The asthmatic child at school - problems and solutions August 16, 2017

Transcription

1 The asthmatic child at school - problems and solutions August 16, 2017 Stanley P Galant MD Medical Director Olga Guijon MD Associate Medical Director

2 Table of Contents 1. Asthma diagnosis/ What are we missing in the school? 2. How do we diagnose asthma? 3. The need for special/modified physical education 4. School Absenteeism 5. Management of Asthma Exacerbation at School 6. Vocal Cord Dysfunction 7. Managing the Complex Asthmatic at School

3 Family support Medical Provider Asthmatic student School nurse

4 Asthma diagnosis/ What are we missing in the school?

5 Asthma is the most common chronic disease in childhood with the reported prevalence in the US of approximately 10% or 9million children. The prevalence of asthma in the inner city is thought to be much higher at approximately 20-30%. In a previous study in inner city children we found the overall prevalence to be 28%, with 24% in the Hispanic population, 22.7% in the Vietnamese population, and 33% for Caucasian children Asthma is the most frequent cause of hospitalization and school absenteeism particularly significant in minority, inner city children

6 Even though this is a frequent problem in inner city kids, school health programs typically don t screen for asthma, with the potential that delay in diagnosis may affect long term outcomes. Asthma screening at school might be of great value, particularly since physician diagnosis of asthma is vastly underappreciated.

7 How do we diagnose asthma?

8 In school age children these are the hallmarks of asthma 1. Chronic cough frequently in the middle of the night and with exercise, which responds dramatically to albuterol. 2. Wheezing which is an expiratory whistle. However, a proportion of children with asthma may not wheeze. 3. Dyspnea or tightness in the chest. 4. Reversibility of airway obstruction by albuterol as shown by a dramatic decrease in symptoms, and an increase in peak flow measurements, if available. 5. Family history of asthma/allergy.

9 Diagnosis in the preschool child particularly, in the first 3 years of life can be estimated by the Modified Asthma Predictive Index (API) which includes the following. Four previously wheezing episodes associated with Major Criteria (need 1) Minor criteria (need 2) Parental asthma allergic rhinitis Eczema wheezing apart from colds Inhalant allergen sensitization eosinophilia 4 % Food allergen sensitization Positive API results in x greater risk of asthma in school age years, while a negative API is associated with 90% absence of asthma in the school years.

10 Screening tool Child s Gender (Male) (Female) Child s age 1. During the last 2 years, has your child had repeated episodes of asthma? (Yes) (No) 2. Does your child have episodes of cough, chest tightness, trouble breathing, or wheezing when they play or exercise? (Select the one best answer) (Never) (Rarely) (Sometimes) (Often Most of the time) 3. In the past 4 weeks, how often has your child had episodes of cough, chest tightness, trouble breathing, or wheezing in the morning or during the daytime? (Select the one best answer) (Never) (Less than two days a week) (Two or more days a week but not everyday) (Everyday) (More than once a day on most days)

11 Survey Results: No Risk Parents answered no to questions 1, 2, and 3 At Risk- Parents answered positive to questions 2 and 3 At Risk Parents answered yes to questions 1 (Asthma) These set of questions had > 86% predictability of detecting children with the more severe persistent asthma and 56% for children with the more mild intermediate asthma.

12 Conclusion 1. For many children asthma remains undiagnosed and a clinical problem. 2. In the preschool child consider the modified API to assign risk of asthma. 3. In school age children- assess the 5 characteristics, after which should lead to a strong suspicion of asthma and referral to the primary care doctor. 4. Asthma screening should be considered part of routine school medical history screening.

13 The need for special/modified physical education??

14 The necessity of exercise in the asthmatic child 1. Exercise is necessary for all children and this is particularly true for the asthmatic since it builds muscles, promotes lung development, improves lung function and asthma control. In addition, it builds confidence and helps with weight control. 2. The asthmatic child should be able to do what other children can do include becoming an Olympic athlete (as seen in our Air Power Games Figure 1).

15 Figure 1 Air Power Games 2017

16 Conclusion 1. Exercise by improving lung function helps control asthma resulting in less school absenteeism, less medication and decreases health care utilization. 2. It is encouraged that the child exercise 5 days out of the week for at least 30 to 60 mins. In order to do that the doctor may suggest using albuterol 15-20mins before exercise. This should be protective for 2-4 hours.

