Controlling Asthma: Preventing Episodes Before | Jindal Chest Clinic

Asthma is a major noncommunicable disease (NCD), affecting both children and adults, and is the most common chronic disease among children. Asthma can cause slight inconveniences or serious problems that interfere with day-to-day activities and can even result in a potentially fatal asthma attack. This presentation gives an overview on how to Control asthma, including: causes, symptoms, management, prevention, and treatment. For more information, please contact us: 9779030507.

1. Controlling Asthma:
Preventing Episodes
Before

2. Is There A Cure For Asthma?
Asthma cannot be cured, but it can be Controlled
“We should expect nothing less”!

3. Goals Of Asthma Control
Prevent Symptoms
•No coughing or wheezing
•No shortness of breath or rapid breathing
•No waking up at night
Maintain normal or near “normal” pulmonary function
Maintain normal activity levels (including exercise and other physical activities
Prevent exacerbations of asthma and minimize ER/UC and hospital visits
Minimal or no adverse effects from medications
Meet patients/family’s expectations and satisfaction with asthma care
Exerts from NAEPP EPR2 Guidelines for Diagnosis and Management of Asthma 1997

4. Asthma Control
Do Most Students Have It?

5. Unfortunately NO!
Many students who have asthma:
•Have poor asthma control
•Use “quick relief” medicine (e.g. albuterol) on a regular basis
•Cough, experience chest tightness, wheezing, or shortness of breath
regularly
•Assume suffering from symptoms are “normal”
•Remain indoors and cannot fully participate in sports, PE or recess
•Miss school due to asthma

6. Examples Of Students Whose Asthma Is
NOTOptimally Controlled
•A 10th grader, says he feels fine except when he runs in PE class, then
his chest hurts. He coughs most mornings and whenever he gets a cold
or virus. He often can’t keep up with the other kids and needs to stop
and rest.
•A 12th grader, carries an OTC Primatine Mist inhaler & uses it a few
times every day. He says he “grew out” of his asthma.

7. Examples Of Students Whose Asthma
IS Optimally Controlled
•A 6th grader, doesn’t need his “reliever”(albuterol) since consistently using
his controller medications twice daily. He now plays soccer without
developing symptoms or having to take pre-exercise albuterol.
•A kindergartener, no longer coughs or wheezes and easily keeps up with the
other kids at recess. Her dad bought special dust mite proof covers for her
mattresses and pillow. She now takes her controllers daily, uses her Asthma
Action Plan, and sees her health care provider every 6 months for a well
asthma check-up.

8. Asthma Severity Level vs Asthma Control
Asthma Severity Levels(Mild Intermittent, Mild Persistent, Moderate
Persistent, and Severe Persistent)
Based on signs and symptoms beforea student starts on controller
medications
Levels can change over time
Asthma Control(or “Current Asthma Severity”)
Is the students currentseverity level-
regardless if they are on medications, experiencing symptoms (episodes)
and/or able to be fully active

9. Asthma Control
Proactive vs Reactive
•Going from a reactiveto a proactive approach
Instead of thinking-
“ How do I treat these symptoms?”
e.g. with albuterolafter the fact
Think-
“ How could have the symptoms have been prevented in the first
place?”
e.g. daily controller medications, pre-exercise meds, asthma
action plan, environmental control

10. Controlling Asthma
Medical
&
Environmental
Management

11. Controlling Asthma Medical
Management

12. How To Achieve Good
Asthma Control
Have regular asthma check-ups with a primary healthcare provider, even when
feeling well
•At least every 6 months (more often if having symptoms)
Monitor symptoms and peak flow readings daily
Ask for and use a personalized Asthma Action Plan
Know personal green-yellow-red zones, what each zone feels like and what
to do in each zone

13. Asthma Control Continued...
Get a flu shot every fall
Avoid asthma triggers
Asthma’s not in control? Check in regularly at school health office for:
•Peak flow check /symptom evaluation
•Lung sounds / respiratory rate check
•Pre-exercise and/or controller meds
•Asthma education
•Care coordination

