Asthma Green Light

Handbook for Childcare Providers

A JOINT PARTNERSHIP BETWEEN: The United Planning Organization and the University of The District of Columbia, through the Research Infrastructure for Minority Institutes (RIMI Project)

Asthma Green Light Handbook for Childcare Providers

Government of the District of ColumbiaAdrian M. Fenty

Mayor

District of Columbia Department of HealthPierre N. D. Vigilance, MD, MPH

Director

Government of the District of ColumbiaDepartment of Health

Community Health AdministrationAsthma Control Program DC Control Asthma Now ( DC CAN )

Community Health Administration825 North Capitol Street, NE

Washington, DC 20002

202.442.5925 www.doh.dc.gov

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DEAR CHILDCARE PROVIDER:

Asthma is on the rise among America’s children. It is the most common chronic disease in childhood. In a District of Columbia childcare center, about one in seven children under five years old will have asthma. Asthma can negatively affect a child’s quality of life in many ways. It can result in many lost nights of sleep, disruption in family routines, and restricted activities. It is one of the leading causes of school absences and can significantly reduce a child’s ability to learn. However, with proper asthma management and treatment, children with asthma can lead normal, active lives.

Many children spend a large amount of time in childcare centers, more than anywhere else. As a childcare provider, you play a major role in the health and safety of the children under your care. To keep these children healthy, it is essential that both childcare providers and parents have a good working knowledge of asthma treatment and management.

We are pleased to provide you with the asthma training program entitled “Asthma Green Light Training for Childcare Providers” to help you gain a good working knowl-edge of asthma treatment and management. This manual is one of many services provided by the District of Columbia Department of Health, Community Health Admin-istration, Asthma Control Program, DC Control Asthma Now (DC CAN). This educational training is a joint partnership between United Planning Organization, The University of the District of Columbia Research Infrastructure for Minority Institutes (RIMI Project), Asthma and Allergy Foundation of America-Maryland, and DC CAN Program. Our goal is to reduce the burden of asthma in Washington, DC.

The Asthma Green Light Handbook for Childcare Providers has information about common asthma symptoms, proper treatment and proper cleaning of asthma equip-ment. The handboook will also provide advice about things that can make asthma worse and how to manage asthma from day to day. We hope this information will help you feel more confident in caring for children with asthma.

Bests,

Theresa Shivers, B.A. Chief of Health Maintenance and Special Needs at the United Planning Organization Office of Preschool and Child Development Center Project Director for the Asthma Green Light Training Program for Childcare Providers

Elgloria Harrison, MS, RRT, NPS, AE-C Associate Professor in the Respiratory Therapy Program at The University of the District of Columbia, RIMI Scholar Subject Matter Expert for the Asthma Green Light Training Program for Childcare Providers

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Acknowledgments

This publication was developed through a collaborative effort between the District of

Columbia Department of Health Asthma Control Program, DC Control Asthma Now (DC

CAN), the United Planning Organization, and The University of the District of Columbia

through the Research Infrastructure in Minority Institutions (RIMI Project)

We gratefully acknowledge the following individuals and organizations for generously

contributing their time and expertise in developing this publication and companion DVD.

Edwina Davis-Robinson, MS, CHES

Program Manager, DC Department of Health Asthma Control Program

LaVerne Jones, MPH

Epidemiologist, DC Department of Health Asthma Control Program

Elgloria Harrison, MS, RRT, NPS, AE-C

Associate Professor Respiratory Therapy Program, The University of the District of

Columbia-RIMI Scholar

Subject Matter Expert for the Asthma Green Light Training Program for Childcare

Providers

Theresa Shivers, BA

Chief of Health Maintenance and Special Needs United Planning Organization Office of

Preschool and Child Development Center

Project Director for the Asthma Green Light Training Program for Childcare Providers

Carolene Charles, MEd

Center Director, The University of the District of Columbia Child Development Center

Connie Webster, PhD, RN, CAN, BC

Project Director, Research Infrastructure in Minority Institutions at The University of the

District of Columbia

William Hughey

Deputy Executive Officer, Office of Child and Family Development at the United

Planning Organization

Elena Reece, MD, FAAP, FACAI

Pediatric Asthma, Allergist Howard University Hospital

David Gaston

Executive Officer of 4.0 Media This publication was supported by the District of Columbia Department of Health Asthma Control Program, DC Control Asthma Now (DC CAN) with funds from the Centers for Disease Control and Prevention (CDC), Preventive Health and Health Services Block Grant – Grant No.3B01D009009-09W1. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the CDC.

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Table of Contents General Asthma ............................................................... 5 What is Asthma? ................................................................................................6 Asthma and the Respiratory System ....................................................................6 Asthma Signs and Symptoms ..............................................................................7

Asthma Triggers .............................................................. 8 Irritants ..............................................................................................................8 Allergens ............................................................................................................9 Other Triggers ....................................................................................................11

Asthma Medications ........................................................ 13 Quick-Relief Medications ..................................................................................13 Long-Term Medications .....................................................................................14 Asthma Medication Chart ..................................................................................16

Asthma Devices ............................................................... 17 Using a Metered Dose Inhaler with a Spacer .......................................................17 Using a Metered Dose Inhaler without a Spacer ..................................................18 Nebulizers ..........................................................................................................18 Cleaning and Care of Asthma Devices ................................................................19

Asthma Management ....................................................... 19 Using a Peak Flow Meter ....................................................................................19 Asthma Action Plans ..........................................................................................20 The Childcare Providers Role in Asthma Management ........................................22 What to do in an Emergency! ..............................................................................22

Activity Page .................................................................... 23

Resources ........................................................................ 24

Asthma Quiz ................................................................... 25

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General AsthmaStatistics of asthmaAsthma is a common disease in the United States •22.2millionAmericanshadasthmain2005,including6.5million childrenunder18yearsofage •About5,000deathsoccureachyearduetoasthma •Mostcommonchronicdiseaseinchildhood •#1causeofmissedschooldays •Childrenages0-4havehighestratesofemergencydepartmentvisitsand hospitalizationsduetoasthma

