ASTHMA BEST PRACTICES FOR SCHOOL NURSES

School Nurses November 2015 1

BACKGROUND AND CURRENT STATS

General definitions and explanations

2

Incidence of Asthma ◦ Centers for Disease Control (CDC) -

◦ 1 in 12 adults have asthma ◦ 65% of these people have persistent asthma ◦ 35% of these people have intermittent asthma

◦ 1 in 11 children have asthma ◦ 60% of these children have persistent asthma ◦ 40% of these children have intermittent asthma

◦ Kansas ranks in the top 8 states in the US for highest number of children with persistent asthma

◦ 9 persons die daily from asthma ◦ In 2009 – 3,388 persons died from asthma

◦ NHLBI – asthma is the most common chronic disease of childhood, affecting 6 million children

3

Asthma Stats ◦ In 2013 – number of missed school days reported related to asthma – 13.8

million ◦ 20 – 25% of persons with asthma overuse their “quick relief medications”

(Kansas)* ◦ Only 40% of persons with asthma used “long term control” medications

(Kansas)* ◦ 40% of children and 47% of adults have uncontrolled asthma (Kansas)* ◦ 22% of persons with asthma smoke [16% without asthma smoke] (Kansas)* ◦ 30% of children and 33% of adults with asthma are obese (Kansas)*

◦ 97% of children and 85% of adults with asthma had insurance coverage (Kansas)*

*National Center for Health Statistics, Division of Health Interview Statistics (2012)

4

What is Asthma? ◦Chronic, obstructive, inflammatory disorder due to hyper-responsiveness of airway, airway edema, airway narrowing, and mucus production. ◦Chronic inflammatory disorder of the airways that results in intermittent and reversible airflow obstruction of the bronchioles.

5

Inflammation

Airway Hyper-responsiveness Airway

Obstruction

Clinical Symptoms

6

Asthma Triad ◦Bronchoconstriction ◦Airway hyper-responsiveness ◦Airway edema (mucus and edema)

◦ Remodeling

7

Reponses ◦ Immediate response ◦ Mast cells activate IgE → release of mediators (histamines, leukotrienes, and

prostaglandins)→ bronchospasms shortly after exposure. Resolves in 1-2 hours.

◦Delayed response ◦ Chemical mediators attract immune system cells (eosinophils, basophils, and

neutrophils) → infiltrate and cause release of additional inflammatory material → damage to smooth muscle cells causing further edema and mucus obstruction of small airways.

8

Responses ◦Bronchoconstriction ◦ Several hours in length → can reoccur

◦Airway hyper-responsiveness ◦ Can last for weeks or months ◦ Blood flow to obstructed alveoli and open alveoli → ventilation-perfusion

mismatch → decreased pO2 → hypoxia

9

Causes of Asthma ◦ Interplay of a host of factors ◦ Innate immunity ◦ Genetics ◦ Environmental factors ◦ Airborne allergens ◦ Viral respiratory infections ◦ Tobacco smoke ◦ Air pollution ◦ Diet

10

Symptoms of Child Asthma ◦ Children typically have more coughing

VS wheezing ◦ Children often present with night

variant asthma ◦ Very young children may have head

bobbing with breathing ◦ Spirometry in children older than 5-6

years may be used for diagnosis ◦ Children may report symptoms but

most likely symptoms are observed and heard

11

EXPERT PANEL REPORT 3 (EPR3)

National Heart Lung and Blood Institute

National Asthma Education and Prevention Program

12

Managing Asthma Long term ◦ Goals: ◦ Improve the quality of life ◦ Prevent troubling and chronic symptoms ◦ Require infrequent use of SABA (< 2 times per week) ◦ Maintain near normal pulmonary function ◦ Maintain normal activity levels ◦ Meet patient and family expectations of satisfaction with asthma care ◦ Prevent recurrent exacerbations of asthma to minimize missed school days,