17 Exercise induced asthma (EIA) or exercise induced bronchospasm (EIB) 1. Definition- When exercise brings on signs and symptoms of asthma, the difference between the two is whether the child has been previously diagnosed with asthma 2. When does it occur? During or more often 10-15mins after strenuous exercise. Usually clears in 30mins. 3. Signs and symptoms are similar to an asthma attack and/or or more subtle as the child who feels more tired with exercise than his peers. 4. Triggers Cold Weather Dry Air Pollution The Presence of URI Exposure to chemicals like chlorine in the pool Pollen 5. The type of exercise that causes EIA from the most to the least likely: Running Bike riding/walking Swimming (note remark about chlorine)

18 Prevention These suggestions may help the asthmatic exercise successfully : 1. The child should not demonstrate signs and symptoms of asthma before exercising. The use of the peak flow meter, comparing the usual best which should be on file, may be needed in some cases. 2. It will be wise not to perform strenuous exercise on days of pollution or high pollen counts, if the child is pollen sensitive. 3. Warming up exercises for 20-30mins beforehand including stretching, jogging or short sprints can be helpful. 4. It is important that the child breathe through the nose. 5. Albuterol 2 puffs 15-20mins before exercise, if needed.

19 Treatment of EIA 1. Short term- albuterol 2 puffs every 4 hours as needed, so there should be an albuterol inhaler at school or in the child s possession, if old enough. 2. Long term- EIA can be a manifestation of previous undiagnosed chronic, persistent asthma, which may require a more definitive asthma work up, and consideration of daily controller medication such as an inhaled corticosteroids (e.g. Qvar) or Montelukast (e.g. Singular)

20 Conclusions 1. Exercise is vital for the asthmatic child s good health and improves asthma control. 2. EIA should not be a problem if the child has well controlled asthma. 3. If the child has frequent EIA the child may have persistent asthma, and requires an asthma assessment and perhaps controller medication. 4. If these suggestions are followed, modified, or special needs physical education should be a Very Rare option indeed.

21 School Absenteeism

22 1. Asthma is one of the leading causes of school absenteeism. It is estimated in the United States that 14.4 million days of school are lost per year due to asthma, in California 1.6 million days. 2. School absenteeism is consistently related to poor school performance with lower scores on standardized reading and math tests, and shows a greater likelihood of dropping out of high school before graduation. (Figure 2).

23 Chronic Absence in Kindergarten Affects 5th Grade Achievement for Poor Children Figure 2-

24 Comparison of absenteeism on asthmatic vs non asthmatic children 1. Overall asthmatic children experience an overall difference in absenteeism of 1.3days a year compared to the non-asthmatic children. The difference is maintained throughout the year which can be cumulative.

25 Absenteeism Over Time of Study Period Figure 3- The x-axis represents the week of absence (starting August 19 and ending June 2) throughout the study period. The y-axis represents the rate of absence (total number of days absent/number of students). The top line demonstrates the rate of absence due to asthma/illness absences for prospectively tracked absences only (N ¼ 543). The middle line is the rate of absence for asthma students (N ¼ 874). The bottom line represents the rate of absence for non-asthma students (N ¼ 8140). Journal of School Health d January 2006, Vol. 76, No.1

26 Factors affecting school absenteeism Minority populations School grade Level- Middle School highest Asthma severity (Figure 4)

27 Figure 4- The x-axis represents asthma severity level. The y-axis represents total days absent. The bars represent the mean days absent (crude/unadjusted) and upper 95% confidence intervals for each severity level. Arithmetic values are used for absence days. However, days absent is a log-normal distribution, and the statistical analysis was performed using the log-transformed values. Journal of School Health d January 2006, Vol. 76, No.1

28 Economic Consequences 1. School- Reimbursement by state as well as accreditation problems are seen with increased absenteeism which affects all students in that school. 2. Individual families- Parents may miss more work which will have economic consequences. 3. The child- Might not graduate from high school with increased absenteeism, which can have long term financial consequences.

29 What can be done? 1. School based approaches- Asthma safe school environments are important which require attention to building problems such as mold allergen and other asthma non-allergic triggers. Diesel fueled buses need to have minimum idling. 2. School based clinics have been shown to be effective, but present funding problems particularly in OC. 3. Open Airways classroom education. (ALA) 4. The flag system to indicate air pollution level. (ALA) 5. The Breathmobile Program (Figures 5a and 5b).

