Key Educational Messages for Patients:Key Educational Messages for Patients:Environmental ManagementEnvironmental Management

of Asthmaof Asthma

April 21, 2009April 21, 2009

Karen Meyerson, MSN, RN, FNP-C, AE-CKaren Meyerson, MSN, RN, FNP-C, AE-CAsthma Network of West MichiganAsthma Network of West Michigan

Patient EducationPatient Education

The goal of all patient education is to The goal of all patient education is to help patients take the actions needed help patients take the actions needed

to control their asthma.to control their asthma.

Key Educational Messages Key Educational Messages

Teach and reinforce at every opportunityTeach and reinforce at every opportunity Basic facts about asthmaBasic facts about asthma

Differences between the airways of those with and without asthmaDifferences between the airways of those with and without asthma

Role of inflammationRole of inflammation

What happens to the airways during an asthma attackWhat happens to the airways during an asthma attack Role of MedicationsRole of Medications

Long-term controlLong-term control• Prevent symptoms, often by reducing inflammationPrevent symptoms, often by reducing inflammation• Must be taken dailyMust be taken daily• Do not expect them to provide quick reliefDo not expect them to provide quick relief

Quick-reliefQuick-relief• SABAs relax airway muscles to provide quick reliefSABAs relax airway muscles to provide quick relief• Do not expect them to provide long-term controlDo not expect them to provide long-term control• Using SABAs Using SABAs >> 2 times/week indicates the need for starting or 2 times/week indicates the need for starting or

increasing long-term controlincreasing long-term control

Key Educational Messages Key Educational Messages continuedcontinued

Patient SkillsPatient Skills Taking medications correctlyTaking medications correctly

• Inhaler technique and use of devicesInhaler technique and use of devices

Identifying and avoiding environmental exposuresIdentifying and avoiding environmental exposures• AllergensAllergens• Irritants – including smokeIrritants – including smoke

Self-monitoringSelf-monitoring• Assess level of controlAssess level of control• Monitor symptoms Monitor symptoms ++PEFPEF• Recognizes early s/s of worsening asthma Recognizes early s/s of worsening asthma

Using a written asthma action plan to know when and how to:Using a written asthma action plan to know when and how to:• Take daily actions to control asthmaTake daily actions to control asthma• Adjust medications in response to worsening asthmaAdjust medications in response to worsening asthma

Seeking medical care as appropriateSeeking medical care as appropriate

Simple??Simple??

Basic facts about asthmaBasic facts about asthma

3 items3 items Role of medicationsRole of medications

2 items2 items

Each with 3 sub-itemsEach with 3 sub-items Patient skillsPatient skills

5 items5 items• 8 sub-items with several sub-items8 sub-items with several sub-items

= 22 items!= 22 items!

How to Approach When Many Items?How to Approach When Many Items?

““Chunking”Chunking”

Basic facts about asthmaBasic facts about asthma• Differences between the airways of those with and without Differences between the airways of those with and without

asthmaasthma• Role of inflammationRole of inflammation• What happens to the airways during an asthma attackWhat happens to the airways during an asthma attack

Build on life experiencesBuild on life experiences

Use problem-based learningUse problem-based learning

Focus on “need to know”Focus on “need to know”

Deliver important messages up front and repeat at the Deliver important messages up front and repeat at the end of the visit/callend of the visit/call

How to Approach When Concepts are How to Approach When Concepts are Complex?Complex?

Orient to discernable human anatomyOrient to discernable human anatomy Use analogiesUse analogies

TitanicTitanic

Burn on skinBurn on skin

Relate to other life experiencesRelate to other life experiences Diabetes, hypertension are “silent” but damage is occurringDiabetes, hypertension are “silent” but damage is occurring

What is Health Literacy?What is Health Literacy?

The ability to read, understand, and effectively use basic The ability to read, understand, and effectively use basic medical instructions and information. Low health literacy can medical instructions and information. Low health literacy can affect anyone of any age, ethnicity, background or education affect anyone of any age, ethnicity, background or education level.level.

People with low health literacy:People with low health literacy: Often less likely to comply with prescribed treatment and self-care Often less likely to comply with prescribed treatment and self-care

regimensregimens

Fail to seek preventive care and are at higher (more than double) risk Fail to seek preventive care and are at higher (more than double) risk for hospitalizationfor hospitalization

Remain in the hospital nearly two days longer than adults with higher Remain in the hospital nearly two days longer than adults with higher health literacyhealth literacy

Often require additional care that results in annual health care costs Often require additional care that results in annual health care costs that are four times higher than those with higher literacy skills.that are four times higher than those with higher literacy skills.

Health Literacy and Social DemandsHealth Literacy and Social Demands

Health literacy is a function of individuals’ skills and social Health literacy is a function of individuals’ skills and social demandsdemands

Sophisticated vocabularySophisticated vocabulary Legal jargonLegal jargon

Medical jargonMedical jargon

Conceptual understanding of risks and benefitsConceptual understanding of risks and benefits Use of scales and measuresUse of scales and measures Decision making under unusual circumstancesDecision making under unusual circumstances Comfort with asking questions (question authority)Comfort with asking questions (question authority) Offer informed consentOffer informed consent

The Harvard School of Public Health: Health Literacy The Harvard School of Public Health: Health Literacy Studies Web Site. Studies Web Site.

http:www.hsph.harvard.edu/healthliteracy.  http:www.hsph.harvard.edu/healthliteracy. 

Health LiteracyHealth Literacy

You may not know which patients have low health literacy You may not know which patients have low health literacy because:because: They are often embarrassed or ashamed to admit they have difficulty They are often embarrassed or ashamed to admit they have difficulty

understanding health information and instructions.understanding health information and instructions.

