Asthma: Information for Asthma: Information for You and Your You and Your

Student AthletesStudent AthletesPresented to WIAA Annual ConferencePresented to WIAA Annual Conference

July 31, 2009July 31, 2009

Greg L. Ledgerwood MD, AAFP, ACAAI, Greg L. Ledgerwood MD, AAFP, ACAAI, AE-CAE-C

Co-Chair Practitioner Support Co-Chair Practitioner Support Washington Asthma InitiativeWashington Asthma Initiative

Private PracticePrivate PracticeBrewster, WashingtonBrewster, Washington

Let’s See What You Know Let’s See What You Know About Asthma!About Asthma!

For an athlete whose asthma is For an athlete whose asthma is well controlled, which is true?well controlled, which is true?

A.A. Only has asthma symptoms at nightOnly has asthma symptoms at night

B.B. Can participate in sports like other Can participate in sports like other athletes only if using albuterol 3 athletes only if using albuterol 3 times/daytimes/day

C.C. Still has abnormal lung function Still has abnormal lung function

D.D. Should never warm up before Should never warm up before exerciseexercise

E.E. None of the aboveNone of the above

What happens in the airway of What happens in the airway of people whose asthma is poorly people whose asthma is poorly

controlled?controlled?A.A. Swelling of the airwaysSwelling of the airways

B.B. Excessive mucous productionExcessive mucous production

C.C. Spasm of the airway musclesSpasm of the airway muscles

D.D. Permanent loss of air capacityPermanent loss of air capacity

E.E. A., B., C correctA., B., C correct

F.F. All are correctAll are correct

You should call 911 if and You should call 911 if and athlete is having which of the athlete is having which of the

following?following?A.A. Rescue medication (albuterol) is not Rescue medication (albuterol) is not

relieving the breathing difficulties or is relieving the breathing difficulties or is not availablenot available

B.B. Symptoms are relieved by using Symptoms are relieved by using “rescue” albuterol twice“rescue” albuterol twice

C.C. Pulse rate stays > 150 beats/minutePulse rate stays > 150 beats/minute

D.D. Peak flow is moving into the “red” zonePeak flow is moving into the “red” zone

E.E. A., B., D. correctA., B., D. correct

F.F. All of the above are correctAll of the above are correct

What is the recommended to What is the recommended to prevent exercise induced asthma prevent exercise induced asthma (EIA)?: T or F(EIA)?: T or FA.A. Albuterol should be used after an Albuterol should be used after an

athlete has started wheezingathlete has started wheezing

B.B. Warming up adequately before Warming up adequately before exerciseexercise

C.C. Take rescue medication 10-15 Take rescue medication 10-15 minutes before activityminutes before activity

D.D. Avoid those sports that cause the Avoid those sports that cause the EIA EIA

Athletes should return to Athletes should return to competition only when they can competition only when they can

breath easily and are free of breath easily and are free of asthma symptomsasthma symptoms

A.A. TrueTrue

B.B. FalseFalse

Some athletes need to takeSome athletes need to take medication every day to prevent medication every day to prevent

asthma symptoms. These asthma symptoms. These medications are call controller medications are call controller medications and should not be medications and should not be

used in an emergency situationused in an emergency situation

A.A. TrueTrue

B.B. FalseFalse

What item(s) is/are used to What item(s) is/are used to evaluate lung function and provide evaluate lung function and provide information on asthma symptoms information on asthma symptoms

and medications?and medications?A.A. Peak flow meterPeak flow meter

B.B. Asthma action planAsthma action plan

C.C. NebulizerNebulizer

D.D. A and B onlyA and B only

E.E. B and C onlyB and C only

Parents should always inform the Parents should always inform the coach that their child has asthma, coach that their child has asthma, provide him/her with an asthma provide him/her with an asthma

action plan, and discuss when and action plan, and discuss when and under what situations to implement under what situations to implement

itit

A.A. TrueTrue

B.B. FalseFalse

What is Asthma???What is Asthma???

