Factors Contributing to - PowerPoint Presentation

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Factors Contributing to Asthma Exacerbations

Trisch Van

Sciver

RN MS

CFNP DOM AE-C

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Ranking the Evidence

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NAEEP Expert Panel Report – 3

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This session will cover…

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Allergens vs. Irritants

(See

Asthma 101 – Asthma Triggers Handout

for examples.)

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Assess EnvironmentIdentify and control triggers to:

Prevent symptoms

Prevent hospitalizations and ED visits

Improve quality of life and self-management skills

Reduce medications

IMPORTANT

: Ask, “Have you noticed anything in your home, work or school that makes your asthma worse?”

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Assess Home TriggersDoes the patient:

Keep a pet?

Have moisture or dampness in their home environment?

Have visible mold in any part of their home?

Smoke or live with a smoker?

Have a wood burning stove or fireplace?

Have unvented stoves or heaters?

SOURCE: EPA ,

Asthma Home Environment Checklist for Home Visitors

at http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf.

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EPA Asthma Home Environment ChecklistInspect Mattress & bedding. Are there carpets, other floor covering, drapes, upholstered furniture, stuffed toys? Cockroaches, rodents in kitchen, bath, basement?

Pets? Types?

Mold in bathroom, kitchen, basement?

Smoke – tobacco second hand?

Gas cooking appliances, fireplaces, woodstoves, unvented heaters? (NO2)

Heating/Cooling system?

Cleaning products/pesticides/air fresheners/cosmetics?

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Common Home Triggers: Allergens

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All warm-blooded animals produce flakes of skin (dander), feces, urine and dried saliva that can cause allergic reactions. Best option - Keep animals out of houseIf you can’t keep the pet outside, keep it out of the bedroom and keep the door shut

Wash hands and clothes after contact with the pet

Remove upholstered furniture and carpets from the home or isolate the pet in areas without these items

Animal Allergens*D

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Require humidity and human dander to survive, thrive in most areas of the United States but usually not present in high altitudes or arid areas High levels are found in bedding, pillows, mattress, upholstered furniture, carpets, clothes and soft toys

IMPORTANT

: The patient’s bed is the most important source of dust mites that need to be controlled.

Dust Mites*A

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Encase the pillow and mattress in an allergen-impermeable cover.Wash all bedding in hot (>130ºF) water weekly*.

Keep humidity below 60% (ideally 30%-50%).

Remove carpets from the bedroom.

Avoid sleeping or lying on upholstered furniture.

In children’s beds, minimize the number of stuffed toys; each week, wash the toys in hot water or freeze them.

Room air filtration devices are not recommended to control dust mite exposure – the allergens are air-borne only briefly and not removed via air filtration.

Dust Mites Control Measures*

B

(*

Exposure to dry heat or freezing kills dust mites but does not remove the allergen.)

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Keep counters, sinks, tables and floors clean and clear of clutter.

Fix plumbing leaks and other moisture problems.

Remove piles of boxes, newspapers and other items where cockroaches may hide.

Seal all entry points.

Make sure trash in your home is properly stored in containers with lids that close securely; remove trash daily

Try using poison baits, boric acid or traps first before using pesticide sprays.

Cockroach Control Measures*

B

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Common Home Triggers: Irritants

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Moisture control = mold control, so - ACT QUICKLY. If wet or damp materials or areas are dried 24-48 hours after a leak or spill, in most cases mold will not grow.

Scrub mold off hard surfaces with detergent and water; dry completely.

Absorbent or porous materials, such as moldy ceiling tiles and carpet, may have to be thrown away.

Dehumidify basements if possible.

Mold Control Measures*

C

(SOURCE:

A Brief Guide to Mold and Moisture in Your Home

, EPA Publication #402-K-02-003.)

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Minimize exposure to strong odors and sprays (perfume, talcum powder, hair spray, paints, new carpets, particle board).Minimize production of nitrogen dioxide*C

Inspect the heating system annually.

Inspect and keep clear the chimney clean-out opening.

Do not use unvented space heaters.

Do not use stoves for heating.

Do not use wood burning fireplaces .

Use kitchen exhaust fans.

Do not let the car idle in the garage.

Smoke and Gas Control Measures

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If you smoke, ask for ways to help you quit. Ask family members to quit too.*C

Do not allow smoking in your home or car.

Be sure no one smokes at your child’s daycare or school.