ED visits, and hospitalizations ◦ Prevent loss of lung function; for children – prevent reduced lung growth ◦ Provide optimal pharmacotherapy with minimal or nor adverse effects of

therapy 13

4 Components of Care 1. Assessment and monitoring 2. Education for a partnership in care 3. Control of environmental factors and comorbid

conditions that affect asthma 4. Medications

14

Component 1: Assessing and Monitoring Asthma Severity and Asthma Control ◦ Severity: intensity of the disease process ◦ Control: degree of control ◦ Responsiveness: ease of control achieved ◦ Impairment: frequency and intensity of symptoms ◦ Risk: likelihood of exacerbation, progressive decline, adverse

effects of medications. For children – risk of reduced lung growth

15

Asthma Classifications

16

Intermittent Mild Persistent Moderate Persistent Severe Persistent

Frequency of symptoms

2x/week >2x/week but not daily

Daily Throughout the day

Nighttime awakenings

0-4 yrs: 0 Older: 1x or less/month

0-4 years old: 1-2x/month Older: 3-4x/month

0-4 yrs old: 3-4x/month Older: > 1x/week but not nightly

0-4 yrs old: >1x/week Older: often, 7x/week

Activity

No limitations

Minor limitation Some limitation Extremely limited

SABA use < 2 d/week 2 d/week only Daily Several x/day Exacerbations Requiring oral systemic corticosteroids

None – 1x/year

0-4 yrs: >2x/yr or 4 wheezing episodes/yr lasting 1 day with risk factors Older: >2x/yr

0-4 yrs: no improvement Older: >2x/yr with risk factors and changes to FEV1

> 2x/yr for all ages with risk factors and changes to FEV1

Component 2: Education of a Partnership in Care

◦ Open communications ◦ Addressing concerns ◦ Developing treatment goals together ◦ Encouraging self-monitoring and self-management ◦ Asthma action plan ◦ Talking about asthma symptoms and plan at every opportunity ◦ (PHCP – selecting medications treatments goals together)

17

Asthma Action Plans

18

Written Care Guidelines are very important… Define what to do when… daily &

acute Define when to be concerned Define when to seek help

o Obtaining a plan is important for the school nurse

o Fax form to office for PHCP to complete and return

o Use of standardized AAPlan form

Peak Flow Measurements ◦Personal Best (PB) ◦Green 80-100% of PB ◦Yellow 50-70% of PB ◦Red >50%

19

20

21

Component 3: Control of Environmental Factors and Comorbid Conditions that Affect Asthma ◦ Identify allergen and pollutants or irritant exposures ◦ Skin testing ◦ HEPA filters ◦ Identify and treat comorbid conditions ◦ GERD ◦ Obesity ◦ Obstructive sleep apnea ◦ Allergies and sinusitis ◦ Stress

22

Triggers in the school… ◦ Cleaning supplies ◦ Smoking areas ◦ Classroom pets ◦ Foods at parties ◦ Fragrances ◦ Building remodeling, painting, new construction, rugs ◦ Bus and parent drop-off holding areas ◦ Weather - bus stops, recess, travel between buildings

23

Component 4: Medications ◦ Corticosteroids ◦ Mast cell stabilizers ◦ Immunomodulators ◦ Leukotriene modifiers ◦ Long acting beta2 agonists (LABA) ◦ Short acting beta2 agonists (SABA) ◦ Methylxanthines ◦ Anticholinergics

24

Treatment by Steps ◦ Appropriate treatment of asthma is not by

classification ◦ Treatment is by steps – progressing from step 1 for

intermittent asthma to steps 2-5 for persistent asthma ◦ Treatment through steps 2-5 is fluid and moves in

either direction based on control assessment of the child ◦ Requires regular visits and changes in asthma action

plans

25

Stepwise Approach to Treatment 0-4 years of age

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

Intermittent Persistent → → → →

Preferred SABA prn Low-dose ICS

Med-dose ICS

Med-dose ICS + LABA or Montelukast

High-dose ICS + LABA or Montelukast

High-dose ICS + Oral steroids + LABA or Montelukast

Alternate Cromolyn or Montelukast

LABA or Montelukast

Quick-relief

SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn

26

Frequent use of SABA may indicate the need to step-up therapy

Stepwise Approach to Treatment 5-11 years of age

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Intermittent Persistent → → → →

