Teach Asthma Management (TAM)

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Teach Asthma Management (TAM)
Provided by
Generously supported by the Robert Wood Johnson
Foundation
Some slides adapted from Physician Asthma Care
Education, developed by Noreen Clark, University
of Michigan, School of Public Health
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Part II of II
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Hand-Held Nebulizer

• Mask lt5yrs., Mouthpiece gt5yrs.
• Assemble equipment
• Sit child upright
• Put mouthpiece in mouth between lips and teeth
  (if using mask, cover nose mouth)
• Turn machine on
• Instruct to take slow deep breaths (mist should
  disappear on inspiration)
• Done when medicine is gone, may need to tap
• Rinse and air dry, Disinfect once per week
• Change filter when dirty

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MDI Technique (Break-out)

• Use with spacer/holding chamber
• Dry powder inhaler close mouth tightly around
  the mouthpiece of the inhaler and inhale rapidly
• If dont have spacer/holding chamber
• Open mouth technique with inhaler 1-2 away
• In mouth (not for use with corticosteroids)

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MDI with Spacer Technique (Break-out)

• Remove cap, attach MDI to a spacer shake
• Breathe out put spacer between lips
• Press canister one time
• Take deep breath in slowly hold for 10 sec
• Breathe out
• Take one more deep breath without pressing
  canister
• Wait 60 seconds before taking next puff
• Rinse Mouth if using inhaled corticosteroid

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MDI with Spacer and Mask (Break-out)

• Remove cap, attach MDI to spacer shake
• Place mask tightly on childs face (cover nose
  and mouth)
• Press canister one time
• Hold mask tightly on face for 6-10 breaths
• Assure valve is opening with each breath
• Take mask off wait 60 seconds before giving
  next puff
• Wash face rinse Mouth if using inhaled
  corticosteroid

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Maxair Autohaler (Break-out)

• Remove cover shake
• Prime if needed (1st use and if not used for 48
  hrs.)
• Load Dose
• Lips tight around mouthpiece
• Take deep steady breath in and hold for 10
  seconds
• Remove from mouth exhale
• Lower lever and repeat if needed

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Turbuhaler (Break-out)

• Prime if this is a new Turbuhaler (twist click
  X2)
• Load a dose (twist click)
• Turn head away exhale
• Place in mouth tightly, take deep, quick breath
• Hold breath for 10 seconds
• Repeat as needed

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Diskus (Break-out)
mouthpiece
grip
lever

• Push grip to open Diskus
• Push lever away until hear feel click
• Turn head away exhale
• Place in mouth tightly, take deep, quick breath
• Hold breath for 10 seconds

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Foradil Aerolizer (Break-out)

• Remove cover and open Aerolizer Inhaler
• Remove capsule from foil, place in
  capsule-chamber
• Twist mouthpiece to close position
• With mouthpiece upright, press buttons ONCE (hear
  click), this will break the capsule
• Turn head away exhale
• Place in mouth tightly, take deep, quick breath
  (if no whirling sound, may be stuck)
• Hold breath for 10 seconds
• Check Aerolizer for left over medicine, if some
  left close and breathe rest of medicine

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Asthma Triggers
Laurie Smrz,RN, BSN Medical College of Wisconsin
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Asthma Triggers

• Objective Teach caregivers to control asthma
  triggers

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Role of Allergy in Asthma Clinical Evidence

• Allergy is common in children (8090 of
  school-aged children with asthma)
• Presence of allergy is associated with more
  severe and persistent asthma
• Allergen exposure is associated with
• Increased risk of developing asthma
• Increased asthma morbidity
• Allergen avoidance can reduce airway
  hyperreactivity (AHR) and asthma morbidity

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Identifying Asthma Triggers

• Avoiding triggers can
• Prevent asthma symptoms and exacerbations
• Reduce need for medication

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Identifying Asthma Triggers

• Hypersensitivity of the immune response to
  allergens initiates an allergic cascade
• Sensitization Initial exposure to allergen
  production of allergen specific IgE
  antibody
• Early phase reaction Subsequent exposure of IgE
  antibody to specific allergen release of
  histamine, tryptase, leukotrienes, cytokines
  inflammation bronchoconstriction
• Late phase reaction mediators continued
  inflammatory reactions
• Stimulation of immune cells produces inflammatory
  response