14. Asthma Action Plan
See MDH Asthma Action Plan F1

15. Written Asthma Action Plans
Developed by the health care provider for each individual child with asthma
Medications are determined by asthma severity level
Based on symptoms and peak flow rates
Lists daily & rescue medications
Symptom management and emergency plan
Copies to be shared by clinic, family and school

16. Asthma Action Plan Zones
Green Zone: All Clear/Breathing Good/Go
–No asthma symptoms and/or
–Peak flow 80-100% Predicted or Personal best
Yellow Zone:Caution/Slow Down
–Some asthma symptoms and/or
–Peak flow 50-80% Predicted or Personal best
Red Zone: Medical Alert/Stop
–Severe asthma symptoms and/or
–Peak flow < 50% Predicted or Personal best

17. What Can A Student Do To Stay In The Green Zone?
Select The IncorrectAnswer
A. Take their controller (anti-inflammatory) medication every day
B. Avoid cigarette smoke and other asthma triggers
C.Take their pre-exercise (usually reliever) medicine before P.E. or at recess
D.Wash their bathroom often with bleach to avoid mold and mildew build-up

18. What Can A Student Do To Stay In The Green
one?
Select The IncorrectAnswer
A.Taketheir controller (anti-inflammatory) medication every day
B.Avoid cigarette smoke and other asthma triggers
C. Take their pre-exercise (usually reliever) medicine before P.E.
or at recess
D.Wash their bathroom often with bleach to avoidmold and
mildew build-up

19. If A Student Is In The Yellow Zone,
They Should:
A.Be cautious. Breathing isn’t their best. Take action
B.Eat a lot of yellow foods such as bananas, which are high in
potassium
C.Automatically stay home from school
D.Call their doctor or nurse practitioner immediately

20. If A Student Is In The Yellow Zone,
They Should:
A.Be cautious. Breathing isn’t theirbest. Take action
B.Eat a lot of yellow foods such as bananas, which are high in potassium
C.Automatically stay home from school
D. Call their doctor or nurse practitioner immediately (correct answer:
call if they aren’t fully back into the green zone within 48-72 hours).
R1

21. Which Is One Symptom/ Clinical Indicator Is NOT
Associated With The Red Zone?
A. Mild coughing
B. Peak Flow reading < 50% of personal best
C.Significant breathing problems
D.Persistent wheezing or no wheezing at all indicating severely limited
aeration

22. Which Is One Symptom/ Clinical Indicator Is
NotAssociated With the Red Zone?
A.Mild coughing
B. Peak Flow reading < 50% of personal best
C. Significant breathing problems
D. Persistent wheezing or no wheezing at all indicating severely limited
aeration

23. Activity
Group Case Discussion
The first month of school, you are called to an elementary school by a
substitute teacher. She sent a 3
rd
grader to the nurse’s office alone, and
told her to lay down.
When you arrive, child has neck vein distension, accessory muscle
retractions, dark/dusky color. No inhaler available
Mom is 45 min. away.Grandma is in town
WHAT DO YOU DO?

24. Controlling Asthma -Environmental
Management

25. Common Environmental Triggers At Schools
•Indoor Triggers
Animals with fur
Dust mites
Mold
Pests
Secondhand smoke
Chemicals (e.g. strong
smelling cleaning supplies,
perfume, air fresheners)
•Outdoor Triggers
Ozone
Particulate matter
Diesel exhaust
Chemicals (e.g. re-
surfacing the playground or
roof, etc.)

