II. ASTHMA BASICS. Overview of Asthma. Why do I need to know about asthma?

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1 II. ASTHMA BASICS Overview of Asthma Why do I need to know about asthma? In the United States, asthma is the most common chronic childhood illness. Asthma affects an estimated 4.8 million children nationally, and more than 125,000 (1 in 10) in Washington State (Washington Asthma Burden Report, 2004). In 1997, the Washington State Joint Legislative Audit and Review Committee (JLARC) completed the Survey of School Nurses Report. This survey found that in Class I School Districts (> 2000 students per district) the average number of students with asthma and who received medications at school was 250 students per district. In Class II districts (< 2000 students per district) the average was approximately 20 students per district. A study of students in the Seattle School District (>47,000 students enrolled) found that approximately 12% (>5600) of the students have asthma. Nationally, asthma is among the leading causes of school absenteeism, accounting for more than 10 million school days lost annually. Asthma can be disruptive not only to the students with breathing problems but also to others around them. All school personnel need to understand this disease, its causes and its treatment. What is asthma? Asthma is a chronic lung condition with ongoing tightening (bronchospasm) and inflammation of the airways, or bronchial tubes. Asthma causes episodes of breathing problems such as coughing, wheezing, chest tightness, or shortness of breath. The inflammation of asthma causes the lining of the airways to swell and produce more mucus. When this happens, the airways narrow and obstruct the flow of air out of the lungs. Many different factors, referred to as asthma triggers, can worsen bronchospasm and inflammation. What happens during an asthma attack? An acute episode of asthma, or asthma attack, occurs when there is a narrowing of the airways caused by the following: Bronchospasm: The muscles that surround the airways tighten and make the airways smaller. Swelling: The lining of the airways swells making the airways even smaller. This swelling is caused by inflammation of the airways. Mucus: The tissues that line the airways secrete extra mucus. This mucus can plug the narrowed airways even further. Together the bronchospasm and inflammation make it harder to move air through the airways. The student with asthma works harder and breathes faster to move enough air through these narrowed airways. The student may appear as if he or she had run a race while sitting quietly. 4

2 What are the early warning signs and symptoms of an asthma attack in a student who is known to have asthma? Most people think that an asthma attack starts suddenly. Many students show early warning signs before the episode begins. Consider developing a list, with the student, of his or her early warning signs and symptoms. If they occur, follow the student s Individual Health or School Emergency Asthma Plan. (Appendix A). Possible Early Warning Signs and Symptoms coughing itchy throat or chin (tickle in throat) stomachache (younger child) funny feeling in chest (younger child) grumpiness or irritability fatigue headache agitation itchy, watery eyes stuffy or runny nose dark circles under eyes behavioral changes decreased appetite drop in peak flow meter persistent coughing to yellow or red zone Early warning signs may progress to an asthma attack. Asthma attack signs and symptoms may include: Possible Asthma Attack Signs and Symptoms becoming anxious or scared shortness of breath rapid labored breathing incessant coughing nasal flaring pull in of neck and chest with breathing requiring rescue medications every four hours or more often tightness in chest wheezing while breathing in or out vomiting from hard coughing unable to talk in full sentences shoulders hunched over sweaty, clammy skin (Not all students will experience all symptoms during an asthma attack.) In the event of an asthma attack, the student s School Emergency Asthma Plan should be followed. 5

3 CALL 911 Call 911 for the following signs and symptoms No improvement minutes after initial treatment with medication and a parent cannot be reached Medications are not available and the student is exhibiting the following: wheezing or incessant coughing, difficulty breathing, chest and neck pulling in with breathing, shoulders hunched over; struggling to breathe Lips or nail beds turning gray or blue (students with light complexions) Paling of lips or nail beds (students with dark complexions) Decreasing or loss of consciousness What Causes an Asthma Attack? Asthma is caused by a variety of factors. An asthma attack is caused, in most cases, by a student s exposure to a trigger. A trigger may be an allergen or an irritant to the respiratory tract. A response to a trigger may be delayed up to six hours following an exposure. The most common triggers include: Respiratory illnesses: colds, viral infections, ear infections, sinus infections, bronchitis, pneumonia Allergens: pollens from trees, grasses and weeds, dander from animals (e.g., gerbils, birds, dogs, cats, mice, rats), dust and dust mites, molds, cockroaches weather: cold air, sudden or marked changes in temperature, humidity or barometric pressure Irritants: cigarette smoke, wood smoke, air pollution, dust, chemicals with volatile organic compounds (such as solvent based permanent and dry erase markers, paints, glues, cleaners), air fresheners, perfumes, disinfectants, cleaners, laboratory & vocational education chemicals, art supplies, pesticides, and diesel exhaust. Emotions: excitement, anxiety, tension, stress, depression, etc. Exercise: the type of asthma in which attacks are triggered by exercise is called Exercise-Induced Asthma (EIA) or Exercise-Induced Bronchospasm (EIB). EIA results from bronchospasm triggered by physical activity or exercise. EIA is very common among students with asthma. For many students the only symptoms of asthma occur with 6

