What You Should Know About AsthmaAlfrina Hany, S.Kp, MN

Nursing School, Medical FacultyBrawijaya University 2012

Learning ObjectivesGeneral

After following this subject the students will be able to apply the nursing care for clients with respiratory disturbances such as Asthma

SpesificThe Students will be able to :

Define, categorize, identify sign & symptoms of clients with AsthmaDescribe & analyze the pathogenesis of Asthma correctlyTake the diagnostic examination for clients with AsthmaApply & manage the best nursing care to clients with Asthma

COPD IS NOT ASTHMA !

Different causes

Different inflammatory cells

Different mediators

Different inflammatory consequences

Different response to treatment

What is Asthma?A disease that:Is chronicProduces recurring episodes of breathing problems :CoughingWheezingChest tightnessShortness of breathCannot be cured, but can be controlledLeading cause of acute and chronic illness in childrenMost frequent admitting diagnosis

WHAT IS ASTHMA?Reversible obstructive airway disease of the lungs bronchial tubes characterized by:Increased airway responsivenessBronchospasm (constriction of bronchial smooth muscle)Inflammation and edema

PrevalencesAsthma prevalence, morbidity, and mortality are increasing in the U.S. and in other countries as well

Affects about 17 to 18 million people in the United States and is becoming more common.

Between 1982 and 1992, the number of people with asthma increased by 42%. Asthma is particularly common in blacks living in urban environments (affecting about 7%) and even more so in Hispanic populations living in urban environments (affecting about 11%).

The condition also seems to be becoming more serious, requiring more people to be hospitalized. Between 1982 and 1992, the death rate from asthma in the United States increased by 35%.

2 or more children are likely to have asthmaIn a classroom of 30 children,

What are the Symptoms of Asthma?SYMPTOMS: WHEEZE, COUGH, SPUTUM, DYSPNOEA,TIGHTNESS.PERIODICITY: DIURNAL, SEASONAL, PROVOKING FACTORS (COLD, EXERCISE, SMELLS. Coughing at night or after physical activity; cough that lasts more than a week

ASSOCIATED: NASAL/SINUS, COLDS, ALLERGIES. Waking at night with asthma symptoms (a key marker of uncontrolled asthma)

SMOKING AND OCCUPATION

Whats Happening in the Lungs with Asthma?The lining of the airways becomes swollen (inflamed)The airways produce a thick mucusThe muscles around the airways tighten and make airways narrower

How Airways Narrow

During an asthma attack, the smooth muscle layer goes into spasm, narrowing the airway. The middle layer swells because of inflammation, and more mucus is produced. In some segments of the airway, the mucus forms clumps that nearly or completely block the airway. These clumps are called mucus plugs.

What Makes Asthma Worse?AllergensWarm-blooded pets (including dogs, cats, birds, and small rodents)House dust mitesCockroachesPollens from grass and treesMolds (indoors and outdoors)

Risk FactorsAllergy / AtopyFamily history of asthma/allergyViral respiratory infections Prematurity : Smaller airways at birth; Low birth weight; underdeveloped chest musclesMale gender - pre-adolescencePoverty, Crowded living conditionsObesityexposure to environmental smoke

TriggersFor people with asthma, exposure to certain substances they are sensitive to can trigger an asthma attack or exacerbation

These substances are known as triggers

Not all people with asthma have the same triggers that will cause an asthma attack

Triggers can include biologic and chemical substances

What Makes Asthma Worse? (cont.)IrritantsCigarette smoke and wood smokeScented products such as hair spray, cosmetics, and cleaning productsStrong odors from fresh paint or cookingAutomobile fumes and air pollutionChemicals such as pesticides and lawn treatments

What Makes Asthma Worse? (cont.)