26. Animals
•Dander, urine & saliva are triggers
•Triggers remain months after animal pet removed
•Actions:
Prohibit/remove animals from schools if able
If removal is not possible:
»Keep animals in cages or localized areas
»Clean cages often
»Keep animals away from fabric furniture, carpet & ventilation system
»Locate sensitive students away from animals
Pre-notify parents if animals with fur/feathers visit
•Sample Animals in School Guidelines in manual R1

27. Dust Mites
•Both cause & trigger asthma; live in pillows, carpet, fabric-covered furniture,
curtains
•Actions:
Keep classrooms clutter-free
Make informed decision: presence of carpet
Vacuum often when people with asthma/allergies are gone (HEPA filter
vacuum cleaners may help)
Pillows/mattress/box spring in dust-mite proof zipped covers
Wash bedding and stuffed toys weekly in HOTwater (>130 degrees F)
Keep room humidity < 50% if possible

28. Mold
•Moisture control is key
•Actions:
Report leaks and wet/moist areas right away
Wash mold off hard surfaces
Replace moldy porous items such as ceiling tiles & carpet
Avoid carpet in areas with regular moisture such as drinking
fountains & sinks
E9

29. Pests
•Droppings or body parts can trigger asthma
•Actions:
Use integrated pest management (IPM) methods
»Don’t leave food, water or garbage exposed
»Don’t eat or drink in classroom
»Seal entry points for pests
»Use pesticides only as needed
Parent Right to Know Act: must notify parents & employees when
using specific pesticides
F32, F33, F34

30. Secondhand Smoke
•Causes asthma in young children & triggers asthma in children & adults
•Contains over 4,000 substances
•State law prohibits tobacco use in K-12 public schools
•Actions:
Enforce smoking bans (for anyone on school property)
Include anti-smoking message in curriculum
Encourage parents/guardians to quit smoking or to not smoke insidetheir
home

31. Outdoor Air
•Ozone & fine particles are concerns in MN
•Staff have little control over outdoor air
•Actions:
Sign up for Air Quality Index notice
»Pollution Control Agency sends e-mail alerts when they expect poor
air quality (regional)
Avoid being outside at high pollen count times, especially if students are
allergic to particular pollen/s

32. The AQI

33. Average Number Of Alerts
6-12 alerts per year in last few years
Most due to PM2.5
Not violation of federal air quality standards thus far
Health issues still valid

34. 2003 –Air Pollution Health Alerts
Expanded AQI to Duluth, St. Cloud, Rochester
Detroit Lakes, Marshall coming soon
Expanded media coverage (Pioneer Press, TV meteorologists,
health reporters, others)
Expanded web & e-mail alert signup

35. MPCA’s AQI web page 1

36. MPCA’s AQI web page 2

37. School Buses
•State law requires:
Reduce unneeded idling in front of schools
Reroute bus parking zones away from air intakes, if possible
•Actions:
Post “no idling” signs
Maintain bus fleet
Invest in cleaner fuels
Purchase newer, cleaner buses over long-term
R2, R3, R4

38. Other Environmental Issues
•Indoor Air Quality Management Plan
•Cleaning & cleaning products
•Flooring
•Air cleaners
R7

39. Home Environment Resources
•US Environmental Protection Agency
Asthma Home Environment Checklist
»8 page checklist of common asthma triggers
»Questions to identify triggers & action steps
Clear Your Home of Asthma Triggersfact sheet
•EPA website
www.epa.gov/iaq/asthma/resources.html

40. Communication & Care Coordination

41. Key Communication Triad
Child
Health Care
Providers
Parent/
Guardian
School
Health Office

42. Care Coordination / Communication
(Health Assistant / Paraprofessional/LPN Role)
Health Assistants / Paraprofessionals / LPNs must alert LSN/PHN/RNs of
students who come in frequently with asthma type symptoms
Monitor students with asthma as directed by LSN/PHN/RN
Perform delegated responsibilities once skills have been validated per
district/school policies

43. Care Coordination /Communication
(LSN/RN/PHN)
•Examples of asthma care coordination activities
Request AAPs on students
Review AAP and/or IHP and develop/modify plan for care coordination
Determine medical insurance status and connect to appropriate provider(s)
Arrange for special transportation (in rare cases) prn
Connect to community resources

44. Care Coordination/ Communication
Communicating with Students
•Educate them to:
Follow an individualized Asthma Action Plan
Avoid or control exposure to their triggers
Use medication appropriately
•Long-term-control medicine
•Quick-relief medicine
Monitor symptoms and response to treatment
•Understand symptoms and peak flow levels
•Seek a health care providers help when needed

45. Communicating w/ Students
Continued..
Get regular follow-up care
Be able to exercise/ play at optimal levels
Be responsible for carrying and using their asthma
medications per school policies
Ask for help when they need it!

