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 po 2 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 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 FEV 1 > 2x/yr for all ages with risk factors and changes to FEV 1 16
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 Written Care Guidelines are very important o o o Define what to do when daily & acute Define when to be concerned Define when to seek help Obtaining a plan is important for the school nurse Fax form to office for PHCP to complete and return Use of standardized AAPlan form 18
Peak Flow Measurements Personal Best (PB) Green 80-100% of PB Yellow 50-70% of PB Red >50% 19
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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 Alternate Quickrelief Cromolyn or Montelukast Med-dose ICS Med-dose ICS + LABA or Montelukast High-dose ICS + LABA or Montelukast High-dose ICS + Oral steroids + LABA or Montelukast LABA or Montelukast SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn Frequent use of SABA may indicate the need to step-up therapy 26
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 Alternate: Cromolyn, LTRA, Nedocromil, or Theophylline Step 3 Preferred: Low-dose ICS + LABA or Montelukast Alternate: Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 4 Preferred: Med-dose ICS + LABA Alternate: Med-dose ICS + either LTRA, Theophyllin, or Zileuton 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 SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn Consider allergy shots for patients who have allergic asthma 28
MEDICATIONS Treatment Recommendations 29
LABA (Long-acting Beta 2 -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 Beta 2 -agonists 31
Inhaled Corticosteroids (long-term control) Beclomethasone (QVAR) Budesonide (Pulmicort) Flunisolide (AeroBid-M, Aerospace) Fluticasone (Flovent) Locally acting antiinflammatories 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 Beta 2 -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
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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 Controversy about pre-treatment with SABA before recess No evidence to support, no recommendation from EPR3 Prior to recess, no rescue is needed 53
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