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Identifying Asthma Triggers

• "Atopy - The genetic tendency to develop the
  "classical" allergic diseases Allergic
  rhinitis, asthma and atopic dermatitis.
  Associated with the capacity to have an IgE
  response to common, generally inhaled, allergens
• "Allergen" - Substances that can induce IgE
  antibody responses
• "Allergy" - IgE antibody responses to allergens
• Irritant" - Cold air, laughing, crying, yelling,
  weather change, air pollution

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Irritants

• Irritate already inflammed sensitive airways
• Air pollutants ETS, wood smoke, ozone, chemicals
  in the air
• Strong odors/sprays perfumes, household
  cleaners, paints, and varnishes
• Airborne particles chalk dust, talcum powder
• Changing weather conditions
• Viral infections
• Exercise
• Strong emotional response crying/laughing

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Allergens

• Any substance that triggers an allergy
• Pollen
• Molds
• Animal Dander
• House dust mites
• Cockroaches

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Identifying Asthma Triggers

• Allergens Confirm
• RAST Blood Test (Radioallergosorbent Test)
• Skin prick (most accurate)
• Irritants Observation
• Ask child or caregiver What do you think makes
  your asthma worse?

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Most Common Triggers

• Tobacco Smoke
• Avoid it!
• Ask smoker to Take it outside
• Even odor of smoke residue is a trigger
• Colds and Infections (most common childhood
  trigger)
• Wash hands before meals and bedtime
• Encourage yearly flu shot
• Exercise
• Plan warm up activities
• Allow time for pre-medication

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Indoor Triggers
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Dust Mites (Der p, Der f)

• Eight legged arachnids (related to spiders,
  chiggers and ticks)
• Thrive in warm moist micro-environments (inside
  pillows, cushions, mattresses)
• Feed on human and animal dander (dead skin
  flakes)
• Focus on the bedroom
• Pillow and mattress covers
• Wash bedding in hot water
• Damp dust
• Cost effective tips
• (cheese cloth)

The weight of a paper clip 1gram of dust
100-19,000 dust mites
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Cockroaches (Bla g1, Bla g2)

• American and German cockroach
• Integrated Pest Management (IPM)
• Minimal use of pesticides
• Eliminate food, water entry points
• Use baits keep away from children

• Children's Health Education Center 1997

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(No Transcript)
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Animal Allergy - Why So Important

• 510 of general population
• 2070 of people with allergies/asthma
• gt50 of US homes have at least one cat or dog
• Homes and public buildings without pets may have
  significant allergen levels
• Other furred animals also are commonly encountered

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Furry and Feathered Friends (Can d1, Fel d1, Mus
m)

• Dander proteins in dead skin, urine and saliva
• Cats (most common)
• Dogs
• Birds
• Rodents

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Cat Dander (Fel d I)

• Unlike dust mite allergen, stays airborne
• Unlike dust mite allergen, it is sticky
• Bind to walls and other surfaces in buildings
• Detected in homes and buildings without cats
• Munir AK, et al. JACI 1993911067-74
• May take months for all allergen to decompose

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Animal Control Measures

• The ideal solution
• Remove pets from house
• If not possible
• Keep pet out of bedroom
• Use HEPA air filtering system
• Remove carpet and other reservoirs for allergens
  in the bedroom
• Encasing on mattress, box springs, and pillow
• Wash pet weekly

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Outdoor Triggers

• Pollens particles released from trees, weeds
  and grasses
• Highest levels at midday (10-2pm)
• Use air conditioning, not fans
• Visit an air-conditioned mall or movie theater
• Not many options (avoidance)

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Mold and Air Pollution

• Molds (indoors and out)
• Damp soil and leaves
• Outdoor plastic toys and equipment
• Poor kitchen/bathroom ventilation
• Leaky faucets
• Clean mold with a mild bleach solution
• Air Pollution
• Small particulate matter ozone, diesel exhaust
• and coal combustion byproduct
• Stay indoors on Ozone Action Days

• Children's Health Education Center 1997

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(No Transcript)
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Non-Specific Triggers - Irritants

• Strong Odors
• Self-care products
• Cleaning products
• Scented candles aerosol spray room
• deodorizers
• Purchase scent-free products
• Weather
• Sudden changes in temperature
• Cold weather
• Cover nose and mouth

• Children's Health Education Center 1997

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Help families focus on their specific triggers

• Keep it simple
• Focus on the patients triggers
• Encourage caregiver to select 1 intervention to
  begin
• Teach simple intervention for a specific trigger

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Key Messages

• Triggers CAN be avoided or controlled
• Use quick-relief medicine before exercise or an
  unavoidable exposure
• Establish a daily weekly - monthly cleaning
  routine break it down into simple steps!
• Advise smoking treatment if smokers in the home
• Provide family with resources to reduce triggers

