Controlling Asthma: Preventing Episodes Before They Occur

1
Controlling Asthma Preventing Episodes Before
They Occur
2
Is There A Cure For Asthma?
Asthma cannot be cured, but it can be
Controlled We should expect nothing less!
3
Goals Of Asthma Control

• Prevent Symptoms
• No coughing or wheezing
• No shortness of breath or rapid breathing
• No waking up at night
• Maintain normal or near normal pulmonary
  function
• Maintain normal activity levels (including
  exercise and other physical activities
• Prevent exacerbations of asthma and minimize
  ER/UC and hospital visits
• Minimal or no adverse effects from medications
• Meet patients/familys expectations and
  satisfaction with asthma care
• Exerts from NAEPP EPR2 Guidelines for
  Diagnosis and Management of Asthma 1997

4
Asthma Control Do Most Students Have It?
5
Unfortunately NO!

• Many students who have asthma
• Have poor asthma control
• Use quick relief medicine (e.g. albuterol) on a
  regular basis
• Cough, experience chest tightness, wheezing, or
  shortness of breath regularly
• Assume suffering from symptoms are normal
• Remain indoors and cannot fully participate in
  sports, PE or recess
• Miss school due to asthma

6
Examples Of Students Whose Asthma Is NOT
Optimally Controlled

• A 10th grader, says he feels fine except when he
  runs in PE class, then his chest hurts. He
  coughs most mornings and whenever he gets a cold
  or virus. He often cant keep up with the other
  kids and needs to stop and rest.
• A 12th grader, carries an OTC Primatine Mist
  inhaler uses it a few times every day. He says
  he grew out of his asthma.

7
Examples Of Students Whose AsthmaIS Optimally
Controlled

• A 6th grader, doesnt need his reliever(albutero
  l) since consistently using his controller
  medications twice daily. He now plays soccer
  without developing symptoms or having to take
  pre-exercise albuterol.
• A kindergartener, no longer coughs or wheezes and
  easily keeps up with the other kids at recess.
  Her dad bought special dust mite proof covers for
  her mattresses and pillow. She now takes her
  controllers daily, uses her Asthma Action Plan,
  and sees her health care provider every 6 months
  for a well asthma check-up.

8
Asthma Severity Level vs Asthma Control

• Asthma Severity Levels (Mild Intermittent, Mild
  Persistent, Moderate Persistent, and Severe
  Persistent)
• Based on signs and symptoms before a student
  starts on controller medications
• Levels can change over time
• Asthma Control (or Current Asthma Severity)
• Is the students current severity level-
• regardless if they are on medications,
  experiencing symptoms (episodes) and/or able to
  be fully active

9
Asthma Control Proactive vs Reactive

• Going from a reactive to a proactive approach
• Instead of thinking-
• How do I treat these symptoms?
• e.g. with albuterol after the fact
• Think-
• How could have the symptoms have been prevented
  in the first place?
• e.g. daily controller medications, pre-exercise
  meds, asthma action plan, environmental control

10
Controlling Asthma

• Medical
• Environmental
• Management

11
Controlling Asthma Medical Management
12
How To Achieve Good Asthma Control

• Have regular asthma check-ups with a primary
  healthcare provider, even when feeling well
• At least every 6 months (more often if having
  symptoms)
• Monitor symptoms and peak flow readings daily
• Ask for and use a personalized Asthma Action Plan
• Know personal green- yellow- red zones, what
  each zone feels like and what to do in each zone

13
Asthma Control Continued...

• Get a flu shot every fall
• Avoid asthma triggers
• Asthmas not in control? Check in regularly at
  school health office for
• Peak flow check /symptom evaluation
• Lung sounds / respiratory rate check
• Pre-exercise and/or controller meds
• Asthma education
• Care coordination

14
Asthma Action Plan

• See MDH Asthma Action Plan F1

15
Written Asthma Action Plans

• Developed by the health care provider for each
  individual child with asthma
• Medications are determined by asthma severity
  level
• Based on symptoms and peak flow rates
• Lists daily rescue medications
• Symptom management and emergency plan
• Copies to be shared by clinic, family and school