30 Breathmobile Figure 5a

31 Baseline Severity: Moderate-Severe Persistent 15 Expected Number of School Days Missed, adjusted mean (95% CI) School Days Missed, mean (95% CI) Pre Year Post Year Pre Year Post Year Pre Year Post Year Pre Year Post Year Normal BMI Overweight Obese Morbidly Obese Figure 5b

32 Peak Flow Meter Rates and Asthma Action Plans

33 Why use Peak Flow Meter? A tool that measures how fast a child can blow air out of their lungs. Alerts when asthma is getting out of control and measure response to treatment. Serves as a basis for Asthma Action Plan. Can be seen as a thermometer for asthma Usually started at about 5 years of age

34 What is a peak flow meter? (cont) 1. PEFR (Peak Flow Meter Rate) is the maximum flow rate generated during forceful exhalation 2. Depends on voluntary effort and muscular strength of patient.

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36 Why Have an Asthma Action Plan? A written plan that guides the child, parent, or caregiver how to take care of asthma symptoms. All children with asthma should have a written plan at home, and at school- part of asthma guidelines Goal is to help a child and their family to manage or control their Asthma and know what to do if their Asthma symptoms worsen. Based on Asthma signs and peak flow numbers Gives information on Asthma medication schedules, what to do in different situations, and when it is time to go to the clinic or ED Shown to help decrease ED and unscheduled office visits.

37 Loss of Asthma Control-Yellow Zone Increase in asthma symptoms especially night time symptoms Increased use of reliever medications PEFR drop of at least 15% or less than 80% predicted. Onset of URI symptoms -if a previously identified trigger.

38 Management of Asthma Exacerbations at School

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40 Case Review: Jane is a 15 year old student that presents to the nurses office with acute onset of respiratory distress. What do you want to assess? Does she have any asthma or respiratory issues? Any signs of respiratory distress? ( unable to talk, blue lips or nails, severe trouble breathing, change in mental status)

41 Immediate assessment: Is it severe? Inability to speak more then short phrases Use of accessory muscles (retractions) Drowsiness Marked breathlessness Blue lips or nails

42 Immediate Assessment: (cont) Is the student a high risk of fatal attack? Asthma history: Intubation or ICU admission 2 or more hospitalizations per year 3 or more ED visits in past year for asthma Hospitalization or ED visit for asthma in last month Using more than 2 canisters per month of SABA per month Difficulty perceiving asthma symptoms or severity of exaccerbations Social history : Low SEC or inner- city residence Illicit drug use Major psychosocial problems Co-morbidities: Cardiovascular disease Other chronic lung disease Chronic psychiatric disease

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44 Immediate Assessment: If severe exacerbation then treat immediately with SABA ( if has at school) Call 911 contact parent Consider epinephrine Do not leave student alone!!

45 Epinephrine use in asthma Consider using if: Patient unable to use SABA due to respiratory distress Agitation prevents adequate inhalation of albuterol For both situations above: nebulized albuterol is NOT available and the asthma exacerbation is life-threatening. Remember : albuterol is treatment of choice- epi is NOT first-line treatment. Use of epinephrine for asthma is rare!!

46 Case Study 2 Jane is not having any signs of severe distress- she states her asthma started to act up during her final exam. She left her inhaler at home. Upon further investigation she has been coming into the office more frequently for her inhaler this semester. What do you do next?

47 Mild to moderate asthma exacerbation Measure PEF if available- If < 50% of predicted or personal best- treat with SABA immediately and call 911 If > 50% of predicted or personal best- then record respiratory rate and PEF rate- start initial SABA treatment

48 Initial treatment Inhaled SABA: Give up to 2 treatments 20 minutes apart of 2-6 puffs of MDI or a nebulizer treatment Medication must be authorized by physician order or standing protocol Restrict physical activity student should be resting Contact parent/ guardian Assess response in 10 minutes

49 Case study -3 Jane has has her first albuterol dose and she feels better and is her peak flow rate is at 75%. What should you do next?

50 Incomplete Response PEF 50-79% or persistent wheezing or dyspnea. Repeat inhaled SABA ( 20 minutes after previous treatment) Reassess after 10 minutes Call parent

51 Good response PEF >80% and no wheezing or dyspnea reassess in 3-4 hours Follow school protocol for returning to class

52 Asthma exacerbations summary 1.Have a school wide emergency asthma protocol 2.All asthmatics should have AAP at school as well as quick relief medication 3.Request individualized emergency asthma supplement plans 4.Identification of high risk asthmatics is important.

53 Vocal Cord Dysfunction-an Asthma Mimic?

54 Case study cont Jane gets 2 albuterol treatments and her peak flow meter number is at 90%. She says she feels like she can t get a breath in. When you observe her, you note that she looks anxious and she is really working to get that breath in. She moves her shoulders up to get each breath in. Although her PEF is now in the green zone- the two albuterol treatments have not significantly helped her shortness of breath. She has no wheezing and nor prolonged expiratory phase. Vitals are normal. Upon further questioning she has been unable to participate in PE as she has significant SOB with exercise- but with rest is quickly resolves. She has been a straight A student and lately her grades have slipped.

