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Breathing problems at school:Pulse Oximetry,
Asthma,and the Return to Control
Harold J. Farber, MD, MSPH
Associate ProfessorBaylor College of Medicine
Section of Pediatric Pulmonology
Associate Medical Director for Chronic Conditions
Texas Children’s Health Plan
How to assess severity breathing problems:
It is more than the It is more than the Oxygen SaturationOxygen Saturation
A child can have severe difficulty breathing but a normal oxygen saturation!
Severe Respiratory Distress:
Symptoms– Anxiety– Agitation– Persistent cough– Trouble speaking more
than a word or two– Grunting
Signs– Tachypnea– Retractions– Wheezing – Stridor– Flaring– Use of accessory
muscles
– Lack of wheezing.
Pulse Oximeters
Oxygen Saturation
Measuring the Oxygen Saturation
Pulse oximetry depends on the
pulse.– If you don’t have
a good pulse wave you have
garbage
Oxygen Saturation Error:
Pulse oximeters only calibrated from 75% to 100% saturation (unethical to take healthy adult to <75% SpO2)
May be inaccurate under 75% SpO2
Sources of error:– Ambient light– Motion Artifact– Nail Polish– Carbon monoxide
– Hypoperfusion Shock Cold finger
Oxygen Saturation:Oxyhemoglobin Dissociation
Curve
97.50%90%
75%
50%35%
13.50%0%
20%
40%
60%
80%
100%
120%
0 50 100 150
PaO2
Oxy
hem
oglo
bin
Sat
urat
ion
SpO2
With PaO2 above 60, SpO2 is > 90%. Oxygen content does not change much
When PaO2 drops <60, SpO2 rapidly decreases. Oxygen content of the blood rapidly decreases.
Processes Leading to Desaturation V-Q mismatch
– Example: Asthma Bronchiolitis Atelectasis Pneumonia
– Treatment: Supplemental O2
Hypoventilation– Examples
Guillaine Barre Syndrome Botulism Neuromuscular diseases
– Treatment: Supplemental
VENTILATION!
Tracheal Obstruction– Severe Croup– Aspirated foreign body–Tracheostomy plug–Treatment:
Open the airway
Peak Flow Meters
Provides a number that measures how hard the child blows out.
Peak expiratory flow is effected by– Effort– Lung size / child size– How open or closed breathing tubes are
How to interpret peak flow readings
Is it a maximal effort using correct technique, or is it garbage?
If maneuver is done correctly with maximal effort interpret in relation to personal best or predicted based on age, ethnicity, and height.
How to interpret peak flow readings
Peak flow over 80% of predicted or personal best: Green zone. All is well
Peak flow 50-80% of predicted or personal best: Yellow zone. Mild asthma flare.
Peak flow below 50% of predicted or personal best: Red zone: Urgent medical attention is needed.
Assessing Asthma Severity
Recognizing Symptoms
Recognizing Symptoms
Recognizing Symptoms
Recognizing Symptoms
Handling an asthma flare at school
Anything I tell you takes a back seat to school policy.
Handling an asthma flare at school
First: Do not leave child alone Second: Assess severity – is it mild,
moderate or severe? Third: Look at the child’s asthma plan – If
appropriate consider giving a quick relief medicine– Albuterol (Ventolin, Proventil, ProAir)– Levalbuterol (Xopenex)
If severe asthma flare
Breathing fast Hardly able to speak a few words between
breaths Nasal flaring Retractions
If severe asthma flare
Breathing fast Hardly able to speak a few words between breaths Nasal flaring Retractions
Give quick relief medicine (if available)Call 911Notify parentsAllow to rest in position of comfortDo NOT leave child alone
Preventing the flare ups:
Asthma is not controlled if:– If frequent asthma symptoms at school– If severe asthma flares needing urgent
treatment at school– If asthma interferes with exercise– If asthma interferes with sleep.
Preventing the flare ups:
If asthma is not controlled: Communicate with child’s parents and health care providers.
Advocate for the child. Asthma can be controlled.
When asthma is well controlled There are no asthma symptoms. No cough. No
wheeze. No chest tightness. Need for quick relief medication for asthma
symptoms is less than twice a week. A child’s sports participation is not limited by
his/her asthma.– Sometimes quick relief medicine is needed before
exercise
There are NO asthma attacks: daytime or nighttime.
There are no Emergency Room visits for asthma
Asthma Control:
Reduce Impairment– No chronic or troublesome symptoms– Day to day activities are not limited by asthma– Normal or near normal lung function
Reduce Risk– Prevent flare ups/ED
visits/hospitalizations/death– Prevent progressive loss of lung function– Minimize medication side effects.