Infections in the upper airways, such as colds (a common trigger for both children and adults)ExerciseStrong expressions of feelings (crying, laughing)Changes in weather and temperature

Indoor Air Triggers

Environmental tobacco smoke (ETS)CockroachesDust mitesAnimal dander Mold, mildewStrong scented products (perfumes, scented cleaners)

Outdoor Air Triggers

Ozone - Eastern Wisconsin, Dane County?Particulate matter Sulfur dioxide - Wisconsin RapidsNitrogen dioxide - vehicle exhaustOutdoor pollens and mold

Additional Triggers

Viral upper respiratory infectionsExerciseAggravating conditions - gastric reflux, sinusitis, rhinitisDietCold air

Is There A Cure For Asthma?Asthma cannot be cured,but it can be controlled.You should expect nothing less.

ClassificationAsma bronkial tipe non atopi (intrinsik)

Asma bronkial tipe atopi (Ekstrinsik).

Asma bronkial campuran (Mixed)

Tipe non atopi (intrinsik)

Keluhan tidak ada hubungannya dengan paparan (exposure) terhadap alergen

sifat-sifatnya adalah: - timbul setelah dewasa- keluarga tidak ada yang menderita asma- penyakit infeksi - pekerjaan atau beban fisik- perubahan cuaca atau lingkungan peka

Tipe atopi (Ekstrinsik).

Keluhan ada hubungannya dengan paparan terhadap alergen lingkungan yang spesifik.

Kepekaan ini biasanya dapat ditimbulkan dengan uji kulit atau provokasi bronkial. timbul sejak kanak-kanak, pada famili ada yang menderita asma

Di Inggris jelas penyebabnya House Dust Mite, di USA tepungsari bunga rumput.

Asma bronkial campuran (Mixed)

Pada golongan ini, keluhan diperberat baik oleh faktor-faktor intrinsik maupun ekstrinsik.

Stepwise approach ( children)

classification mild IntermittentMild persistentModerate persistentSevere persistentMinor symptoms< 1/week1-3 /week4-5/weekContinuousexacerbation/ nocturnal< 1/month1 /month2-3/month> 4 /monthPEF between attacks>80%>80%60-80%< 60%Step 1Step 2Step 3Step 4

Stepwise approach ( adult)

classification mild IntermittentMild persistentModerate persistentSevere persistentMinor symptoms< 2 /week 2-3 /week4-5 /weekContinuousexacerbation/ nocturnal< 2 /month2-3 /month4-5 /month> 5 /monthPEF between attacks>80%>80%60-80%< 60%Step 1Step 2Step 3Step 4

PATHOPHYSIOLOGYThere are 2 primary components to asthma:inflammationbronchospasm and obstruction

Pathophysiology1. BronchospasmThe smooth muscles that wrap around the windpipe (bronchi) tighten, reducing the size of the airway. normalAsthma attack

Pathophysiology2. InflammationThe mucosal lining of the windpipe becomes inflamed and swells, thereby reducing the size of the airway even further.

3. MucusIncreased mucus production takes up more space; now the airway is very constricted.

Alergen atau Antigen yang telah terikat oleh IgE yang menancap pada permukaan sel mast atau basofil

Lepasnya macam-macam mediator dari sel mast atau basofilKontraksi otot polosSpasme otot polos, sekresi kelenjar bronkus meningkatPenyempitan/obstruksi proksimal dari bronkus kecil pada tahap inspirasi dan ekspirasi

Edema mukosa bronkus

EosinophilMast cellAllergenTh2 cellMODERN VIEW OF ASTHMAVasodilatationNew vesselsPlasma leak Oedema

NeutrophilMucushypersecretionhyperplasiaMucus plugMacrophageBronchoconstrictionHypertrophy/hyperplasiaCholinergic reflexEpithelial sheddingSubepithelialfibrosisSensory nerve activationNerve activation

Increasing number of smooth muscles fibresIncreasing number of mucous glandsOngoing of inflammatory cellsRelease of fibrogenetic factorsElastolysisSever bronchospasms during exacerbationIncrease of mucous secretion during exacerbationInflammationDeposition of collagen in basal and epithelial membranesDecrease of elasticity of the wallPathogenetic process of inflammation