They are using well-practiced coping mechanisms that effectively mask They are using well-practiced coping mechanisms that effectively mask their problem.their problem.

The average American reads at the 8th-9th grade level; The average American reads at the 8th-9th grade level; however, health information is usually written at a higher however, health information is usually written at a higher reading level.reading level.

Most patients - regardless of their reading or language skills - Most patients - regardless of their reading or language skills - prefer medical information that is simple and easy to prefer medical information that is simple and easy to understand.understand.

Additional factors that may hinder understanding include: Additional factors that may hinder understanding include: Intimidation, fear, vulnerability Intimidation, fear, vulnerability

Extenuating stress within the patient's family Extenuating stress within the patient's family

Multiple health conditions to understand and treat Multiple health conditions to understand and treat

Foreign languageForeign language: Some words have several : Some words have several meanings – trigger, peak flow, scale, meanings – trigger, peak flow, scale, environment, normal, symptomsenvironment, normal, symptoms

Reading labelsReading labels: We rarely say “pass the sodium”: We rarely say “pass the sodium”

Informed ConsentInformed Consent: “I have discussed the likelihood of : “I have discussed the likelihood of major risks or complications from this procedure (if major risks or complications from this procedure (if applicable) but not limited to…”applicable) but not limited to…”

Reading instructionsReading instructions: “Take one teaspoon by : “Take one teaspoon by mouth”… can everyone recognize a teaspoon?mouth”… can everyone recognize a teaspoon?

Pictures as tools?Pictures as tools? One interpretation: “After One interpretation: “After exposure to radiation, it is important to consider exposure to radiation, it is important to consider that you may have mutated to gigantic that you may have mutated to gigantic dimensions; watch your head…”dimensions; watch your head…”

Health Literacy BarriersHealth Literacy Barriers

Health Literacy: What Can We Do?Health Literacy: What Can We Do?Ask Me 3Ask Me 3

Ask Me 3Ask Me 3 promotes three simple but essential questions promotes three simple but essential questions that patients should ask their providers in every health that patients should ask their providers in every health care interaction. Providers should always encourage their care interaction. Providers should always encourage their patients to understand the answers to: patients to understand the answers to:

1.1. What is my main problem?What is my main problem?

2.2. What do I need to do?What do I need to do?

3.3. Why is it important for me to Why is it important for me to

do this?do this?

www.askme3.org

Asthma TriggersAsthma Triggers

A variety of stimuli or “triggers” can A variety of stimuli or “triggers” can cause airway inflammation (swelling) cause airway inflammation (swelling) and bring on an asthma flareand bring on an asthma flare

Eliminating or reducing exposure to Eliminating or reducing exposure to these triggers will decrease the need these triggers will decrease the need for asthma medications and reduce for asthma medications and reduce symptomssymptoms

Asthma TriggersAsthma Triggers

Description:Description: Agent or factor that Agent or factor that

contributes to asthma contributes to asthma

severityseverity Additive in natureAdditive in nature Variable sensitivityVariable sensitivity Trigger locations: home, school, Trigger locations: home, school,

workplace, outdoors, workplace, outdoors,

car, entertainmentcar, entertainment Step-wise levels of control:Step-wise levels of control:

• Keep bedroom “asthma-safe”Keep bedroom “asthma-safe”

Categories of TriggersCategories of Triggers

AllergensAllergens IrritantsIrritants Respiratory Infections (colds)Respiratory Infections (colds) ExerciseExercise Weather ChangesWeather Changes StressStress Other TriggersOther Triggers

Classification of Environmental TriggersClassification of Environmental Triggers

AllergensAllergens IrritantsIrritants

IndoorIndoor

AnimalsAnimals Dust mitesDust mites CockroachesCockroaches MoldsMolds

OutdoorOutdoor

PollensPollens

-- Trees-- Trees

-- Grasses-- Grasses

-- Weeds-- Weeds MoldsMolds

Environmental Environmental tobacco smoketobacco smoke

Combustion by-Combustion by-products - wood products - wood smokesmoke

Outdoor air pollutantsOutdoor air pollutants Scented or unscented Scented or unscented

consumer products consumer products Cold airCold air

Indoor Asthma TriggersIndoor Asthma Triggers

Why Indoor Air?Why Indoor Air?

>90% of time is spent indoors – “Annette Funicello >90% of time is spent indoors – “Annette Funicello Phenomenon”Phenomenon”

Outdoor air pollutants come insideOutdoor air pollutants come inside

Pollutants are added to indoor airPollutants are added to indoor air

Health effectsHealth effects Respiratory irritantsRespiratory irritants

AllergensAllergens

Fetal effectsFetal effects

Reducing exposure to indoor allergens and irritants Reducing exposure to indoor allergens and irritants can reduce asthma symptomscan reduce asthma symptoms

Prevention is an important asthma management toolPrevention is an important asthma management tool

Common Indoor Air PollutantsCommon Indoor Air Pollutants

Asthma triggersAsthma triggers• Chemical Chemical

• BiologicalBiological

Second-hand SmokeSecond-hand Smoke Cleaners, fragrancesCleaners, fragrances Products of Incomplete combustionProducts of Incomplete combustion

• Carbon MonoxideCarbon Monoxide

Outdoor air pollutants entering homeOutdoor air pollutants entering home MoldsMolds

Triggers - AllergensTriggers - Allergens

““An allergy is a condition in which the body’s An allergy is a condition in which the body’s immune system overreacts to a foreign substance immune system overreacts to a foreign substance that has been breathed in, swallowed, touched, or that has been breathed in, swallowed, touched, or injected.”injected.”11

Allergic reaction - body identifies a normally Allergic reaction - body identifies a normally harmless object as an invader and reacts.harmless object as an invader and reacts.11

Approximately 70% to 90% of children with Approximately 70% to 90% of children with asthma have allergyasthma have allergy22, and 50% of adults with , and 50% of adults with asthma have allergies.asthma have allergies.11

11Plaut, T, Asthma Guide for People of All Ages, 1999, p. 58.Plaut, T, Asthma Guide for People of All Ages, 1999, p. 58.2 2 Pediatric Asthma Guide for Managing Asthma in Children, 1999. Pediatric Asthma Guide for Managing Asthma in Children, 1999.