Asthma is an obstruction of the Asthma is an obstruction of the pulmonary (lung) system that is pulmonary (lung) system that is completely reversible (most of the time).completely reversible (most of the time).

Untreated asthma that starts in Untreated asthma that starts in childhood and goes untreated often childhood and goes untreated often cannot be distinguished from lung cannot be distinguished from lung obstruction seen in a smoking individualobstruction seen in a smoking individual

Who has Asthma???Who has Asthma???

How many listening to this How many listening to this presentation think they have asthma?presentation think they have asthma?

How many had asthma and “outgrew” How many had asthma and “outgrew” it as an adult?it as an adult?

How many have had MD diagnosis of How many have had MD diagnosis of asthma?asthma?

How many of you have had PFT’S How many of you have had PFT’S (breathing tests)?(breathing tests)?

Variability of Untreated Variability of Untreated AsthmaAsthma

Time

Sym

pto

ms

MildMild

SevereSevere

For purposes of illustration only.

Asthma in America Survey. SRBI. December 1998.

Students Over-estimate Students Over-estimate Their Asthma ControlTheir Asthma Control

Of patients who report symptoms that meet Of patients who report symptoms that meet NIH criteria for moderate-persistent asthma NIH criteria for moderate-persistent asthma 61% still consider their asthma to be 61% still consider their asthma to be

“well controlled” or “completely controlled”“well controlled” or “completely controlled” Of patients who report symptoms that meet Of patients who report symptoms that meet

NIH criteria for severe-persistent asthma NIH criteria for severe-persistent asthma 32% still consider their asthma to be 32% still consider their asthma to be

“well controlled” or “completely controlled”“well controlled” or “completely controlled”

Rickard K et al. J Allergy Clin Immunol. 1999;103:A655.Asthma in America Survey. SRBI. December 1998.

The Goals of Asthma The Goals of Asthma Therapy Are Inadequately Therapy Are Inadequately

RealizedRealized

Patients(%)

3032

48

23

0

20

40

60

Sleep DisruptionOnce/Week

Missed School/Workin Past Year

LimitedSports/Recreation

Unscheduled EDVisits in Past Year

Deaths in our state still primarilyin the youth!!!

Asthma Information for You And Your Family

Early-Onset AsthmaEarly-Onset Asthma

Infants colonized by bacteria at early Infants colonized by bacteria at early age significantly more likely to wheeze age significantly more likely to wheeze at age 5 than other children*at age 5 than other children* H.influenzaH.influenza M. catarrhalisM. catarrhalis S. pneumoniaeS. pneumoniae

S. aureus not associated with increased riskS. aureus not associated with increased risk

*N. Engl. J. Med. 2007;357:1545

Infection Early in Life and Infection Early in Life and AsthmaAsthma

In male childrenIn male children, early life , early life exposure to infection is associated exposure to infection is associated with lung impairment as adults:with lung impairment as adults: ~60% higher of overall mortality in ~60% higher of overall mortality in

adulthoodadulthood 2-fold increase in COPD mortality2-fold increase in COPD mortality Significant increase in MD diagnosis of Significant increase in MD diagnosis of

asthma in adulthoodasthma in adulthoodThorax; BMJ; November, 2007Glasgow University 1948-19689544 students; 4044 f/u in 2007

Asthma, Antibiotics, Asthma, Antibiotics, Antihistamines/DecongestaAntihistamines/Decongesta

ntsnts Recent study shows:Recent study shows:

Antihistamine/decongestants Antihistamine/decongestants plusplus NSAIDS given during severe lower NSAIDS given during severe lower respiratory track infection in first year of respiratory track infection in first year of life ilife increasesncreases risk of having asthma at risk of having asthma at age 6 by 2-fold!!! age 6 by 2-fold!!! (50% vs 24%, P= .001) (50% vs 24%, P= .001)

((NoNo association with the use of antibiotics association with the use of antibiotics

in the first year of life and the presence in the first year of life and the presence of asthma at age 6) of asthma at age 6)

Roberg, KA; Presentation AAAAI Annual meeting; Philadelphia, March 2008; Abstract #357

What about What about Vitamins/Nutrients?Vitamins/Nutrients?

