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					30.2010 Chronic Illnesses

ASTHMA

Asthma is the most common chronic respiratory disease in children. Asthma is characterized by airway obstruction (or airway narrowing) that is reversible, airway inflammation, and airway hyperresponsiveness to a variety of different stimuli. The airway obstruction in asthma is caused by bronchial smooth muscle construction, airway edema, mucous production and inflammation. As the obstruction or narrowing of the airway occurs, breathing becomes more difficult. Signs and symptoms include labored breathing and chest tightness, wheezing, tight cough, and prolonged expiration. As an asthma episode continues, respiratory rate increases, and the use of accessory muscle (intercostals and abdominal retractions) is observed. The degree of severity of asthma symptoms can vary from a mild cough to severe respiratory distress resulting in fatal asphyxia. It should be noted that not all students with asthma wheeze; many may present with only a troublesome chronic cough (See Asthma Symptoms Table).

Signs and Symptoms Peak Expiratory Flow Rate (PEF) Respiratory Rate Alertness Dyspnea

Accessory Muscle Use

Color Auscultation with stethoscope

ASTHMA SYMPTOMS Mild Moderate 70-90% predicted or 50-70% predicted or baseline baseline Normal to 30% above 30-50% increase mean above mean Normal Normal Absent or mild, speaks Moderate, speaks in in complete sentences phrases or partial sentences None to mild Moderate intercostal intercostal retractions retractions with (spaces between ribs tracheosternal are drawn in) (tracheal area is drawn in) retractions, use of sternocleidomastoid (neck) muscles Good Pale Wheeze only at end of Inspiratory and expiration expiratory wheezing

Severe < 50% predicted or baseline > 50% above mean May be decreased Severe, speaks only in single words or short phrases Moderate intercostal retractions, tracheosternal retractions with nasal flaring during inspiration Possible cyanosis Breath sounds inaudible

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AVERAGE RESPIRATORY RATES AT REST (BREATHS/MINUTE) AGE RATE (BREATHS/MINUTE) Newborn 35 1-11 months 30 2 years 25 4 years 23 6 years 21 8 years 20 10 years 19 12 years 19 14 years 18 16 years 17 18 years 16-18 The cause of asthma is undetermined, but many researchers believe it is an autoimmune disorder with a hereditary component. If one parent has asthma, children have a 20 to 30 percent chance of developing asthma. If both parents have asthma, the chance increases to 50 to 60 percent. The prevalence, morbidity and mortality from asthma appear to be increasing throughout the world. Among 5-24 year olds, the asthma death rate has nearly doubled from 1980-1993. In the United States, African-American and impoverished children have a much higher prevalence of asthma. Many believe it is the single most important cause of morbidity in childhood. Asthma is the leading cause of missed school days. Persons can be affected by asthma at any age, but the majority of cases have their onset by age five. Precipitating Factors Asthma is a chronic illness with acute episodes. Children whose asthma is in control may go for long periods of time without symptoms. There are a great many factors that can precipitate an asthma attack. The precipitating factors vary greatly among people with asthma, and these factors may change from year to year. These may include: 1. 2. 3. 4. 5. 6. 7. Exercise (running – most likely, swimming – least likely). Viral infections (mostly upper respiratory tract). Weather changes (especially cold weather). Allergies (environmental, foods, aspirin, etc.). Emotional upsets, fatigue, or excitement. Smoke, perfumes, or other irritants. Emotional stress.

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Management Asthma is treatable. There are four basic steps to treat asthma: 1. 2. 3. 4. Educating students and their families about asthma. Using environmental measures to control allergens and irritants. Treating with medications. Generate overall asthma treatment plan for family to follow at home and specific plan for school.

General Goals of Asthma Therapy 1. Prevent chronic asthma symptoms and asthma exacerbations during the day and night. (Indicators: No sleep disruption by asthma. No missed school or work due to asthma. No or minimal need for emergency department visits or hospitalizations.) Maintain normal activity levels – including exercise and other physical activities. Have normal or near-normal lung functions. Be satisfied with the asthma care received. Have no or minimal side effects while receiving optimal medications.

