-4 years 5-11 years > 12 yoa

12. Determining severity • Symptoms • Nighttime awakenings • Use of beta agonists for symptoms • Interference with normal activity • Lung function • Consider use of oral steroids

13. Educate & have a plan • Pathophysiology • Action Plan • Assessment of symptoms • Appropriate response to symptoms • Early and aggressive treatment • Plan for stepping up medications • Plan for getting help

14. Why would a plan fail? • Lack of Adherence • Check refills • Reeducate • Cultural issues? • Multiple caregivers? • Poor technique in use of delivery device • Teach, return demonstrate, recheck technique • Prescribe according to ability • Mishandling of meds • Not cleaning delivery device • Damage to product (heat, moisture) • Funding for meds

15. Rolling out the plan… • Reeducating the care community • Primary care providers • Emergency responders • Pharmacists • Respiratory care practitioners • School health team • Third party payors • A new way of thinking for families • Daily treatment no matter what • Getting past the “steroid” word • Rapid response • The place for specialists

16. More & Better Medications

17. Preventer medicines • Are for children who have frequent asthma symptoms (at least weekly) • Are taken daily • PREVENT most asthma episodes • Help children live normal lives • Parents OFTEN do not give these medicines reliably.

18. Preventer Medicines Flovent Pulmicort Singulair Dulera Qvar Serevent Advair Symbicort

19. Combination Therapies Dulera: combined Asmanex and formoterol; MDI Symbicort: combinedPulmicort and formoterol; MDI Advair: combinedFlovent and Serevent; MDI or DPI All come in different dosages and dose counters

20. Rescue Medicines Albuterol Maxair Duo-Neb Xopenex Alupent Prednisone

21. 2012 Only 12 pages!

24. The numbers are climbing… 7.1 million children With Asthma

25. Data from the Florida Asthma Program

28. Educate/Asthma Plan • Pathophysiology • Action Plan • Assessment of symptoms • Appropriate response to symptoms • Early and aggressive treatment • Plan for stepping up medications • Plan for getting help

29. In Gainesville: In 2011, the largest number of ED visits among children occurred in the zip codes 32609, 32607, 32641, 32608, and 32605

30. Requested data for seven counties…

31. In the plus column? • We know how to identify asthma • We have medications that work • We have asthma specialists • We have a step by step plan for any provider to follow • We have health care coverage for kids • We have great programs like CMS! • We know who is at risk • We know where they live! • …and we know where they go to school

32. Minus column? No change in outcomes!

33. Florida Asthma Program: 2009 • 100% federally funded by the CDC • Goals • increase the number of individuals with asthma who receive self-management education • reduce the number of deaths, hospitalizations, emergency department visits, school or work days missed, and limitations on activity due to asthma. • Facilitates the Florida Asthma Coalition • conducts asthma surveillance • program evaluation • works to increase the number of childcare centers, schools, and hospitals that implement asthma management programs.

34. Targets

35. Creating Asthma-Friendly Schools& Earning the Asthma-Friendly School Award

36. Asthma’s Impact on Students • Absenteeism • Academic Performance • Physical Activity

37. Asthma Prevalence is on the Rise • In 2012, 1 out of 5 Florida middle and high school students (20.6%) had ever been told by a doctor or nurse that they had asthma. Source: Florida Youth Tobacco Survey, 2012

38. More than 441,000 instructional hours were lost in Florida due to asthma-related absences in 2011-2012 Source: 2011 Florida Youth Tobacco Survey and 2010 Florida Child Health Survey

39. Asthma-Friendly Schools Award Criteria Bronze • School-Based an Asthma Leadership Team (or existing health or wellness team). • Professional development for school nurses, faculty and staff (ALA’s Asthma 101). • School ensures immediate access to asthma medications per Florida statute. • School provides student centered asthma management support. • identifying children with asthma at the beginning of the school year, having asthma action plans on file for students with known asthma, and coordinating between parents and health care providers • School posts asthma posters in high-traffic areas. • Physical education and activity opportunities meet needs of children with asthma. Silver (All Bronze and Criterion 7 and 8) • School provides self management education to students with asthma (ALA’s Open Airways for Schools Program). • School provides education to parents about asthma management (ALA’s Asthma 101). Gold (All Bronze, Silver and criterion 9) • School implements an indoor air quality program. Platinum (All Bronze, Silver, and Criterion 10) • School implements comprehensive asthma procedures or a policy which includes the activities listed in criterion 1-9 and a comprehensive tobacco free campus policy.

40. Coming soon!

44. What’s our role? • Be part of the Florida Asthma Coalition • Because asthma is an overwhelming problem • Because in 2014 they will be seeking more funding • The costs affect everyone • Spread the word • School Health Guidelines • School recognition program • Childcare recognition program • Teach parents • Early and aggressive treatment • Use of medications • Primary care not Emergency care

45. The basics • Diagnose • Manage triggers • Use medications to prevent episodes • Call early for exacerbations • Treat aggressively and early