16
Asthma Action Plan Zones

• Green Zone All Clear/Breathing Good/Go
• No asthma symptoms and/or
• Peak flow 80-100 Predicted or Personal best
• Yellow Zone Caution/Slow Down
• Some asthma symptoms and/or
• Peak flow 50-80 Predicted or Personal best
• Red Zone Medical Alert/Stop
• Severe asthma symptoms and/or
• Peak flow lt 50 Predicted or Personal best

17
What Can A Student Do To Stay In The Green Zone?
Select The Incorrect Answer

• A. Take their controller (anti-inflammatory)
  medication every day
• B. Avoid cigarette smoke and other asthma
  triggers
• C. Take their pre-exercise (usually reliever)
  medicine before P.E. or at recess
• D. Wash their bathroom often with bleach to avoid
  mold and mildew build-up

18
What Can A Student Do To Stay In The Green one?
Select The Incorrect Answer

• A.Take their controller (anti-inflammatory)
  medication every day
• B. Avoid cigarette smoke and other asthma
  triggers
• C. Take their pre-exercise (usually reliever)
  medicine before P.E. or at recess
• D. Wash their bathroom often with bleach to avoid
  mold and mildew build-up

19
If A Student Is In The Yellow Zone, They Should

• A.Be cautious. Breathing isnt their best.
  Take action
• B.Eat a lot of yellow foods such as bananas,
  which are high in potassium
• C.Automatically stay home from school
• D.Call their doctor or nurse practitioner
  immediately

20
If A Student Is In The Yellow Zone, They Should

• A. Be cautious. Breathing isnt their best. Take
  action
• B. Eat a lot of yellow foods such as bananas,
  which are high in potassium
• C. Automatically stay home from school
• D. Call their doctor or nurse practitioner
  immediately (correct answer call if they arent
  fully back into the green zone within 48-72
  hours).
• R1

21
Which Is One Symptom/ Clinical Indicator Is NOT
Associated With The Red Zone?

• A. Mild coughing
• B. Peak Flow reading lt 50 of personal best
• C. Significant breathing problems
• D. Persistent wheezing or no wheezing at all
  indicating severely limited aeration

22
Which Is One Symptom/ Clinical Indicator Is
Not Associated With the Red Zone?

• A. Mild coughing
• B. Peak Flow reading lt 50 of personal best
• C. Significant breathing problems
• D. Persistent wheezing or no wheezing at all
  indicating severely limited aeration

23
ActivityGroup Case Discussion

• The first month of school, you are called to an
  elementary school by a substitute teacher. She
  sent a 3rd grader to the nurses office alone,
  and told her to lay down.
• When you arrive, child has neck vein distension,
  accessory muscle retractions, dark/dusky color.
  No inhaler available
• Mom is 45 min. away. Grandma is in town
• WHAT DO YOU DO?

24
Answer

• Provide emergency care and medication per AAP/
  Management plan and
• CALL 911!

25
Controlling Asthma - Environmental Management
26
Common Environmental Triggers At Schools

• Indoor Triggers
• Animals with fur
• Dust mites
• Mold
• Pests
• Secondhand smoke
• Chemicals (e.g. strong smelling
  cleaning supplies, perfume, air fresheners)

• Outdoor Triggers
• Ozone
• Particulate matter
• Diesel exhaust
• Chemicals (e.g. re-surfacing the
  playground or roof, etc.)

27
Animals

• Dander, urine saliva are triggers
• Triggers remain months after animal pet removed
• Actions
• Prohibit/remove animals from schools if able
• If removal is not possible
• Keep animals in cages or localized areas
• Clean cages often
• Keep animals away from fabric furniture, carpet
  ventilation system
• Locate sensitive students away from animals
• Pre-notify parents if animals with fur/feathers
  visit
• Sample Animals in School Guidelines in manual
• R1

28
Dust Mites

• Both cause trigger asthma live in pillows,
  carpet, fabric-covered furniture, curtains
• Actions
• Keep classrooms clutter-free
• Make informed decision presence of carpet
• Vacuum often when people with asthma/allergies
  are gone (HEPA filter vacuum cleaners may help)
• Pillows/mattress/box spring in dust-mite proof
  zipped covers
• Wash bedding and stuffed toys weekly in HOT water
  (gt130 degrees F)
• Keep room humidity lt 50 if possible

