AsthmaMay 20, 2013

DefinitionInvolves bronchial airways, not lung tissueCharacterized by REVERSIBLE narrowing

Peribronchial muscle spasmMucous production, excess volume and

tenacityEdema of airway liningReverses spontaneously or in response to meds

Asthma effects on airways

Prevalence

12.7% of children under 18 with at least one episode of wheezing

9.6% of all US children with active asthma, equal to 9 million children

Martinez,FD JACI 2011; 128:939-45

Acute SymptomsCoughing

From tight, dry, “croupy” to very “wet”WheezingTachypneaChest pain or back painDyspneaSpeaking in incomplete sentencesPoor exercise tolerance

Symptoms Cough : localized in large airways, trachea

and main bronchial tubesWheeze: localized in medium sized airways,

secondary bronchial tubesSilent but dyspneic: localized in small

airways, terminal bronchioles

Asthma ClassificationBy Severity and Frequency

NAEPP By types of triggers: allergic, non-allergic,

both

Severity and FrequencyMild Intermittent

Needing rescue medication < twice weeklyOK to need pre exercise treatmentNo HS wheeze/cough

Mild PersistentNeeding single maintenance medication dailyNo breakthrough need for rescue or HS symptoms

Moderate PersistentNeeding two maintenance medications daily

Severe PersistentNeeding rescue medications despite three or more

daily medications

Asthma ClassificationBy Severity and Frequency

NAEPP By Types of Triggers:

AllergicNon-allergicBoth

Classic TriggersViral infectionExercise: alone or only if already inflamedIrritants: Cigarette smoke, Perfumes, VOCsWeather changesAllergens

Dust mitesPollensMold sporesPet dandersFoods : Egg, milk, peanut, wheat, chocolate

Goals of Treatment

No loss of school daysNo restriction on sports/activitiesNo loss of sleep from asthma or from medsNo or minimal side effects from medicationsMaintain lung function/prevent permanent

injury

TreatmentBased on Triggers

Allergic Control of foods in school Control of pollen exposure Control of pet dander exposure School projects designed with allergens in mind

Non Allergic Exercise modification when necessary Minimize irritants in classroom

Treatment Based on Severity and Frequency

NAEPP Guidelines: Step up Step downBased on Triggers

Environmental controls Allergens Irritants Infection avoidance Exercise management

Step up Step downAlbuterol alone: for exercise asthma or for

rescue up to twice weekly, with no night symptoms

Step Up I: add Singulair or ICS if albuterol needed more than 2 times weekly or at all at night; consider allergy IT if appropriate

Step Up II: add combination ICS-LABA or increase ICS dose if still not controlled

Step up Step down IIStep Up III: combine Singulair and higher

dose combined ICS-LABAStep Up IV: add oral corticsteroid to all of

the aboveStep Up V: consider Xolair for appropriate

candidateStep Down: to preceding level if symptoms

are controlled for an appropriate amount of time

NAEPP 2007 EPR-3

Rescue MedicationsAlbuterol

Proventil, Ventolin, ProAir, albuterol HFAXopenex (Lev albuterol)

MDI vs nebulizer

PreventersAnti Leukotrienes – Singulair, Zyflo,

AccolateMast cell stabilizers – IntalInhaled corticosteroids – Flovent, Qvar,

Pulmicort, Alvesco, AsmanexCombination ICS with LABAs – Advair,

Symbicort, DuleraOral corticosteroids – prednisone, Medrol

(methylprednisolone) Orapred (prednisolone)

Your RolePrevention

Assess and address risks in classroom and school

Identify students at risk – asthma control test Consider environmental strategies:

Air conditioningTiming of outdoor activitiesTypes of class projects or field trips

Educate students and faculty

Red Flags

Refilling rescue inhaler more than once per month

“Sudden” or gradual loss of interest in sports/playing

Needing rescue inhaler at night…even onceNeeding rescue inhaler more than every 4

hoursRescue inhaler doesn’t “work”

May repeat every 15 minutes for 3 doses only

Your Role TreatmentAssess

Peak FlowO2 SatPulseRespiratory rateRespiratory effortSkin, mucous membrane colorEase of speaking/quality of speech

Treat per asthma action planCommunicate

CommunicatePreventive measures

With classroom personnelWith cafeteria personnelWith gym departmentWith janitors (via principal, school doctor)

After an acute episodeWith emergency personnelWith parentsWith individuals involved at time of episode