46. Care Coordination/ Communication
•Communicating with parents/guardians
Review parent/guardian and student questionnaires
Determine current asthma severity levels
Provide education to family/student as needed
Encourage questions and give feedback
Contact parent/guardian every time a student has asthma symptoms and
or if having poor asthma control
Obtain a signed consent to release/ share information
F11, F14, F3, E1, F7

47. Care Coordination / Communication
•Communicating with health care providers
Report status changes and re-evaluation needs
Advocate for pre-exercise and /or controller medications as appropriate
Arrange for asthma education
Complete IHP and/or ECP ifneeded
Document as appropriate in Pupil Health Record
Evaluate symptoms, lung sounds and peak flow regularly on poorly
controlled students
F17, F18

48. Communicating With School Staff
Share information with staff on a need to know basis only
Maintain student confidentiality
Provide general asthma education to staff proactively
Provide asthma first aid training to staff
Act as a resource to school staff for questions and concerns

49. Health Office Scenario
•A 4th grade student who you have not seen in the health office this
year for asthma symptoms, has a diagnosis of asthma in her record,
and has albuterol MDI / orders in the health office at school, but no
Asthma Action Plan. She comes into the health office with a persistent
cough.
•What would you do for her?

50. Health Office Scenario Continued...
•Actions
Physical Assessment (respiratory rate, breath sounds, severity of
symptoms)
Ask what she was doing before coming into the health office / what
may have precipitated symptoms
Ask frequency of day / nighttime symptoms
Check height/PF chart for predicted PF and initiate Asthma Record
F5

51. Health Office Scenario Continued...
Check her Peak Flow reading and document in SHOAR F4
»Instruct the child how to do a PF reading
Give albuterol (observe inhaler technique)
Teach/reinforce proper inhaler technique, use of spacer or holding
chamber with inhaler
Monitor her for response to medication
Send note home with the child using the AVN F8 anda PAQF11

52. Health Office Scenario Continued...
•Two days later, she returns to the health office, with cough and
shortness of breath
•What would you do for this 4th grader first?
•What would be the next steps or what else should you do at this
point?

53. Health Office Scenario Continued…
•What else should you do now?
Re-evaluate her respiratory status and treat as appropriate
Call her parent / guardian to notify, ask for parent questionnaire/more
info.
Suggest she see her health care provider
Ask the child to come see you the next day for a follow up check
If you have consent, fax Asthma Medical Referral/Request to health
care provider
F9

54. Asthma Management In The School
Health Office

55. Sample Forms For Optimal School
Asthma Management

56. Key Asthma Tools
•Components of Asthma Management in the Health Office E2, E3
•Asthma Action Plan w/ imbedded consents, parent letter F1, F2
•Asthma Visit Notification form F7, F8
•Asthma Medical Request/Referral F9, F10
•Pathway for Acute School Asthma Care E6,E7
•Emergency Care Plan -Asthma F18
•Individualized Health Plan -Asthma F17

57. Key Asthma Tools
•Parent/Guardian Breathing/Asthma Questionnaire F11, F12, F13
•Student Breathing/Asthma Questionnaire F14, F15, F16
•School Health Office Asthma Record F4, F5, F6
•Self-administration Asthma Medication Authorization F19, F20
•First Aid for Asthma poster / pocket cardsE4, E5
•Asthma Green/Yellow Zone Update F23, F24
•Permanent Health Office Pass F25

58. Components Of Asthma Management In
School Health Office
Two Models Provided in School Asthma Manual
•LSN + Health Assistant (Mpls. Public Schools model) E2
•LSN + Secretary (St. Paul Public Schools model) E3
Purpose:Provides job specific instructions for providing quality asthma care
in the school health office
•Licensed School Nurse, Public Health Nurse, Registered Nurse
•Licensed Practical Nurse
•Health Aid/Service Assistant / Paraprofessional
•Secretary / Administrative Assistant

59. Asthma Screening Questions
Include these 3 questions into your existing student health
questionnaire
1.Does your child have asthma or other breathing problems?
2.Has your child ever been diagnosed by a doctor as having
asthma?
3.Has your child had episode(s) of wheezing (whistling in the
chest) in the last 12 months?

