Asthma and the School Nurse

Transcription

1 Asthma and the School Nurse University of Vermont Medical Center Vermont Children s Hospital Children s Specialty Center Julie Hounchell MSN, FNP-BC Pediatric Pulmonology Objectives Discuss Pathophysiology of Asthma Identify Signs and Symptoms of Asthma Describe Basic Asthma Management Describe Role of School Nurse in Asthma Management 1

2 Is it Asthma? NHLBI defines asthma as a lung disease with the following characteristics: a chronic inflammatory disorder of the airways recurrent or persistent episodes associated with variable airflow obstruction that is often reversible either spontaneously or with treatment bronchial hyperresponsiveness to a variety of stimuli Normal Asthma 2

3 Pathophysiology of Asthma Key Words: Airways Inflammation Bronchial Hyper-responsiveness Bronchial Wall Edema Excess Mucus Production Smooth Muscle Contraction Reversibility Airway Remodeling American Lung Association Asthma Pathophysiology Early phase within minutes bronchoconstriction Late phase influx of inflammatory cells epithelial damage, edema, hypertrophy of smooth muscle 3

4 Airway Remodeling Chronic pulmonary inflammation may lead to irreversible airway changes Premature decline in pulmonary function Preserve ultimate lung function Controversy: does early aggressive treatment change outcome in kids? Clinical Presentation in Children Extremely variable Symptoms: cough, wheeze, shortness of breath, fatigue, exercise intolerance Signs: none, or tachypnea, wheeze, decreased aeration, retractions, prolongation of the expiratory phase, increased AP diameter 4

5 Differential Diagnosis Infection (bronchiolitis, pneumonia) Recurrent/chronic aspiration Cystic fibrosis Hypersensitivity pneumonitis Vocal cord dysfunction Dynamic airway collapse Foreign body aspiration Making the Diagnosis Often not straightforward Objective measurement of pulmonary function is difficult in the very young Episodic nature and confusing array of possible triggers may confound the clinical picture Infants: diagnosis usually not made until at least 2 nd episode/exacerbation 5

6 Risk Factors Family history of asthma, allergic rhinitis Atopic disease: allergies, eczema Premature birth Viral infection (rhinovirus) Environment Environmental Factors Early allergen exposure may differ according to geography, e.g. importance of dust mite/ cockroach/ animal dander Pollution ozone, particulates Exposure to tobacco smoke effect of maternal smoking prenatal exposure 6

7 Is Early Exposure Beneficial? Lower risk of asthma for infants in day care with + family hx (Arch Pediatr Adolesc Med 2002) Heavy exposure to pet dander during first year may be protective (JAMA 2002) Does decreased exposure to infection lead to immunomodulation: endotoxin leading to immunologic shift? Lower risk with rural upbringing Infection-The Role of Viruses Viral infections (e.g. rhinovirus) may predispose children to developing asthma, as well as trigger exacerbations in preexisting asthmatics RSV is a risk factor for recurrent wheeze under 5 years ( with + family history) RSV is NOT a risk for wheezing > age 13 Immune factors will dictate clinical response (IL-4, IL-13, IFN- ) 7

8 Objective Measures of Bronchial Reactivity Peak flow measurements (variability) (+) can be done at home, inexpensive (- ) effort dependent Spirometry (%predicted FEV 1 ) (+) reliable modality (- ) interpretation can be difficult Exhaled Nitric Oxide (+) predicts steroid responsiveness in atopic pts (- ) less useful for non-atopic disease, expensive Testing = 8

9 NHLBI Guidelines (2007) Symptom frequency Nocturnal symptoms Intermittent < twice/week < twice/month Mild persistent < daily > twice/month Moderate persistent Daily, >2 exacerbations per week > once/week Severe persistent Continual frequent 9