Demographics of asthma •Childrenlivinginpovertyand/orinnercitieshavehigherratesof hospitalizationsandmortalityduetoasthma •AfricanAmericanchildrenhavesignificantlyhigherratesofemergency departmentvisitsandhospitalizationsduetoasthma •AfricanAmericansaretwiceaslikelytodiefromthedisease •Youngboyshavehigherratesofemergencydepartmentvisitsand hospitalizationthangirls

Asthma in younger children in the District of Columbia (under 5 years of age) •In2007,15%ofchildrenunderfiveyearsoldhad“currentasthma” •Childrenunderfiveyearsoldhavethehighestemergencydepartmentvisit ratewhencomparedtoolderchildren •Youngboyshavehigheremergencydepartmentvisitratethangirlsinthis agegroup

Why has there been such an increase in asthma?Thereisnocertainanswer...manyexpertsbelievethatitislinkedto:

1. Indoor Air Quality •TheaverageAmericannowspends80-90%ofhisorhertimeindoors •Moreirritantsandallergensaretrappedindoorsduetoincreased insulationandinadequateventilationinhomesandbuildings •Poorlivingconditionsthatincreaselevelsofindoorirritantsand allergensexistinmanycommunities2. Outdoor Air Pollution •Researchhaslinkedpoorairqualitywithanincreaseinasthmain somecities

3. Other Possible Explanations •Increasedasthmaawareness •Doctorsarediagnosingasthmamorefrequently

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What is asthma?Asthma is a chronic (long-term) disease that inflames and narrows the airways, which makes it difficult to breathe.What is the difference between acute and chronic diseases?

1. Acute Diseases: •Occurwithasuddenonset •Lastforshorterperiodoftime2. Chronic Diseases: •Lastforalongerperiodoftime;usuallyforlife •Involvesmanagementofthedisease •RequireschangesinhealthbehaviorsSome examples of chronic diseases: •Asthma •Diabetes •Heartdisease

Is there a cure for asthma? Asthmaisalifelongdiseasewithnocure

Asthma and the respiratory systemHealthyairwaysallowairtoflowinandoutofthelungs.

Asthma affects the airways (bronchial tubes) of the respiratory system •Causestheairwaystobecomeinflamed(swollen) andirritated •Theinflammationintheairwaysmakesthemextrasensitive •Theairwaysthenreacttodifferenttriggers

Exposure to a trigger, may result in: •Increasedinflammation(swelling)insidetheairway •Musclesaroundairwaystighteningandconstricting •Increasedmucusproduction,whichclogsairways

Theseprocessesmaketheairwaysmorenarrow,anditishardertogetairinandoutofthelungs!

See Activity Sheet on page 24

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Risk factors for children with asthmaPrimary Risk Factors •Allergies(includingskinallergy,eczema) •FamilyHistory •ViralrespiratoryinfectionsOther Risk Factors •Exposuretotobaccosmokeearlyinlife •Smallerairwaysatbirth •Lowbirthweight

Asthma signs and symptoms1. Early Warning Signs and Symptoms

Thebodywillgive“earlywarning”signsbeforeasevereasthmaepisode.Thesesignsandsymptomswillvaryfromchildtochild.

Early Warning Signs and Symptoms: •Coughing(dayornight) •Wheezing •Breathingfasterthanusual •Feelingtired •Chesttightness •RunnynoseorscratchythroatWhen you see these signs: •Administerquick-reliefmedication •Refertothechild’sasthmaactionplan •Monitorchildtomakesuretheyimprove

2. Emergency Warning Signs and Symptoms

Callyourdoctororgetmedicalhelpimmediatelyifyouseeemergency warningsigns: •Breathingveryquicklyorhunchedover •Severewheezing •Nostrilsopeningwiderwitheachbreath •Hardtimewalking,talking,oreating •Theskinbetweentheribsispulledtight •Lips,skin,orfingernailsareblue-CALL 911 •Quick-reliefmedicineisn’tworkingafter20or30minutes- CALL 911

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If you see any of these symptoms: •Callthedoctororgetmedicalhelprightaway •Refertotheasthmaactionplan •Administerquick-reliefmedication

What are triggers?Atriggerisanyenvironmentalsubstancethataffectstheairwaysofapersonwithasthmacausinghimorhertohaveanepisode.Theairwaysbecometight,swollen,andproduceexcessmucus.Therearevarioustypesofasthmatriggersinourenvironment,andeverypersonhasdifferenttriggers.

Know What Triggers Affect the Children in Your Care!

Triggerscancauseachildwithasthmatohavetroublebreathing,andtheycanalsoleadtothedevelopmentofasthmainsomechildren.

Herearesomeexamplesofcommontriggers: •Respiratoryinfections(cold,flu,bronchitis) •Environmentalirritantsandallergens(smoke,mold,dust,etc) •Exercise •Emotions •Weather

Reducing a Child’s Exposure to Triggers

Byreducingthetriggersinthechild’severydayworld,youwillhelpto maintaincontroloftheirasthma!

IrritantsTheseinclude: •Tobaccosmoke •Perfume •Householdcleaners •Insecticides •Indoorandoutdoorfires •Airpollution

Tobacco Smoke

Childrenofsmokersaretwiceaslikelytodevelopasthmaaschildrenwhoseparentsdonotsmoke.Childrenwhoareexposedtotobaccosmokearealsomorelikelytosufferfrompneumonia,bronchitis,otherlungdiseases,andearinfections.