Normal Airway Looking at the Main Carina

Airway During Asthma Exacerbation

Edema mukosa bronkusKeluarnya sekrit ke dalam lumen bronkusSesak napas

Oksigen pada peredaran darah menurun

HipoksemiaCO2 mengalami retensi pada alveoli hipokapneaRRHipoventilasi

Kadar CO2 dalam darah meningkatrangsang pusat napas HiperventilasiGagal napasTekanan partial oksigen di alveoli menurun

Ventilation: PerfusionIts never perfect

EXAMINATIONFEVERWHEEZES AND HYPERINFLATIONTACHYCARDIA (>100 BPM)PULSUS PARADOXUS (>10 MMHG)PEAK FLOW (

Diagnostic TestsCXR INFILTRATESSEVERE BLOOD EOSINOPHILIAPOSITIVE SEROLOGY OR SKINPRICKORGANISM IN SPUTUMCOMPLICATIONS - APICAL FIBROSIS, BRONCHIECTASISPulmonary function tests reveal a decreased forced expiratory volume, increased residual volume from air trapping and decreased vital capacity (max amount of air exhaled)Skin tests to identify allergens

Asthma Patient: Mucous Plug, Pneumothorax and Chest Tube

CASE SCENARIOTuginem 14 years old come to the clinic c/o shortness of breath for one day duration.He is a known asthmatic patient for more than 8 years, he visited A/E frequently.His school performance is below average, with frequent absence from school due to his illness.

HOW YOU WILL PROCEED?

How Is Asthma Controlled?Follow an individualized asthma management planAvoid or control exposure to things that make asthma worseUse medication appropriatelyLong-term-control medicineQuick-relief medicine

How Is Asthma Controlled? (cont.)

Monitor response to treatmentSymptomsPeak flowGet regular follow-up care

Therapeutic Management1999 Canadian Asthma GuidelinesControl of the diseaseControl the environmentAsthma education, favoring self-managementInhaled short acting bronchodilator as 1st lineAdditional therapy (long-acting B2 agonists, leukotriene-receptor antagonists)

Asthma MedicationsLong-term ControllersUsed to control and prevent asthma symptomsMust be taken daily

Quick-ReliefProvides quick relief of an acute asthma episode by opening up the bronchiolesUsed as needed for symptoms and before exercise

Long Term Controller MedicationsControl and prevent asthma symptomsMake airways less sensitive to triggers and prevent inflammation that leads to an acute asthma episodeTaken on a daily basis

Quick Relief MedicationsProvide relief of an acute asthma episode

Short acting inhaled bronchodilators - albuterol, pirbuterol (Maxair)Oral prednisone burst, when albuterol alone is not effective

Tata Laksana Medikamentosa

Obat asma dapat dibagi dalam 2 kelompok besar, yaitu obat pereda (reliever) dan obat pengendali (controller) : Reliever, sering disebut obat serangan, digunakan untuk meredakan serangan atau gejala asma jika sedang timbul. Bila serangan sudah teratasi dan sudah tidak ada gejala lagi, maka obat ini tidak digunakan lagi. beta agonis (inhaler/spray) kerja pendek (short acting 2-agonist, SABA); bronkodilator: golongan xantin kerja cepat (teofilin)

Controller, sering disebut obat pencegah, digunakan untuk mengatasi masalah dasar asma, yaitu inflamasi respiratorik kronik (peradangan saluran napas menahun). Dengan demikian pemakaian obat ini terus-menerus dalam jangka waktu relatif lama, tergantung derajat penyakit asma, dan responnya terhadap pengobatan/penanggulangan. Controller diberikan pada Asma Episodik Sering dan Asma Persisten. budesonid ; Anticholinergic Drugs: ipratropium, block acetylcholine ; Corticosteroids

Delivery of asthma medication

Delivery System

Nebulizer

Inhaler alone

Inhaler/aerochamber

Turbuhaler

Diskus

Recommended age

All ages (with O2)