2. 3. 4. 5.

Assessment of Asthma Severity The table “Classification of Asthma Severity” is adapted from the Practical Guide for the Diagnosis and Management of Asthma from the National Institute of Health. This table assists in estimating the severity of chronic asthma patients. These levels of severity correspond to the table, “Stepwise Approach for Managing Asthma” also adapted from the Practical Guide for the Diagnosis and Management of Asthma and describes pharmacologic therapy. (See table “Potency of Inhaled Corticosteroids” for further explanation.)

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STEP 4 Severe Persistent

STEP 3 Moderate Persistent

STEP 2 Mild Persistent

STEP 1 Mild Intermittent

CLASSIFICATION OF ASTHMA SEVERITY Continual symptoms, limited PEF < or = to 60%, PEF physical activity, frequent variability is >30%. exacerbations and frequent nighttime symptoms Daily symptoms, daily use of PEF 60–80% predicted, PEF inhaled short-acting Beta (2)variability is > 30%. agonist, exacerbations > or = to two times per week that affect activity and may last days, nighttime symptoms > one time per week. Symptoms > two times per PEF > or = 80% predicted, week but < one time per day, PEF variability 20-30%. exacerbations may affect activity, nighttime symptoms > or = two times per month. Symptoms < or = two times per PEF > or = predicted, PEF week, asymptomatic and variability < 20%. normal PEF between exacerbations, brief exacerbations with varying intensity, nighttime symptoms < or = two times per month.

Notes:  Students should be assigned to the most severe step in which any feature occurs. Clinical features for individual students may overlap across steps.  A student’s classification can change over time.  People at any level of severity of chronic asthma can have mild, moderate or severe exacerbations of asthma. Some people with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms.  People with two or more asthma exacerbations per week (i.e., progressively worsening symptoms that may last hours or days) tend to have moderate-to-severe persistent asthma. STEPWISE APPROACH FOR MANAGING ASTHMA Long-Term Control Step 4 (Severe Persistent) Daily medications: Anti-inflammatory: inhaled steroid (high dose) AND
long-acting bronchodilator: Either long-acting Beta (2) – agonist inhaled or oral, sustained release theophylline, AND oral corticosteroid.

Step 3 (Moderate Persistent) Daily medications:

Either anti-inflammatory: inhaled steroid (medium dose) OR inhaled steroid (low to medium dose) and add a long-acting bronchodilator: either long-acting inhaled or oral beta (2) -agonist, or sustained release theophylline. Anti-inflammatory: either inhaled steroid (low dose) or Cromolyn or nedocromil. Sustained-release theophylline is an alternative but not preferred. Leukotriene modifiers such as singuliar, zafirlukast or zilueton. Singulair is used most often with children and adolescents.

Step 2 (Mild Persistent)

Daily medications:

Step 1 (Mild Intermittent) All Patients

Daily medications: No daily medications needed. Quick-Relief Inhaled short-acting Beta (2)-agonists as needed MMSD Rev. 6/06

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Asthma Medications Quick Relief/Rescue Medications Taken to provide prompt treatment of acute airflow obstruction and accompanying symptoms such as cough, chest tightness, shortness of breath, and wheezing. Generic Name Albuterol Bronchodilators Brand Name Proventil HFA, Ventolin Xopenex Maxair Brethaire, Brethine, Bricanyl How it works Relaxes muscles to open the airways. Should be taken first if other inhalers are taken at the same time. Begins to work in about 5 minutes and lasts 4-6 hours. Side Effects Increased heart rate Hypertension Hyperactivity Headaches Anxiety Weakness Nervousness Nausea/vomiting Generic Name Methylprednisolone Prednisone Oral Corticosteriods Brand Name Medrol Prednisone, Deltasone, Orasone, Liquid Pred, Prednisone Intensol Prelone, Pediapred Orapred How it works Decreases swelling, inflammation and mucus in the airways. Works in 6-12 hours. Use as prescribed by health care provider. Oral corticosteroids should not be a long term management solution. Side Effects Weight gain Increased appetite Moodiness Fluid retention Facial flushing Joint pain Increased potential for infection

