Managing Asthma In Minnesota
Schools
“A Comprehensive Resource &
Training for School Personnel”
Developed and Provided by:

Susan K. Ross RN, AE-C
MDH Asthma Program Staff
651-201-5629
Susan.Ross@health.state.mn.us
&
Denise Herrmann LSN, CNP, AE-C
St. Paul Public Schools
Denise.Herrmann@spps.org

www.health.state.mn.us/asthma

Our Advisory Group consisted of participants from every region of the state!
See the acknowledgements page at the beginning of the manual.
Special thanks to:
Denise Herrmann from SPPS
Minneapolis Public Schools
“Healthy Learners Asthma Initiative”
Cheryl Smoot MDH
Funding grant awarded by:
Centers for Disease Control and Prevention (CDC )

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GlaxoSmith Kline Pharmaceuticals
AstraZeneca Pharmaceuticals
Starbright Foundation
Hennepin County Medical Center
For contributing PFM’s, Spacers, Diskus, asthma booklets and CD-Rom games for our participants

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Asthma Basics
 Asthma triggers and irritants
 Diagnostic/ assessment process
 NIH/NHLBI/NAEPP asthma guideline overview
 Severity level workout
Medication Overview
 Asthma “gadgets”
Controlling Asthma
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
Tools available (MDH website-Manual)
Coordinated School Health

 Complete the post test
 Complete the program evaluation
 Complete your goals sheet
 Hand everything in before you leave
 You will be eligible to receive credit for
7.2 C.E.U’s after attending today's presentation

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Consider how you would use the tools provided today.
How can you take this information and use it to establish an asthma program in your school or district?
How can you promote involvement by other school personnel outside the health office?

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Resource and Training document
Each Section is all-inclusive to each staff member’s role
Lift out the entire section - copy it and use as a basis for teaching about asthma
Supplemental forms/handouts are in the back folders and provided on CD and website
Full resources section w/websites are listed
Power Point presentations are also on our asthma website and CD in back of your manual

This manual contains suggestions for action and you are strongly urged to consult your school district policies and guidelines before implementing these suggestions.

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School health staffing varies greatly across the entire state
The manual provides a few suggested staffing models in the “All Health Staff” section
Today’s program is based on a school that has at least some LSN/PHN/RN staffing in the school on regular basis

PRE- TEST

From GlaxoSmithKline and
Allergy & Asthma Network, Mothers of Asthmatics
(AANMA)

Asthma kills people equally regardless of severity level

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1/3 of deaths are in those with mild asthma
1/3 of deaths are in those with moderate asthma
1/3 of deaths are in those with severe asthma

 Accounts for 14 million lost school days annually 3
 Is the most common chronic disease causing absence from school 2
 Is the 3 rd leading cause of hospitalizations among children under 15 2
 1 in 13 school children have asthma 1
 6.3 million children under 18 have asthma 1
1 Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC
2 Morbidity and Mortality Report, National Center for Health Statistics (NCHS), U.S. CDC, 2003
3 Surveillance for Asthma - United States, 1980-99, MMWR Surveillance Summaries, CDC, March 29, 2002

In a 2005 MDH re-surveyed 3,500 7th & 8th graders at 12 junior highs outside the metro area-
 1 in 10 reported they currently have asthma

In a 2001 MDH survey of 13,000, 9th - 11th graders in rural MN-
1 in 11 reported they currently have asthma

..
In a class of 30 children, you can expect
2 to 3 students WILL have asthma
This number varies depending on age and geographical location

Do School Children
Action Plans?
Asthma
In MDH’s survey of 7th and 8th graders in greater Minnesota:


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40% of the children who had asthma did not if they had a written asthma action plan know
24% did not have an asthma action plan
Overall, only 35% of children who have asthma actually had asthma action plans

Of the 7th & 8th graders with asthma:
 31% reported missing recess, sports or other physical activities due to asthma symptoms
 25% reported missing a day or more of school in the past year due to asthma symptoms
 70% reported wheezing “ sometimes ” or “ a lot ”