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Where to Get Allergy Products

• Local Department Stores
• National Allergy Supply Company
• 1-800-522-1448
• Allergy Supply Company
• 1-800-323-6744
• American Allergy Supply
• 1-800-321-1096

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Tobacco Interventions
Mary Balistreri (Cywinski), MS UW Center for
Tobacco Research and Intervention Education
Outreach [phone] mc3_at_ctri.medicine.wisc.ed
u
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Objectives

• Know what works best to help adults quit
• Learn about available resources
• Know why you should be an anti-smoking advocate

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Risks to Children

• Asthma
• Respiratory infections
• - bronchitis, pneumonia
• Otitis media (ear infections)
• Low birth weight
• Poorer school achievement
• Sudden Infant Death (SIDS)
• Half of parents likely to die prematurely

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Treating Tobacco Dependence

• Quitting smoking is one of the best things
  parents can do for
  themselves and their children.
• Intervention from health care providers is
• clinically effective and cost
  effective.
• Nicotine is addictive, relapse is prevalent.
• AAAAI Guide

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A Systematic Approach to Every Patient at Every
Visit is Most Effective

• Ask smoking status and readiness to quit
• Advise to quit
• Assess willingness to quit
• Assist plans to quit
• Arrange follow-up

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What Works Best to Help Smokers Counseling and
Medications

• Practical counseling, even brief, along with FDA
  approved medications can triple success.
• Counseling messages should be clear, strong, and
  personal.
• Medicaid covers cessation treatments.

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Wisconsin Tobacco Quit Line 1-877-270-STOP toll
free

• Counseling by trained professionals
• Individualized for each patient
• Highly effective
• 7 days/week, 7am to 11pm
• Connection to clinicians and local program
• To order Quit Line materials
• Email quitline_at_ctri.medicine.wisc.edu or
• Fax [phone]

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First-line pharmacotherapies

• Bupropion SR
• Nicotine gum
• Nicotine inhaler
• Nicotine nasal spray
• Nicotine patch
• Nicotine lozenge

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Resources
UW Center for Tobacco Research Intervention
www.ctri.wisc.edu - Resources
for health care providers, smokers, family
members US PHS Clinical Practice Guideline
Treating Tobacco Use and Dependence
- Current research and support materials
www.surgeongeneral.gov/tobacco/
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Asthma Care Plans
Erin Lee, FAM Allies Coordinator Childrens
Health Education Center
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Objective

• Teach caregivers to recognize symptoms, adjust
  medications, and seek help according to the
  written action plan

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What are the Symptoms of Asthma?

• Cough
• Shortness of breath
• Wheezing
• Tightness in the chest
• Coughing at night or after physical activity
  cough that lasts more than a week
• Waking at night with asthma symptoms (a key
  marker of uncontrolled asthma)

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Asthma Diary

• A record that helps patients track
• Asthma symptoms
• Medication use
• Peak flow numbers
• Trigger contact
• Diaries can help
• Improve communication with healthcare team
• Doctors evaluate and establish asthma control

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Asthma Care Plan

• Problem solving tool, tailored to individual
  patients
• Based on information from both parent and
  provider
• Mutually developed between parent, patient, and
  provider

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Care Plan Checklist

• Patient name
• Provider name and phone number
• Medications, dosages, and frequency of use for
  Green, Yellow, and Red zones
• List symptoms for each zone
• Peak flow zones (when appropriate)
• List who to call with questions or in an emergency

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Communication Tips for the Asthma Care Plan

• Color Code the Symptoms and peak flow numbers
• Give parent confidence to read childs symptoms
• Explain how to use the plan to adjust medications
  
• Reassure that help can be reached
• Provide a clinic contact for questions
• Emphasize who must be called if in red zone.