55 Case Study You ask Jane more about her day today. She was doing well this morning with no symptoms She states she was in her final when she suddenly started to have trouble catching her breath. She states she is worried she won t get an A in the class and then she won t get into college. She is very worried about her slipping grades. What could be going on with Jane?

56 Vocal Cord Dysfunction Vocal cords are not acting normally, making it hard to get air into the lungs Vocal cords close when breathing in (instead of staying open) Tight muscles are seen in the neck, shoulders and throat area during an episode or when one takes a deep breath When taking a deep breath, shoulders may rise instead of the stomach A sore throat which may be caused by reflux, coughing, vocal abuse/overuse, allergies or medications

57 Asthma and VCD Similarities Have similar symptoms: SOB, wheeze, cough, episodic Have similar triggers: Viral upper respiratory illness GERD Exercise Chemical irritants stress

58 Vocal Cord Dysfunction- differences Asthma Difficulty breathing air out- wheezing is expiratory Albuterol improves symptoms Onset is minutes to hours Involves swelling and constriction of bronchial airways VCD Difficulty breathing air in ( can have inspiratory stridor. Albuterol does not help much Onset is seconds Is due to dysfunction of vocal cords.

59 VCD Symptoms Shortness of breath with exercise Hard to breath in Throat tightness and soreness Trouble breathing occurs suddenly Wheezing or noisy breathing when breathing in Dizziness Coughing/throat clearing Hoarse voice or change in voice Asthma medications usually do not help symptoms

60 Typical VCD patient Athlete or performer Type-A, high achieving personality Patient with asthma, reflux, post nasal drip and/or anxiety History of or current anxiety issues Occurs more with females than males Age ranges from school age to college

61 VCD diagnosis Patient reports signs and symptoms as well as medical history Laryngoscopy (not always done): a test to see what the vocal cords are doing during breathing Vocal cords can appear to work normally when not having breathing difficulty at testing Spirometry: a test to see how much air a patient breathes in and out

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63 Managing the Complex Asthmatic in School

64 Jane s grades have declined and she has been missing at least 5 school days a month due to her asthma symptoms. She admits that she has been non adherent with her medications. She realizes she needs to take her medications every day but she is so stressed about her homework that she forgets to take her medications every day. Her parents are usually at work and are not always home to remind her to take her medications. What else can be done to help Jane?

65 Case study cont: With parental consent-you discuss the case with Jane s provider and you are informed that she is very non adherent with her medications as well as her visits. At her last visit, her pulmonary function test were very abnormal and her provider is very concerned. What options are available?

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67 504 plans and asthma Nature of concern: Jane has been diagnosed with asthma and is having difficulty understanding what asthma is an her treatment regimen. She is fearful of becoming short of breath and becomes anxious about having an asthma attack. Basis of determining handicap: Jane has missed 10 school days in the last 2 months. She is unable to participate fully in her PE class due to becoming SOB. Her academic performance has dropped due to anxiety, absences, and inability to concentrate in class. She uses her inhalers throughout the school day. Per her provider- her lung function is abnormal and her asthma is poorly controlled. How does the handicap affect a major life activity? Jane has difficulty in keeping up with her peers in physical education. Requires routine medication administration- comes to office for her inhalers frequently Has increased absences due to asthma exacerbations.

68 Sample 504 accommodations for asthma Detailed medication dosing plans at school- including emergency management Develop an adaptive ( but inclusive) plan for PE. Teacher communication regarding planned field trips/outings regarding trigger management and asthma medications. Missed class work plan Trigger management at school: No furry pets in class Plan for grass cutting/pesticide spraying days/ remodelling projects Sitting away from chalk board/windows Teacher/nurse/parent/provider open communication as to changes in asthma management plan or level of control.

69 Future direction

70 1. Providing controller medication at school for the high risk asthma patient who is not adherence to both medication and keeping Breathmobile appointments. a) The school nurse or appropriate personnel could provide controller medication to the child once or twice a day if 504 eligible. 2. Plans for Breathmobile staff to set up asthma services at school-based health clinics are being considered. 3. Implementation of programs which have proved effective, but require funding such as SBHC, SAMPRO and Step Up programs. 4. Telemedicine program 5. Population Health Programs- electronic monitoring of peak flow measures