 There is substantial uncontrolled asthma among school children in this age group
 This lack of control is manifested by the high rate of morbidity as measured by school absence and missed activities among children who have been diagnosed with asthma
 The survey also suggests that there may be substantial undiagnosed asthma

School Performance:
 Poorly controlled asthma has a negative impact on school performance in both academic achievement and physical education

Impact Of Asthma On Students cont...
Psychosocial:
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Poor self-esteem
Anxiety about asthma
Fear of becoming ill at school
Anxiety about exercise at school
Fear of being different

Asthma is a chronic disease that causes:
 Bronchoconstriction (obstruction that is reversible)
 Inflammation of the bronchioles ( small airways )
 Hyper-responsive “twitchy” airways
 Excessive mucus production in the bronchioles

Normal Bronchiole Inflamed Bronchiole with Mucus


During an asthma attack, smooth muscles located in the bronchioles of the lung constrict and decrease the flow of air in the airways. Inflammation or excess mucus secretion can further decrease the amount of air flow.


Copyright 3M Pharmaceuticals 2004

A Lot Going On Beneath The Surface
Symptoms
Airflow obstruction
Bronchial hyperresponsiveness
Airway inflammation
Slide courtesy of ALAMN - PACE program 2004

© 2003 Genentech, Inc. and Novartis Pharmaceuticals Corporation.

Mediator Phases
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Early-phase reaction caused by mediator release, usually peaks within an hour after initial exposure to the allergen.
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Three to four hours after an acute asthma episode, a "late-phase reaction" may occur and may last up to 24 hours

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Localized mucosal edema in the walls of the small bronchioles
Secretion of thick mucus into the bronchiolar lumens
( Clogs and narrows the airways )
Spastic contraction of bronchiolar smooth muscle

1.
Stand up
2.
Place the straw in your mouth
3.
Try to breathe!
This is what is may feel like when a child is having a severe asthma episode

 Frequent cough, especially at night
 Shortness of breath or rapid breathing
 Chest tightness
 Chest pain
 Wheezing
 Fatigue

Signs Of An Asthma
“Episode”
 Mild cough
 Drop in Peak Flow reading
 Itchy, watery or glassy eyes
 Itchy, scratchy or sore throat
 Runny nose
 Stomachache
 Headache
 Sneezing
 Congestion
 Restlessness
 Dark circles under eyes
 Irritability

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An asthma episode occurs when a child is exposed to a trigger or irritant and their asthma symptoms start to appear
This can occur suddenly without a lot of warning, or brew for days before the symptoms emerge
Episodes are preventable by avoiding exposure to triggers and taking daily controller medications (if prescribed)

Handling Acute Asthma Episodes
At School
 Remain calm and reassure the child
 Have the child sit up and breathe slowly- in through the nose slowly, out through pursed lips very slowly
 Have the child sip water / fluids
 Check peak flow ( with severe symptoms: skip PF & give quick-relief or reliever medication immediately )
 Child should not be left alone

Handling Acute Asthma
Episodes At School Cont…
 Give asthma reliever (bronchodilator) per the child's
Asthma Action Plan / medication orders
 Assess response to medication
 After ~5-10 minutes recheck peak flow
 Call parent/guardian/health care provider prn
 Call 911 if escalating symptoms or no improvement

 Lips or nail beds are bluish
 Child has difficulty talking, walking or drinking
 Quick relief or “rescue” meds (albuterol) is ineffective or not available
 Neck, throat, or chest retractions are visible
 Nasal flaring occurs when inhaling
 Obvious distress
 Altered level of consciousness/confusion
 Rapidly deteriorating condition

“There should not be any delay once a child notifies school staff of a possible problem or developing asthma episode”

 Of the 21 million asthma sufferers in the
US, 10 Million (approx. 60%) have allergic asthma. 3 million of those are children 1
 Exposure to certain allergens trigger asthma symptoms to begin
 Exposure to certain irritants can also set an asthma episode in motion
1
National Institute of Environmental Health Sciences

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Asthma may be caused by genetic, immune and/or environmental factors, and is often associated with eczema and allergies

Researchers do not understand all of the causes of asthma or its increasing prevalence
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It boils down to “We just don’t really know for sure”