Levalbuterol Pirbuterol Terbutaline

Prednisolone

Prednisolone sodium phosphate

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Long Term Control Medications Taken daily to achieve and maintain control of persistent asthma. Generic Name Beclomethasone Brand Name Qvar (40 mcg and 80 mcg/puff) Vanceril / Vanceril DS Beclovent Pulmicort Turbuhaler ≥ 6 yr Pulmicort Respules ≥ 1 yr AeroBid Nasarel Flovent ≥ 12 yr. Azmacort ≥ 6 yr. Kenalog Asmanex twisthaler ≥ 12 yr How it works Prevents swelling, inflammation and mucus in the airways. May take days to weeks to work. Preventative medication, not to be used as quick relief. Take as prescribed by health care provider. Rinse mouth after use to prevent some side effects. Side Effects Mouth Sores Throat irritation Voice changes Thrush

Inhaled Corticosteriods

Budesonide

Flunisolide

Fluticansone Triamcinolone

Mometasone

Generic Name Long- acting Bronchodilators Formoterol Inhaled Salmeterol Theophylline Oral

Brand Name Foradil Aerolizer Serevent Diskus Slobid TheoDur Uniphyl

How it works Relaxes muscles to open airways.

Side Effects Side effects are rare.

Must be taken regularly each day. Works in 4-6 hours, lasts 8-12 hours.

Nausea/vomiting Tremors Sleep problems Bedwetting Behavior changes

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Mast Cell Stabilizer

Generic Name Ipratropium

Brand Name Atrovent

How it works Used in combination with other medicines to open airways, increases airway relaxation. *do not use if allergic to soy protein.

Side Effects Dry mouth Fast heartbeat Flushed skin

Generic Name Fluticasone & Salmeterol

Brand Name Advair Diskus

How it works Works to control both airway swelling and muscle constriction. Should not be used for quick symptom relief.

Side Effects Tremor Sleepiness Increased heart rate Hyperglycemia Thrush Throat irritation Voice changes

Combination Medications

Albuterol & Ipratropium

Duoneb Combivent MDI

Relieves bronchospasm. *do not use if allergic to soy protein.

Non steroidal antiinflammatories

Generic Name Cromolyn Nedocromil

Brand Name Intal Tilade

How it works Prevents swelling and inflammation. Blocks the reaction to triggers. May take up to a week to work.

Side Effects Side effects are very rare.

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Generic Name Leukotriene Modifiers Montelukast Zafrilukast Zileuton

Brand Name Singulair ≥ 1 yr. Accolate ≥ 5 yr. Zyflo

How it works Prevents swelling, inflammation, and mucus. Not to be used to relieve symptoms. * Accolate should not be taken on an empty stomach.