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Practice Using the Plan

• Make sure parent understands how to read
  childs breathing in each zone
• Encourage parent to talk often to child about
  their breathing
• Go over what to do if breathing changes
• Ask parent to identify when/how meds will be
  given
• In a daily routine
• Preventatively, if child gets a cold or flu
• If yellow zone treatment isnt working
• Make sure parent knows when they should contact
  the clinic and who to talk to

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Update Asthma Care Plans

• If there is a change in the following
• Medication
• Peak flow zones
• Provider
• Symptoms persist or worsen
• Triggers
• Encourage parents to take care plan to all
  visits so plan can be reviewed and modified as
  needed by MD

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A mother brings her 3 year old son to clinic
because he has a bothersome daytime cough. For
the past 2 weeks, he has coughed 3 days per week,
but has no nighttime symptoms. For the past
year, he has been coughing and wheezing every
time he gets a cold. He was diagnosed with
mild persistent asthma. The physician ordered
Flovent 44mcg 2 puffs BID, (increase to 4 puffs
BID in yellow zones X2 weeks), and albuterol 2-4
puffs as needed for asthma symptoms and prior to
exercise.
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Improving Clinician-Patient/Family Communication

• Linda Gehring, PhD
• Alverno College

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Objectives

• Clinician can utilize communication skills to
• Identify family concerns,
• Improve teaching effectiveness,
• Promote patient self-confidence

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Improving clinician-patient/family communication

• Good communication between patient and staff
  helps
• Identify patients concerns that may block their
  ability to follow a care plan.
• Make patient teaching more effective
• Promote patients self-confidence to follow the
  self-care plan.
• Identify traditional folk health practices being
  used.
• AAAAI Guide

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Barriers To Effective Communications
Studies show that patients often

• Feel they are wasting the clinicians valuable
  time
• Omit details they deem unimportant
• Are embarrassed to mention things they think will
  make them look bad

• Dont understand medical terms
• Believe the clinician has not really listened and
  therefore doesnt have the information needed to
  give proper treatment

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Strategies for open Communication with
patients/families

• Interactive conversation is based on
• Being attentive
• Addressing immediate concerns
• Giving reassurance
• Discussing mutual goals in tailoring their plan
• Finding out underlying worries and concerns
• Giving verbal and non-verbal praise

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Purnell Model for Cultural Competence

• Heritage
• Communication
• Family roles and organization
• Work force issues
• High-risk behaviors

• Nutrition
• Spirituality
• Health care practices
• Health care practitioners

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Disparity Considerations

• Work with each family to develop an action plan
  that takes into consideration
• The families cultural, ethnic, and socioeconomic
  background
• The asthma regimen needed
• The families ability to implement the plan,
  physically, socially and economically
• The families high-risk behaviors that may
  sabotage the plan

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Interventions

• Provide explanations for all Rx and OTC products
  at level appropriate to client/family
• Involve family in teaching
• Provide written instructions in clients
  preferred language

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Explaining Asthma

• Provider wants to
• Explain what happens during an asthma attack
• Inflammation Airway lining swells and produces
  too much mucus
• Bronchospasm Airway muscles squeeze too much
• Asthma episodes are reversible

• Parent want
• An explanation that takes away the mystery about
  asthma, so can see what is going on in the
  lungs
• Reassurance that asthma is manageable and can be
  controlled

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Communication Tips for Explaining Asthma

• Make it simple and use pictures of airways
• Use the fist example, asking parent/patient to
  do it with you.
• Convey the dynamic
• of open/shut airways

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Teachable Moments

• Office visits
• Checking in
• Rooming
• Phone calls
• Grocery Store
• Health fairs
• Mentoring

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Parents can ask

• Does my child need a "quick-relief inhaler" more
  than TWO TIMES A WEEK?
• Does my child wake up at night with asthma more
  than TWO TIMES A MONTH?
• Do we refill the "quick-relief inhaler" more than
  TWO TIMES A YEAR?
• Rules of TwoTM is a registered trademark of the
  Baylor Health Care System.

If yes, the asthma may not be in control.
Contact the physician.
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Implementing Change in the Primary Care Setting

• How can all this information be implemented into
  your office setting?
• What has worked in your setting?

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Wrap-Up

• Erin Lee

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Fight Asthma Milwaukee Allies
FAM Allies works together with children and
families connecting them to caring people,
reducing hospital stays, and supporting healthy
lives

• Clinical Quality Improvement
• Family and Community Education
• Care Coordination and Case Management
• Parent and Neighborhood Organizing
• Public Communication
• Surveillance and Evaluation
• For more info, contact Erin Lee,
• 414-390-2179, elee_at_chw.org

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Wisconsin Asthma Coalition

• Clinical Care
• Enhanced Covered Services
• Education
• Health Disparities
• Public Policy
• Environment
• Work-Related
• Surveillance
  For more info, contact Kristen Grimes,
• 414-390-2189, kgrimes_at_chw.org

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Evaluation

• General evaluation needs to be completed by all
  participants
• In addition, nurses will need to complete the
  program objective evaluation for CEU credits

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THANK YOU!