Pets: Leashing the DanderPets: Leashing the Dander

Dander, urine, feces, and salivaDander, urine, feces, and saliva

Allergens are present even in homes and public Allergens are present even in homes and public places that do not contain animals.places that do not contain animals.

Keep pet out of main living areas and bedrooms.Keep pet out of main living areas and bedrooms.

Install HEPA air cleaners in main living areas and Install HEPA air cleaners in main living areas and bedrooms.bedrooms.

Avoid furry and feathered pets and products Avoid furry and feathered pets and products made with feathers - e.g., pillows and comfortersmade with feathers - e.g., pillows and comforters

Pets: Leashing the DanderPets: Leashing the Dander

Use a vacuum cleaner with integral Use a vacuum cleaner with integral HEPA filter and double-thickness bagsHEPA filter and double-thickness bags

Remove pet from home, if necessaryRemove pet from home, if necessary

www.petfinder.org - website for adoption/ foster - website for adoption/ foster care, will not destroy animals if no home is foundcare, will not destroy animals if no home is found

Even if clean aggressively after removal, allergen Even if clean aggressively after removal, allergen levels fall over a period of weeks to monthslevels fall over a period of weeks to months

Controversial: Some studies have found pet Controversial: Some studies have found pet washing ineffectivewashing ineffective

RodentsRodents Rodent proteins are potent sources of Rodent proteins are potent sources of

allergensallergens

Major allergens are found in urineMajor allergens are found in urine

Rodent allergens accumulate in high quantities in the Rodent allergens accumulate in high quantities in the litter, which is a major source of airborne allergenlitter, which is a major source of airborne allergen

NCICASNCICAS 33% inner city homes33% inner city homes

21% rat sensitivity21% rat sensitivity

21% in bedroom21% in bedroom

Related to missed school, ER visits, hospitalizationsRelated to missed school, ER visits, hospitalizationsJ Allergy Clin Immun, Aug 03J Allergy Clin Immun, Aug 03

Managing the MitesManaging the Mites The #1 indoor allergenThe #1 indoor allergen

Perennial with seasonal increases in summer and fallPerennial with seasonal increases in summer and fall

Major allergen contained in fecal pelletsMajor allergen contained in fecal pellets

Particles settle quickly after disturbance such that most Particles settle quickly after disturbance such that most mite exposure occurs when we are in intimate contact with mite exposure occurs when we are in intimate contact with themthem

Make bedroom “asthma safe”Make bedroom “asthma safe”

• Encase mattress, pillow, and box springs in allergen-Encase mattress, pillow, and box springs in allergen-impermeable coverimpermeable cover

• Reduce clutterReduce clutter

• Clean and dust weeklyClean and dust weekly

• Replace carpets with linoleum or woodReplace carpets with linoleum or wood

Managing the MitesManaging the Mites

Reduce indoor humidity to < 50% (air conditioning Reduce indoor humidity to < 50% (air conditioning or a dehumidifier - esp. in basement - may be or a dehumidifier - esp. in basement - may be helpful)helpful)

Use humidifiers/vaporizers with caution Use humidifiers/vaporizers with caution Wash bed linens weekly in hot water (Wash bed linens weekly in hot water (>> 130°F). 130°F). Minimize upholstered furnitureMinimize upholstered furniture Replace blinds with shades or easily washable Replace blinds with shades or easily washable

curtainscurtains Hot wash/freeze soft toysHot wash/freeze soft toys Remove carpets from the bedroom, and carpets in Remove carpets from the bedroom, and carpets in

other rooms laid on concreteother rooms laid on concrete

CockroachesCockroaches

Cockroach saliva, feces, skin shedding, Cockroach saliva, feces, skin shedding, and dead bodies decay and become airborneand dead bodies decay and become airborne

Levels in bedroom may be most associated with Levels in bedroom may be most associated with sensitization and diseasesensitization and disease

Significant levels have been found in inner-city Significant levels have been found in inner-city schoolsschools

Cockroach is Cockroach is thethe dominant indoor allergen in many dominant indoor allergen in many urban areas – sensitivity found in 30-50% of inner-urban areas – sensitivity found in 30-50% of inner-city children with asthmacity children with asthma

Exposure and sensitivity is BEST predictor of Exposure and sensitivity is BEST predictor of asthma morbidity in the NCICAS (asthma study)asthma morbidity in the NCICAS (asthma study)

Controlling CockroachesControlling Cockroaches

Block their entrances - caulk or seal cracks Block their entrances - caulk or seal cracks in plaster, flooringin plaster, flooring

Dry them out - reduce humidityDry them out - reduce humidity

Do not leave garbage or food exposedDo not leave garbage or food exposed

Use poison bait, gel, or traps to controlUse poison bait, gel, or traps to control

Use professional extermination services, if necessary – keep Use professional extermination services, if necessary – keep person with asthma outperson with asthma out

Thorough cleaning after exterminationThorough cleaning after extermination

Extermination of neighborhood dwellingsExtermination of neighborhood dwellings

Possible to reduce allergen levels but not reduce disease Possible to reduce allergen levels but not reduce disease due to the degree of infestationdue to the degree of infestation

To Reduce Pests and Pesticide UseTo Reduce Pests and Pesticide UseIntegrated Pest ManagementIntegrated Pest Management