Copyright 2004, 3M Pharmaceuticals

Common Allergens (Triggers)
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Seasonal Pollens
Animal dander saliva/urine
Dust Mites
Cockroaches/Mice/Rat droppings and urine
Mold
Some medications
Some Foods

Common Irritants (Triggers)
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Exercise
Cold Air
Chalk Dust
Viral/upper respiratory infections
Air pollution
Tobacco smoke or secondhand smoke
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Chemical irritants and strong smells
Strong emotional feelings
Diesel fumes
Cleaning supplies

VRIs And Hospitalizations
For Asthma
Hospital admissions for asthma correlate with virus isolation peaks and school terms
URIs
Total pediatric and adult hospitalizations
School holidays
20
15
10
5
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Adapted with permission from Johnston SL et al.
Am J Respir Crit Care Med. 1996;154:654. Official Journal of the American Thoracic Society. ©American Lung Association.

RV-Induced Airway Inflammation
Plasma leakage
Mucus hypersecretion
Inflammatory cell recruitment and activation
Airway
Hyperresponsiveness
Virus-infected epithelium
Neural activation
Adapted from Gern JE, Busse WW. J Allergy Clin Immunol . 2000;106:201.

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Viruses cause asthma exacerbations in children
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RVs cause ~60% of virus-induced exacerbations of asthma
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RVs directly infect the bronchial airways
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The response to viral infection is shaped by the host’s antiviral response

Induced
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Tightening of the muscles around the airways
(bronchospasm)
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Distinct from allergic asthma in that it does
NOT cause swelling and mucus production in the airways
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Can be avoided by taking pre-exercise medications and by warming up/cooling down

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Symptoms include coughing, wheezing, chest tightness and shortness of breath
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Symptoms may begin during exercise and can be worse 5 to 10 minutes after exercise
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EIA can spontaneously resolve 20 to 30 minutes after starting
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Can be avoided by doing the following:

Preventing Exercise Induced
Asthma (EIA)
 Become familiar with Asthma Action Plans
 Use reliever (Albuterol) 15 -30 minutes before activity
 Do warm-up/ cool-down exercises before and after activities
 Check outdoor ozone/air quality levels www.aqi.pca.state.mn.us/hourly/
 Never encourage a child to “tough it out” when having asthma symptoms

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Exercise can be a trigger for those who have
“chronic” asthma
Their pre-exercise treatment is the same but -
 These children will have the underlying inflammation and require daily controller medication

Assess Need For Pre-Medication
 Take note of medication order wording
“As needed” vs. “prior to exercise”
 Evaluate if activity level requires premedication
 Pre-medicate for strenuous activity only
 Contact parent/ HCP if questioning need for pre-exercise medication

Coach’s Asthma Clipboard Program
“Winning With Asthma”
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100% online education for:
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Coaches
Referee’s
Physical Education Teachers
Coaches will receive:
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Coach’s asthma clipboard
Special Coach’s asthma education booklet
Certificate of completion
The satisfaction of knowing what to do during an asthma episode!
www.WinningWithAsthma.org

www.WinningWithAsthma.org

Asthma Myths
 It is a psychological / emotional illness
 It is only an acute disease
 It always limits normal activities
 It limits a child's ability to fully participate in physical activities, especially sports
Asthma Truths
 Asthma is a very real, physical disease
 Asthma is a chronic disease, even when symptoms are not active
 Taking proper asthma medications allow children to fully participate in any activity, including sports

Myths & Truths Continued..
Asthma Myths
 Medication is addictive
 Medication becomes ineffective if used regularly
 Children do not die from asthma
•
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•
Asthma Truths
Asthma medications are not addictive
Anti-inflammatories
(controllers) are most effective when used everyday
Children and adults die from asthma each year

Myth Truth
• Use “reactive airway disease” instead of
“asthma” for a diagnosis – that way the insurance company will never know
• Reactive airway disease’s code is the same code used for asthma!
• Any order for albuterol (or other rescue inhaler) flags the insurance company