29
Mold

• Moisture control is key
• Actions
• Report leaks and wet/moist areas right away
• Wash mold off hard surfaces
• Replace moldy porous items such as ceiling tiles
  carpet
• Avoid carpet in areas with regular moisture such
  as drinking fountains sinks
• E9

30
Pests

• Droppings or body parts can trigger asthma
• Actions
• Use integrated pest management (IPM) methods
• Dont leave food, water or garbage exposed
• Dont eat or drink in classroom
• Seal entry points for pests
• Use pesticides only as needed
• Parent Right to Know Act must notify parents
  employees when using specific pesticides
• F32, F33, F34

31
Secondhand Smoke

• Causes asthma in young children triggers asthma
  in children adults
• Contains over 4,000 substances
• State law prohibits tobacco use in K-12 public
  schools
• Actions
• Enforce smoking bans (for anyone on school
  property)
• Include anti-smoking message in curriculum
• Encourage parents/guardians to quit smoking or to
  not smoke inside their home

32
Outdoor Air

• Ozone fine particles are concerns in MN
• Staff have little control over outdoor air
• Actions
• Sign up for Air Quality Index notice
• Pollution Control Agency sends e-mail alerts when
  they expect poor air quality (regional)
• Avoid being outside at high pollen count times,
  especially if students are allergic to particular
  pollen/s

33
Sept. 14, 2000/June 28, 2001
34
The AQI
35
Average Number Of Alerts

• 6-12 alerts per year in last few years
• Most due to PM2.5
• Not violation of federal air quality standards
  thus far
• Health issues still valid

36
2003 Air Pollution Health Alerts

• Expanded AQI to Duluth, St. Cloud, Rochester
• Detroit Lakes, Marshall coming soon
• Expanded media coverage (Pioneer Press, TV
  meteorologists, health reporters, others)
• Expanded web e-mail alert signup

37
MPCAs AQI web page 1
38
MPCAs AQI web page 2
39
School Buses

• State law requires
• Reduce unneeded idling in front of schools
• Reroute bus parking zones away from air intakes,
  if possible
• Actions
• Post no idling signs
• Maintain bus fleet
• Invest in cleaner fuels
• Purchase newer, cleaner buses over
  long-term
• R2, R3, R4

40
Other Environmental Issues

• Indoor Air Quality Management Plan
• Cleaning cleaning products
• Flooring
• Air cleaners
• R7

41
Home Environment Resources

• US Environmental Protection Agency
• Asthma Home Environment Checklist
• 8 page checklist of common asthma triggers
• Questions to identify triggers action steps
• Clear Your Home of Asthma Triggers fact sheet
• EPA website
• www.epa.gov/iaq/asthma/resources.html

42
Communication Care Coordination
43
Key Communication Triad
Parent/
Guardian
Child
Health Care
School Health
Providers
Office
44
Care Coordination / Communication
(Health Assistant / Paraprofessional/LPN Role)

• Health Assistants / Paraprofessionals / LPNs must
  alert LSN/PHN/RNs of students who come in
  frequently with asthma type symptoms
• Monitor students with asthma as directed by
  LSN/PHN/RN
• Perform delegated responsibilities once skills
  have been validated per district/school policies

45
Care Coordination /Communication (LSN/RN/PHN)

• Examples of asthma care coordination activities
• Request AAPs on students
• Review AAP and/or IHP and develop/modify plan for
  care coordination
• Determine medical insurance status and connect to
  appropriate provider(s)
• Arrange for special transportation (in rare
  cases) prn
• Connect to community resources

46
Care Coordination/ Communication

• Communicating with Students
• Educate them to
• Follow an individualized Asthma Action Plan
• Avoid or control exposure to their triggers
• Use medication appropriately
• Long-term-control medicine
• Quick-relief medicine
• Monitor symptoms and response to treatment
• Understand symptoms and peak flow levels
• Seek a health care providers help when needed

47
Communicating w/ Students Continued..

• Get regular follow-up care
• Be able to exercise/ play at optimal levels
• Be responsible for carrying and using their
  asthma medications per school policies
• Ask for help when they need it!

