ASTHMA IN CHILDREN:NEW APPROACHES TO IMPROVING OUTCOMESCindy Capen MSN, RNPediatric Pulmonary CenterUniversity of Florida capencl@peds.ufl.edu

What I plan to discuss:• Pathophysiology• Medications• EPR Guidelines• Florida initiatives• Ways to get involved/Help needed

History Lesson

Goals of Asthma Management

• Minimizing daily symptoms• Minimizing nighttime symptoms• Eliminating ER and hospital visits• Rare use of rescue inhalers• Normal activities• No school/work absences

What happens during an asthma episode?

The insides of the airways get irritated and inflamed

The linings of the airways get swollen

Irritated airways make more mucus

The muscles around the airways spasm and get tight

inflammation and bronchoconstriction prevent air from reaching the alveoli

When do you suspect it’s asthma?

Cough

Wheeze

Short ofBreath

What can precipitate an asthma episode?

• Things called asthma TRIGGERS• Everyone has their own “recipe”…SO

• Identify triggers • problem solve ways to avoid triggers

National Heart, Lung and Blood Institute

Expert Panel

Guidelines for the diagnosis and management of Asthma

Expert Panel Report

1991EPR-1

1997EPR-2

2002EPR-2update

2007EPR-3

493 pages

Components of Asthma Management1. Assessment/identify severity2. Education/partnership w family3. Control of environment/other conditions4. Medications

0-4 years 5-11 years > 12 yoa

Guidelines for the diagnosis and management of asthmaExpert Panel Report 3

• Symptoms• Nighttime awakenings• Use of beta agonists for symptoms• Interference with normal activity• Lung function• Consider use of oral steroids

Determining severity

Educate & have a plan

• Pathophysiology• Action Plan

• Assessment of symptoms• Appropriate response to symptoms

• Early and aggressive treatment• Plan for stepping up medications• Plan for getting help

• Lack of Adherence• Check refills• Reeducate• Cultural issues?• Multiple caregivers?

• Poor technique in use of delivery device• Teach, return demonstrate, recheck technique • Prescribe according to ability

• Mishandling of meds• Not cleaning delivery device• Damage to product (heat, moisture)

• Funding for meds

Why would a plan fail?

• Reeducating the care community• Primary care providers• Emergency responders• Pharmacists• Respiratory care practitioners• School health team• Third party payors

• A new way of thinking for families• Daily treatment no matter what• Getting past the “steroid” word• Rapid response

• The place for specialists

Rolling out the plan…

More&

BetterMedications

Preventer medicines• Are for children who have frequent asthma symptoms (at least

weekly)• Are taken daily• PREVENT most asthma episodes• Help children live normal lives• Parents OFTEN do not give these medicines reliably.

Preventer Medicines

Singulair

Flovent

Serevent

Pulmicort

Advair Symbicort

Qvar

Dulera

Combination Therapies

Symbicort: combined Pulmicort and formoterol; MDI

Advair: combined Flovent and Serevent; MDI or DPI

Dulera: combined Asmanex and formoterol; MDI

All come in different dosages and dose counters

Rescue Medicines

Albuterol

Prednisone

Xopenex Alupent

MaxairDuo-Neb

2012

Only 12 pages!

The numbers are climbing…

7.1 MILLION CHILDRENWITH ASTHMA

Data from the Florida Asthma Program

Educate/Asthma Plan

• Pathophysiology• Action Plan

• Assessment of symptoms• Appropriate response to symptoms

• Early and aggressive treatment• Plan for stepping up medications• Plan for getting help

In Gainesville: In 2011, the largest number of ED visits among children occurred in the zip codes 32609, 32607, 32641, 32608, and 32605

Requested data for seven counties…

In the plus column?• We know how to identify asthma• We have medications that work• We have asthma specialists• We have a step by step plan for any provider to follow• We have health care coverage for kids• We have great programs like CMS! • We know who is at risk• We know where they live! • …and we know where they go to school

Minus column?

No change in outcomes!

Florida Asthma Program: 2009• 100% federally funded by the CDC• Goals

• increase the number of individuals with asthma who receive self-management education

• reduce the number of deaths, hospitalizations, emergency department visits, school or work days missed, and limitations on activity due to asthma.

• Facilitates the Florida Asthma Coalition• conducts asthma surveillance• program evaluation• works to increase the number of childcare centers, schools,

and hospitals that implement asthma management programs.

Targets

Childcare Centers

Schools

Emergency Departments

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CREATING ASTHMA-FRIENDLY SCHOOLS& EARNING THE ASTHMA-FRIENDLY

SCHOOL AWARD

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Asthma’s Impact on Students• Absenteeism• Academic Performance • Physical Activity

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Asthma Prevalence is on the Rise

• In 2012, 1 out of 5 Florida middle and high school students (20.6%) had ever been told by a doctor or nurse that they had asthma.

Source: Florida Youth Tobacco Survey, 2012

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More than 441,000 instructional hours were lost in Florida due to asthma-related

absences in 2011-2012

Source: 2011 Florida Youth Tobacco Survey and 2010 Florida Child Health Survey

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Asthma-Friendly Schools Award Criteria

Bronze1. School-Based an Asthma Leadership Team (or existing health or wellness team).2. Professional development for school nurses, faculty and staff (ALA’s Asthma 101). 3. School ensures immediate access to asthma medications per Florida statute. 4. School provides student centered asthma management support.

1. identifying children with asthma at the beginning of the school year, having asthma action plans on file for students with known asthma, and coordinating between parents and health care providers

5. School posts asthma posters in high-traffic areas. 6. Physical education and activity opportunities meet needs of children with asthma.

Silver (All Bronze and Criterion 7 and 8)7. School provides self management education to students with asthma (ALA’s Open

Airways for Schools Program). 8. School provides education to parents about asthma management (ALA’s Asthma 101).

Gold (All Bronze, Silver and criterion 9)9. School implements an indoor air quality program.

Platinum (All Bronze, Silver, and Criterion 10)10.School implements comprehensive asthma procedures or a policy which includes

the activities listed in criterion 1-9 and a comprehensive tobacco free campus policy.

Coming

soon!

What’s our role?• Be part of the Florida Asthma Coalition

• Because asthma is an overwhelming problem• Because in 2014 they will be seeking more funding• The costs affect everyone

• Spread the word• School Health Guidelines• School recognition program• Childcare recognition program

• Teach parents• Early and aggressive treatment• Use of medications• Primary care not Emergency care

The basics• Diagnose• Manage triggers• Use medications to prevent episodes• Call early for exacerbations• Treat aggressively and early