Advocate for smoke free workplaces.

IMPORTANT

: An estimated 46.5 million adults in the United States smoke cigarettes = 23.25 million deaths.

Tobacco Smoke Control Measures

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Exposure is linked to increased asthma symptoms, decreased lung function and greater use of health services among those who have asthma.Message to person with asthma or caregiver – Quit or at least smoke outside (may not adequately reduce exposure).

Provide smoking cessation support if possible.*

B

Secondhand Smoke

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ACTIVE

SMOKING &

ASTHMA

More frequent exacerbations, hospitalizations, ER visits

Therapeutic response to corticosteroids impaired

Increased theophylline clearance

Higher risk of developing worsening fixed airway obstruction -COPD- asthmatics smoking 15 or > cigarettes /day have an 18% decline in FEV1 over 10 yrs compared with a 10% decline in nonsmokers with asthma*

Increased risk of cancer, heart disease, gerd, chronic sinusitis

*Apostol et al

“

Early life factors contribute to the decrease in lung function between ages 18 and 40

”

AJRespCritCM 2002;166:166-172

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10/21/201321PASSIVE TOBACCO SMOKING (SHS*) & ASTHMA

Children exposed to passive smoke have increased risk of developing asthma of between 21% and 37% ** and of having increased respiratory infections

Implicated in some cases of new onset adult asthma particularly women (60% in one study, no increase in men -Toren et al Int J Tuberc Lung Dis 1999;3(3): 192-197

Non smoking asthmatics have increased risk for asthma symptoms and episodes

Frequent exposure to passive smoke can increase risk of development of COPD and other smoking related diseases- lung cancer and cardiovascular disease

*SHS =second hand smoke

**California Environmental Protection Agency: Health effects assessment for environmental tobacco smoke. Office of Environmental Health Hazard Assessment Sacramento, CA 2005

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Vacuum 1-2 times per weekGet someone else to do this if possible or wear a dust maskDamp mop

Air conditioning during warm weather recommended for asthma patients*

C

Dehumidifiers to reduce house-dust mite levels in high-humidity areas

HEPA filters to reduce airborne cat dander, mold spores and particulate tobacco smoke.

Not a substitute for more effective measures!

Techniques That May Modify Indoor Air

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Humidifiers not recommended for use in homes with dust-mite sensitive patients*c

Insufficient evidence to recommend cleaning air ducts in HVAC systems*

D

Insufficient evidence to recommend using indoor air cleaning devices

Techniques Not Recommended

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It is recommended that allergen immunotherapy be considered for patients with persistent asthma if evidence is clear of a relationship between symptoms and exposure to an allergen to which the patient is sensitive.*

B

Immunotherapy

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Immunotherapy is usually reserved for patients whose symptoms occur all year or during a major portion of the year, and in whom controlling symptoms with pharmacologic management is difficult because the medication is ineffective, multiple medications are required, or the patient is not accepting the use of medication.

Immunotherapy

(EPR – 3, pg. 173)

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Schools: Potential Concerns

Poor indoor air quality

Leaky roofs/wet carpeting = Molds

New carpeting/chemicals = Toxic fumes

Building repairs/renovations = Dust

Idling school busses =

Diesel fumes

Unventilated portable classrooms

Fragrances (Magic Markers, air fresheners, art supplies)

Animals in classroom

Cleaning supplies

Classroom environment (old carpeting, furniture)

Insecticides, herbicides, fungicides

Chalk dust, foods

Access to medications

Access to a school nurse

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It is recommended that a clinician prepare a written asthma action plan for the school setting. In addition to medications and emergency response, this plan should identify factors that make students’ asthma worse so that the school may help avoid exposure.

Asthma Friendly School Resources

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Gabriel is a five-year-old boy with asthma who will begin kindergarten in the fall. His moderate-persistent asthma has been well managed at home and the family wants to inquire about the environment of the school setting prior to enrollment.

Activity: How Asthma Friendly Is Your School?

(SOURCE: CDC.

How Asthma Friendly Are Your Schools?)

Role-play

: School Employee & Asthma Educator

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Tobacco free campus? Good indoor air quality?Policy on inhalers?Written asthma emergency plan for teachers & staff ?Updated asthma action plans for students with asthma on file at school?School nurse?Education for school staff/teachers about asthma?Degree of participation asthma student has in PE, sports, recess, field trips?

