A Guide for Students and Parents

Transcription

1 A Guide for Students and Parents February 20, 2009 This program was made possible through an unrestricted grant from: Monaghan Medical Corporation, Lupin Pharmaceuticals Inc., and Forest Laboratories Inc. American Association for Respiratory Care 9425 N. MacArthur Blvd., Suite 100 Irving, Texas Phone: (972) Fax: (972)

2 3 Asthma Management Tools/Information The effective management of asthma relies on both medicinal and nonmedicinal therapies directed at reaching specific therapeutic goals. Management of asthma should have the following goals: Maintain normal activity levels (including exercise). Maintain (near) normal pulmonary function rates. Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion). Prevent recurrent worsening symptoms (exacerbations) of asthma. Avoid adverse effects from asthma medications. General Treatment Principles Asthma is a chronic condition with acute exacerbations. Treatment requires a continuous care approach to control symptoms, to prevent exacerbations, and to reduce chronic airway inflammation. Prevention of exacerbations is an important principle of therapy. This includes avoidance of triggers (and for allergic patients, the avoidance of allergens), especially in the indoor environment. It also includes around-theclock medication treatment for many patients. Those with poor exercise tolerance, recurring symptoms, and frequent night ime symptoms even patients with mild-moderate asthma will often benefit from the regular administration and more aggressive use of asthma education, especially anti-inflammatory medicine. In contrast, patients with mild intermittent asthma, uninterrupted sleep at night, and good exercise tolerance may require only occasional treatment for the relief of symptoms. Periodic assessment of these patients by a physician knowledgeable in asthma management will assure that their therapy is appropriate. The treatment of asthma should be based on an understanding of the underlying pathophysiologic mechanisms and on the objective assessment of the severity of the disease. Therapy should include efforts to reduce underlying inflammatory components of asthma and to relieve or prevent symptomatic airway narrowing. It is hoped that therapy will lead to reduction in airway hyperresponsiveness and prevention of irreversible obstruction. Anticipatory or early interventions in treating acute exacerbations of asthma reduce the likelihood of developing severe airway narrowing. Asthma therapy has several integral components: patient education, environmental control, and medicinal therapy, as well as the use of objective measures to monitor the severity of disease and the course of therapy.

3 4 Nonpharmacologic Therapy Optimal nonpharmacologic (nonmedicinal) treatment of asthma includes consideration of the following: Individual and family education Avoidance of agents that induce or trigger asthma allergens, irritants such as cigarette smoke and reasonable attempts at reducing exposure to respiratory viruses Appropriateness of immunotherapy. Asthma patients, by definition, have hyperresponsive airways; therefore, avoiding exposure to irritants that produce airway narrowing is essential. Irritants and allergens that provoke acute symptoms also increase airway hyperresponsiveness, which in turn, increases vulnerability to further irritant or allergen exposure. Nonspecific irritants include tobacco smoke, dust, strong odors, and industrial or environmental air pollutants. If allergies play a role in an individual s disease, environmental control measures to avoid specific allergens are of paramount importance, and immunotherapy may be indicated in selected patients. Pharmacologic Therapy Pharmacologic (medicinal) therapy is used to treat reversible airflow obstruction and airway hyperesponsiveness. Medications include bronchodilators and antiinflammatory agents; some drugs may deliver two drugs at once to do both. Anti-inflammatory agents interrupt the development of bronchial inflammation and have a preventive action. They may also modulate or terminate ongoing inflammatory reactions in the airways. Anti-inflammatory agents include inhaled corticosteroids and cromolyn sodium or cromolyn-like compounds. Bronchodilators act principally to dilate the airways by relaxing bronchial smooth muscle. Bronchodilators include beta-adrenergic agonists, methylxanthines, and anticholinergics. The following discussion reviews pharmacologic approaches to asthma therapy that relate the choice of medication to the pathophysiology of asthma and therapeutic goals. Whatever medication is used, it is essential for both the patient and the clinician to recognize that a poor or short-lasting response to treatment in the face of progressively worsening asthma demands immediate, intensive medical care.