Preferred SABA prn Low-dose ICS

Low-dose ICS + LABA, LTRA. or Theophylline

Med-dose ICS + LABA

High-dose ICS + LABA

High-dose ICS + LABA + Oral steroids

Alternative

Cromolyn , LTRA, Nedocromil, or Theophylline

Med-dose ICS

Med-dose ICS + LTRA or Theophylline

High-dose ICS + LTRA or Theophylline

High-dose ICS + LABA + Oral steroids

Quick-relief SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn

27

Stepwise Approach to Treatment > 12 years and adults

Intermittent Persistent → → → → Step1 Preferred: SABA prn

Step 2 Preferred: Low-dose ICS

Step 3 Preferred: Low-dose ICS + LABA or Montelukast

Step 4 Preferred: Med-dose ICS + LABA

Step 5 Preferred: High-dose ICS + LABA AND Consider Omalizumab for allergy patients

Step 6 Preferred: High-dose ICS + LABA + oral steroids AND consider Omalizumab for allergy pts

Alternate: Cromolyn, LTRA, Nedocromil, or Theophylline

Alternate: Low-dose ICS + either LTRA, Theophylline, or Zileuton

Alternate: Med-dose ICS + either LTRA, Theophyllin, or Zileuton

SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn

28 Consider “allergy shots” for patients who have allergic asthma

MEDICATIONS Treatment Recommendations

29

LABA (Long-acting Beta2-agonists)

◦ Salmeterol (Serevent) ◦ Famoteral ◦ Dry powder inhalers ◦ Bronchodilators ◦ Children under 4 should not

use

30

Combined Medications ◦ Fluticasone/Salmeterol –

(Advair) ◦ Budesonide/Famoterol -

(Symbacort) ◦ Decreases inflammation ◦ Enhances bronchodilation of

Beta2-agonists

31

Inhaled Corticosteroids (long-term control)

◦Beclomethasone – (QVAR) ◦Budesonide – (Pulmicort) ◦ Flunisolide – (AeroBid-M, Aerospace) ◦ Fluticasone – (Flovent) Locally acting anti-inflammatories

32

Mast cell Inhibitors ◦ Cromolyn ◦ Nedocromil ◦ Interferes with chloride

channels ◦ Stabilizes mast cells

33

Leukotriene Modifiers (LTRA) ◦ Montelukast – (Singular) ◦ Take at night ◦ Decreased inflammation ◦ Bronchodilator

◦ Zafirlukast – (Accolate)

34

Oral Systemic Corticosteroids ◦ Methylprednisone ◦ Prednisone ◦ Prednisolone ◦ Growth suppression ◦ Taper doses ◦ Children respond to lower

doses

35

Methylaxanthines ◦ Theophylline Liquid, capsules, or sustained -release tablets Monitor serum levels (5-15 mcg/mL at steady state)

36

Anticholinergics ◦ Ipratropium – (Atrovent) Decreases concentrations of cGMP to produce bronchodilation No systemic anticholinergic effects

37

Immunomodulators ◦ Omalizumab – (Xolair) Decreases amount of IgE receptors on basophils Inhibits binding of IgE to receptors on mast cells and eosinophils Sub-q injection every 2-4 weeks

38

SABA (Inhaled) “rescue” ◦ Albuterol ◦ Levalbuteral – (Xopenex) Binds to Beta2-andronergic receptors in smooth airway muscles Bronchodilators Neblizers or MDIs

39

SCHOOL NURSE Roles and Impact of the School Nurse

40

Asthma resources for school nurses

◦EPR3 from the NHLBI – National Asthma Education and Prevention Program ◦NASN website ◦CDC ◦American Lung Association

41

Student Contact ◦ School personnel (teachers and school nurses) spend more

weekday time with students than most parents ◦ Better day-to-day picture of how they are functioning ◦ Able to correlate missed school days with performance ◦ Evaluate effectiveness of asthma treatment plan ◦ Input into plans ◦ Evaluate student’s understanding about asthma, their plan, and

control ◦ Provide education about asthma

42

School Nurse Asthma Checklist (or - The Nursing Care Plan) ◦Assessment (Assessment) ◦Diagnosis (NANDA) ◦Outcomes (Goals) ◦Planning (Interventions) ◦ Implementation (Interventions) ◦Evaluation (Evaluation)