48
Care Coordination/ Communication

• Communicating with parents/guardians
• Review parent/guardian and student questionnaires
• Determine current asthma severity levels
• Provide education to family/student as needed
• Encourage questions and give feedback
• Contact parent/guardian every time a student has
  asthma symptoms and or if having poor asthma
  control
• Obtain a signed consent to release/ share
  information
• F11, F14, F3, E1, F7

49
Care Coordination / Communication

• Communicating with health care providers
• Report status changes and re-evaluation needs
• Advocate for pre-exercise and /or controller
  medications as appropriate
• Arrange for asthma education
• Complete IHP and/or ECP if needed
• Document as appropriate in Pupil Health Record
• Evaluate symptoms, lung sounds and peak flow
  regularly on poorly controlled students
• F17, F18

50
Communicating With School Staff

• Share information with staff on a need to know
  basis only
• Maintain student confidentiality
• Provide general asthma education to staff
  proactively
• Provide asthma first aid training to staff
• Act as a resource to school staff for questions
  and concerns

51
Health Office Scenario

• A 4th grade student who you have not seen in the
  health office this year for asthma symptoms, has
  a diagnosis of asthma in her record, and has
  albuterol MDI / orders in the health office at
  school, but no Asthma Action Plan. She comes
  into the health office with a persistent cough.
• What would you do for her?

52
Health Office Scenario Continued...

• Actions
• Physical Assessment (respiratory rate, breath
  sounds, severity of symptoms)
• Ask what she was doing before coming into the
  health office / what may have precipitated
  symptoms
• Ask frequency of day / nighttime symptoms
• Check height/PF chart for predicted PF and
  initiate Asthma Record
• F5

53
Health Office Scenario Continued...

• Check her Peak Flow reading and document in SHOAR
  F4
• Instruct the child how to do a PF reading
• Give albuterol (observe inhaler technique)
• Teach/reinforce proper inhaler technique, use of
  spacer or holding chamber with inhaler
• Monitor her for response to medication
• Send note home with the child using the AVN F8
  and a PAQ F11

54
Health Office Scenario Continued...

• Two days later, she returns to the health office,
  with cough and shortness of breath
• What would you do for this 4th grader first?
• What would be the next steps or what else should
  you do at this point?

55
Health Office Scenario Continued

• What else should you do now?
• Re-evaluate her respiratory status and treat as
  appropriate
• Call her parent / guardian to notify, ask for
  parent questionnaire/more info.
• Suggest she see her health care provider
• Ask the child to come see you the next day for a
  follow up check
• If you have consent, fax Asthma Medical
  Referral/Request to health care provider
• F9

56
Asthma Management In The School Health Office
57
Sample Forms For Optimal School Asthma Management
58
Key Asthma Tools

• Components of Asthma Management in the Health
  Office E2, E3
• Asthma Action Plan w/ imbedded consents, parent
  letter F1, F2
• Asthma Visit Notification form F7, F8
• Asthma Medical Request/Referral F9, F10
• Pathway for Acute School Asthma Care E6, E7
• Emergency Care Plan - Asthma F18
• Individualized Health Plan - Asthma F17

59
Key Asthma Tools

• Parent/Guardian Breathing/Asthma Questionnaire
  F11, F12, F13
• Student Breathing/Asthma Questionnaire F14, F15,
  F16
• School Health Office Asthma Record F4, F5, F6
• Self-administration Asthma Medication
  Authorization F19, F20
• First Aid for Asthma poster / pocket cards E4,
  E5
• Asthma Green/Yellow Zone Update F23, F24
• Permanent Health Office Pass F25

60
Components Of Asthma Management In School Health
Office

• Two Models Provided in School Asthma Manual
• LSN Health Assistant (Mpls. Public Schools
  model) E2
• LSN Secretary (St. Paul Public Schools model)
  E3
• Purpose Provides job specific instructions for
  providing quality asthma care in the school
  health office
• Licensed School Nurse, Public Health Nurse,
  Registered Nurse
• Licensed Practical Nurse
• Health Aid/Service Assistant / Paraprofessional
• Secretary / Administrative Assistant

61
Asthma Screening Questions

• Include these 3 questions into your existing
  student health questionnaire
• 1. Does your child have asthma or other
  breathing problems?
• 2. Has your child ever been diagnosed by a
  doctor as having asthma?
• 3. Has your child had episode(s) of wheezing
  (whistling in the chest) in the last 12 months?
  