3 Lines of Defense
Manage the Environment– Reduce triggers
Manage the Breathing Tubes– Medication to make airways less sensitive
Manage the Flare ups– Recognize attacks early and head them off at
the pass
Types of asthma triggers
Irritants– Smoke– Air pollution– Strong Chemicals– Air “fresheners
Allergens– Furry or feathered animals– Dust and mold– Pollens
Reducing Asthma Triggers at School (see EPA IAQ Tools for Schools)
– No air fresheners or sprays in classroom– No furry or feathered animals in classroom– No smoking in or around school– Building maintenance – to reduce dust and
mold problems. – Use integrated pest management to reduce
chemicals– Don’t cut grass, etc. when children are present– Don’t idle motor vehicles (cars, buses, etc.)
near school, when children are waiting.
Smoke and asthma
When a child is smoke exposed– Asthma medications don’t work as well – Viral infections are more severe
Parents are the most important source of a child’s smoke exposure
FREE help is available– National Cancer Institute/American Cancer
Society QUITLINE: 1 800 QUIT NOW
Graphic from Farber HJ, Boyette M. Control Your Child’s Asthma: A Breakthrough Program for the Treatment and Management of Childhood Asthma. Owl Books, 2001. Used with Permission.
Guide to asthma medicines
Quick Relivers– Short Acting Beta Agonists
Albuterol (inhaled)– Impairment:
Symptom relief within minutes, lasts about 4 hours Useful to prevent exercise induced asthma
– Risk: Overuse associated with increased risk
hospitalization, ED visit, mortality Warning: Be stingy with SABA refills!
Guide to asthma medicines
Long Acting Beta Agonists– Salmeterol: Onset in ½ hour, lasts about 12 hrs– Formoterol: Onset in minutes, lasts about 12 hrs
IMPAIRMENT: – When used with an inhaled corticosteroid day to day asthma
control is improved. RISK:
– When used without an inhaled corticosteroid, risk of hospitalization, ED visit, mortality is increased.
– LABA + ICS combo reduces impairment, has minimal impact on risk.
Guide to asthma medicines
Inhaled corticosteroids– Regular use:
Impairment:– Reduces asthma symptoms– Onset 1-2 weeks, max effect ~ 4-6 weeks
Risk: – Reduces risk of flare ups– Reduces risk for hospitalization/ED visit/mortality– Most of benefit achieved at low to moderate doses– Adherence to regular use is major challenge.
Guide to asthma medicines
Leukotriene modifiers– Impairment:
Equivalent to low dose ICS
– Risk: Inferior to low dose ICS
– Gives additional symptom reduction when combined with low to moderate dose ICS.
– Possible benefit in Viral triggered asthma Smoke triggered asthma
Guide to asthma medicines
Oral corticosteroids (Prednisone, Prednisolone)– Speeds resolution and attenuates severity of
moderate to severe asthma flare up– Steroid toxicity minimized by occasional use
and short bursts– Poorly controlled moderate to severe asthma
may need longer steroid taper to reverse long-standing airways inflammation
Teaching Role of Medication
Teaching Role of Medication
Albuterol/ Xopenex
Teaching Role of Medication
Albuterol/ Xopenex
Inhaled corticosteroid
Teaching Role of Medication
Albuterol/ Xopenex
Prednisone/ Prednisolone
Teaching Role of Medication
Albuterol/ Xopenex
Prednisone/ Prednisolone
Teaching Role of Medication
Albuterol/ Xopenex
Prednisone/ Prednisolone
Inhaled corticosteroid
Asthma Action Plans are Important!
In summary
Appropriately assess severity of an asthma flare.– If in doubt, believe the child
Asthma flares can be prevented by good asthma control
Written asthma action plans are essential If a child’s asthma is not in control
– Talk to their parents, physician, or care manager
– Texas Children’s Health Plan care management (if child is TCHP member):
832 828 1430
Asthma Research at TCH
Gene-Environments and Admixture in Latino Asthmatics (GALA-2) study– NIH funded multi-center case-control study– Objective: Determine genetic factors and gene-
environment interactions associate with asthma in Latinos
GALA-2 Study Eligibility:
– Age 8-21 years– Latino parents and grandparents– CASES:
Has physician diagnosed asthma Has been symptomatic within past 2 years
– CONTROLS Does not have asthma or allergies
GALA-2 Study
Study Procedures– All subjects:
FREE Allergy skin testing for common inhalant allergens
FREE Lung function testingQuestionnaireBlood Draw
GALA-2 Study
Locations– Texas Children’s Hospital– Ben Taub General Hospital
Compensation– $40 per visit completed– Parking Validation– Small gift provided for children
All study materials and personnel are bilingual (English/Spanish)
GALA-2 Study
Call 832 – 822 – GALA
(832 822 4252)
for information or to enroll
Summary
GALA– 8-21 years– Latino Ancestry– Asthma cases and healthy controls– Free allergy skin testing and lung function testing– To refer:
Call 832 822 GALA We can send you recruitment flyers.
– $40 per visit compensation for patients