4 exercise. These symptoms include cough, chest pain, and shortness of breath, chest tightness or wheezing. Students may have a hard time keeping up with their friends when running and playing. They may feel Winded, tired or dizzy after physical activity, and may even experience a stomachache. EIA may begin during or after exercise has ended. Parents, health care providers, teachers and even the students themselves frequently overlook EIA in children. Many students with EIA learn to avoid outdoor play, sports or other physical activities that produce symptoms. Untreated EIA can limit normal activities. This may result in lasting negative physical and psychological effects such as poor conditioning and poor selfimage. If you suspect that a student has EIA, talk with the parent or school nurse. Physical activity is critical for a student s health, especially the student with asthma. Most students can participate fully in physical activities if EIA is properly treated and the underlying asthma is well controlled. See Section IV and Appendix B for information about minimizing triggers in the school environment. How is Asthma treated? MANAGING ASTHMA Management of asthma uses two basic approaches: minimizing contact with triggers and use of medications. Asthma medications belong to two broad categories based on whether they provide quick relief or long-term control of asthma symptoms. Quick relief medications (bronchodilators) open the airways by relaxing the muscles around the bronchial tubes. Bronchodilators are taken when symptoms begin to occur or when they are likely to occur (e.g., prior to recess, physical education classes or sports events or if you are using a peak-flow meter, when readings are in the yellow or red zone.) This category of drugs includes shortacting inhaled beta-two (ß2)-agonist and anticholinergics. Long-term control medications generally are anti-inflammatory medications and taken daily on a long-term basis to gain and maintain control of persistent asthma, even in the absence of symptoms. This category includes long-acting inhaled b2-agonist, inhaled anti-inflammatory drugs (corticosteroids and noncorticosteroids), anti-leukotriene drugs, combination medications, theophylline and anti-ige immunotherapy. 7

5 Oral steroids may be used to treat severe, acute asthma episodes, or be given for a longer period when needed to gain control of severe asthma. Since the side effects of oral steroids could be serious, depending on the dosage and duration of the therapy, they should always be taken in consultation with your child s health care provider. Instructions for use of oral steroids should be closely followed. Tables of common Asthma Medications Appendix V General Notes on Common Asthma Medications: If you use an inhaler: To relieve dry mouth or throat irritation caused by inhaler use, rinse your mouth with water, chew gum, or suck sugarless hard candy after each use. Rinsing is required after each use of a corticosteroid inhaler so that small amounts of the medicine do not remain in your mouth to be swallowed over time. Inhalation devices require regular cleaning. Once a week, remove the drug container from the plastic mouthpiece, wash the mouthpiece with warm tap water, and dry it thoroughly. The mouthpiece area of dry powder devices should be cleaned inside with a cotton-tipped applicator once a week. Side Effects: Side effects may or may not be common depending on the medication, dosage, or duration of the therapy. Tell your doctor if unexpected symptoms are severe or do not go away after 2-3 days. Side effects may include: dry mouth, headache, upset stomach, dizziness, or shakiness. Severe side effects are indicated in italics in the table. Call your doctor or health care provider as soon as possible if you have any of the following side effects. Call 911 if necessary. Difficulty breathing Increased heart rate Chest pain or discomfort Irregular heartbeat Severe rash Swollen face, throat or other parts of the body How are asthma medications given? Medications may be administered in a number of ways. The student s health care provider determines the type of medication delivery. Medication delivery may be by: mouth (oral) nebulizer 8

6 metered dose inhaler (MDI) diskhaler dry powder inhaler (DPI) Appendix C contains information regarding use and care of these delivery methods. A student using a metered dose inhaler, may also use a device called a spacer or holding chamber (Appendix D). Holding chambers are useful for all patients, particularly for young children and persons with coordination problems. They are recommended for use with bronchodilators, but should always be used with an inhaled anti-inflammatory containing steroids. Neither bronchodilators nor antiinflammatories should be withheld, however, if a holding chamber or spacer is not available. What is a peak flow meter and how is it used? The peak flow meter measures how fast the student can blow air out through the airways. It lets the student and supervising adult know how much airway narrowing is present at a given time. There are many different types of peak flow meters, but they all do the same thing. A peak flow meter can: Tell how well air is moving through the airways. Give early warning of an asthma attack, sometimes before symptoms develop or before a student notices asthma symptoms. Signal when medication can prevent worsening asthma. Measure how well the student s asthma medications are working. Help identify asthma as the cause of shortness of breath, chest tightness, coughing, or fatigue during physical activities e.g., physical education, recess, or sports. Help adults share information about the student s asthma. The following students may benefit from having a peak flow meter at school: Students with frequent asthma attacks. Students requiring asthma medications at school. Students who have asthma symptoms at school. The usefulness of a peak flow meter is dependent upon having a baseline or personal best peak flow reading. The baseline is used in the development of an asthma management plan. Peak flow zone are created based on the peak flow obtained when the student is feeling well and does not have symptoms. It is important to remember, however, that management decisions should be based on symptoms as well as peak flow readings. 9

7 The school nurse may talk with the student s family and health care provider about having a peak flow meter at home and another at school. For children whose health coverage is through the Department of Social and Health Services, the nurse can call Medical Assistance Administration at for questions about Medicaid coverage of these devices or use the ASK DSHS line at Appendix V for Tables of Common Asthma Medication Appendix E for information regarding peak flow monitor use and care. Appendix F for a sample Peak Flow Record. 10

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