4 5 Indications of diminished control of asthma may be an increased use of bronchodilators or a lack of an expected therapeutic response to the administration of the medication. In fact, recent data suggest that increased patient use of bronchodilators on an outpatient basis in the face of worsening asthma may be associated with increased asthma disease and death. (See Rules of Two on page 9) A decreasing therapeutic response may develop over a short period of time or gradually during a period of days to weeks. Failure to appreciate the severity of asthma or ignoring an inadequate response to therapy represent two major risk factors associated with increased disease and death during acute exacerbations of asthma. Keep in mind that inhaled anti-inflammatory medicine is the long-term control medicine and is used on a daily basis to suppress and prevent inflammation, thus controlling symptoms and preventing episodes. Bronchodilators such as albuterol are the quick-relief medicines. They are used primarily for management of acute episodes or for preventive treatment prior to exercise. It is important to remember that increased use of beta-2 agonists is an indication of worsening asthma that warrants medical attention. Aerosol Therapy All aerosolized medications that are used to treat asthma are available as metered-dose inhalers (MDIs). The advantage of delivering drugs directly into the airways is that high concentrations of drugs can be delivered to the airways, while systemic side effects are usually avoided. Students should be instructed in the use of a metered-dose inhaler, and their technique should be checked periodically. For the individual who uses the MDI incorrectly, a valved holding chamber improves bronchodilator effectiveness. Valved holding chamber devices allow discharge of the drug in the MDI into a chamber where particles of medication are suspended for three to five seconds. During this time, the patient can inhale the drug. Valved holding chambers eliminate rapid initial particle velocity, reducing the irritant properties of the aerosol and the tendency to cough. They also reduce deposition in the mouth and oropharynx, decreasing cough as well as the possibility of oral candidiasis (thrush) when used to deliver steroids. Valved holding chamber devices are indicated principally for young patients, for patients who have coordination problems that prevent the correct use of the MDI, and for patients who have particularly irritable airways.

5 6 If a child has difficulty using an MDI device, is under three years of age, or has been admitted to the hospital or an emergency room more than once, it may be necessary to use a compressor-driven nebulizer. The nebulizer can reduce the patient errors or difficulty in administration that can occur with MDIs. The nebulizer is also easier to use for children who have too much difficulty breathing during an episode to use an MDI. Appropriateness of Medications The appropriateness of using any medication is a decision to be made by the managing health care provider on a specific patient-evaluation basis. Individuals with asthma should always be instructed to discuss any questions about that treatment plan with their health care provider.

6 7 The Asthma Episode The main symptoms of acute asthma episodes are shortness of breath, wheezing, tightness in the chest, and/or recurrent cough. However, symptoms vary among those afflicted with asthma. Not all patients wheeze; persistent cough alone may be the only symptom, especially for young children. Although the term attack, (which is sometimes used to describe an episode) implies that asthma episodes are sudden and unpredictable, this is not always the case. The changes leading up to an episode usually take place slowly and can be detected with monitoring. There are three features of an asthma episode. One is the contraction of the involuntary muscles surrounding the airways. This is known as bronchospasm, which causes airflow obstruction. Bronchospasm can be reversed quickly by using an inhaled bronchodilator. Secondly, inflammation of the lining of the airways edema results from the release of chemicals made by cells in the airway. This inflammation further narrows the airways. Inflammation can persist for weeks after an episode. Medications such as inhaled corticosteroids are used to reduce inflammation. Inhaled corticosteroids used early in the course of a serious episode may speed its resolution and prevent recurrence. Thirdly, excessive, thick mucus that narrows the airways is often produced during an asthma episode. Again, inhaled corticosteroids may help reduce the production of mucus. When the acute phase of an asthma episode is over, deep coughing may help remove the mucus. The keys to controlling asthma are knowledge, skill, and behavior. Thoughtful and proper management should be encouraged and supported.

7 8 Assessment and Observation Once a student is diagnosed with asthma and a treatment plan is prescribed, the student s asthma should be monitored by the child s parents and school staff. To help prevent asthma episodes, the student s physician should periodically reassess the student. When an episode does occur, the student s parents, school staff, and the physician should assist the student in controlling the episode. Assessment should include the use of a peak flow meter like the one provided with the Peak Performance USA program. This device measures how well the air moves out of the lungs (or peak flow) and works as an early warning device. Assessment of the student should also include identifying the student s personal asthma triggers. A variety of triggers can cause an asthma episode. Triggers include: allergens, irritants in the air, respiratory infections, overexertion, weather, some medications, and strong emotional expression such as laughing or crying. School personnel, through observation, can play a key role in assisting the student with asthma. Asthma episodes are usually preceded by certain signs. These can occur hours or days before audible wheezing appears or an episode is in full progress. Signs vary among individuals but may include a drop in peak flow (the highest exhaled flow rate the student can produce after a maximal deep breath). Use of a peak flow meter can help detect potential problems because peak flow may decrease before an episode begins. Other symptoms are an itchy chin or throat, tiredness, light wheezing or coughing, a pain or tightness in the chest, or shortness of breath. Being aware and looking for these signs and symptoms can help students use selfmanagement techniques. Early action can help the student defend against a severe asthma episode.