Some suggestions: •Don’tsmoke •Haveanon-smokingpolicyatyourcenter •Ifyoudosmoke,donotsmokearoundchildrenandwashyour handstoeliminateleftoverirritants/fumes •Remembersmokeresidueleftonclothingcanalsotriggerasthma •Encourageparentsnottosmoke

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Other Environmental Irritants

Some suggestions: •Eliminateuseofwoodstovesandfireplacesinhome •Havechildrenstayindoorsandkeepwindowsclosedwhen pollutionmeasurementsarehigh •Obtaincurrentairqualityreadingsbycheckingthe“weather section”ofthelocalnewspaperortheEnvironmental ProtectionAgencywebsitelistedontheresourcepage. •Donotusestrongsmellingperfumes,andavoidotherthingsthat containstrongfragranceslikesoapsandlotions •Useunscentedhouseholdcleaners

AllergensDust MitesThesearetinyinsectsthataretoosmalltoseeandliveinbedding,carpeting,stuffedanimals,andfurniture.Theyfeedondeadskincellsandthriveinhumidenvironments.Theydonotbiteorspreaddiseaseandareonlyharmfultopeoplewhoareallergictothem.Itisthedroppingsofthedustmitethatisthe allergen,notthebugitself.

Interesting Fact: A single gram of dust can have over 18,000 dust mites.

Some suggestions: •Changebeddingatleastonceaweek,andwashinhotwater (above140degrees) •Enclosepillows,mattresses,andboxspringsinallergyproof mattresscovers(availableatWalmart,Target,etc) •Removestuffedanimalsfromchildcarecenter,orwashthem frequentlyinhotwater •Dustfrequentlywithdampcloth •Storetoysbehindclosedcabinetdoors •Havechildavoidupholsteredfurniture,carpeting •Vacuumwhenchildrenarenotpresent •HaveavacuumwithaTrueHepa-filtrationsystem-thistypeof vacuumiscapableofgettingupmicroscopicallergenslikedust mitesandmoldspores

MoldsMoldsalsothriveinmoisture-richenvironments.Moldsreleasesporesintheair,whichcanbeharmfulforpeoplewithallergiesandasthma.Moldscanbetoxiciffoundinlargeconcentrationsindoors.Moldsarefoundin: •Oldcarpets •Darkplaces •Householdplants •KitchensandBathrooms •Placeswheretherearewaterleaks

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Some suggestions: •Moldscanbehardtofind.Itisimportanttocheckunderneath carpetingandsinks,andbehindobjectsagainstwalls •Keepbathroomsandkitchenswellaired •Cleanmoldwithadilutedbleachsolution (1partbleach:10partswater) •Fixleakyfaucetsandpipes •Getprofessionalhelpifmoldgrowthisbiggerthan 3ftby3ftinsize •Avoidusingvaporizersandhumidifiers •Removehouseholdplantsfromhome(ifnecessary) •Airplantsdonotharbormoldandareagoodalternativesto regularhouseholdplants

CockroachesCockroachescanbeanasthmatrigger.Smallpiecesofdeadroachesandroachdroppingssettleinhouseholddustandendupintheairwebreathe.Cockroachallergensarelikelytoplayasignificantroleinasthmainmanyinnercityareas.Cockroacheslikefood,water,andshelter(clutter).Some suggestions: •Donotleavefoodorgarbageexposed •Fixleakyfaucetsandpipes •Storefoodinsealablecontainersandcleanupcrumbs •Washdishesimmediatelyaftereating •Cleanupclutteredareas

PesticidesPesticidescanalsobeharmfultoachild’shealthandcanbeanasthmatriggerforsomechildren.

Some suggestions: •Tryusingpoisonbaits,boricacid,roachgel,ortrapsfirst beforeusingsprays-besuretoplacetheseitemsoutof children’sreach •Limitspraytotheoutdoorsortotheinfestedarea •Donotspraywhereyouprepareorstorefood •Donotspraywherechildrenplay,crawl,andsleep •Makesuretheroomisairedoutandeverythingiswipeddownafter sprayingwithpesticides •CALLaprofessionalexterminatorifpestproblemissevere

Pets: Animal DanderAnimalallergensareanothercommonasthmatrigger.Itisusuallynottheanimalfuritselfthatcausesthereaction,butsubstancesinanimalsaliva,urine,andskinsecretions.

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Some suggestions: •Donothavepets,ifpossible •Keeppetsoutsidewhenchildrenarepresentatdaycare •Washpetweekly •Keeppetoffbeds,upholsteredfurniture,andcarpets

PollensSomechildren’sasthmaistriggeredasanallergicreactiontopollen,whichisfoundinfloweringgrasses,trees,shrubs,andflowers.

Some suggestions: •Findoutwhenthepollencountishighfromyourlocal newspaperorTVnews,andkeepthechildrenindoorsduringthe earlymorningandlateafternoononthesedays •Checkcurrentpollenlevelsinyourareaat: http://www.pollen.com •Keepwindowsclosedduringseasonswhenpollencountishigh (MayandOctober) •Useairconditioning,ifpossible

FoodsCertainfoodscancauseanallergicreactionthatmaytriggerasthmasymp-tons.Somecommonfoodallergiesincludepeanuts,eggs,chocolate,wheat,andpineapples.

Some suggestions: •Findoutwhatfoodstriggerthechild’sasthma •Avoidthesefoodsatalltimes •Readingredientsonlabelsofallfoodproducts

Other triggersRespiratory InfectionsThisisacommontriggerofasthma,especiallyinchildrenunder5yearsofage.Youngchildrengetsickfrequently.Theirimmunesystemisstilldevel-opingandcontinuestogetstrongerastheygetolder.Forthisreasonitisdifficultforchildrentoavoidthe“coldandflu”especiallyduringtheseasonsoffallandwinter.Itisthebacteriaandvirusesthatirritatetheairwaysandincreaseasthmasymptoms.

Some suggestions: •Remindparentsthatchildrenwithasthmashouldhaveannual fluvaccinations •Keepchildrenawayfromothersickchildren •Remindparentstoleavesickchildrenathome •Havechildrenwashhandsfrequently

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WeatherChangesinweathercanhaveaneffectonachild’sasthma.Coldanddryweather,suddenchangesofweather,orhumidconditionscan triggerasthma.