Dry them out Dry them out (reduce sources of water)(reduce sources of water)

SStarve them out tarve them out (reduce sources of food)(reduce sources of food)

Keep them out Keep them out

(reduce shelter)(reduce shelter) Least amount of least toxic pesticides, when needed Least amount of least toxic pesticides, when needed

(judicious, careful use of pesticides when needed (judicious, careful use of pesticides when needed and always Read the LABEL and use accordinglyand always Read the LABEL and use accordingly))

MoldsMolds

Molds are fungi that appear as cottony tuftsMolds are fungi that appear as cottony tufts

Reproduce by making and releasing spores, Reproduce by making and releasing spores, which range in size from 2 to 100 which range in size from 2 to 100 micrometersmicrometers

Spores become airborne when released by Spores become airborne when released by the mold or when disturbed through physical the mold or when disturbed through physical contactcontact

Certain molds contain substances called Certain molds contain substances called mycotoxins that act as irritants in both mycotoxins that act as irritants in both allergic and non-allergic peopleallergic and non-allergic people

MoldsMolds

Many molds are allergensMany molds are allergens

Mold allergy is related to asthma and asthma Mold allergy is related to asthma and asthma severity in children and adultsseverity in children and adults

Mold allergy is related to rhinitisMold allergy is related to rhinitis

Interior water damage is related to Interior water damage is related to respiratory disease in infants and childrenrespiratory disease in infants and children

High humidity and dampness in home permit High humidity and dampness in home permit the growth in heating, ventilating, and air the growth in heating, ventilating, and air conditioning (HVAC) units, dehumidifiers, conditioning (HVAC) units, dehumidifiers, damp insulation, plaster/drywall, and carpetsdamp insulation, plaster/drywall, and carpets

Managing MoldsManaging Molds

Repair leaks, clean moldy surfacesRepair leaks, clean moldy surfaces

Reduce indoor humidity to < 50% Reduce indoor humidity to < 50%

Avoid carpeting on cement floorsAvoid carpeting on cement floors

Use bathroom and kitchen exhaust fansUse bathroom and kitchen exhaust fans

Avoid handling wet leaves, compost piles, Avoid handling wet leaves, compost piles, wet newspapers, garden debris or soilwet newspapers, garden debris or soil

Professional mold testing may be indicatedProfessional mold testing may be indicated

Triggers - IrritantsTriggers - Irritants

Airway irritants are those inhaled substances that Airway irritants are those inhaled substances that trigger inflammation and resulting bronchospasm trigger inflammation and resulting bronchospasm in the hyperresponsive airways of those individuals in the hyperresponsive airways of those individuals with asthma (i.e., no IgE involvement).with asthma (i.e., no IgE involvement).

Tobacco SmokeTobacco Smoke

Tobacco Smoke-Universal IrritantTobacco Smoke-Universal Irritant

ActiveActive (Primary)(Primary)

• Direct assault on lungs (and Direct assault on lungs (and

throughout the body)throughout the body)

Passive (Secondary)Passive (Secondary)

• Environmental Tobacco Smoke (ETS) Environmental Tobacco Smoke (ETS)

Non Smokers’ Movement of Australia, 1997 - 2001.Non Smokers’ Movement of Australia, 1997 - 2001.U.S.Environmental Protection Agency. Fact Sheet: U.S.Environmental Protection Agency. Fact Sheet: Respiratory Health Effects of Passive SmokingRespiratory Health Effects of Passive Smoking” 1993” 1993

Tobacco SmokeTobacco Smoke

Tobacco Smoke - effects of active and passive (ETS) Tobacco Smoke - effects of active and passive (ETS) exposure on asthma patients:exposure on asthma patients:

Contains more than 4,000 substances (over 40 Contains more than 4,000 substances (over 40 are carcinogenic)are carcinogenic)

Profound irritation of the upper airwayProfound irritation of the upper airway

Increased incidence of lower respiratory tract Increased incidence of lower respiratory tract infectionsinfections

Increased frequency of asthma exacerbationsIncreased frequency of asthma exacerbations

Can lead to development of asthma in pre-Can lead to development of asthma in pre-school age childrenschool age children

Tobacco Control MeasuresTobacco Control Measures

Realistic, supportive approachRealistic, supportive approach Impact of health care professional’s warning - Do Impact of health care professional’s warning - Do

not smokenot smoke Educate about negative health effects of ETS Educate about negative health effects of ETS

exposureexposure Practical plan of control:Practical plan of control:

• Smoke outdoorsSmoke outdoors

• Use “smoking jacket”Use “smoking jacket”

• Never allow smoking in carNever allow smoking in car

• Choose smoke-free child care settingsChoose smoke-free child care settings

CotinineCotinine Cotinine* is a major metabolite of nicotineCotinine* is a major metabolite of nicotine

Exposure to nicotine can be measured by Exposure to nicotine can be measured by analyzing cotinine levels in the blood, saliva, or analyzing cotinine levels in the blood, saliva, or urineurine

Nicotine is highly specific for tobacco smoke so Nicotine is highly specific for tobacco smoke so serum cotinine levels track exposure to tobacco serum cotinine levels track exposure to tobacco smoke and its toxic constituentssmoke and its toxic constituents

Recent study (Mannino, et al. CHEST 2002) Recent study (Mannino, et al. CHEST 2002) found that asthmatic children with high levels of found that asthmatic children with high levels of smoke exposure (compared to those with low smoke exposure (compared to those with low levels) were more likely to have moderate or levels) were more likely to have moderate or severe asthmasevere asthma

*CDC Fact Sheet – Exposure to Environmental Tobacco Smoke and Cotinine Levels, 2002.