Recent evidence suggest that young Recent evidence suggest that young students that are “relative” vitamin students that are “relative” vitamin D deficient are twice as likely to D deficient are twice as likely to develop asthma.develop asthma.

ASTHMA and it’s natural ASTHMA and it’s natural history is evolving; what do history is evolving; what do

we know about asthma in we know about asthma in our state? our state?

The Burden of Asthma in The Burden of Asthma in Washington State 2008Washington State 2008

Prevalence of lifetime asthma by Prevalence of lifetime asthma by grade:grade:

6th---15%6th---15%

8th---17%8th---17%

10th--19%10th--19%

12th---21%12th---21%

The Burden of Asthma in The Burden of Asthma in Washington State 2008Washington State 2008

Prevalence of lifetime asthma by Prevalence of lifetime asthma by grade and sex:grade and sex:

66thth----16% male, 13% female----16% male, 13% female

88thth----18% male, 16% female----18% male, 16% female

1010thth---18% male, 20% female---18% male, 20% female

1212thth---20% male, 22% female---20% male, 22% female

The Burden of Asthma in The Burden of Asthma in Washington State 2008Washington State 2008

Prevalence of Prevalence of CURRENTCURRENT asthma by asthma by grade:grade:

66thth---7%: ---7%: 8% male, 7% female8% male, 7% female

88thth---8%: ---8%: 8% male, 8% female8% male, 8% female

1010thth--9%: --9%: 7% male, 11% female7% male, 11% female

1212thth--9%: --9%: 7% male, 11% female7% male, 11% female

African American youth 30% moreLikely to have asthma than white youth

The Burden of Asthma in The Burden of Asthma in Washington State 2008Washington State 2008

Prevalence highest in Whitman, Prevalence highest in Whitman, Cowlitz, Grays Harbor and San Juan Cowlitz, Grays Harbor and San Juan countiescounties

Lowest in Adams, Grant, Chelan and Lowest in Adams, Grant, Chelan and Skamania countiesSkamania counties

WHY?????????WHY?????????

Pat

ien

ts w

ith

ast

hm

a,

%Asthma Incidence by Asthma Incidence by

Age*Age*

30%30%

21%21%

12%12%

0

5

10

15

20

25

30

35

40

45

20-39 40-59 60+

8%8%

19%19%

10%10%

0-19

37%37%

0-5

6-14

15-19

*National Data

In Washington State in In Washington State in 2003, Asthmatic Students 2003, Asthmatic Students

are:are: 2 ½ times more likely to 2 ½ times more likely to

require emergency carerequire emergency care 2 times as likely to need 2 times as likely to need

specialty carespecialty care Almost 5 times more likely Almost 5 times more likely

to require daily medications! to require daily medications!

Asthma Diagnosis and Asthma Diagnosis and Treatment:Treatment:

Achieving ControlAchieving Control There needs to be a concerted effort There needs to be a concerted effort

by all persons involved with the by all persons involved with the patient diagnosed with asthma:patient diagnosed with asthma: Primary Care ProvidersPrimary Care Providers Nursing staffNursing staff PharmacistsPharmacists School contacts: teachers, School contacts: teachers,

coaches, etc.coaches, etc. Parents, care giversParents, care givers

Assessment & Assessment & MonitoringMonitoring

Remember:Remember:Students with asthma and normal Students with asthma and normal

daily function are still be at risk daily function are still be at risk for frequent acute asthma for frequent acute asthma attacks if their asthma is not attacks if their asthma is not controlled!!!controlled!!!

What can Teachers do?What can Teachers do?