Some suggestions: •Havechildwearascarfoverthenoseandmouthoncolddays •Useairconditioningindoors,ifpossible,inhot,humidweather •Makesureheatingandairconditioningfiltersareclean •Changefiltersaccordingtomanufacturer’sinstruction

ExerciseExercisecanbeatriggerforsomechildrenwithasthma,butshouldnotbeavoided!

Some suggestions: •Allowachildtowarmupbeforeexercise •Provideresttimeswhenplaying,especiallyoutdoors •Beawareofothertriggerslikepollen,mold,andpollution,while childrenareexercising •Administerquickreliefmedicationtochild20-30minutespriorto exercise,ifdirectedbyahealthcareprofessional

EmotionsAsthmacanbetriggeredbyemotions.Strongemotionslikecryingor laughingcanaffectachild’sbreathingandtriggeranasthmaepisode.

Help the child to stay calm, have them sit down, relax, and do breathing exercises as follows: •Havethechildtakeaslow,deepbreaththroughthenose •Whenhisorherlungsarefullofair,havethechildpursehisorherlips andlettheairoutslowlythroughhisorhermouth,likethepersonis blowingoutthroughastraw •Asthechildbreathesout,hisorhershouldersshouldgolimpandhisor herheadshouldsagdown •Thechildshouldbreatheinandoutfivetimesasdirectedandrepeatthe exerciseasneeded

Remember: It is important to discuss with parents and document the

triggers for every child with asthma!

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Remember: Quick-reliefmedicationsdonothelptheswellingintheairways.Theyonlyhelpapersonfeelbetter

temporarilybyrelaxingthemuscles.

Asthma medicationsThereisnocureforasthma,butitcanbecontrolledbyavoidingasthma triggersandtakingtherightmedications.Asthma Medicines: •Verysafeandeffectivewhenusedcorrectly •Nothabit-formingoraddictive •Importanttoadministerasprescribed

There are two main kinds of asthma medications

1. Quick-relief Medications Othercommonnamesforthesemedications •Relievers •Openers •RescueMedications •Bronchodilators

2. Long Term Control Medications Othercommonnamesforthesemedications •Controllers •PreventiveMedications

Quick-relief medications(Short-acting bronchodilators)Thesemedicationsareusedtoprovidereliefofsymptoms.Bronchodilatorsquicklyrelaxthebronchialmusclesandopenuptheairways.Everychildwithasthmawillbeprescribedaquick-reliefmedicationtoprovidereliefoftheirsymptoms.AcommonnameforthiskindofmedicationisAlbuterol. •Important!Itisimportanttohaveaquick-reliefmedicationatthe childcarefacilityforeachchildwithasthma. •Prescriptionwillindicate“takeasneeded”and“nottoexceed everyfourhours” •Administerquick-reliefmedicationswhenyouseeasthma symptoms(coughing,wheezing,etc) •Theyworkwithinafewminutesandcanlastupto4hours •Afteradministeringaquick-reliefmedicine,achildmaybecome hyperoragitated.Thisisanormalreactiontothedrug. •Quick-reliefmedicationismostcommonlyadministeredthrough ametereddoseinhaleroranebulizer.

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Quickreliefmedicationsaresimilartopainrelievers.AsapersononlytakesTylenoloraspirintorelievepain,similarlyapersonwithasthmaonlyusestheirquickreliefmedicationtoprovidereliefoftheirasthmasymptoms.

Important!Ifachildusesquickreliefmedicinemorethan2-3timesaweek,theyneedtobeonacontrollermedication.Overuseofquickreliefmedica-tionsdecreasetheirabilitytowork.

Long-term control medicationsLong-termcontrolmedicationsaretakeneverydaytocontroltheinflamma-tionintheairways.Childrenthatareonlong-termmedicationarelesslikelytosufferfromasthmasymptomsandsevereasthmaepisodesbecausetheyarelesssusceptibletoasthmatriggers.

Long-Term Medications •Begintoworkoveraperiodofafewweeks •Reduceinflammationinairways •Reducenumberoftimesachildneedstousequick reliefmedication •Mustbetakenonadailybasis,evenifchildisfeelingwell •Haveminimalsideeffects •Mostcommonandmosteffectivelong-termmedicationsare inhaledcorticosteroids.CommonnamesareAzmacort, Pulmicort,Flovent,Advair,andSymbicort •Anothernewtypeofcontrollermedicationisa leukotrienemodifier.ThecommonnameforitisSingulair

Oral steroidsOralsteroidsareusuallytakenforafewdaysafterasevereasthmaepisode.Theycomeintheformofapillorsyrup.Long-termuseofthiskindofmedi-cationcancausesideeffects.Oralsteroidsarealsogiveninlowdosesasdailymedicationforchildrenwithveryseverepersistentasthma.

Formoredetaileddescriptionsofthedifferenttypesofasthmamedications,pleaserefertothemedicationchart.

TreatmentBothofthesetypesofmedicationsarenormallyprescribedaccordingtotheseverityoftheasthma.Asthmaseverityisdeterminedmainlybythefre-quencyofsymptoms.Thisisnormallydiscussedbetweentheparentsandthedoctor.