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11 Approach to Management Intermittent as needed 2 adrenergic receptor agonist Mild persistent prophylactic anti-inflammatory therapy prn agonist Moderate persistent inhaled corticosteroid long-acting bronchodilator or leukotriene modifier as needed agonist Severe persistent inhaled corticosteroid (high dose) long-acting bronchodilator +/- LT modifier systemic corticosteroid + prn agonist 11

12 Short Acting 2 Agonist Examples- albuterol, levalbuterol Rapid onset of action Inhaled route is preferred (no syrup!) MDI administration with spacer is optimal Should not be used chronically Levalbuterol Racemic albuterol = both R- and S- isomers: levalbuterol is only S-isomer R-albuterol thought to be active form S-albuterol-? Increased adverse effects No significant difference in tolerability, adverse effects J Pediatr. 2003: hospitalizations with levalbuterol in ED No other convincing benefit 12

13 Inhaler Technique Able to be used with infants and young children Does not require a breath hold Shorter administration time MDI deposition without spacer use may drop by 70% Long Acting 2 Agonist Examples- salmeterol, formoterol Duration of 12 hours Not beneficial during acute exacerbations Approved for > 5 years Combination with inhaled steroid may provide improved control Useful in management of nocturnal and exercise-induced symptoms Tolerance develops 13

14 FDA Warning LABA Excess asthma related deaths seen in salmeterol multi-center asthma research trial (SMART) In SMART: African-American males at 5x increased risk Meta-analysis found no excess deaths if LABA used in combination with inhaled corticosteroids (Thorax 2010) LABA no longer available as monotherapy in U.S.( only fluticasone/salmeterol, budesonide/formoterol, mometasone/formoterol) Leukotriene Antagonists Oral agents LTR antagonists- montelukast, zafirlukast 5-lipoxygenase inhibitor- zileuton Less effective than inhaled corticosteroids Safety data in infants > 6 months (montelukast) Additive effect with inhaled steroids Not all asthmatics will respond FDA warning**: adverse behavioral/psychiatric effects 14

15 Other Therapies Mast cell stabilizerscromolyn, nedocromil No HFA formulation available Efficacy for EIB Methylxanthines- sustained release theophylline Anticholinergics No role in chronic treatment Ipratropium helps during acute exacerbations ( with albuterol) Inhaled Corticosteroids Most efficacious prophylactic therapy Examples older agents: flunisolide, triamcinolone newer agents: budesonide, fluticasone HFA, beclomethasone HFA, Available as MDI, DPI, nebulized forms Important to educate patient/family on administration Improves asthma mortality rates 15

16 Inhaled Steroid: Examples Fluticasone/salmeterol Budesonide DPI Budesonide respule Fluticasone HFA Budesonide/formoterol Mometasone DPI Beclomethasone HFA Inhaled Steroids: Adverse Effects Oral candidiasis- limit with spacer use/ rinsing Hoarseness Adrenal suppression Growth- CAMP study, decreased growth velocity for 1st year, then no difference Bone density, cataracts, glucose intolerance??? Ann Allergy Asthma Immunol. 2005: budesonide safe for 3 yrs in mild persistent asthma 16

17 How Do Inhaled Steroids Work? Bioavailability and potency differ by particular agent Newer compounds have less systemic bioavailability Bind intracellular glucocorticoid receptors, which affect inflammation and UPREGULATE -2 RECEPTOR Do Inhaled Steroids Work? CAMP (Childhood Asthma Management Program) - (ages 5-12, 4-6 year F/U) Findings: asthmatic children who received budesonide vs. cromolyn or placebo had: - exacerbations, hospitalizations, ED visits, symptoms, airway responsiveness, obstruction, symptom free days - no change in FEV 1 17

18 Controlling Allergic Asthma Omalizumab Monoclonal anti-ige antibody Injections every 2 to 4 weeks Approved for > 12 years May provide improved control Treatment of Exacerbations Recognize symptoms Define: cough, dyspnea, wheeze Know your patient s pattern Seasonal? Rapid onset? Triggers? Respond with short-acting agents No established benefit of increasing ICS dose acutely Systemic steroids (3-7 day treatment) Prolonged tapers not indicated 18