62
Asthma Action Plan (AAP)

• Purpose
• Provides a plan to guide the asthma
  management of individual students
• Includes imbedded consents
• Allow parents/guardians and providers to give
  permission for medications to be given at school
• Allow for sharing/release of information between
  school, clinic, hospital, child care provider and
  home care
• Available in English and Spanish

63
Asthma Visit Notification Form (AVN)

• Purpose
• Increases communication between the school
  health office, parents/guardians, and primary
  care/asthma care providers
• Fill out and send home whenever the student is in
  the health office with asthma symptoms
• Or when delegated by the LSN/PHN/RN
• F7,F8

64
Asthma Medical Request (AMR)

• Purpose
• To facilitate communication and care
  coordination between the health care provider and
  the school nurse about the students asthma
  status/management
• Fill out and fax, mail to health care providers
• You must have the parents written consent to
  collect medical information first
• F9, F10

65
Pathway for Acute School Asthma Care

• Purpose
• Assists school nurses in making decisions
  regarding the provision of acute asthma care in
  the school health office or other school setting
  
• Designed to be used for students experiencing
  mild, moderate or severe asthma symptoms
• E6, E7

66
Asthma Emergency Care Plan (ECP)

• Purpose
• Provides special instructions to selected school
  staff on how to respond to an asthma emergency
• Used with students with severe or labile asthma
• Individualized for each student with asthma
• F18

67
Asthma Individualized Health Plan (IHP)

• Purpose
• Provides a Nursing Plan of Care and promotes care
  coordination and communication between the school
  nurse and health office staff regarding students
  whose asthma is not in good control
• Also used to document special education nursing
  services
• F17

68
Parent / Guardian Asthma Questionnaire (PQ)

• Purpose
• Used To
• Gather baseline information about the childs
  asthma symptoms
• Determine the childs asthma severity level
• Determine if the childs asthma is under control
• Develop an appropriate plan of care
• Typically used for students in 5th grade or lower
• F11, F12, F13

69
Student Breathing Questionnaire (SBQ)

• Purpose
• Used to
• Determine the students asthma severity level
• Determine if the students asthma is under
  control
• Develop an appropriate plan of care
• Determine students familiarity of their meds,
  triggers, symptoms etc.
• Used with students in grades 6th grade or
  higher
• F14, F15

70
School Health Office Asthma Record (SHOAR)

• Purpose
• Provides a user-friendly document on which to
  record many aspects of a students asthma care
• Allows health office staff to
• Record Asthma Medication
• Record Peak Flow Readings
• Document Asthma Symptoms
• Document Education
• F4, F5

71
Self-Administration Of Asthma Medication
Authorization / Agreement

• Purpose
• To systematize practice regarding
  self-carrying of asthma medications between
  schools
• Promotes strong asthma self care skills in
  students
• Agreement between student and school nurse
• Used in conjunction with an Asthma Action Plan
  or may stand alone
• F19, F20

72
First Aid For Asthma Poster / Pocket Cards

• Purpose
• Provides basic first aid care for asthma and
  asthma symptoms with directions when to call 911
• Place posters in locations in the school where
  students and staff are usually present
• Pocket cards may be given to physical education
  teachers or coaches or other staff as
  needed E4, E5

73
Prioritizing In A Busy School Health Office
74
Theres Never Enough Time, What Can I
Do?

• It isnt possible for school health office staff
  to get deeply involved with every student who has
  asthma so -
• Prioritization is essential!
• Determine which students seem to be having the
  most difficulty, and focus on them first

75
How Do I Prioritize?

• Prioritize by current asthma control / severity
  level
• Focus first on students with the poorest asthma
  control regardless of severity level
• Start working with students whose asthma is
  poorly controlled in the moderate to severe
  persistent asthma levels