10 years and up

All ages (yellow 4 months to 5 years blue 4 years up)

5 years and older

5 years and up

NebulizerWash hands and prepare medication and diluent as ordered and empty into nebulizerDo chest assessment, put mask on child and set 02 to 5-7 LPMTreatment usually takes 10-15 minutesDo post assessment and rinse the nebulizerwith water, allow to air dry

HOW TO DIAGNOSE BRONCHIAL ASTHMA ?Consultation skillRelevant History -Symptom -history of allergic disease -Family history -Environmental history -Exclusion of other medical condition

NURSING CAREWhat Should People with Asthma Be Able To Do?Be active without having asthma symptoms; this includes participating in exercise and sportsSleep through the night without having asthma symptomsPrevent asthma episodes (attacks)Have the best possible lung function (e.g., good peak flow number)Avoid side effects from asthma medicines

Prevention-environmental controlIrritants, smoke and allergensGoal is to decrease the frequency and severity of attacks by recognizing and controlling triggersAllergy testing If dust mites are the source of allergy- wash sheets Qweekly, cover mattresses and pillows with impermeable covers and remove carpets from the childs room

Prevention- exerciseExercise induced asthma is triggered by rapid breathingWarm air by breathing through nose or covering mouth and nose with scarfUsing inhaled bronchodilator before exerciseUsing techniques to decrease hyperventilation (ie. muscle relaxation and diaphragmatic breathing)

Prevention- infectionViral infections are the most frequent triggerAvoid exposureInfluenza vaccine

Prevention- emotionsAsthma is not caused by psychosocial problemsLaughing, crying or shouting can act as a mechanical trigger to bronchoconstrictionAnxiety can cause hyperventilation

Health TeachingConsult a physicianWhen there is no relief 15-20 minutes after inhalerInhaler is needed earlier than 4 hoursInhaler is required 4-6 times a day after 2-3 daysHelp client live with disease

Crisis Plan for AsthmaBegin this plan when I have:These Symptoms:Taking these medications:________________________________________________________________________Call my doctor:Name: _______________Phone number: _________________If I cannot reach my doctor immediately:Take ______________________________________________________

If I have severe symptoms or I am getting worse very quickly:Go to the emergency room if within ten minutes distance:Location of emergency room ________________________Contact and emergency transport system____________________________________________Phone number _____________________________ Name of system ________________________Planning for Travel ____________________________________________________________________

Key Elements of Asthma Therapy

Suggested ReadingBrunner & Suddarth (2002). Buku Ajar Keperawatan Medikal Bedah. Volume I. EGC : JakartaBlack & Jacobs (1997). Medical Surgical Nursing : Clinical Management for Continuity Care. 5th edition. Philadelphia : WB Saunders CompanyPrice & Wilson (1995). Patofisiologi : Konsep Klinis Proses Penyakit. Edisi IV. Volume II. Jakarta : EGCSoeparman & Waspadji (1995). Ilmu Penyakit Dalam. Jilid II. Jakarta : Balai Penerbit FKUIKapita Selekta KedokteranTuberculosis by Frederick Southwick (University of Florida), 2003Permasalahan TB kini, masa datang & penanggulangaannya oleh Pokja TB Balitbangkes Jakarta

Additional ResourcesAllergy & Asthma Network/Mothers of Asthmatics, Inc. -- http://www.aanma.org

American Academy of Allergy, Asthma, and Immunology -- http://www.aaaai.org

American Academy of Pediatrics -- http://www.aap.org

American College of Allergy, Asthma, and Immunology -- http://www.allergy.mcg.edu

American Association of Respiratory Care -- http://www.aarc.org

Additional ResourcesAmerican Lung Association -- http://www.lungusa.orgAsthma & Allergy Foundation of America -- http://www.aafa.org/homeNational Asthma Education and Prevention Program -- http://www.nhlbi.nih.govUS Environmental Protection Agency -- http://www.epa.gov/iaqCenters for Disease Control and Prevention -- http://www.cdc.gov/nceh/airpollution/asthmaAsthma and Schools -- http://www.asthmaandschools.org