Know which students have asthmaKnow which students have asthma Have general idea of the different types Have general idea of the different types

of asthmaof asthma Understand what triggers affect asthmaUnderstand what triggers affect asthma Understand asthma “action” plansUnderstand asthma “action” plans Recognize how the classroom may Recognize how the classroom may

contribute to asthma flarescontribute to asthma flares When to be concernedWhen to be concerned

Asthma occurs in all age Asthma occurs in all age groupsgroups

Myth: You do not “out grow” asthma Myth: You do not “out grow” asthma in most casesin most cases

Male children more apt to have Male children more apt to have asthma until pubertyasthma until puberty

Obesity in females increases asthma Obesity in females increases asthma riskrisk

Highest percentage of asthma occurs Highest percentage of asthma occurs in the school-aged populationin the school-aged population

Asthma MythsAsthma Myths

Exercise should be avoided!Exercise should be avoided! People with asthma should People with asthma should

not participate in sportsnot participate in sports Use of medications before/during Use of medications before/during

exercise/games should be prohibitedexercise/games should be prohibited If athletes just run more, they will If athletes just run more, they will

“out-condition” their asthma“out-condition” their asthma

Asthma typesAsthma types Intermittent: often mild or occurring Intermittent: often mild or occurring

with infectionswith infections Persistent: mild, moderate, severePersistent: mild, moderate, severe Exercise induced (EIA)Exercise induced (EIA)

Asthma triggersAsthma triggers

InfectionInfection Environmental irritants/allergensEnvironmental irritants/allergens Cold airCold air Exercise: particularly Exercise: particularly

running, swimming, bikingrunning, swimming, biking SmokingSmoking Any strong odorAny strong odor

“ “School Irritants”School Irritants”

Animals in classroomAnimals in classroom Dust or mold in the classroomDust or mold in the classroom Overuse of perfumes/hairspraysOveruse of perfumes/hairsprays Smoke or other noxious fumesSmoke or other noxious fumes Physical activityPhysical activity Others?Others?

Exercise-induced Asthma Exercise-induced Asthma (EIA)(EIA)

All coaching and training staff need to be All coaching and training staff need to be able to recognize symptoms of asthma.able to recognize symptoms of asthma.

Desiccation (rapid drying) of the airway Desiccation (rapid drying) of the airway principle cause.principle cause.

Ignorance/lack of recognition can result Ignorance/lack of recognition can result in a life-threatening event with a in a life-threatening event with a student. student.

Understanding of the disease creates a Understanding of the disease creates a win/win environment.win/win environment.

EIA (continued)EIA (continued) Symptoms seen with EIASymptoms seen with EIA

Coughing after running, both early in Coughing after running, both early in “season” and after “adequate” conditioning“season” and after “adequate” conditioning

Frequent muscle cramping: so-called “side-Frequent muscle cramping: so-called “side-aches”aches”

Lactic acid build-upLactic acid build-up Poor performance during practice and Poor performance during practice and

gamesgames Oxygen debtOxygen debt

““Dogging it”Dogging it” Increase in sx during cold weather Increase in sx during cold weather

participation (Sport specific)participation (Sport specific)

Asthma MedicationsAsthma Medications

InhalersInhalers Quick-acting: albuterolQuick-acting: albuterol Controller type: salmeterol, steroids, cromolynController type: salmeterol, steroids, cromolyn

Oral medicationsOral medications Singulair®Singulair® SteroidsSteroids TheophyllineTheophylline

When to be concerned In When to be concerned In Students with AsthmaStudents with Asthma

Repetitive coughingRepetitive coughing Fever Fever During infectious disease seasonsDuring infectious disease seasons Rapid heart rate/breathing rateRapid heart rate/breathing rate Complaints of air hungerComplaints of air hunger ““Color” changes particularly with lips Color” changes particularly with lips

or finger tipsor finger tips

Action PlansAction Plans

All asthma students All asthma students

should have one.should have one. Are steps that a person Are steps that a person

will initiate with asthma will initiate with asthma

flare or in anticipation of flare or in anticipation of

asthma symptoms.asthma symptoms.