43

Assessment (Subjective and Objective Data collection) ◦Know which students have asthma ◦Get history (triggers, concerns, contact numbers) ◦Needs ◦Knowledge ◦Baseline data ◦ Triggers in the school

44

Diagnosis (NANDA nursing diagnosis)

◦Which category of asthma does the student fall into: ◦ Intermittent ◦ Persistent Mild ◦ Persistent Moderate ◦ Persistent Severe ◦Allergic ◦ Exercise Induced

45

Outcomes (Goals) ◦Must be measureable ◦Must be made with student (parents) ◦Must be attainable ◦ Include a time frame ◦Establish short term, intermediate term, and long term goals ◦ Fall into PHCP outcomes

46

Planning (Interventions) ◦Current asthma action plan ◦ Individualized health care plan ◦Emergency plan ◦ Input into IEPs when appropriate

47

Implementation (Interventions) ◦Complete actions ◦Communicate with teachers and other staff clear and directed at their level of understanding of asthma ◦Educate teachers and staff *

48

Evaluation (Evaluation) ◦ Frequently assess outcomes toward

goals ◦ Re-evaluate the plan and update as

needed ◦ Evaluate further education needs of

staff ◦ Barriers to student compliance with the

plan ◦ Address all aspects (cultural,

developmental, emotional) ◦ Revise at least yearly

49

Routine occurrences ◦Nebulizers – allows water or saline, medication, and air to come together and then be inhaled into the respiratory tree. Desired benefits are clearance of pulmonary secretions and opening of airways for greater gas exchange, ◦ May be used when children are unable to master

an MDI and spacer ◦ May be needed for a short period of time after an

exacerbation of URI

50

Routine occurrences ◦ Steps to using a nebulizer: ◦ Add medication (liquid only) to the cup ◦ Close cup and connect tubing to the air

compressor ◦ When compressor is turned on, it will vaporize

the medication, creating a mist ◦ The mist is inhaled by the student through the

mouthpiece – treatment lasts until all the liquid is gone ◦ Encourage the student to take deep breaths

during the treatment Important to clean the cup & mouthpiece

after each use – use lemon-free soap and water; dry on a clean towel

51

52

Routine occurrences ◦ Inhalers ◦ School/district policy about student carrying of inhalers ◦ Frequency of use of rescue inhalers (SABA i.e. Albuterol) ◦ Routine use before recess or exercise ◦ Dx: exercise induced asthma

◦Correct use of inhalers ◦ Aerochamber or spacer ◦ Slow inhalation, count, exhale, wait, repeat

53

Controversy about pre-treatment with SABA before recess No evidence to support, no recommendation from EPR3 Prior to recess, no rescue is needed

Routine occurrences ◦ How to use a metered dose inhaler (MDI) with a spacer or

aerochamber (a long tube that slows the delivery of medication from a pressurized MDI) ◦ Shake the inhaler well before use (3-4 shakes) ◦ Remove caps from MDI and spacer ◦ Attach the MDI to the spacer ◦ Exhale ◦ Bring the spacer to the mouth, put the mouthpiece between teeth and close lips around it ◦ Press the top of the inhaler once ◦ Breathe very slowly until a full breath has been taken. **hearing a

whistling sound indicates breathing was too fast** ◦ Hold breathe for about 10 seconds, then exhale. ◦ Wait 3-5 minutes and repeat if 2 puffs have been prescribed

54

Emergency injections ◦ Epinephrine pens ◦ Epinephrine (Epi) injection is used to treat life-threatening allergic

reactions caused by insect bites, foods, medications, latex, and other causes. ◦ Symptoms include: wheezing, shortness of breath, tachypnea, hives,

itching, swelling, stomach cramps, diarrhea, and loss of bladder control. ◦ Epinephrine is a sympathomimetic agent; works by relaxing the

muscles in the airways and tightening the blood vessels.

*school/district policy regarding student carry and stock epinephrine 55

Emergency injections ◦ Steps to giving a pen epinephrine injection

56

PRACTICE Hands on practice as desired

57

QUESTIONS

58