60. Asthma Action Plan (AAP)
•Purpose
Provides a plan to guide the asthma management of individual students
Includes imbedded consents:
»Allow parents/guardians and providers to give permission for medications
to be given at school
»Allow for sharing/release of information between school, clinic, hospital,
child care provider and home care
•Available in English and Spanish

61. Asthma Visit Notification Form (AVN)
•Purpose
Increases communication between the school health office, parents/guardians,
and primary care/asthma care providers
Fill out and send home whenever the student is in the health office with
asthma symptoms
Or when delegated by the LSN/PHN/RN
F7,F8

62. Asthma Medical Request (AMR)
•Purpose
To facilitate communication and care coordination between the health care
provider and the school nurse about the student’s asthma status/management
Fill out and fax, mail to health care providers
You must have the parents written consent to collect medical information
first
F9, F10

63. Pathway for Acute School Asthma Care
•Purpose
Assists school nurses in making decisions regarding the provision of acute
asthma care in the school health office or other school setting
Designed to be used for students experiencing mild, moderate or severe
asthma symptoms
E6, E7

64. Asthma Emergency Care Plan
(ECP)
•Purpose
Provides special instructions to selected school staff on how to respond to
an asthma emergency
Used with students with severe or labile asthma
Individualized for each student with asthma
F18

65. Asthma Individualized Health Plan (IHP)
•Purpose
Provides a Nursing Plan of Care and promotes care coordination and
communication between the school nurse and health office staff regarding
students whose asthma is not in good control
•Also used to document special education nursing services
F17

66. Parent / Guardian Asthma Questionnaire
(PQ)
•Purpose
Used To:
Gather baseline information about the child’s asthma symptoms
Determine the child’s asthma severity level
Determine if the child’s asthma is under control
Develop an appropriate plan of care
•Typically used for students in 5th grade or lower
F11, F12, F13

67. Student Breathing Questionnaire (SBQ)
•Purpose
Used to:
Determine the student’s asthma severity level
Determine if the student’s asthma is under control
Develop an appropriate plan of care
Determine student’s familiarity of their meds, triggers, symptoms etc.
•Used with students in grades 6th grade or higher
F14, F15

68. School Health Office Asthma Record
(SHOAR)
•Purpose
Provides a user-friendly document on which to record many aspects of a
student’s asthma care
•Allows health office staff to:
Record Asthma Medication
Record Peak Flow Readings
Document Asthma Symptoms
Document Education
F4, F5

69. Self-Administration Of Asthma Medication
Authorization / Agreement
•Purpose
To systematize practice regarding self-carrying of asthma medications
between schools
Promotes strong asthma self care skills in students
Agreement between student and school nurse
Used in conjunction with an Asthma Action Plan or may stand alone
F19, F20

70. First Aid For Asthma Poster / Pocket Cards
•Purpose
Provides basic first aid care for asthma and asthma symptoms with directions
when to call 911
Place posters in locations in the school where students and staff are usually
present
Pocket cards may be given to physical education teachers or coaches or other
staff as needed
E4, E5

71. Prioritizing In A Busy School Health
Office

72. There’s Never Enough Time,
What Can I Do?
•It isn’t possible for school health office staff to get deeply
involved with every student who has asthma so -
•Prioritization is essential!
Determine which students seem to be having the most
difficulty, and focus on them first

73. How Do I Prioritize?
1.Prioritize by “current asthma control / severity level”
2.Focus first on students with the poorest asthma control
regardless of severity level
3.Start working with students whose asthma is poorly
controlled in the moderate to severe persistent asthma levels