Side Effects Headache Fatigue Stomachache Ear or leg pain, Uticaria

Medication to Reduce Allergic Response Allergy medications treat allergies or irritants that may trigger an attack. Antihistamines – Relieves histamine-mediated effects of itching, sneezing, runny nose with postnasal drip and cough, and conjunctivitis. Drugs – Atarax, Benadryl, Chlor-Trimeton, Claritin, Zyrtec, Allegra, Dimetane, Tavist, Temaril, etc. Decongestants – Produce vasoconstriction which reduces blood flow in the congested area. The decongestants shrink nasal mucous membranes, reduce nasal congestion and increase nasal airway patency. Drugs – Dorcol, Novafed, Propagest, Sudafed, Sudrin, etc. Antihistamine/Decongestant Combinations – Combination of antihistamine and decongestant. Symptoms of both runny nose and nasal congestion may be alleviated. The drowsiness often produced by the antihistamine may be offset by the stimulation produced by the decongestant. Drugs – Actifed, Bromfed, Deconamine, Dimetapp, Drixoral, Fedahist, Naldecon, Pediacare, Rondec, Ryantan, Traminic, etc. Intranasal Medications to Reduce Inflammation and Inhibit Release of Mediators Drugs – Beclomethasone (Vancenase, Beconase inhaler), Beclomethasone – aqueous inhalation (Vancenase AQ, Beconase AQ, Vancenase AQ 84), Budesonide (Rhincort), Dexamethasone (Dexacort Turbinaire, Decadron Turbinaire), Flunisolide (Nasalide, Nasarel), Fluticasone (Flonase), Triamcinolone (Nasacort), Triamcinolone AQ (Nasacort AQ). Correct Use of Inhaled Medications Metered Dose Inhaler (MDI): A metered dose inhaler is one method to administer asthma medications. It delivers small particles of medication to lower airways so there are fewer side effects. MDI’s are small, pressurized canisters that require a propellant. These propellants are being replaced for environmental reasons. Although MDIs appear simple to use, simultaneous coordination of inhalation and activation of the aerosol may be difficult.

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Using the Inhaler 1. 2. 3. 4. Sit upright and remove the cap. Shake the inhaler, holding the canister firmly between thumb and forefingers. Tilt the head back slightly and breathe out. Use the inhaler in any of these ways a. b. c. 5. 6. 7. Using spacer. Open mouth with inhaler 1 to 2 inches away. In the mouth.

Press down on the inhaler to release the medicine as the student starts to breathe in slowly. Breathe in slowly for 3 to 5 seconds. Student holds their breath for 10 seconds to allow the medicine to reach deeply into the lungs. If a second puff is prescribed, wait 1-2 minutes between puffs.

8.

Checking How Much Medicine is Left in the Canister 1. If the canister is new, it is full. If the inhaler is used daily, it should be replaced when the number of sprays in it have been used. If the inhaler is used intermittently, the user (or parent or school nurse) should track the number of sprays used and replace it when there are no more sprays left.

2.

Dry Powder Inhalers (DPI): Unlike pressurized metered-dose inhalers, DPIs do not require propellants. They are activated and driven by students’ own rapid inspiratory force, so the user must breathe in vigorously and quickly to receive the correct dose of inhalation. Advantages include the fact that students do not have to coordinate activation with inhalation for effective delivery, spacers are not necessary, and dosing can be monitored by the number of doses left. Because DPIs are breath activated, they are not recommended for children less than 5 years of age. Disadvantages include poor penetration at times to lower airways and inhalation of the powder itself may cause irritation. Using the Diskus: The Diskus is a pocket-sized plastic device which resembles a flying saucer. It consists of a mouthpiece, thumbgrip, lever, dose indicator, and an outer-case. 1. Sit upright and hold Diskus in horizontal position with one hand while the thumb of the other hand is placed on the thumbgrip. The thumbgrip is pushed to expose the lever.

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2.

Hold the inhaler with the mouthpiece towards you. Slide the lever away from you as far as it will go until you hear and/or feel a click. The inhaler is ready to be used. Exhale, then put the mouthpiece to the lips. Breathe in steadily and deeply through the inhaler, not through your nose. Remove the inhaler from your mouth. Hold your breath for about 10 seconds, or for as long as it is comfortable. To close the device, put your thumb in the thumbgrip, and slide the thumbgrip back towards you, as far it will go. When the inhaler is closed, it clicks shut. The lever automatically returns to its original position and is reset.

3.

4.

5.