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Type of Medication Quick-Relief of Long Term How they WorkShort-acting Beta-agonists Quick-relief Quicklyrelaxesmuscles aroundairways

Anticholinergic Quick-relief Workstokeepairwaysfrom closing Normallyprescribedto patientswithsevereasthma Usedinconjunctionwith otherquick-reliefmedicines

Inhaled Corticosteriods Long-term Reducesairway inflammation

Oral Corticosteriods Long-term Reducesairway inflammation

Leukotriene Modifiers Long-term Blocksairwayinflammation

Long-acting Beta-agonists Long-term Blocksbronchialmuscles

Sloweronset,longer durationthanshort-term beta-agonists

Cromolyn Sodium Long-term Blocksairwayinflammation

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When are they Used? How they are Taken Common Names•Forquick-reliefofasthma symptoms•Usedtotreatexerciseinduced asthma

Nebulizer AlbuterolMeteredDoseInhaler MaxairSyrup ProventilDryPowder Ventolin Serevent

•Forquick-reliefofsymptoms•Usedforpatientsthatdonot tolerateshort-acting beta-agonists•Possibleadditivebenefitto inhaledbeta-agonists

Nebulizer AtroventMeteredDoseInhaler CombiventNasalSpray

•Usedformanagementof persistentasthma•Reducesasthmasymptoms andneedforquick-relief medications

MeteredDoseInhaler AerobidDryPowder AzmacortInhaler Beclovent Flovent Pulmicort Vanceril

•Givenforashortperiodof timetogainquickcontrol ofpoorlycontrolledasthma•Givenlong-termforchildren withseverepersistentasthma

Tablets PediapredSyrup Prelone Prednisone

•Usedasalternativetreatment toinhaledsteroids•Reducesasthmasymptoms andneedforquick-relief medications

Tablets SingulairChewableTablets Zyflo Accolate

•Usedtogetherwithanti- inflammatorymedicationsto controlsymptoms•Notusedtotreatacute symptoms•Veryeffectivefor nighttimesymptoms

MeteredDoseInhaler SereventDry-powder ForadilTablet Proventil Volmax Advair

•Usedasanalternative treatmenttolow-dose inhaledsteroids•Reducesneedforquick- reliefmedications

MeteredDoseInhaler IntalNebulizer

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Asthma devicesUsing a Metered Dose Inhaler (MDI) with a spacer Fact: •Eachtimeaninhalerisused,thesameamountofmedicineis releasedasaveryfinemistthatcangetdeepintothelungs

•Medicationstakencorrectlywithinhalerstendtobemore effectiveandhavefewersideeffectsthanwhenthesame medicationistakenorally •Spacersarerecommendedforanyonethatusesametered doseinhalerFour Reasons to Use a Spacer •Helpsdelivermoremedicationintothelungs,andless isdepositedinthemouth •Helpseliminatetasteofmedicine •Decreasescoughingafterusinginhaler •DecreasessideeffectsfrommedicationsUsing an MDI with a Young Child 1. Removethecaptotheinhaler 2. Shaketheinhaler4-5vigoroustimes 3. AttachinhalertospacerSpacer with MouthpieceRecommendedforchildrenover5yearsofage.(Afterdoingsteps1-3) 4. Askthechildtobreatheout 5. Havechildplacethemouthpieceoftheholdingchamber betweentheteethandabovethetongue,closinglipsaroundit 6. Pressdownoninhaleronce 7. Askchildtotakeaslowdeepbreathin 8. Encouragechildtoholdbreathfor5-10secondsafter inhalingmedication 9. Removemouthpiecefrommouth,allowingforexhalation 10. Waitatleast1minutebeforeadministeringsecondpuff, ifindicated 11. Ifdevicewhistles,encouragechildtobreathslowerSpacer with MaskRecommendedforchildrenages0to5(Afterdoingsteps1-3) 4. Placemaskfirmlyonchild’sface 5. Pressdownoninhaleronce 6. Encouragechildtotake5-6normalbreaths 7. Removemask 8. Waitatleast1minutebeforesecondpuff

Remember: A young child cannot use an MDl effectively without a spacer!

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Using an MDI without a spacer •Canonlybeusedwithquick-reliefmedications •Notrecommendedforchildren •Twotechniques:ClosedMouthTechnique,OpenMouthTechniqueClosed Mouth Technique •Removethecap •ShakeMDI •Havechildbreathoutnormally •Puttheinhalermouthpiecebetweenteeth,withtongueunderneathit •Pressdownoninhalerasthechildbreathesinslowlyandcompletely •Havechildholdbreathfor10secondsallowingmedicationtogodeep intolungs •Waitoneminutebetweenpuffs,repeatifindicatedOpen Mouth Technique Followclosedmouthtechniqueexcept: •Openmouthwide •Holdinhaler2fingerwidthsfrommouth •Pressdowninhalerandtakeslowdeepbreathinfor5-10secondsDry Powder Inhalers •Youngerchildrenandinfantsnotabletousethistypeofmedication •Importanttokeepinhalersawayfrommoisture •Breathinneedstobefast,deep,andforceful

Nebulizers-breathing machine •Purposeistogetmedicationdeepintothelungs •Medicationisaddedtothenebulizerthatispoweredbyasmall compressor.Thecompressorthenpushesairthroughthemedication andchangesthemedicationfromaliquidtoafinemist. •Nebulizersaremostoftenusedbyyoungchildrenandindividuals whodonotgetrelieffrommetereddoseinhalersUsing a Nebulizer •Putthenebulizertogether.Readtheinstructionsoraskyourdoctor toshowyouhow •Makesurethemachineisonaflatsurface •Putthemedicineinthecup •Connectthetubingtothemachineandturniton.Amistshould comeout •Putthemouthpieceinthemouthorputthemaskon.Themaskshould fitsnuglyoverthenoseandmouth •Breatheinandoutslowlyanddeeplyuntilthemedicineisgone. •Holdeachbreathfor1or2seconds •Turnthecompressoroffanddisconnectthetubing. •Rinsemouthwithwater •Storethenebulizerunitinaplasticbag

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Cleaning and care of devicesKnow How Much Medicine is Left in the Inhalers!

Differenttypesofmedicinescontainvaryingamountsofmedication.