Cotinine LevelsCotinine Levels

0.050 ng/mL 0.050 ng/mL limit of detectionlimit of detection 0.050 – 0.115 ng/mL 0.050 – 0.115 ng/mL low levellow level 0.116 – 0.6390.116 – 0.639 intermediate levelintermediate level 0.640 – 20 ng/mL 0.640 – 20 ng/mL high levelhigh level

Identifying Other IrritantsIdentifying Other Irritants

Other sources of smoke (e.g., Other sources of smoke (e.g., fireplaces, unvented stoves or heaters, wood fireplaces, unvented stoves or heaters, wood burning stoves, kerosene heaters, camp fires, burning stoves, kerosene heaters, camp fires, etc.)etc.)

Avoid outdoor fires, incl. leaf and grass firesAvoid outdoor fires, incl. leaf and grass fires

Outdoor or industrial pollutantsOutdoor or industrial pollutants

Other irritants (e.g., perfumes, cleaning Other irritants (e.g., perfumes, cleaning agents, sprays, cold air, etc.)agents, sprays, cold air, etc.)

Chemical OdorsChemical Odors

Given off from a variety of materials: Given off from a variety of materials: PaintPaint

SolventsSolvents

PesticidesPesticides

AdhesivesAdhesives

ParticleboardParticleboard

Vinyl flooring and tilesVinyl flooring and tiles

Dry-cleaned clothesDry-cleaned clothes

Toner from photocopiersToner from photocopiers

Cleaning agents used in homeCleaning agents used in home

Work-Related AsthmaWork-Related Asthma

Breathing for a Living:Breathing for a Living:

Definition:Definition: asthma caused by exposure to an asthma caused by exposure to an agent encountered in the work environmentagent encountered in the work environment

SensitizersSensitizers (e.g., isocyanates, plant or animal (e.g., isocyanates, plant or animal products)products)

IrritantsIrritants or physical stimuli (e.g., cold/heat, or physical stimuli (e.g., cold/heat, dust, humidity, smoke)dust, humidity, smoke)

Most common occupational respiratory Most common occupational respiratory disorder in industrialized countries.disorder in industrialized countries.

Global Initiative for AsthmaGlobal Initiative for Asthma, National Institutes of Health, 2002., National Institutes of Health, 2002.

Work-Related AsthmaWork-Related Asthma

Recognize patterns of symptoms:Recognize patterns of symptoms:

Timing of symptoms Timing of symptoms • Improvement during vacations or days off Improvement during vacations or days off

may take a week or moremay take a week or more• Symptoms worsen as work week progresses Symptoms worsen as work week progresses

Initial symptoms may occur after high-level Initial symptoms may occur after high-level exposure (e.g., “WTC cough,” Gulf War)exposure (e.g., “WTC cough,” Gulf War)

PEF variability of >20% between work and non-PEF variability of >20% between work and non-work suggests occupational asthmawork suggests occupational asthma

Work-Related AsthmaWork-Related Asthma Common triggers in the work or school setting:Common triggers in the work or school setting:

Mold and fungi (air ducts, plants, and books)Mold and fungi (air ducts, plants, and books)

Dust and dust mites (blinds, boxes, and papers in Dust and dust mites (blinds, boxes, and papers in storage rooms, and in carpeting)storage rooms, and in carpeting)

Copier fumes (from improperly vented machines)Copier fumes (from improperly vented machines)

Perfumes and colognes (from co-workers)Perfumes and colognes (from co-workers)

Tobacco smoke (may travel through air vents or flow Tobacco smoke (may travel through air vents or flow from smokers’ lounge)from smokers’ lounge)

CockroachesCockroaches

Cleaning productsCleaning products

Animals (classrooms)Animals (classrooms)

Work-Related AsthmaWork-Related Asthma

Discussion points:Discussion points:

Tobacco-free environmentTobacco-free environment

AvoidanceAvoidance• Change in job function or locationChange in job function or location• Adequate ventilationAdequate ventilation• Respiration protectionRespiration protection

Seek occupational asthma specialistsSeek occupational asthma specialists

Complete cessation of exposure to agent (not Complete cessation of exposure to agent (not always realistic) always realistic)

Outdoor Asthma TriggersOutdoor Asthma Triggers

Polishing off the PollensPolishing off the Pollens

Limit exposure during season by staying indoors Limit exposure during season by staying indoors with windows closedwith windows closed

Monitor local weather forecast - monitor pollen Monitor local weather forecast - monitor pollen countcount

Use air conditioning, if possibleUse air conditioning, if possible

Optimize antihistamines and other allergy medsOptimize antihistamines and other allergy meds

Bathe the body - wash hands, face, and hair Bathe the body - wash hands, face, and hair after being outsideafter being outside

RhinitisRhinitis

Studies indicate that inflammation of the Studies indicate that inflammation of the upper airway contributes to lower airway upper airway contributes to lower airway hyperresponsiveness and asthma symptomshyperresponsiveness and asthma symptoms

Treatment of the upper respiratory tract is an Treatment of the upper respiratory tract is an integral part of asthma managementintegral part of asthma management

Symptoms include sneezing, runny or itchy nose Symptoms include sneezing, runny or itchy nose or congestion or congestion Exam: Clear discharge, crease in nose, dark circles Exam: Clear discharge, crease in nose, dark circles

under eyesunder eyes

The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.

RhinitisRhinitis

Allergic rhinitis - inflammation of tissue lining the Allergic rhinitis - inflammation of tissue lining the inside of the noseinside of the nose

Provoked by allergens and can be seasonal Provoked by allergens and can be seasonal (grasses, weeds, and trees), or year-round (molds, (grasses, weeds, and trees), or year-round (molds, dust mites, animal danders)dust mites, animal danders)

May increase sensitivity to triggersMay increase sensitivity to triggers

Treatment: avoid offending allergens, nasal Treatment: avoid offending allergens, nasal irrigation with saline, oral antihistamines and irrigation with saline, oral antihistamines and decongestants, inhaled nasal steroidsdecongestants, inhaled nasal steroids

The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.The American Academy of Allergy, Asthma and Immunology. The Allergy Report, 2000.

