Control of Environmental Factors that Affect Asthma

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Control of Environmental Factors thatAffect
Asthma

• Mary Bouthiette RN, AE-C
• Dartmouth Hitchcock Manchester
• December 2008

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4 Components of Asthma Management

• Component 1 Measures of Asthma Assessment and
  Monitoring
• Component 2 Education for a Partnership in
  Asthma Care
• Component 3 CONTROL OF ENVIRONMENTAL FACTORS AND
  COMORBID CONDITIONS THAT AFFECT ASTHMA
• Component 4 Medications

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Inhalant Allergens

• Patients with persistent asthma should be
  evaluated for the role of allergens as possible
  contributing factors
• Determine the patients exposure to allergens
• Assess sensitivity to the allergens
• Medical History
• Skin Testing
• RAST

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Rationale for Allergy Testing for Perennial
Indoor Allergens

• Sensitivity to a perennial indoor allergen is
  usually not possible with medical history alone
• Increased symptoms during vacuuming or bed making
  and lt symptoms when away from home are suggestive
  but not sufficient
• Skin or RAST are necessary to educate patients
  about the role of allergens in their disease

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Management

• Reduce exposure to relevant indoor and outdoor
  allergens to which the patient is sensitive
• Avoidance requires a multifaceted, comprehensive
  approach (Evidence A)
• Individual steps alone are generally ineffective

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Animal Allergens

• If patient is sensitive to an animal, the
  treatment of choice is removal of pet from home
• If removal of pet is not acceptable
• Keep pet out of bedroom
• Keep bedroom door closed
• Remove upholstered furniture and wall to wall
  carpets from home

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Animal Allergens Continued

• All warm-blooded animals produce dander, urine,
  feces and saliva that can cause allergic
  reactions
• Recent evidence has shown that exposure to cat
  allergens can be significant in homes, schools
  and offices without animals!
• Mouse and rat allergen exposure and sensitization
  are common in urban children who have asthma

De Blay et al. 1991 b, Popplewell et al. 2000,
Phipatanakul
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House-Dust Mite Allergen(Recommended Actions)

• Encase the mattress and pillow in an
  allergen-impermeable cover
• Wash the sheets and blankets weekly in hot water
• Temperature of gt 130 F is necessary for killing
  house- dust mites
• Chemical agents for killing mites are not
  recommended
• Vacuuming is inefficient at removing live mites

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House-Dust Mite Allergen(Actions to Consider)

• Reduce indoor humidity, ideally between 30-50
  percent
• Remove carpets from bedroom
• Avoid sleeping or lying on upholstered furniture
• Remove from the home carpets that are laid on
  concrete
• In childrens beds, minimize stuffed toys and
  wash weekly

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Cockroach Allergen

• Cockroach sensitivity and exposure are common
  among patients who have asthma and live in inner
  cities
• Do not leave food or garbage exposed
• Poison baits, boric acid and traps are preferred
  to other chemical agents
• Home should be well ventilated

Call et al. 1992
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Indoor Mold

• Indoor mold is prominent in humid environments
• Children who live in homes dampness problems have
  gt respiratory symptoms
• Measures to control dampness or fungal growth in
  the home may be beneficial
• Moisture in the home must be controlled

Institute of Medicine2004
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Outdoor Allergens(Expert Panel Recommendations)

• Patients who are sensitive to seasonal outdoor
  allergens consider staying indoors with windows
  closed and air conditioning
• If possible, during peak pollen
  times-particularly midday and afternoon (may not
  be realistic)
• Strongest associations between mold-spore
  exposure and asthma have been with outdoor fungi,
  such as Alternaria

Halonen et al. 1997
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Immunotherapy(Expert Panel Recommendations)

• Be considered for patients with persistent
  allergic asthma
• Patients that medications are ineffective
• Multiple medications are required
• Patient not accepting use of medications

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Immunotherapy

• Typically 3-5 years duration
• Severe reactions are more frequent among patients
  with asthma compared to those who have allergic
  rhinitis
• Should only be administered in physicians office
  with trained personnel and emergency equipment
• Patients must wait after shot for 30 minutes

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Assessment of Devices that MayModify Indoor Air

• Vacuuming once a week to reduce accumulation of
  house dust
• Avoid using conventional vacuum cleaners
• If patients vacuum, they can use a dust mask,
  central cleaner with the collecting bag outside
  the home or a cleaner fitted with a HEPA filter
  or with a double bag

Popplewell et al 2000
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Air Conditioning

• During warm weather for patients who have asthma
  and are allergic to outdoor allergens
• Central air will also help to control humidity
• Reducing humidity is a practical way to control
  house-dust mites and their allergens in homes in
  temperate climates

Arlian et al. 2001
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Dehumidifier

• House-dust mites levels can be reduced by use of
  dehumidifiers to maintain levels to or below 60
  percent, ideally 30-50 percent

Cabrera et al. 2003
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Indoor Air Cleaning Devices

• There is insufficient evidence to recommend
  indoor air cleaning devices
• They may reduce some but not all airborne
  allergens
• Evidence is limited regarding their impact on
  asthma control
• Most studies have failed to demonstrate an affect
  on asthma symptoms or pulmonary function

Wood et al. 1998
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Humidifiers

• Not generally recommended for use in homes of
  house-dust mite-sensitive patients who have
  asthma
• Potentially harmful because gt humidity may
  encourage growth of old and house-dust mites
• If not properly cleaned, they can harbor and
  aerosolize mold spores

Solomon 1974
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Occupational Exposures

• Occupational asthma is generally defined as
  a lung disorder caused by inhaling fumes, gases,
  dust or other potentially harmful substances
  while "on the job." With occupational asthma,
  symptoms of asthma may develop for the first time
  in a previously healthy worker, or childhood
  asthma that had previously cleared may recur due
  to this exposure. In another form of work-related
  asthma, pre-existing asthma may be aggravated by
  exposures within the work place. (American
  Academy of Allergy, Asthma and Immunology)

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Occupational Exposures

• Workplace Exposures
• Does the patient cough or wheeze during the week,
• but not on weekends when away from work?
• Do the patients eyes and nasal passages get
• irritated soon after arriving at work?
• Do coworkers have similar symptoms?
• What substances are used in the patients
  worksite?
• (Assess for sensitizers.)