Using the Turbuhaler: The Turbuhaler device has two basic components: a storage chamber for the dry powder and a dosing unit through which the dry powder is delivered. The lower portion of the inhaler contains a turning grip, which, when turned back and forth once, loads a dose. The Turbuhaler must be held in the upright position mouthpiece up) whenever a dose is being loaded and in the horizontal position during inhalation. 1. 2. 3. Sit upright and turn the cover and lift off. Hold inhaler in upright position (mouthpiece on top) during loading. Prime unit for the very first time it is used. To prime, twist the brown grip fully to the right, then fully back again to the left until it clicks. Repeat. After priming, load the first dose. Twist the brown group fully to the right and fully to the left until it clicks. Breathe out. Do not breathe out through the mouthpiece. Do not shake the turbuhaler after loading it. Place the mouthpiece gently between your teeth; close your lips and breathe in forcefully and deeply through your mouth. Before breathing out, remove the inhaler from your mouth. Replace the cover and twist shut.

4.

5.

6.

7.

Nebulizers: The main advantage of the nebulizer is that it requires little patient coordination. It therefore seems to be the preferred way to deliver inhaled medications to infants and small children and those with severe asthma. There are two types of nebulizer devices: jet and ultrasonic. The jet nebulizer passes compressed air over a tube, one end of which rests in the liquid to be aerosolized. The pressure drop drops liquid up the tube, where it is broken into droplets of various sizes. Ultrasonic nebulizers generate particles by concentrating vibrations from a piezoelectric transducer on the surface of the liquid to be aerosolized.

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Using the Nebulizer: (See package instructions for use).

PROCEDURES FOR CLEANING EQUIPMENT Cleaning Equipment:  Wash hands.  Run hot tap water for 2 minutes (rinses impurities through tap).  Take apart equipment and soak in dish soap (Ivory, Joy, etc.) and water. Scrub or brush vigorously.  Rinse again with hot water. Disinfecting Equipment:  Disinfect with a vinegar and water solution. Soak in a mixture of one part white vinegar (5% solution from grocery store) to a two part water (e.g., 1 cup vinegar to 2 cups water). Make sure equipment is completely covered; soak from 30 minutes to 2 hours.  After disinfecting, rinse with hot water.  Air dry on a clean towel.  Assemble when completely dry and store between clean towels.  Brushes used for scrubbing should be disinfected with the vinegar/water solution.  The vinegar/water solution can be reused for one week if store in a covered container. Throw away at end of one week, and clean the container using the cleaning procedure. Cleaning Equipment:  The spacer must be cleaned weekly by hand washing with dish soap and warm water. Rinse with warm water and air dry on a towel.  If spacer is not used, clean the inhaler mouthpiece weekly. Wash the mouthpiece with warm water and mild dishwashing soap. Let it dry before using again. Cleaning Equipment:  Wipe/clean mouthpiece with dry cloth or tissue after doses are completed.

Nebulizer (should be cleaned and disinfected every 2 days to destroy bacteria)

Inhaler

Dry Powder

Peak Flow Meters A peak flow meter is a tool that objectively measures a student’s asthma. The value it measures is called a peak expiratory flow (PEFR), that is, the amount of air that can be forcefully moved out of lungs in one second. During an asthma episode, the airways of the lungs narrow. The peak flow meter is used to find out the amount of narrowing in the airway.

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Peak flow monitoring of a student helps the student, health office staff and health care provider: 1. 2. Assess the severity of the asthma. Monitor the response to treatment during an acute episode and help determine when emergency medical care is needed. Monitor the response to chronic treatment. Detect deterioration in lung function early in a student who is not having problems and facilitate intervention.

3. 4.