74. Which Of These Students With Asthma
Would You Focus On First?
1.A boy with diagnosed moderate persistent asthma who can run, play, attend
school without symptoms and rarely uses his albuterol
2.A girl with current mild persistent asthma who is unable to fully participate
in PE class
3.A girl who’s original severity level was severe persistent but whose
“current asthma severity level” (control) is moderate persistent. She can
play outside better than originally, but still needs albuterol for symptoms 3-
4 times a week at school

75. Which Of These Students With Asthma
Would You Focus On First?
3.A boy with diagnosed moderate persistent asthma who can run, play, attend
school without symptoms and rarely uses his albuterol.
2.A girl with current mild persistent asthma who is unable to fully participate in
PE class.
1.A girl who’s original severity level was severe persistent but whose “current
asthma severity level” (control) is moderate persistent. She can play outside
better than originally, but still needs albuterolfor symptoms 3-4 times a
week at school.

76. Education In The School Health
Office

77. Components Of Student
& Family Education
Concept of asthma control
Pathophysiology of asthma
Environmental control and triggers
Controller vs. reliever medications and refilling medications
Use of Asthma Action Plan and treatment of episodes
Peak flow meter use

78. Components Of Student
& Family Education Cont…
Signs and symptoms of respiratory distress and when to seek help
MDI with spacer / DPI technique
Nebulizer use and technique (prn)
Importance of relationship with provider and well-asthma check-ups
Flu shot every fall
Self-care, especially for students as they get older

79. Strategies To Educate When Time Is
Limited
Give short asthma education messages when meeting with with students
Use innovative / interactive asthma education tools (computerized asthma
games, internet-based asthma control tools, videos) with students /
families

80. The Best Laid Plans..
You can increase the likelihood of asthma management success
(compliance) by:
1.Reviewing Asthma Action Plan and making sure student understands
how to use it
2.Ask how controller medications fit into the student’s daily routine (can
they handle it?)
3.Identify obstacles or barriers to the student/family carrying out the plan
as prescribed

81. “I Can’t Manage This By Myself.
Who Else Should Be Involved”?

82. Referring To Community Resources For
Education And Case Management
LSN/PHN/RNs can utilize case managers, home visiting professionals, and
asthma educators from health plans, hospitals, clinics, public health, to help
educate and/or case manage students whose asthma is poorly controlled
Connect students/family to community education, asthma camp, other
community resources

83. Coordinated School Health: Partnering
For Optimal Asthma Management In
Schools

84. CDC’s Strategies For Addressing Asthma
Within A Coordinated School Health
Program
Six Strategies
1.Establish management and support systems for asthma-friendly
schools
2.Provide appropriate school health and mental health services for
students with asthma
3.Provide asthma education and awareness programs for students and
school staff

85. Strategies Continued…
4.Provide a safe and healthy school environment to reduce asthma
triggers
5.Provide safe, enjoyable physical education and activity opportunities for
students with asthma
6.Coordinate school, family, and community efforts to better manage
asthma symptoms and reduce school absences among students with
asthma

86. Asthma Goals For School
Health
Healthy school environment
Health services in school
Asthma education
Supportive policies
Sound communication
1997 National Asthma Education and Prevention Program
(NAEPP)

87. Spearheading School-wide Asthma Best
Practices At Your School
See Checklist in manual for suggestions
Create a multi-disciplinary plan for improving asthma management in your
health office, school and/or district
Improve own practice
Educate other school staff
Involve all disciplines within the school setting

88. Community Involvement
Get involved with the Minnesota Asthma Coalition, and/or the regional
Asthma Coalition in your area
Contact your legislators and insist on legislation to support asthma-friendly
policies
Anti-smoking laws
Healthy housing initiatives
Supporting Clean Indoor act
Support stricter pollution control measures

89. Conclusion
Asthma is a big challenge for Minnesota
Working together with parents and health care providers, we
have the ability to positively and dramatically impact the health
of children who have asthma!