Action Plan (cont)Action Plan (cont) Steps:Steps:

STAY CALM!!!STAY CALM!!! Repeat medication (inhaler) as frequently Repeat medication (inhaler) as frequently

as neededas needed If respiratory distress not improving If respiratory distress not improving

quickly (5 minutes, or so) consider calling quickly (5 minutes, or so) consider calling EMT servicesEMT services

Use oxygen if availableUse oxygen if available Continue monitoring vital signs: pulse Continue monitoring vital signs: pulse

rate, breathing rate, color of digitsrate, breathing rate, color of digits Contact appropriate “emergency Contact appropriate “emergency

services”services”

Coaching/Trainer Action Coaching/Trainer Action PlanPlan

Know which of your athletes have asthmaKnow which of your athletes have asthma Recognize when is an athlete “in trouble”!Recognize when is an athlete “in trouble”! Know what medications are availableKnow what medications are available Steps to consider when concerned:Steps to consider when concerned:

Stop activityStop activity Check vital signs Check vital signs Let student/athlete administer own meds—Let student/athlete administer own meds—

remember they should also know what to doremember they should also know what to do Have someone else call for assistanceHave someone else call for assistance

Influenza 2009, 2010Influenza 2009, 2010School YearSchool Year

It will be VERY important that all It will be VERY important that all teachers/coaches and student athletes teachers/coaches and student athletes get annual influenza vaccine this year. get annual influenza vaccine this year.

Also this year we WILL be adding the H1N1 Also this year we WILL be adding the H1N1 vaccine with a separate injection.vaccine with a separate injection.

Federal Federal RegulationsRegulations

In 2004, The Asthmatic/School In 2004, The Asthmatic/School Children’sChildren’s Treatment and Health Treatment and Health Management Act of 2004 was enacted Management Act of 2004 was enacted into lawinto law Prior to federal legislation only 18 states Prior to federal legislation only 18 states

had laws protecting student access to had laws protecting student access to asthma medsasthma meds

Brought WA State into complianceBrought WA State into compliance Without Passing, Washington State could Without Passing, Washington State could

have lost federal funding in schoolshave lost federal funding in schools

Washington State Asthma Washington State Asthma InitiativeInitiative

As of 2006/2007, students are allowed to As of 2006/2007, students are allowed to carry their own inhalers and carry their own inhalers and epinephrineepinephrine They may use whenThey may use when they they feel it is needed feel it is needed School personnel need to become familiar School personnel need to become familiar

with the medications with the medications and and side effects side effects Albuterol: rapid heart rate, shakinessAlbuterol: rapid heart rate, shakiness Epinephrine: rapid heart rate, shakiness, nausea, Epinephrine: rapid heart rate, shakiness, nausea,

vomiting, increase BPvomiting, increase BP

Asthma Asthma RegistryRegistry

Will be “mandated” for ALL schools in Will be “mandated” for ALL schools in Washington State beginning 2010 school Washington State beginning 2010 school yearyear

Several “pilot” school districts have begun Several “pilot” school districts have begun their registrytheir registry

Will require continuous updatingWill require continuous updating Will eventually improved asthma care and Will eventually improved asthma care and

hopefully decrease the number of hopefully decrease the number of “emergencies” for all students“emergencies” for all students

Are Our Students With Are Our Students With Asthma Asthma

Achieving Good Control?Achieving Good Control?

Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. NIH, NHLBI. May 2007 (reprint). NIH publication 02-5075.

NIH Goals of Asthma NIH Goals of Asthma TherapyTherapy

Minimal or no symptoms day or night Minimal or no symptoms day or night [[Minimal use of inhaled rescue (albuterol):<Minimal use of inhaled rescue (albuterol):<22 uses per uses per

week]week]

Minimal or no exacerbations (flares)Minimal or no exacerbations (flares) No limitations on activities; no missed No limitations on activities; no missed

school/workschool/work Maintain (near) normal breathing testsMaintain (near) normal breathing tests Minimal or no adverse effects from Minimal or no adverse effects from

medicationsmedications

Evidence/Poor Control: Evidence/Poor Control: Uncontrolled Asthma in Children Uncontrolled Asthma in Children Age 4-11*Age 4-11*

In US during 2007, ~70% of In US during 2007, ~70% of asthmatics had asthma exacerbation asthmatics had asthma exacerbation in the past year. in the past year.