 Gecko liquid tonic
 Herbal supplements
 Acupuncture/pressure, chiropractic adj.
 Cockroach tea
 Asthma diets
 Pranic healing with mantras
 Owning a Chihuahua

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Two Aspects :
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Initial assessment and diagnosis of asthma
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Periodic assessment and monitoring
Excerts from NHLBI/NIH presentations @http://nih.nhlbi.nih.gov/naepp_slds/menu.htm

Determines That:
 Patient has a history or presence of episodic symptoms of airflow obstruction
 Airflow obstruction is at least partially reversible
 Alternative diagnoses are excluded

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Detailed medical history
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Physical exam
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Spirometry to demonstrate reversibility

History or Current Episodic
Symptoms of Airflow
Obstruction?
 Wheezing, shortness of breath, chest tightness, or cough?
 Asthma symptoms vary throughout the day?
 Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma!

 Spirometry is Gold standard to assist in asthma diagnosis
 Assess need to start, step up, or step down asthma medications
 Should be done at least yearly in children with persistent asthma
 Spirometry is easily done at any health care providers office

Continued
…
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Performed before and after bronchodilator dose to look for airway reversibility obstruction
Can also be done with a cold-air or methylcholine challenge, or an exercise challenge in the case of exercise-induced asthma

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Spirometry is a painless study of air volume and flow rate within the lungs.
Spirometry is frequently used to evaluate lung function in people with obstructive or restrictive lung diseases such as asthma or cystic fibrosis.

Is Airflow Obstruction At
Least Partially Reversible?
Use spirometry to establish airflow obstruction
 FEV
1
< 80% of predicted
 FEV
1
/FVC <65% or below the lower limit of normal
Use spirometry to establish reversibility
 FEV
1 increases >12% and at least 200 mL after using a short-acting inhaled beta
2
-agonist

Have Alternative Diagnoses
Been Excluded?
Examples:
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Vocal cord dysfunction
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Vascular rings
Foreign body aspiration
Other pulmonary diseases
Cystic Fibrosis
Gastroesophageal reflux

Under Diagnosis Of Asthma
In Children
The majority of people who have asthma experience onset before age 5
Commonly misdiagnosed as:
 Chronic or wheezy bronchitis
 Bronchiolitis
 Recurrent croup
 Recurrent upper respiratory infection
 Recurrent pneumonia

Guidelines for the Diagnosis &
Management of Asthma
EPR 2002 Update
NAEPP, NHLBI, NIH- EPR2 2002

1.
2.
3.
4.

NAEPP Classification of Asthma Severity:
Clinical Features Before Treatment
Days With Nights With PEF or PEF
Symptoms Symptoms
Variability
FEV
1
Continuous Frequent

60%

30% Step 4
Severe
Persistent
Step 3
Moderate
Persistent
Step 2
Mild
Persistent
Step 1
Mild
Intermittent
Daily
>2/week, <1x/day >2 nights/month

80% 20-30%

2 days/week
> 1night/week

60%-<80%

30%

2/month

80%

20%
Footnote: The patient’s step is determined by the most severe feature.

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Is the difference between the child’s morning and evening PFM readings
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Peak flow readings tend to be higher in the evening than in the morning

NAEPP Stepwise Approach To
Asthma Therapy

Reliever:
Inhaled beta agonist prn
PEF: ≥80%
STEP 1:
Intermittent
Outcome:
Control of Asthma
Outcome:
Best Possible Results
Controller:
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One daily medication
Possibly add long acting b r onchodilator
Anti-leukotrienes
Reliever:

Inhaled beta agonist prn
PEF: ≥80%
STEP 2:
Mild Persistent
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Controller:
Daily inhaled corticosteroid
Daily long acting bronchodilator
Anti-leukotriene

Reliever:
Inhaled beta agonist prn
PEF: 60-80%
STEP 3:
Moderate Persistent
Controller:
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Daily inhaled corticosteroid
Daily long acting bronchodilator
Daily/alternate day oral corticosteroid
Reliever:

Inhaled beta agonist prn
PEF: <60%
STEP 4:
Severe Persistent
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When controlled, reduce therapy
Monitor
Step-down