INTERNET SITEGuidelines NHLBI/ WHO report http://www.ginasthma.comCochrane Site: http://www.cochrane.org/Clinical Evidence: http://www.clinicalevidence.org

Types of Long Term Controller MedicationsBrand names are listed as examples only, and are not inclusive.Inhaled corticosteroids - Flovent, Pulmicort, QVAR, Azmacort, Aerobid, Pulmicort Respules (only nebulized form), Vanceril , Beclovent . Preferred therapy for persistent asthma.

Long acting bronchodilators - Serevent, Foradil.

Types of Long Term Controller Medications (cont.)Brand names listed as examples only, and are not inclusive.Combination inhaled corticosteroids/long-acting brochodilator - AdvairLeukotriene modifiers - Singulair, Accolate. A pill, not an inhaler, not a steroid

Inhaled nonsteroid anti-inflammatory medications - Intal, Tilade

Oral steroids

Using a Peak Flow MeterA peak flow meter is a useful tool for objectively measuring the severity of asthma

The value obtained is called a peak expiratory flow rate (PEFR)

The PEFR shows the degree of airway obstruction or narrowing

Determining a Personal Best ValueEach person has a normal PEFR based on height and gender. This is a predicted value.

Many physicians prefer to use the persons personal best value

The personal best represents the highest rate obtained over a specific period of time.

Correct Technique for Using a Peak Flow MeterPlace indicator at the base of the numbered scaleStand upTake a deep breathPlace the meter in the mouth and close lips around the mouthpieceBlow out as hard and fast as possibleWrite down the achieved valueRepeat the process two more timesRecord the highest of the 3 numbers achieved

Using a Metered Dose Inhaler(MDI)MDIs deliver asthma medication directly to the lungs. To use:Remove the cap and hold inhaler uprightShake the inhalerKeep the head and neck in a neutral position and breathe outPosition the inhaler in one of the following ways:Open mouth and hold inhaler 1-2 inches awayUse holding chamber (recommended for young children)Put in the mouth

Using a MDI (cont)Press down on inhaler to release medication as you start to breathe inBreathe in slowly (3 to 5 seconds)Hold breath for 10 seconds to allow medicine to reach deeply into lungsRepeat puffs as directed

Rules of 2When do you need more than a rescue bronchodilator?Do you take your quick relief inhaler more than 2 times per week?Do you awaken at night with asthma more than 2 times per month?Do you refill your quick relief inhaler more than 2 times per year?

If the answer to these questions is yes, a long term controller anti-inflammatory medication may be needed.

**Many children wheeze in their early years. Not all wheezing is asthma and some of these children outgrow the wheezing episodes by age 5. Children over age 5 do not usually outgrow asthma. They may be symptom free for long periods of time, but the tendency for an asthma flare is always there. They may have any one of these symptoms or experience all of them over the course of time.

*According to the latest prevalence data for asthma in children, somewhere between 4% and 10% of children under age 18 have asthma.*Some asthmatics never wheeze, but only cough. This is sometimes called cough variant asthma.Whenever you see a diagnosis of chronic cough, reactive airway disease, recurrent pneumonia, wheezy bronchitis, bronchiolitis or recurrent croup, one needs to consider the diagnosis of asthma.

*In asthma, the airways of the lungs become narrow and obstructed. Swelling and increased mucous in the airway wall causes the airway to become more rigid and interfere with airflow. As the airways become obstructed, it becomes harder to breathe out and the lungs get filled up with air. This causes chest tightness and shortness of breath.There is the potential that a patients airways may become too narrow to wheeze as they constrict. Therefore, sometimes as a child progresses with a severe asthma attack, he or she actually begins to wheeze less, rather than more.