8 9 The Rules of Two The Rules of Two (self-assessment asthma tool) can help determine if the student s asthma is out of control: When is quick relief not enough? Does the student Have asthma symptoms or take quick relief medication more than two times a week? Awaken at night with asthma symptoms more than two times per month? Refill quick relief inhalers more than two times per year? Measure peak flow at less than two times 10 (20%) from baseline with asthma symptoms? If the student has asthma, is more than four years of age and answered yes to any of these questions, then the student s asthma may not be in control and may need to add a second medication to help gain control as specified in the student s Asthma Action Plan. Talk to your student s physician. Rules of Two is a federally registered service mark of Baylor Health Care System.

9 10 Peak Expiratory Flow (PEF) Measurement at Home or School Measurement at School or Home Results of peak expiratory flow (PEF) monitoring are helpful in making decisions when to begin or end treatment or to seek emergency care. PEF is the flow rate or speed of air that can be expelled from the lungs during one rapid forced exhalation. This is similar to the initial effort used to blow out a candle. Daily measures upon awakening and when going to bed help identify patterns of airway obstruction that may indicate a need for additional treatment. The peak flow meter should be used at school whenever a breathing problem is suspected or when the student exercises. PEF is measured with a peak flow meter. The school nurse or respiratory therapist will teach the student how to use this device at school. The meter measures how fast air can be expelled by the lungs during one rapid, forced exhalation. By exhaling as hard as possible into the meter, the student moves a mechanical pointer up a numbered scale, which stays at the maximum value attained. This corresponds to the student s PEF. The student s personal best PEF is determined by the student s physician after a monitoring period of a few weeks when the asthma is under effective control. It is important to record the student s best PEF for regular use in determining if the student s asthma is under control. Always compare the peak flow measurement with the student s personal best reading. If the student has never had a peak flow measurement, compare the student s effort to the average for a child of the same height. If an episode is pending, the student will experience a drop in PEF. This is often the first warning sign of an episode. The following benefits of home and school PEF measurement have been reported: Detects early stages of airway obstruction so that therapy can be started before obstruction becomes more serious Determines when emergency medical care is needed Obtains multiple daily measures of air flow to investigate specific allergens or exposures that may exacerbate symptoms Measures day-night variations in PEF to assess the degree of bronchial hyperactivity or instability of asthma Facilitates communication between patient and clinician by providing assessment of asthma severity Provides feedback to help students who have poor perception of the severity of their obstruction Helps children distinguish between asthma and other causes of breathlessness It is important that a peak flow trend chart be used to record the best PEF and track changes in the PEF, listing the medications a student is using. Use the Asthma Peak Flow Rate Trend Chart provided in this Guide for this purpose. Also, keep a record of symptoms observed on this form. This will provide you with a valuable record that will be useful in the management of a student s Asthma Action Plan.

10 11 How to Measure Peak Expiratory Flow (PEF) Equipment In addition to the standard office peak flow meter, several portable peak flow meters are available. Specific instructions are contained in the literature accompanying each meter. Because different brands and models of peak flow meters often yield different values when used by the same person, ideally patients should use the same model in the home, school, and the clinician s office and should bring his or her own meter to the office to compare readings. Technical standards for peak flow meters have recently been established by a National Heart, Lung, and Blood Institute task force. Technique for Measurement Because PEF measurement is effort-dependent, students may need to be coached, initially, to give their best effort. Nose clips are unnecessary. Instruct the student to: Place the indicator at the bottom (baseline) of the numbered scale. No food or gum should be in the student s mouth. Sit straight up or stand up. Take in a deep breath. Place the meter in the mouth and close lips around the mouthpiece. Blow out as hard and fast (blast) as possible as in the initial effort to blow out a candle. Write down the achieved measurement or value. Repeat the process two more times. Record the highest of the three numbers achieved. Manufacturers often enclose charts with peak flow meters. Frequency of Recording, and Interpreting PEF Measurement Frequency depends on the severity of asthma and the student s individual requirements, as judged by the clinician. PEF can be recorded in a table format or a graph. Predicted values of PEF are determined by age, height, sex, and sometimes weight and race using ranges that vary among peak flow meters. Refer to charts accompanying each meter for the appropriate, specific ranges. However, it is recommended that PEF objectives for therapy be based upon each student s personal best rather than using a percent of normal predicted value. There may be wide variations between the a.m. and p.m. measurements of PEF, particularly at the start of therapy before good control is achieved. It is