Of These:Of These: >50% required ER visit >50% required ER visit

>50% required oral steroids>50% required oral steroids

~10% were hospitalized~10% were hospitalized

*Asthma USA Summary---Summer 2007

Are There Tools That Are There Tools That Teachers/ School Nurses Can Teachers/ School Nurses Can Use to Help Assess Asthma Use to Help Assess Asthma

Control?Control?

Asthma Control Test

Asthma Control TestAsthma Control Test™™ (ACT) (ACT)1.1. In the past 4 weeks, ho much of the time did your asthma In the past 4 weeks, ho much of the time did your asthma

keep you from getting as much done at work, school or at keep you from getting as much done at work, school or at home?home?

2.2. During the past 4 weeks, how often have you had shortness During the past 4 weeks, how often have you had shortness of breath?of breath?

3.3. During the past 4 weeks, how often did your asthma During the past 4 weeks, how often did your asthma symptoms symptoms (wheezing, coughing, shortness of breath, chest tightness (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the or pain) wake you up at night, or earlier than usual in the morning?morning?

4.4. During the past 4 weeks, how often have you used your rescue During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?inhaler or nebulizer medication (such as albuterol)?

5.5. How would you rate your asthma control during the past How would you rate your asthma control during the past 4 weeks?4 weeks?

Score

Patient Total ScoreCopyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.

3210

Childhood Asthma Control Test Childhood Asthma Control Test Questions Completed by Child age 4-11 yrs

3. Do you cough because of your asthma?

4. Do you wake up during the night because of your asthma?

3210

1. How is your asthma today?

2. How much of a problem is your asthma when you run, exercise or play sports?

3210

It’s a big problem, I can’t do what I want to do. It’s a problem and I don’t like it. It’s a little problem but it’s okay. It’s not a problem

Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

SCORE

3210

Very bad Bad Good Very Good

Childhood Asthma Control TestChildhood Asthma Control Test Questions Completed by Parent/CaregiverQuestions Completed by Parent/Caregiver

5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms?

5

Not at all

6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?

7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?

4

1-3 days/mo

3

4-10 days/mo

1

19-24 days/mo

0

Everyday

2

11-18 days/mo

5

Not at all

4

1-3 days/mo

3

4-10 days/mo

1

19-24 days/mo

0

Everyday

2

11-18 days/mo

5

Not at all

4

1-3 days/mo

3

4-10 days/mo

1

19-24 days/mo

0

Everyday

2

11-18 days/mo

TOTAL

Benefits of ACTBenefits of ACT

• Reflects the multidimensional Reflects the multidimensional nature nature of asthma controlof asthma control

• May raise coach and patient May raise coach and patient expectationsexpectations

• Encourages patient communication Encourages patient communication with coaching staffwith coaching staff

• Simple 5-question quiz Simple 5-question quiz • Score of ≤Score of ≤19 suggests asthma 19 suggests asthma

may not be controlled as well as it may not be controlled as well as it could becould be

Nathan RA, et al. J Allergy Clin Immunol. 2004;113:59-65.

Washington State Asthma PlanWashington State Asthma Plan

-Developed by the WAI-Developed by the WAI

-Released November 2005-Released November 2005

-Contains chapter on Asthma in -Contains chapter on Asthma in educational settings educational settings

Washington State Asthma Washington State Asthma PlanPlan

By 2010, increase the number of schools By 2010, increase the number of schools reporting policies in place that implement reporting policies in place that implement emergency care plansemergency care plans for all identified for all identified students with asthmastudents with asthma

By 2007, expand asthma-related school-By 2007, expand asthma-related school-based data collection systems in based data collection systems in Washington StateWashington State

By 2010, increase the number of schools By 2010, increase the number of schools using an evidence-based school using an evidence-based school environmental assessment programenvironmental assessment program

More Information about State More Information about State Asthma PlanAsthma Plan

WAI web page: WAI web page: www.alaw.org/asthmawashington www.alaw.org/asthmawashington asthma initiativeasthma initiative

DOH Asthma Program webpage:DOH Asthma Program webpage: www.doh.wa.gov/cfh/asthma/

THANK YOU! Questions??THANK YOU! Questions??