*Patients with a genetic tendency for allergy respond to normally harmless environmental substances with production of a particular antibody called IgE. This IgE antibody resides on mast cells in the lungs, and causes the release of inflammatory chemicals from these cells when allergen interacts with IgE.All furry or feathered pets can be allergenic to the allergic child. They are allergic to the dander, fur, feathers, saliva, and urine of these animals. The best thing is to remove the pet from the home. We know that most people will not agree to do that. Therefore it is critical to at least keep the animal out of the bedroom. A HEPA air filter in the enclosed room placed on a hard surface may help.The most important measures of dust mite control is to encase the pillows and mattress in an allergen proof cover and wash the bedding and stuffed animals weekly in hot (130 degree) water. Clutter, upholstered furniture, and drapes in the bedroom should be avoided. Humidity in the home should be kept under 50% as humidity increases dust mite growth.Cockroach control measures include keeping the eating areas meticulously clean. Store food in tight containers. Eliminate moisture by repairing leaks around pipes and improving ventilation. Bait traps may be placed out of reach from children and pets. If there is cockroach infestation, extermination must be done professionally. Cockroaches are more common in multiple dwellings in urban environments and warm climates.Children should shower and shampoo after playing outdoors in the grass as pollen sticks to the clothes and hair. Use air-conditioning when possible. Mold can grow on any substance or surface where there is moisture. Keep humidity under 50%; dehumidify where necessary. Avoid carpet on basement or concrete floors. Clean moldy areas with a 1-10 bleach solution. Do not put damp shoes or clothes in closet. Do not store firewood in the home.

*Atopy = hereditary predisposition toward developing certain hypersensitivity reactions, including asthma, upon exposure to specific antigens or triggers

There is increasing evidence that asthma is a highly heritable disease, with a significant genetic component.

But, these are all theories, were still not completely certain of all the pathways involved in the development of asthma for any particular person.

One theory - genetics cant have changed that much in the past 20-30 years to explain all the increase in asthma prevalence. Maybe its the environment that is changing, and pushing more people on the continuum toward asthma.

*Triggers are not things that cause asthma to develop, they are things that can cause an attack to occur.*Irritants cause asthma symptoms, but are not IgE mediated.Cigarette smoke contains 4,000 substances, with 40 of them linked to cancer. Secondhand smoke can trigger an asthma exacerbation, pneumonia, and bronchitis or cause the development of asthma in young children. Young children also have more ear infections with secondhand smoke exposure. Smoking should not be allowed in the home or in the car. If someone needs to smoke, they should smoke outside.Limit prolonged outdoor physical activity on air pollution alert days. Encourage people to refuel their cars and use their gas powered lawn equipment after 7 pm on air pollution alert days.Other substances such as oil based paints, cleaning products, or hair spray trigger asthma.

*Upper respiratory infections in young children are the most common cause of asthma exacerbations.

Exercise dries and cools the airways, triggering more airway closures.

Crying or laughing can trigger asthma symptoms when the asthma is not under good control.

Weather conditions, such as cold weather, can make asthma worse.

***

Use sponge roller for demonstration*Use sponge roller for demonstration*****Every child with asthma should have an asthma management plan that tells what medications are to be taken and when. Their plan should list the environmental triggers that are unique to that child.

*The asthma management plan may be written according to peak flow monitoring or by symptoms only. It is critical for the child to have regular check-ups with their provider in order to keep his/her asthma under control. It is sometimes hard for parents to make accurate assessments of their childs asthma.Regular doctor visits are also important to review the medication program the child is on, check inhaler technique, monitor for any medication side effects, ensure refills are up-to-date, and answer any questions the child or parent may have.

*There are two main medications used for asthma. They are called long term controllers and quick relief (or rescue). The long term controller medication is sometimes called a preventer. The quick relief medication is sometimes called a reliever. It is important for the child and family to understand the difference in the medicines.

Quick relief medicines are used as needed for symptoms and before exercise.

*This medication may need to be taken even when there are no symptoms in order to maintain control of the asthma.