Signs and Symptoms of Signs and Symptoms of Allergic RhinitisAllergic Rhinitis

Itchy, watery eyesItchy, watery eyes Red eyesRed eyes Itchy noseItchy nose SneezingSneezing Postnasal dripPostnasal drip Sore throatSore throat Sinus headachesSinus headaches Nasal obstructionNasal obstruction

CongestionCongestion Allergic shinersAllergic shiners Allergic creaseAllergic crease Watery, profuse nasal Watery, profuse nasal

dischargedischarge Ocular symptomsOcular symptoms FatigueFatigue

Joint Task Force RecommendationsJoint Task Force Recommendations

““Nasal steroids provide the most effective symptom Nasal steroids provide the most effective symptom relief of allergic rhinitis.”relief of allergic rhinitis.”

Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, November 1998.

Weather ChangesWeather Changes

Effect of weather is not the same in all seasons:Effect of weather is not the same in all seasons:

Fall - noticeable effect on asthma, esp. following Fall - noticeable effect on asthma, esp. following the first cold mass to come in the fallthe first cold mass to come in the fall

Summer - lowest number of ED visits because Summer - lowest number of ED visits because weather is least variable though high pollen and weather is least variable though high pollen and air pollutionair pollution

Spring - some day to day variability though not as Spring - some day to day variability though not as extreme as fall - high tree pollenextreme as fall - high tree pollen

American Lung Association, 2002.American Lung Association, 2002.

Weather ChangesWeather Changes

Cold air - airway irritant (esp. for those with EIB)Cold air - airway irritant (esp. for those with EIB)

Hot, humid air - patients report some SOB with Hot, humid air - patients report some SOB with increased humidity though mechanism unclear - increased humidity though mechanism unclear - molds?molds?

Wind - pollen and mold spores become airborne Wind - pollen and mold spores become airborne and more likely to be breathed in by susceptible and more likely to be breathed in by susceptible individualsindividuals

American Lung Association, 2002American Lung Association, 2002

Weather ChangesWeather Changes

Thunderstorms - Thunderstorms - (J of Epid and Comm Health, 1997)(J of Epid and Comm Health, 1997) 10 times the asthma-related calls made on the night of 10 times the asthma-related calls made on the night of storms compared to night of clear weatherstorms compared to night of clear weather Mechanism: winds blow in large amounts of allergens from Mechanism: winds blow in large amounts of allergens from

the countrysidethe countryside

Also, ozone is created by thunderstorms - well established Also, ozone is created by thunderstorms - well established asthma triggerasthma trigger

Barometric Pressure - patients refer to it as a “change Barometric Pressure - patients refer to it as a “change in weather.” Many anecdotal reports but lack of in weather.” Many anecdotal reports but lack of studies. studies. Key may be temperature fluctuations Key may be temperature fluctuations along withalong with increased increased

barometric pressure - need more data.barometric pressure - need more data. American Lung Association, 2002American Lung Association, 2002

Air PollutionAir Pollution

Consider the effect of weather on pollution:Consider the effect of weather on pollution:

““Inversion”: a weather system where air sits Inversion”: a weather system where air sits stillstill

Concentrates all the airborne pollutantsConcentrates all the airborne pollutants

Pollutants worsen asthma - act as irritantsPollutants worsen asthma - act as irritants

When heat and sunlight react with pollutants, When heat and sunlight react with pollutants, creates a large amount of ground-level creates a large amount of ground-level ozone - a well known asthma triggerozone - a well known asthma trigger

More likely to occur in larger citiesMore likely to occur in larger citiesAmerican Lung Association, 2002American Lung Association, 2002

Watching the WeatherWatching the Weather

Watching the WeatherWatching the Weather

Monitor the daily local weather forecastMonitor the daily local weather forecast

Monitor pollen count and smog indexMonitor pollen count and smog index

Limit exertion in cold, dry airLimit exertion in cold, dry air

Wear a scarf or mask over the nose and mouth when Wear a scarf or mask over the nose and mouth when outside in very cold weatheroutside in very cold weather

Stay indoors with windows closed on peak pollen days Stay indoors with windows closed on peak pollen days and especially on windy days during pollen seasonand especially on windy days during pollen season

Keep symptom diaryKeep symptom diaryAmerican Lung Association, 2002American Lung Association, 2002

Other Common Asthma Other Common Asthma TriggersTriggers

Exercise, GERD, Exercise, GERD, Pregnancy, Nocturnal Pregnancy, Nocturnal

Asthma, and Asthma, and Respiratory InfectionsRespiratory Infections

Exercise Induced Bronchospasm (EIB)Exercise Induced Bronchospasm (EIB)

Approximately 90% of asthmatics have exercise Approximately 90% of asthmatics have exercise as a triggeras a trigger

Caused by loss of heat and water from the Caused by loss of heat and water from the airways during exercise resulting in transient airways during exercise resulting in transient airflow obstructionairflow obstruction

Initially, bronchodilation occurs when Initially, bronchodilation occurs when catecholamines are releasedcatecholamines are released

This is followed by an after-exercise fall in PEFR This is followed by an after-exercise fall in PEFR associated with bronchoconstrictionassociated with bronchoconstriction

Sx: cough, SOB, chest pain/tightness, wheezing Sx: cough, SOB, chest pain/tightness, wheezing or endurance problems during exerciseor endurance problems during exercise

Canadian Lung Association, 2002.Canadian Lung Association, 2002.