11 12 important to establish personal best values when the student is under effective treatment to prevent airway obstruction. During a monitoring period of two to three weeks (or longer, if necessary), the student should record PEF measurements at least twice a day. The personal best is the highest PEF measurement achieved in the middle of a good day after using a bronchodilator. Peak expiratory flow rate objectives (personal best values) should be reevaluated yearly to account for the student s growth.

12 13 Using Peak Expiratory Flow (PEF) Measurements to Manage Asthma To help students manage their asthma at home and in the school, a system of PEF zones has been suggested. The specific zones are established as a function of the individual s personal best value. The emphasis is not on an isolated reading but rather on the variability patients experience from their personal best or from one reading to the next. It is recommended that home monitoring be done in the morning and evening (about 7 a.m. and 7 p.m.). If patients take an inhaled medication, PEF should be measured both before and after treatment. The zone system has been adapted to a traffic light system to make it easier to use and remember. Peak Expiratory Flow Rate Zones Green Zone (80%-100% of personal best): Signals all clear. No asthma symptoms are present, and the daily routine treatment plan for maintaining control can be followed. Yellow Zone (50%-80% of personal best): Signals caution. Acute symptoms may be present, and a temporary increase in medication may be indicated. Parents should be advised of measurements in this zone. Red Zone (below 50% of personal best): Signals a medical alert. The bronchodilator prescribed for the individual should be administered immediately, and the student s physician should be notified if PEF measures do not increase immediately and stay in yellow or green zones and out of the red zone. Therapy should be initiated when PEF declines more than 10% 20%, particularly if the student is exhibiting other warning signs. It should be continued every four to six hours until PEF stabilizes or there is sustained improvement of symptoms.

13 14 Using the Peak Flow Meter A peak flow meter is useful for measuring the severity of asthma. It measures the top speed of air that can be blown out after taking in the deepest breath possible. The value obtained is called a PEF, which indicates the degree of airway obstruction or narrowing. A normal peak flow value is based on an individual s age, sex, height, and race and weight. However, for the individual student, you should use his or her personal best value. The personal best peak flow rate should be determined by the child s physician after a monitoring period of a few weeks when the asthma is under effective control. The peak flow meter is an important tool in assessing the severity of the episode. Poor perception of the severity of an asthma episode has been cited as a major factor causing delay in treatment, and thus may contribute to increased severity and mortality. The device can help determine the correct plan of action to take. Another advantage of peak flow meters is that their use may contribute to more appropriate use of medications.

14 15 Instructions for the Student Refer to the instructions provided with the device to determine if the peak flow meter should be held vertically or horizontally with the indicator at the bottom of the numbered scale. Stand up (if possible) and take the deepest possible breath. Place the peak flow meter in the mouth and close lips tightly around the mouthpiece. Forcibly blow out as hard and fast as possible. This will cause the marker to move up the scale. Write down the achieved value. Repeat the process two more times (if possible). Record the highest of the three numbers achieved. Recording and Evaluating the Student s Peak Flow Record the highest peak flow and the student s symptoms on the Trend Chart. The personal best peak flow rate should be determined by the student s physician after a monitoring period of a few weeks when the asthma is under effective control. The student s personal best peak flow number should be written in the student s Asthma Action Plan by the student s physician and should be updated regularly. Compare the student s best value peak flow to the actual peak flow to determine if the student s readings are in the green, yellow, or red zone. Evaluate the student s history, previous symptoms, current symptoms, and breath sounds. Use the student s written Asthma Action Plan to determine the appropriate action and then document this action.

15 16 Care of the Peak Flow Meter The Mouthpiece If using a disposable cardboard mouthpiece, dispose of it after use. If using a reusable mouthpiece, it should be cleaned before using it with another individual. To clean the mouthpiece, rinse it in water and then submerge in a disinfectant solution for 10 minutes. Rinse with water and allow to air dry. The Peak Flow Meter Be careful not to drop the peak flow meter. To clean the peak flow meter, wipe with a damp paper towel. Let dry and store in its case. The peak flow meter should never be placed in boiling water or in a dishwasher. It should not be exposed to high temperatures.