To know how long the medicine will last: •Findouttotalnumberofpuffsincanisterofmedicine(writtenonlabel) •Keepawrittenrecordeverytimeapuffisgiventoachild •NotifyparentswhencanisterisrunninglowSteps to cleaning devices: Asthmadevicesshouldbecleanedaftereveryusetopreventinfection.1. Inhalers and Spacers •InhalerandspacerdevicesshouldNEVERbesharedamongchildren andshouldbecleaneddaily. •Removecanisterfrominhalerdevice •Soakinhalerandspacerinsoapandwateroronepartvinegar to3partswaterfor30minutes •Airdry2. Nebulizers •TubingandmouthpieceshouldNEVERbesharedamongchildren •Soakmouthpieceandmaskinsoapandwateroronepartvinegar to3partswaterfor30minutes •Airdry •Donotsoaktubing •Shakeexcessmoistureoutoftubingaftereveryuse •Wipedownnebulizerandoutsideoftubingwithdampcloth •Storeincleanplasticbag •Checkfilterperiodically,andreplaceifnecessary

Asthma managementUsing a Peak Flow MeterGenerally for children over 5 years of ageThepeakflowmeterisanasthmamanagementtoolthatmeasurestheairflowoutofachild’slungs.Thepeakflowmeterissmall,convenient,andeasytouse.Itcanbeusedatadoctor’soffice,home,oratschool. •Evaluatechangesinairflowoutofthelungs •Findouthowwellmedicineisworking •Warnofabreathingproblembeforeacrisis •Helpidentifyspecifictriggersofasthma •Findouttimesandpatternsofbreathingproblem

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Proper Use •Askchildtostandup •Positionpeakflowindicatoratthebottomofthenumbers •Knowwhatvaluesarenormalforthechildbasedontheirasthmaaction planpersonalbestpeakflowreading •Havethechildtakeadeepbreathandplacemouthpiecebetweenteeth, closinglipstightlyaroundmouthpiecewithoutblockingtheopening withtongue •Havechildexhalehardandfastintometer(thismovestheindicator) •Readnumberatthepositionoftheindicator •Dothetestthreetimesandtakethehighestreadingthencompareto hisorherpersonalbestontheindividual’sasthmaactionplan •CleanmouthpieceA child’s personal best is obtained by the parent recording the child’s peak flows every day over a two week period of time and taking the best average reading.

Green Zone- 80-100% of their best Yellow Zone- 50-80% of their best Red Zone-50% or below their best

Asthma action plansAnasthmaactionplanisasetofwritteninstructionsfromthedoctor.Theactionplanhelpsparentsandprovidersunderstandwhatmedicationstogiveaccordingtochild’ssymptoms.Itisimportantforparentsandchildcareproviderstofollowtheplanaccordingtoachild’ssymptoms.Ifachildisovertheageoffive,asthmaactionplanscanbeusedinconjunctionwithpeakflowreadings.Parentscanrequestthisfromtheirdoctor.Everyperson’sasthmaactionplanismadeespeciallyforhimorher.For examplethisoneisdividedintostoplightcolorsGreen Zone-GO! •Peakflowsareat80-100%oftheirpersonalbest •Minimalornosymptomspresent •Takemedicationsasprescribedbythedoctor •AsthmaActionPlansYellow Zone- CAUTION! •PeakFlowsare50-79%ofpersonalbest •Asthmasymptomsarepresent •Givequick-reliefandlong-termmedication,asprescribed bythedoctor •Keepchildawayfromtriggersbecausetheycanbearealproblemin theyellowzoneRed Zone-DANGER! •PeakFlowsarebelow50% •Emergencysignsandsymptomsarepresent •Quick-reliefmedicationsarenotworkingwell •Followemergencyplanandcalldoctorandparents

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www.dcasthma.org

www.doh.dc.gov

(202) 442-5925

SCHOOL MEDICATION CONSENT AND PROVIDER ORDER FOR CHILDREN/YOUTH: Possible side effects of rescue medicines (e.g., albuterol) include tachycardia, tremor, and nervousness. Healthcare Provider Initials:

______This student is capable and approved to self-administer the medicine (s) named above.

______This student is not approved to self-medicate.

As the RESPONSIBLE PERSON: I hereby authorize a trained school employee, if available, to administer medication to the student. I hereby authorize the student to possess and self-administer medication. I hereby acknowledge that the District and its schools, employees and agents shall be immune from civil liability for acts or omissions under D.C. Law 17-107 except for criminal acts, intentional wrongdoing, gross negligence, or willful misconduct.

You have ANY of these:

First sign of a cold Cough or mild wheeze Tight chest

Problems sleeping, working, or playing

Peak flow in this area: ______ to _____ (50%-80% of Personal Best)

You have ANY of these: Can’t talk, eat, or walk well Medicine is not helping Breathing hard and fast Blue lips and fingernails Tired or lethargic Ribs show

Peak flow in this area: Less than _____ (Less than 50% of Personal Best)

_________________, puffs MDI with spacer every 15 minutes, for THREE treatments Fast-acting inhaled -agonist OR

________________ , __ nebulizer treatment every 15 minutes, for THREE treatments Fast-acting inhaled -agonist

Call your doctor while giving the treatments. Other

IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 for an ambulance or go directly to the Emergency Department!

No control medicines required.

___________ _____________ , _ puff(s) MDI with spacer ____ times a day Inhaled corticosteroid or inhaled corticosteroid/long-acting -agonist

_________________________________, _____ nebulizer treatment(s) ____ times a day Inhaled corticosteroid

___________________________________, take by mouth once daily at bedtime Leukotriene antagonist

For asthma with exercise, ADD: ________ , puffs MDI with spacer 15 minutes before exercise Fast-acting inhaled -agonist

For nasal/environmental allergy, ADD:

____________________________________________________________________

Name Date of Birth Date / /

Health Care Provider Provider’s Phone

Parent/Responsible Person

Parent’s Phone School

Additional Emergency Contact Contact Phone Last 4 Digits of SS#

__, ____ puffs MDI with spacer every ____ hours as needed Fact-acting inhaled -agonist OR

_________________, ____ nebulizer treatment(s) every ____ hours as needed Fast-acting inhaled -agonist

Other __________________________________________________________

Call your DOCTOR if you have these signs more than two times a week or

if your rescue medicine doesn’t work!