EIBEIB

Dx.: exercise challenge or PEF or FEVDx.: exercise challenge or PEF or FEV11 (15% (15% decrease before and after exercise at 5 min. intervals decrease before and after exercise at 5 min. intervals for 20 - 30 min. is compatible with EIB).for 20 - 30 min. is compatible with EIB).

Early phase:Early phase: Usually begins during exercise and peaks 5 - 10 minutes Usually begins during exercise and peaks 5 - 10 minutes

after stopping the activityafter stopping the activity

Refractory period (“grace period”):Refractory period (“grace period”): After the initial bout of EIB, there may be less bronchospasm After the initial bout of EIB, there may be less bronchospasm

for up to 2 hoursfor up to 2 hours

Late phase:Late phase: Symptoms may occur again, beginning 3 to 10 hours after Symptoms may occur again, beginning 3 to 10 hours after

exercise exercise Canadian Lung Association, 2002.Canadian Lung Association, 2002.

Factors that Influence EIBFactors that Influence EIB

Cold air, low humidity, pollutantsCold air, low humidity, pollutants

Duration, type, and intensity of exerciseDuration, type, and intensity of exercise

Poor physical conditioningPoor physical conditioning

Inhaled allergens (in sensitive individuals)Inhaled allergens (in sensitive individuals)

Respiratory infectionsRespiratory infections

Poor level of asthma controlPoor level of asthma control

Emotional stress/fatigueEmotional stress/fatigue

Canadian Lung Association, 2002.Canadian Lung Association, 2002.

Ways to Reduce EIBWays to Reduce EIB Avoid exercise if symptoms are presentAvoid exercise if symptoms are present

Pre-medicate per doctor’s instructionsPre-medicate per doctor’s instructions

Adequate warm-up - at least 10 - 15 minutesAdequate warm-up - at least 10 - 15 minutes

Modified exerciseModified exercise

Avoid triggers that may cause or worsen EIB, i.e., cold air, high pollen Avoid triggers that may cause or worsen EIB, i.e., cold air, high pollen countcount

Adequate cool down - at least 10 minutesAdequate cool down - at least 10 minutes

Breathe through nose, if possible, to warm airBreathe through nose, if possible, to warm air

Exercise regularlyExercise regularly

Get adequate rest and drink plenty of fluidsGet adequate rest and drink plenty of fluidsCanadian Lung Association, 2002.Canadian Lung Association, 2002.

GERDGERD

Gastroesophageal reflux disease (GERD) - Gastroesophageal reflux disease (GERD) - acid from stomach contents stimulates nerve acid from stomach contents stimulates nerve endings in esophagus causing chronic coughendings in esophagus causing chronic cough

Symptoms include heartburn and sour tasteSymptoms include heartburn and sour taste

Acidic materials may also enter the airways Acidic materials may also enter the airways and trigger the asthma reaction - possible and trigger the asthma reaction - possible cause of nocturnal asthmacause of nocturnal asthma

Possible Causes of GERDPossible Causes of GERD

Combination of Combination of conditions that increase conditions that increase the presence of acid the presence of acid reflux in the esophagusreflux in the esophagus

Transient relaxation of Transient relaxation of the sphincter, delayed the sphincter, delayed gastric emptying, gastric emptying, decreased salivation decreased salivation and impaired and impaired esophageal clearanceesophageal clearance

Lifestyle factorsLifestyle factors

Risk Factors for GERDRisk Factors for GERD

SmokingSmoking Large mealsLarge meals Fatty foodsFatty foods CaffeineCaffeine PregnancyPregnancy ObesityObesity Body positionBody position DrugsDrugs HormonesHormones

How Does GERD How Does GERD Trigger Asthma?Trigger Asthma?

Refluxed material gets past the upper esophageal sphincter, it Refluxed material gets past the upper esophageal sphincter, it can aspirated into the larynx and tracheobronchial treecan aspirated into the larynx and tracheobronchial tree

Pulmonary symptoms may be caused by:Pulmonary symptoms may be caused by:

DirectDirect aspiration of acid into the bronchial tree (micro aspiration of acid into the bronchial tree (micro aspiration of stomach contents – usually during sleep)aspiration of stomach contents – usually during sleep)

IndirectlyIndirectly - acid leaking from the lower esophagus - acid leaking from the lower esophagus stimulates the vagus nerve which triggers stimulates the vagus nerve which triggers bronchoconstriction (even if symptoms of GERD are not bronchoconstriction (even if symptoms of GERD are not grossly apparent)grossly apparent)

Combination of two is also very likelyCombination of two is also very likely

GERD TreatmentGERD Treatment

Don’t smoke or drink alcoholic Don’t smoke or drink alcoholic beverages – they increase stomach acid beverages – they increase stomach acid production and cause irritationproduction and cause irritation

Avoid caffeine and chocolate – caffeine is a Avoid caffeine and chocolate – caffeine is a muscle relaxant and weakens the LES tonemuscle relaxant and weakens the LES tone

Avoid carbonated drinks, citrus, onions, Avoid carbonated drinks, citrus, onions, tomatoes, fatty and fried foods, peppermint, and tomatoes, fatty and fried foods, peppermint, and spicy foodsspicy foods

Wait 2 – 4 hours after eating before bending Wait 2 – 4 hours after eating before bending over, lying down or going to sleepover, lying down or going to sleep

GERD TreatmentGERD Treatment

Thick feedings – infantsThick feedings – infants

Elevate the head of your bed 6 – 8”Elevate the head of your bed 6 – 8”