19 Asthma Action Plan: Green Zone No signs of asthma No problems sleeping Able to do normal activities Everyday controller medications as usual Pre-treat exercise as needed WATCH FOR EARLY SYMPTOMS 19

20 Early Warning Signs Cough Wheeze Chest tightness Shortness of breath Runny nose or stuffy nose Sneeze feeling funny in chest Poor appetite Itchy throat Glassy eyes Feeling tired Coughing or waking up at night Headache Stomach ache Asthma Action Plan: Yellow Symptoms are present: Cough, wheeze, chest tightness, upper respiratory symptoms Increased need for inhaled quick-relief medications Usual activities somewhat limited Awakening at night due to asthma symptoms 20

21 Asthma Action Plan: RED Late Signs: EMERGENCY Very short of breath Usual activities are severely limited Asthma medications have not reduced symptoms Call doctor or nurse Call emergency number if needed Take additional medicines as prescribed Recognizing Emergency Late Signs No improvement in minutes after initial treatment Retractions: chest and neck pulled in with breathing Stops playing and unable to start again Trouble walking or talking Quick relief medications don t help Emergency help needed! 21

22 Integrating Action Plan into the School School nurse available to help write plans, give guidance to students with asthma about medicines, physical education and field trips Can children take medications at school (May children carry their own asthma medications) Does school have an emergency plan for treating an asthma exacerbation (Is the plan clear? Who do you call? When do you call?) Does the nurse teach school staff about asthma (including management plans and other classmates how to help?) Integrating Action Plan into the School Do students with asthma have good options to fully participate in physical education and recess? CAN THEY TAKE THEIR MEDICATIONS PRIOR TO EXERCISE CAN THEY MODIFY THEIR ACTIVITY WHEN MEDICALLY NECESSARY? 22

23 Asthma Friendly School? School nurse? Educates staff and students about Asthma and management of symptoms Free from tobacco smoke all of the time. Maintain good indoor air quality. Reduce or eliminate allergens and irritants that can trigger an asthma exacerbation. Leaky roofs/wet carpet= mold New carpeting/chemicals = toxic fumes Building repairs/renovations = dust Unventilated portable classrooms Insecticides, herbicides, fungicides Chalk dust, animals, foods Asthma Treatment Plan Monitoring is the key Quarterly assessments (minimum) to adjust maintenance treatment Ascertain other risk factors Track exacerbation frequency, severity, need for steroids/ed visits/hospitalization 23

24 Poor Control? Other Factors Allergic rhinitis/postnasal drip syndromes Skin testing, serum IgE, omalizumab Sleep disordered breathing with lymphoid hypertrophy Consider ENT consult GER related symptoms Controversial causal relationship, empiric treatment Infections responding to frequent antibiotics Sweat testing, immunologic evaluation Lack of bronchodilator/steroid responses Tracheomalacia, foreign body Poor Control: Adherence May be a critical factor Try to assess adherence at each visit Review proper spacer use Check refill history Identify barriers to adherence (schedule, supervision, adverse effects) School may be able to help 24

25 School nurses are an important member of the health care team they provide acute, chronic, episodic and emergency health care to their students. They also provide health education, health counseling and are advocates for the students. The Role of the School Nurse American Academy of Pediatrics (AAP) manual School Health: Policy and Practice: Ensure access to primary health care (medical home) Provide a system for dealing with crisis medical situations Provide mandated screening and immunization monitoring Provide a process for identification and resolution of students health care needs that affect educational achievement 25

26 Suggested School Nurse Roles Act as a case manager for 504 students with health needs Prepare, implement and evaluate individual student health care plans as needed Educate the school community about chronic diseases Collaborate with local health care providers and local health care agencies Assess, plan, implement and evaluate the health needs of students and the school environment Provide health education and information to students and staff Thank you for all you do! 26