Asthma Severity (see reverse side) Intermittent or

Persistent: Mild Moderate Severe Asthma Control

Well-controlled Needs better control

Asthma Triggers Identified (Things that make your asthma worse): Colds Smoke (tobacco, incense) Pollen Dust Animals_____

Strong odors Mold/moisture Pests (rodents, cockroaches)

Stress/emotions Gastroesophageal reflux Exercise

Season: Fall, Winter, Spring, Summer Other:___________________

Date of Last Flu

Shot: __/__/_ __

Green Zone: Go! — Take these CONTROL (PREVENTION) Medicines EVERY Day

You have ALL of these:

Breathing is easy

No cough or wheeze Can work and play Can sleep all night

Peak flow in this area: ______ to ______ (More than 80% of Personal Best)

Personal best peak flow: ______

Yellow Zone: Caution! - Continue CONTROL Medicines and ADD RESCUE Medicines

Red Zone: EMERGENCY! Red Zone: EMERGENCY! Red Zone: EMERGENCY! ——— Continue CONTROL & RESCUE Medicines and Continue CONTROL & RESCUE Medicines and Continue CONTROL & RESCUE Medicines and GET HELP!GET HELP!GET HELP!

Always rinse mouth after using your daily inhaled medicine.

Asthma Action Plan

REQUIRED Healthcare Provider Signature:

___________________________ Date: ___________

REQUIRED Responsible Person Signature:

___________________________ Date: ___________

Follow up with primary doctor in 1 week or:

_________________ Phone: _______________

GREEN means Go! Use CONTROL medicine daily

YELLOW means Caution! Add RESCUE medicine

RED means EMERGENCY! Get help from a doctor now!

Adapted from NHLBI by Children’s National Medical Center Coordinated by the National Capital Asthma Coalition

This publication was supported in part by a grant from the DC Department of Health Asthma Control Program, with funds provided by the Cooperative Agreement Number U59/CCU324208-

03 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

Permission to reproduce blank form. Updated December 2008

PATIENT COPY

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What should childcare providers do for children with asthma? •Identifywhichchildrenhaveasthma •Fillout“MeandMyAsthma”documentwithparents •Documentchild’sasthmatriggersandasthmasymptomsonform •Haveparentsdemonstratehowtouseasthmamedications anddevices •Getacopyofthechild’sactionplanorprescriptionfrom doctororparent •Alwayshavequickreliefmedicationavailableforeachchild withasthma •Reporttoparentsifyounoticeanyasthmasymptoms •Reporttoparentsifyouadministermedicationtothechild •Treatchildcareenvironmenttoreduceasthmatriggers. •Ifsomeonetakestoomuchmedicine,orthewrongmedicine, CALLthePoisonControlCenterrightaway:1-800-222-1222.

What to do if a child has an asthma episode?Thesearesimpleimportantinstructionstofollowincaseofanemergency.Oftenwhenweareunderstress,eventhesimplestthingsareforgotten. •Havechildsitdown(rememberchildcannotbreatheas welllyingdown) •StayCalm(keepallchildrencalm) •Havechildfocusontheirbreathing(refertobreathingexercisepage11) •GetHelp:CallParents,AdministerQuick-ReliefMedications, Call911ifnecessary •Alwaysmonitorchild20-30minutesafteradministeringquick-relief medicationsWhen to call 911- Emergency Warning Signs: •Coloroflips,skin,orfingernailsturngrayorblue •Thechildshowsnosignsofimprovementafteradministering quick-reliefmedication •Thechildisnon-responsiveorhasdifficultymoving

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ACTIVITYFindoutwhatitfeelsliketohaveasthma:Exercisewithastraw

Materials: asmallcocktailstrawInstructions:•Takethestrawandbreathethroughitfor30seconds Thisisthefeelingsomeonehaswhenthereisinflammationandmucusin theairways.Are you out of breath?•Takethestrawandpinchithalfwayclosedandbreathethroughit Thisisthefeelingapersonhaswhenthemusclearoundtheairways tightenandconstrict,makingitharderforairtomoveinandout ofthestraw.Thisiswhatitfeelslikewhenapersonishavingan asthmaepisode!Thinkofuncontrolledasthmaasbreathingthrough astrawexceptontheinsideofthebody!

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ResourcesLocal ResourcesAmerican Lung Association of the District of Columbia“http://www.aladc.org/”www.aladc.org(202)546-5864

DC Control Asthma Now (DC CAN), Asthma Control Program“http://dchealth.dc.gov/doh/cwp/view,a,1374,q,601366.asp”http://dchealth.dc.gov/doh/cwp/view,a,1374,q,601366.asp(202) 442-5925

National Website ResourcesAllergy and Asthma Network Mothers of Asthmatics Asthmainformationandresourcesforparents“http://www.aanma.org”www.aanma.org

American Academy of Allergy, Asthma, and Immunology Educationalresourcesandinformationonasthma“http://www.aaaai.org”www.aaaai.orgAmerican Lung AssociationEducationalresourcesandinformationonlunghealth “http://www.lungusa.org”www.lungusa.org

Environmental Protection Agency IndoorAirQualityInformation“http://www.epa.gov/iaq”www.epa.gov/iaqObtaincurrentairqualityreadings“http://www.epa.gov/airnow”www.epa.gov/airnow

National Asthma Education and Prevention Program NationalHeart,Lung,andBloodInstituteInformationCenter Educationalresourcesandinformationonasthma“http://www.nhlbi.nih.gov”www.nhlbi.nih.gov

Resource for Pollen Levels“http://www.pollen.com”www.pollen.com

Starbright FoundationInteractiveasthmagameforchildrenandparentresources“http://www.starbright.org”www.starbright.org

Other Resrouces

DCTobaccoFreeFamiliesCampaign“http://www.tff.org/”www.tff.orgDCQuitlineat1800QUIT-NOW(TTY1-800-332-8615)Available24/7www.tff.org