Wear loose clothingWear loose clothing

Eat smaller meals more frequentlyEat smaller meals more frequently

Weight loss, if appropriateWeight loss, if appropriate

Use appropriate pharmacotherapyUse appropriate pharmacotherapy

Surgery for refractory cases – Nissen Surgery for refractory cases – Nissen fundoplicationfundoplication

Nocturnal AsthmaNocturnal Asthma

Normal fluctuations in circadian rhythmNormal fluctuations in circadian rhythm

Chemical and temperature changes in the body Chemical and temperature changes in the body during the night increase inflammation and during the night increase inflammation and narrowing of the airwaysnarrowing of the airways

Delayed allergic responses can occur from Delayed allergic responses can occur from exposure to allergens during the dayexposure to allergens during the day

Toward the early morning, the effect of inhaled Toward the early morning, the effect of inhaled medications may wear off and cause an medications may wear off and cause an exacerbationexacerbation

PregnancyPregnancy

Poorly controlled asthma during pregnancy can Poorly controlled asthma during pregnancy can result in increased perinatal mortality, increased result in increased perinatal mortality, increased prematurity, and low birth weight.prematurity, and low birth weight.

Maintaining sufficient lung function and blood Maintaining sufficient lung function and blood oxygenation to ensure adequate oxygen blood oxygenation to ensure adequate oxygen blood supply to the fetus is essential.supply to the fetus is essential.

For most medications used to treat asthma and For most medications used to treat asthma and rhinitis, there are little data to suggest an increased rhinitis, there are little data to suggest an increased risk to the fetus.risk to the fetus.

PregnancyPregnancy Most asthma medications are as safe to use in Most asthma medications are as safe to use in

pregnancy as in the non-pregnant state.pregnancy as in the non-pregnant state.

Budesonide is preferred ICS because more data Budesonide is preferred ICS because more data are available on its use in pregnant women.are available on its use in pregnant women.

Other ICS may be continued in patients who were Other ICS may be continued in patients who were well controlled on by these agents prior to well controlled on by these agents prior to pregnancy.pregnancy.

Little data on LTM during pregnancy but Little data on LTM during pregnancy but reassuring animal data; LABA safety profile similar reassuring animal data; LABA safety profile similar to albuterol (safety data available).to albuterol (safety data available).

It is safer for pregnant women with asthma to be It is safer for pregnant women with asthma to be treated with asthma medications than to have treated with asthma medications than to have asthma symptoms and exacerbations.asthma symptoms and exacerbations.

PregnancyPregnancy

Treating asthma is paramount. All long-term control Treating asthma is paramount. All long-term control medications and short-acting betamedications and short-acting beta22-agonists appear to be -agonists appear to be safe in pregnancy.safe in pregnancy. Inhaled meds preferred to oral agentsInhaled meds preferred to oral agents Exacerbations more common at the endExacerbations more common at the end of 2of 2ndnd trimester and the trimester and the

early 3early 3rdrd trimester trimester Medications with some possibility of risk to the fetus include:Medications with some possibility of risk to the fetus include:

Decongestants, some antibiotics, live virus vaccines, iodides, Decongestants, some antibiotics, live virus vaccines, iodides, brompheniramine, epinephrinebrompheniramine, epinephrine

For more information, see For more information, see Managing Asthma During Managing Asthma During Pregnancy: Recommendations for Pharmacologic Pregnancy: Recommendations for Pharmacologic Treatment Treatment (NAEPP, 2004)(NAEPP, 2004)

http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdfhttp://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdf

Nocturnal AsthmaNocturnal Asthma

An increase in acid reflux during the night may An increase in acid reflux during the night may cause airway constriction.cause airway constriction.

Postnasal drip that occurs during sleep may Postnasal drip that occurs during sleep may contribute to higher nighttime risk.contribute to higher nighttime risk.

Airway cooling secondary to drop in body Airway cooling secondary to drop in body temperature during sleep.temperature during sleep.

Sleep apnea in the upper airways may trigger Sleep apnea in the upper airways may trigger asthma exacerbation in the lower airways.asthma exacerbation in the lower airways.

Hormones have been found to follow the Hormones have been found to follow the circadian cycle that corresponds to changes in circadian cycle that corresponds to changes in lung function at night.lung function at night.

Respiratory InfectionsRespiratory Infections

Mechanisms:Mechanisms:

RSV, rhinovirus, and influenza virus have been RSV, rhinovirus, and influenza virus have been implicated.implicated.

May cause epithelial damage and airway May cause epithelial damage and airway inflammation.inflammation.

May be responsible for the generation and release May be responsible for the generation and release of allergic mediators. of allergic mediators.

Viruses have been shown to potentiate the allergic Viruses have been shown to potentiate the allergic response to allergens by increasing the release of response to allergens by increasing the release of inflammatory mediators. inflammatory mediators.

Global Initiative for AsthmaGlobal Initiative for Asthma, National Institutes of Health, 2002., National Institutes of Health, 2002.

Respiratory InfectionsRespiratory Infections

Risk for Patients with AsthmaRisk for Patients with Asthma May increase airway hyper-responsiveness for weeksMay increase airway hyper-responsiveness for weeks

Prevention/Control Prevention/Control Proper nutrition and restProper nutrition and rest

Annual influenza vaccine – injection, not nasal sprayAnnual influenza vaccine – injection, not nasal spray

Hand washingHand washing

keep hands away from facekeep hands away from face

Avoid those with active respiratory infectionAvoid those with active respiratory infection

Use antibiotics when appropriate for bacterial infectionsUse antibiotics when appropriate for bacterial infections

Birth Birth

Th2Th2

The Hygiene HypothesisThe Hygiene Hypothesis

Day Care

Older Sibs

Many infections

(Th1 stimuli)

Allergen

exposure

Only child

Few infections

Th1

Healthy

Still Th2

Allergies

Asthma