*Rescue medications have a quick onset of action, usually in 5-10 minutes. However they last only 4-6 hours at the most. They are to be used only when needed, prior to exercise induced asthma, and in acute exacerbations. If, because of asthma symptoms, patients have to use this medicine twice a week or more, more than twice a month at nighttime, or have it refilled more than twice a year, their asthma may not be in good control. They need to notify their provider as additional medication may be needed.

Oral steroids take several hours to be effective, but are often given in acute exacerbations for 3-7 days.

***I would encourage you to use any or all of these resources for additional information and support.**Inhaled corticosteroids, also known as anti-inflammatory medications, are considered the first line of therapy. It is important to stress to the child and parent that there may not be an immediate response to this medicine. Leukotriene modifiers are an alternative controller for mild persistent asthma. Long term controller medications improve symptoms, peak flow values and spirometry. The goal with these medicines is to decrease airway hyperresponsiveness and prevent exacerbations.You will notice that the long acting bronchodilators are also controller medications. They do not act quickly like the rescue medications, but have a duration of up to 12 hours.*Combinations of inhaled corticosteroids at low to medium doeses with inhaled long-acting bronchodilators are considered the preferred therapy for moderate persistent asthma.Leukotriene modifiers are used as a single agent in mild asthma in place of an inhaled corticosteroid, or in combination with an inhaled corticosteroid for more severe asthma. They can be effective in blocking triggers such as exercise, cold air, and allergens. Intal and Tilade are mast cell stabilizers that inhibit early and late phase responses. They have an excellent safety profile. May need a 4-6 week trial to show improvement. Intal needs to be taken 4 times a day to be effective. Tilade may be titrated down to twice a day. *The peak flow meter measures the amount of air one can blow out of the large airways in one second. *Show proper technique for using peak flow meter. Each patient that uses a peak flow meter should know how to obtain his/her personal best number. This is done by the patient taking their peak flow at least once a day, at the same time each day, as asthma has a 24 hour variation. The peak flow rates will be best between 12 and 5 pm. It is best to take the peak flow in the early afternoon and/or after AM medications; this should be done for a few days to ensure the number is stable. If the peak flow is stable, readings should be taken for 2 weeks, recording each day the best number out of three blows. The highest number (as long as it isnt a result of coughing or inappropriate technique) over this 2 week period is their personal best number.

The personal best should be reestablished every 6 months to allow for lung changes. Also reestablish the personal best with each new peak flow meter.

*It is extremely important that the child always stands.Observe the child closely making sure the tongue is not in the way or that the cheeks are not puffed out as they blow. These two things will give an improper reading.If the child coughs as they are blowing, this too will alter the accuracy of the peak flow reading. If they cough, they need to do an additional blow.*Demonstrate proper MDI technique for audience.Holding chambers are recommended for children unable to properly use an MDI, and when an inhaled corticosteroid MDI is being used.Placing canisters in water to estimate fullness has been found to be highly inaccurate. Teach the child/parent to count doses on the anti-inflammatory medication. Have them divide the number of doses to be taken per day into the number of doses in the canister and that will give you the number of days to take the medication. Have the child write the date of the last dose on the canister and on a calendar to remind them to get a refill. The patient may also divide the number of doses in the canister by the average number of times used each week and then refill accordingly. Families can also take the canisters to a pharmacist to weigh and determine the number of doses remaining.

Also demonstrate the turbuhaler, diskus, and aerolizer (Foradil).

*Demonstrate the three different techniques of using the inhaler.Inhaler with spacer/holding chamberOpen mouthClosed mouth (do not use for corticosteroids)

Emphasize that the inhaler with a spacer/holding chamber is the preferred method for children unable to do proper MDI technique without a spacer and for use of MDI-type inhaled corticosteroids.*Rules of 2 is a good rule of thumb to use to determine if a child needs more than rescue medication for his asthma.

Rules of 2 is a trademark of Baylor Health Care Systems, 1997.