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Self-Study Module Quiz1. Asthma is a common disease in the United States. a.True b.False2. What ethnicity is more likely to suffer from asthma? a.Caucasians b.Hispanics c.AfricanAmericans3. Which of the following has been linked as a possible cause for increased rates of asthma in the U.S.? a.Indoorenvironment b.Outdoorenvironment c.Increasedasthmaawareness d.Alloftheabove4. List two primary risk factors for asthma. 1. 2.5. Asthma is an acute disease that a person has for a short period of time. a.True b.False6. What happens to a person’s respiratory system during an asthma episode? a.Contractionofbronchialmuscles b.Inflammationofairwaylining c.Overproductionofmucus d.Alloftheabove7. Name two early warning signs and symptoms of an asthma episode. 1. 2.8. Name two emergency warning signs and symptoms of an asthma episode. 1. 2.9. Which of the following triggers can cause an asthma episode? a.Tobaccosmoke b.Respiratoryinfections c.Dustmites d.Alloftheabove10. It is important to document the triggers for each child with asthma. a.True b.False

11. Annual flu vaccinations are recommended for children with asthma. a.True b.False

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12. Which of the following is NOT an irritant for children with asthma? a.Pollution b.Cleaningproducts c.Unscentedsoap d.Tobaccosmoke13. Which of the following is NOT an effective way to control dust mites? a.Usingahepa-filtervacuum b.Washinglinensincoldwater c.Usingmattressandpillowcovers d.Alloftheabovearegoodmethods

14. A person needs professional help if mold growth is bigger than 3ft by 3ft. a.True b.False15. Name one product that can be used as an alternative to pesticide sprays. 1.16. Administering quick-relief medication before exercise can be beneficial for children with exercise induced asthma. a.True b.False17. Asthma medications are addictive and habit-forming. a.True b.False18. Which of the following is NOT true about quick-relief medications? a.Providesreliefofsymptoms b.Lastupto4hours c.Controlsinflammation d.Relaxthebronchialmuscles19. When are oral steroids given to children? a.Afterasevereasthmaepisode b.Ifasthmaisnotundercontrol c.Aslong-termtreatmentforchildrenwithseverepersistentasthma d.Alloftheabove20. Which of the following is NOT true about long-term control medications? a.Takendaily b.Provideimmediatereliefofsymptoms c.Makeschildlesssusceptibletotheirasthmatriggers d.Controlinflammationintheairways21. Which of the following is NOT true about the use of a spacer? a.Improvesdeliveryofmedicationintothelungs b.Eliminatestasteofthemedication c.Reducessideeffectsofmedication d.Onlyrecommendedforchildrenunder5years

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22. A spacer with a face mask is NOT recommended for children under 5 years. a.True b.False23. It is important to shake a metered dose inhaler before using it. a.True b.False24. Nebulizers are used by young children and individuals who do not get relief from metered dose inhalers. a.True b.False25. Which of the following devices CANNOT be soaked in a germ killing solution? a.Nebulizercup b.Inhaler c.Nebulizertubing d.Spacer26. A peak flow meter and an asthma action plan are tools used to manage asthma. a.True b.False27. Which of the following steps are important to do if you have a child with asthma in your childcare center? a.Obtaincopyofprescriptionplan b.Haveparentsdemonstratehowtouseasthmadevices c.Documenttriggersandsymptoms d.Teachotherchildrenaboutasthma e.Alloftheabove28. A person should call 911 if the child does not improve 20-30 minutes after administering quick-relief medication. a.True b.False

Answers:1.(a)2.(c)3.(d)4.refertopageseven5.(b)6.(d)7.refertopageseven8.refertopageseven9.(d)10.(a)11.(a)12.(c)13.(b)14.(a)15.refertopageten16.(a)17.(b)18.(c)19.(d)20.(b)21.(d)22.(b)23.(a)24.(a)25.(c)26.(a)27.(e)28.(a)

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WewouldliketothanktheAmericanLungAssociationofSanDiego,ImperialCountyforallowingUnitedPlanningOrganizationandtheAsthmaGreenLightProjectpermissiontomodifytheirasthmaself-

studymoduleforchildcareprovidersandallowingustocreatea handbooktobeusedforAsthmaGreenLightTrainingforChildcare

ProvidersinWashington,DC.

Thank You!

Notes:

Me and My AsthmaInstructionstochildcareproviders:Filloutthisformwiththeparentsofeachchildwithasthma.

My Child’s Asthma

Child’sName: _____________________________________________________________________

Mychild’searlywarningsignsofanasthmaepisodeare:(examples:cough,wheeze)

Mychild’semergencywarningsignsofanasthmaepisodeare:(examples:troublewalking,talking)

Mychild’sasthmatriggersare:(examples:dogs,dust,colds)

Youcanhelpmychildfeelbetterby:(sittinghimorherdown,rubbinghisorherback)

Ifmychild’sasthmaepisodegetsworse,pleasedothefollowing:

1. _______________________________________________________________________________

2. _______________________________________________________________________________

3. _______________________________________________________________________________

Emergency ContactsFamilymember: ___________________________________________________________________

Phone: ___________________________________Work: _________________________________

Doctor: ___________________________________Phone: ________________________________

Thenearestemergencyroomis: _______________________________________________________

Address: ______________________________________________Phone: ____________________

Important!•Haveparentsdemonstratehowtousemedicationsanddevices•Followinstructionsinselfstudymoduleonhowtousedevices

• Obtain copy of written prescription (asthma action plan) from parents or doctor

My Child’s MedicationsName of Medicine When to take it Device Used Medication Expiration

Place DVD Here

For further information on the Asthma Green Light Training for Childcare Providers contact either Theresa Shivers at UPO (202) 238-4600 or Elgloria Harrison at the University of The District of Columbia

(202) 274-6366 or email eharrison@udc.edu