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Occupational Exposures

• Documentation of work-relatedness of airflow
  limitation
• Serial charting for 23 weeks (2 weeks at work
  and up to 1 week off work, as needed to identify
  or exclude work-related changes in PEF)
• Record when symptoms and exposures occur.
• Record when a bronchodilator is used.
• Measure and record peak flow (or FEV1) every 2
  hours while awake.
• Immunologic tests.
• Referral for further confirmatory evaluation
  (e.g., bronchial challenges).

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Irritants

• Irritants are substances that trigger asthma
  symptoms when they are inhaled by sensitive
  people. They are different from allergens, in
  that they do not trigger the allergic response
  from the immune system. But they do irritate the
  nose, mouth, and airways. Examples are chemical
  fumes, strong odors, and tobacco or wood smoke
• The Expert Panel recommends that clinicians
  query patients who have asthma at any level of
  severity about exposures to irritants that may
  cause their asthma to worsen, and advise them
  accordingly about reducing relevant exposures
  (EPR?2 1997).

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Irritants

• Common indoor environmental irritants include
• Pet fur or feathers, urine, saliva and dander.
• Mold and mildew spores.
• Tobacco smoke and wood smoke.
• Perfumes and hairsprays.
• Cleaning solutions, pesticides and paints

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Irritants

• Common outdoor environmental irritants include
• Pollen from trees, grasses, and weeds.
• Mold and mildew spores.
• Changes in humidity.
• Exposure to cold air.
• Industrial emissions and other air pollutants.

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Environmental Tobacco Smoke

• As a routine part of their asthma care,
  patients should be counseled concerning the
  negative effects of smoking and environmental
  tobacco smoke or ETS.

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Environmental Tobacco Smoke

• ETS is associated with increased symptoms,
  decreased lung function, and greater use of
  health services among those who have asthma
  (Sippel et al. 1999) in all age groups. Effects
  of ETS on a childs asthma are greater when the
  mother smokes than when others in the household
  smoke (Agabiti et al. 1999 Austin and Russell
  1997 Ehrlich et al. 2001).

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Environmental Tobacco Smoke

• Smoking out of doors to avoid exposing others
  may not adequately reduce exposure for children
  (Bahceciler et al. 1999).

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Indoor Air Pollution

• Americans spend up to 90 of their time
  indoors. Therefore, indoor allergens and
  irritants can play a significant role in
  triggering asthma attacks. It is important to
  recognize potential asthma triggers in the indoor
  environment and reduce your exposure to those
  triggers. (Environmental protection Agency)
• Secondhand Smoke
• Dust Mites
• Molds
• Cockroaches and Pests
• Pets
• Nitrogen Dioxide
• Outdoor Air

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Outdoor Air Pollution

• Small particles and ozone come from things like
  exhaust from cars and factories, smoke and road
  dust. When inhaled, outdoor pollutants can
  aggravate the lungs, and can lead to chest pain,
  coughing, shortness of breath and throat
  irritation. Outdoor air pollution may also worsen
  chronic respiratory diseases, such as asthma. On
  days when ozone air pollution is highest, ozone
  has been associated with 10-20 of all
  respiratory hospital visits and admissions.
• Watch for the Air Quality Index, or AQI, during
  your local weather report. The AQI is a tool that
  offers you clear information every day on whether
  air quality in your area could be a health risk.
  The AQI uses colors to show how much pollution is
  in the air. Green and yellow mean air pollution
  levels are low. Orange, red or purple mean
  pollution is at levels that may make asthma
  worse.

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Outdoor Air Pollution
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Outdoor Air Pollution

• State agencies will use television and radio
  to notify citizens of ozone alerts. On days when
  your State or local air pollution control agency
  calls an Ozone Action Day, people with asthma
  should limit prolonged physical activity
  outdoors. Consider adjusting outdoor activities
  to early in the morning or later in the evening

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Outdoor Air Pollution

• Also, on Ozone Action Days, you can do the
  following 10 things to help keep ozone formation
  to a minimum
• Instead of driving, share a ride, walk or bike.
• Take public transportation.
• If you must drive, avoid excessive idling and
  jackrabbit starts.
• Don't refuel your car or only do so after 7 p.m.
• Avoid using outboard motors, off-road vehicles or
  other gasoline powered recreational vehicles.
• Defer mowing your lawn until late evening or the
  next day. Also avoid using gasoline-powered
  garden equipment.
• Postpone chores that use oil-based paints,
  solvents or varnishes that produce fumes.
• If you are barbecuing, use an electric starter
  instead of charcoal lighter fluid.
• Limit or postpone your household chores that will
  involve the use of consumer products.
• Conserve energy in your home to reduce energy
  needs

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References

• EPR 3 August 28, 2007