Personal Best Peak Flow Number – This number is the highest peak flow number a student can achieve over a two-week period when asthma is under control. Each student’s asthma is different and their best peak flow may be higher or lower than the usual number for someone of the same height, weight and gender. The student’s own scores are used as the standard for comparison. If this information is not available, use the Peak Flow – Predicted Values Chart. PEAK FLOW – PREDICTED VALUES

CHILD AND ADOLESCENT MALE: AGE 6 TO 25 YEARS Height (inches) Age (yrs) 44 99 119 139 159 178 198 218 238 258 278 288 48 146 166 186 206 226 246 266 286 306 326 336 52 194 214 234 254 274 293 313 333 353 373 383 56 241 261 281 301 321 341 361 381 401 421 431 60 289 309 329 349 369 389 408 428 448 468 478 64 336 356 376 396 416 436 456 476 496 516 526 68 384 404 424 444 464 484 503 523 543 563 573 72 431 451 471 491 511 531 551 571 591 611 621 76 479 499 519 539 559 579 599 618 638 658 668

6 8 10 12 14 16 18 20 22 24 25

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CHILD AND ADOLESCENT FEMALE: AGE 6 TO 20 YEARS Height (inches) Age (yrs) 42 134 153 171 190 209 228 247 266 46 164 182 201 220 239 258 277 295 50 193 212 231 250 269 288 306 325 54 223 242 261 280 298 317 336 355 57 245 264 283 302 321 340 358 377 60 268 287 305 324 343 362 381 400 64 297 316 335 354 373 392 411 429 68 327 346 365 384 403 421 440 459 72 357 376 395 414 432 451 470 489

6 8 10 12 14 16 18 20

Peak Flow Zone System – Once a personal best peak flow number has been established, the student’s health care provider will put the peak flow numbers into zones that are set up like a traffic light. Green Zone (80 to 100 percent of the personal best number) signals all clear. No asthma symptoms are present. Yellow Zone (50 to 80 percent of the personal best number) signals caution. The student may be having an episode of asthma that requires an increase in medicines. Red Zone (below 50 percent of the personal best number) signals a medical alert. The students to take an inhaled beta-agonist right away and call the doctor immediately if the peak flow number does not return to the Yellow or Green Zone and stays in the Red Zone. Using a Peak Flow Meter 1. 2. 3. 4. 5. 6. 7. Stand up. Make sure the indicator is at the base of the numbered scale. Take a deep breath. Place the meter in the mouth and close lips around the mouthpiece. Blow out as hard and fast as possible. Repeat steps 1-4 two more times. Record the highest of the three numbers.

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Breathing Exercises All children with asthma should use and practice breathing exercises. This enables the child to actively do something to treat asthma and helps them to feel in control. And it works! A brief description follows: To practice: 1. 2. 3. 4. 5. Sit up straight on a chair or lie down on the bed or floor and bend your knees. Place both hands on your belly. Breathe in slowly through your nose. Take the air into your belly and feel it flow up big like a balloon. Keep your chest still. Blow the air slowly out of your mouth through puckered lips. Feel your belly get small. Repeat this exercise slowly 10 times – it will make breathing easier and it will make you feel relaxed.

Intervention During an Asthma Attack 1. 2. Coach student with breathing exercises (see above). Do Peak Flow meter reading. Student should use beta-agonist inhaler if it is available at school. This inhaler usually relieves symptoms within 15 minutes. Reassess and redo Peak Flow meter in 20 minutes. Further intervention is needed if there is no improvement within 20 minutes of inhaler use. This intervention may include nebulizer treatment if order, home contact or rescue squad call. If attack resolves, student may return to class.

3.

4.

Implications for Normal Growth and Development 1. Students with asthma may have a tendency for increased absenteeism. Asthma is the number one reason children are absent from school. Missed school days impact school performance and social adjustment. If allergies are a triggering factor, classroom modifications may be needed. Participation in physical activities may need individual evaluation and/or modification. Medication may be used preventively or to reduce symptoms as they occur. Asthma attacks can happen abruptly in any setting which may be upsetting to a student who is already “feeling different.” Health teaching must be directed towards the individual student with asthma as well as his or her peers to promote understanding and acceptance. Think about referrals to American Lung Association Asthma Camp for 8-13 year-olds. Need to be on daily meds to qualify. Camp is one week in June in the Wisconsin Dells area. Scholarships are available.

2. 3.

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