 Symptoms  2 days/week with nighttime symptoms  2 nights/month
 Asymptomatic with normal peak flows between exacerbations
 Exacerbations are brief (hours to a few days)
 Peak Flows  80% predicted with variability
 20%

 Symptoms > 2 days /week but < 1x/day with nighttime symptoms greater than 2 nights/month
 Exacerbations may affect activity
 Peak flow 80% of predicted with variability of
< 20-30%

 Child is likely to have daily symptoms and use reliever daily
 Child is waking up at least once a week due to asthma symptoms
 Peak flows 60-80% of predicted with variability of
>30%
 Activity is affected and exacerbations may last days

 Continual daytime symptoms with frequent nighttime symptoms
 Very limited physical activity
 Frequent exacerbations
 Peak flows  60% of predicted and variability of more than 30%
 Treatment involves a combination of many drug therapies

IF a child has:
 Daytime symptoms greater than two times per
-orweek
 Nighttime symptoms greater than two times per month -or-
 Albuterol (reliever) refills of canisters more than two times per year
* The child needs to be assessed if he/she requires controller medication or a step up in therapy

MDH Interactive Asthma
Action Plan (IAAP)
Available at MDH website: www.health.state.mn.us/asthma

Click on “Asthma Action Plan”

Click on “Medical Professionals”

Choose to download desktop version or use online version

Which of These Does Not Fit With
Persistent Asthma?
A.
Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptoms
B.
Limited physical activity
C.
Near normal Pulmonary Function Test
(Spirometry)
D.
Frequent asthma exacerbations

Which Of These Does Not Fit
With
Persistent Asthma?
A.
Continual coughing, wheezing or shortness of breath during day, frequent nighttime symptoms
B.
Limited physical activity
C.
Near normal Pulmonary Function Test
(Spirometry )
D.
Frequent asthma exacerbations

Which Of These Does Not Fit With
Moderate Persistent Asthma?
A.
Daily daytime symptoms, nighttime symptoms > 1 night per week
B.
Nighttime Symptoms < 2 times a week
C.
Daily use of albuterol/bronchodilators
D.
Asthma exacerbations can last for days

Which Of These Does Not Fit With
Moderate Persistent Asthma?
A.
Daily daytime symptoms, nighttime symptoms > 1 night per week
B.
Night time Symptoms < 2 times a week
C.
Daily use of albuterol/bronchodilators
D.
Asthma exacerbations can last for days

Which Of These Does Not Fit With
Mild Persistent Asthma?
A.
Daytime symptoms > 2 times a week, but < 1 time a day
B.
Symptoms may affect activity
C.
Need for albuterol 3 times a week, sometimes twice a day (not related to EIA)
D.
Nighttime symptoms > 2 times a month

Which Of These Does Not Fit With
Mild Persistent Asthma?
A.
Daytime symptoms > 2 times a week, but < 1 time a day
B.
Symptoms may affect activity
C.
Need for albuterol 3 times a week, sometimes twice a day (not related to EIA)
D.
Nighttime symptoms > 2 times a month

Which Of These Does Not Fit
With Mild Intermittent Asthma?
A.
Daytime symptoms < 2 times a week
B.
Nighttime symptoms > 2 times a month
C.
No symptoms and normal Peak Flow between exacerbations
D.
Exacerbations are brief and may last from a few hours to a few days

Which Of These Does Not Fit
With Mild Intermittent Asthma?
A.
Daytime symptoms < 2 times a week
B.
Nighttime symptoms > 2 times a month
C.
No symptoms and normal Peak Flow between exacerbations
D.
Exacerbations are brief and may last from a few hours to a few days

Which Level Does Not Need Daily
Controller Medication?
A.
Mild Intermittent
B.
Mild Persistent
C.
Moderate Persistent
D.
Severe Persistent

Which Level Does Not Need Daily
Controller Medication?
A.
Mild Intermittent
B.
Mild Persistent
C.
Moderate Persistent
D.
Severe Persistent