76
Which Of These Students With Asthma Would You
Focus On First?

• A boy with diagnosed moderate persistent asthma
  who can run, play, attend school without symptoms
  and rarely uses his albuterol
• A girl with current mild persistent asthma who is
  unable to fully participate in PE class
• A girl whos original severity level was severe
  persistent but whose current asthma severity
  level (control) is moderate persistent. She can
  play outside better than originally, but still
  needs albuterol for symptoms 3-4 times a week at
  school

77
Which Of These Students With Asthma Would You
Focus On First?

• 3. A boy with diagnosed moderate persistent
  asthma who can run, play, attend school without
  symptoms and rarely uses his albuterol.
• 2. A girl with current mild persistent asthma
  who is unable to fully participate in PE class.
• 1. A girl whos original severity level was
  severe persistent but whose current asthma
  severity level (control) is moderate persistent.
  She can play outside better than originally, but
  still needs albuterol for symptoms 3-4 times a
  week at school.

78
Education In The School Health Office
79
Components Of Student Family Education

• Concept of asthma control
• Pathophysiology of asthma
• Environmental control and triggers
• Controller vs. reliever medications and
  refilling medications
• Use of Asthma Action Plan and treatment of
  episodes
• Peak flow meter use

80
Components Of Student Family Education Cont

• Signs and symptoms of respiratory distress and
  when to seek help
• MDI with spacer / DPI technique
• Nebulizer use and technique (prn)
• Importance of relationship with provider and
  well-asthma check-ups
• Flu shot every fall
• Self-care, especially for students as they get
  older

81
Strategies To Educate When Time Is Limited

• Give short asthma education messages when meeting
  with with students
• Use innovative / interactive asthma education
  tools (computerized asthma games, internet-based
  asthma control tools, videos) with students /
  families

82
The Best Laid Plans..

• You can increase the likelihood of asthma
  management success (compliance) by
• Reviewing Asthma Action Plan and making sure
  student understands how to use it
• Ask how controller medications fit into the
  students daily routine (can they handle it?)
• Identify obstacles or barriers to the
  student/family carrying out the plan as prescribed

83
I Cant Manage This By Myself. Who Else Should
Be Involved?
84
Referring To Community Resources For Education
And Case Management

• LSN/PHN/RNs can utilize case managers, home
  visiting professionals, and asthma educators from
  health plans, hospitals, clinics, public health,
  to help educate and/or case manage students whose
  asthma is poorly controlled
• Connect students/family to community education,
  asthma camp, other community resources

85
Coordinated School Health Partnering For Optimal
Asthma Management In Schools
86
CDCs Strategies For Addressing Asthma Within A
Coordinated School Health Program

• Six Strategies
• Establish management and support systems for
  asthma-friendly schools
• Provide appropriate school health and mental
  health services for students with asthma
• Provide asthma education and awareness programs
  for students and school staff

87
Strategies Continued

• Provide a safe and healthy school environment to
  reduce asthma triggers
• Provide safe, enjoyable physical education and
  activity opportunities for students with asthma
• Coordinate school, family, and community efforts
  to better manage asthma symptoms and reduce
  school absences among students with asthma

88
Asthma Goals For SchoolHealth

• Healthy school environment
• Health services in school
• Asthma education
• Supportive policies
• Sound communication
• 1997 National Asthma Education and Prevention
  Program (NAEPP)

89
Spearheading School-wide Asthma Best Practices At
Your School

• See Checklist in manual for suggestions
• Create a multi-disciplinary plan for improving
  asthma management in your health office, school
  and/or district
• Improve own practice
• Educate other school staff
• Involve all disciplines within the school setting

90
Community Involvement

• Get involved with the Minnesota Asthma Coalition,
  and/or the regional Asthma Coalition in your area
  
• Contact your legislators and insist on
  legislation to support asthma-friendly policies
• Anti-smoking laws
• Healthy housing initiatives
• Supporting Clean Indoor act
• Support stricter pollution control measures

91
Conclusion

• Asthma is a big challenge for Minnesota
• Working together with parents and health care
  providers, we have the ability to positively and
  dramatically impact the health of children who
  have asthma!