 Whether or not the child is taking his/her controller medication at home (are they prescribed for him/her)
 Is he/she taking it everyday and how often
 How often is he/she using reliever inhalers
 About his/her home environment
 Pets
 Adults smoking in the home
 Moist basements or obvious mold
 Mattress and pillow covers
 Cockroaches, mice, rats etc.
E2, E3

Physical Assessment Of Asthma
In The School Health Office
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Symptoms (daytime, nighttime and exerciserelated)
Peak Flow Meter readings
Respiratory assessment (breath Sounds / lung auscultation, respiratory rate, physical assessment)

Ask about:
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Coughing / wheezing / tight chest
Frequency of daytime symptoms
Frequency of nighttime symptoms
Symptoms with activity or exercise

Respiratory Assessment in the
School Health Office
 Physical inspection
(including respiratory rate)
 Auscultation of the lung fields

Age Rate
Newborn 35
1-11 mo. 30
2 years 25
4 years 23
6 years 21
8 years 20
Age Rate
10 years 19
12 years 19
14 years 19
16 years 17
18 years 16-18
(rate=breaths/minute) Whaley & Wong, 1991

Why Lung Assessment Is
Important
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It provides additional clinical information
Provides a good baseline for comparison in future assessments
Gives a better picture of the child’s perception of symptoms vs. what is actually assessed
When consulting w/the HCP, they will ask for lung sounds
Form F26

Physical Respiratory Inspection

Respiratory rate

Rhythm (regular, irregular or periodic)

Depth (deep or shallow, presence of retractions)

Quality (effortless, automatic, difficult, or labored)

Character (noisy, grunting, snoring, or heavy)

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Breath sounds best heard in a quiet environment
Wheezing and crackles are best heard as the student takes deep breaths
Absent / diminished breath sounds are abnormal and should be investigated
Absence of wheezing does not necessarily mean absence of asthma

Breath Sounds: Crackles
 Coarse Crackle: Intermittent, interrupted explosive sounds, loud, low in pitch (heard when airs passes through larger liquid)
Crackles of a 9 yo boy with pneumonia airways containing
 Fine Crackle: Intermittent, interrupted explosive sounds, less loud and of shorter duration; higher in pitch than coarse crackles (heard when airs passes through smaller airways containing liquid)
This wheezing and coarse crackles were recorded over the right posterior lower lung of an 8 month old boy with viral bronchiolitis.

Breath Sounds: Wheeze And
Rhonchus (Rhonchi)

Wheeze: continuous sounds, high pitched; a hissing sound (e.g. with airway narrowed by asthma)
Expiratory wheezing was recorded over the right anterior upper chest of an 8 yo boy with asthma
Wheezing over trachea and right lower lung of 11 yo girl with asthma

Rhonchus: continuous sounds, low -pitched; a snoring sound (caused by large upper airway partially obstructed by thick secretions)
Sounds from The R.A.L.E. Repository @http://www.rale.ca/Recordings.htm

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Measures how well the student’s lungs are doing at that moment
Associated with the Green-Yellow-Red system of managing asthma symptoms
Congruent with asthma action plans
Helps students and families self-manage asthma
Form F31

How to use a Peak Flow Meter
 Review the steps
 Place indicator at the base of the numbered scale
 Stand up
 Take a deep breath
 Place the meter in the mouth and close lips around the mouthpiece
 Blow out into the meter as hard and fast as possible
 Write down the achieved number
 Repeat the process twice more
 Record the highest of the three numbers achieved

Personal Best Peak Flow Values




Determined by twice daily Determined when healthy and not experiencing symptoms
PFM measurements over the course of two weeks
Is the weeks
BEST reading obtained during those two
Is used to calculate percentages for AAP’s

Predicted Peak Flow Values





Are based on a child's height
Are not individualized
Do not take into account other personal factors
Can be identified immediately
Are used when it is impossible or difficult to obtain personal best peak flow levels
Form F6

 Wheezing and coughing are the most common symptoms -but-
 No two children will have the exact same symptoms or the same trigger
 Every child who has a diagnosis of asthma should have access to a rescue inhaler!
 Every child with persistent asthma should have an asthma action plan at school (AAP)

Together- We Can Make A
Difference!