/a

How Asthma-Friendly is your School?

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Assess Work Triggers - Occupational

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Possible Occupational Exposures

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Occupations associated with Asthma

Bird breeders

Seafood & food processors

Beekeepers, farmers, granary workers silk processors, dockworkers

Pharmaceutical industry, health care workers

Mushroom workers, Bakers

Beauticians

Miners, cement, electroplating and tanning workers, metal workers and diamond polishers, alloy makers

Plastics and printing industry

Shellac/lacquer industry workers

Foresters, woodworkers and furniture makers

Polyurethane, foam coatings, adhesives production, spray painters

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10/21/201333Causes of

Irritant-induced OA

Chlorine gas Hydrochloric acid

Hydrogen sulfide

Anhydrous ammonia

Fumigating fog

Smoke Inhalation

Heated acids

1984 Bhopal, India - toxic cloud of methyl

isocyanate

gas released from chemical plant killed thousands and caused thousands to develop persistent respiratory disease (some with reversible airway obstruction)

2001 WTS, NYC- complex mixture of airborne dusts and pollutants associated with RADS (and other respiratory disorders) in exposed rescue and recovery workers and residents of the surrounding area

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10/21/201334Material Safety Data Sheets (MSDS)

US Occupational Safety & Health Administration requires that suppliers include a MSDS with each shipment of an industrial material or chemical and workers are entitled to receive copies of these

Helpful in identifying respiratory hazards in the workplace

May omit information, but can focus subsequent literature review to obtain additional info.

(materials present in concentrations <1% need not be reported)

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Outdoor Environment

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Other Contributing Factors

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Influenza Consider inactivated influenza vaccination for patients with asthma. Vaccinate due to increased risk of complications from influenza. Do not expect reduced frequency or severity of asthma exacerbations during influenza season.*

B

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

http://www.cdc.gov/hicpac/2007ip/2007ip_part3.html

Female hormones and dietary constituents

There is insufficient evidence to make specific recommendations on these topics.

Other Contributing Factors

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Aspirin sensitivity – Avoid aspirin and other NSAIDs as these drugs could precipitate severe and fatal exacerbations.*C

Other medications

– Recommend avoidance of non-selective β–blockers

(

eye drops

used for glaucoma) and HTN

B

& ACE inhibiters –used for HTN.

Sulfite sensitivity

– Avoid processed potatoes, shrimp, dried fruit, or drinking beer and wine to avoid sulfite exposure.*

C

Other Contributing Factors

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10/21/201339

ASPIRIN

INDUCED ASTHMA

SAMPTER

’

S

SYNDROME

ASTHMA TRIAD

- Aspirin / NSAID induced respiratory reactions Asthma and Nasal Polyps - these 3 things make up the Asthma Triad

- occurs in 4.3-21% asthmatic

Develop persistent rhinitis in 3rd or 4th decade associated with viral URI

Usually asthma is severe and poorly responsive to corticosteroids

Women affected 2.5X > men

Mechanism:

“

shunting

”

of

arachidonic

acid metabolism away from

prostanoid

production, leading to increased leukotriene production and resultant bronchoconstriction

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10/21/201340

DRUG

TRIGGERS

Non Selective Beta2 Blocker - Inderal /

Propanolol

- the beta 2 receptors in the lungs are responsible for relaxation of the bronchial muscle when you take a beta 2 blocker it does the opposite it constricts airways. Used to

rx

migraines, heart disease

- Selective Beta Blockers -

Metoprolol

, Labetalol,

Carvedilol

,

etc

- primary affect Beta 1 receptors in the heart

-Eye drops for Glaucoma

ACE Inhibitors - can induce

cough

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CHEMICAL/MEDICATION ASTHMA TRIGGERS (con

’

t)

Sulfites -sulfur dioxide is a gas that can irritate airways and provoke asthma symptoms

Some preservatives- widely used n wine, beer, & cider, may contain additives in fresh sausages, previously used in salad bars

Most dried fruits (especially dried apricots) are treated with sulfur dioxide

If sensitive, read labels- sodium sulphite, sodium hydrogen sulphite, sodium metabisulphite, potassium metabisulphite, calcium sulphite

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Exercise-Induced Bronchospasm (EIB)EIB should be anticipated in all asthma patients. A history of cough, shortness of breath, chest pain or tightness, wheezing and/or endurance problems during exercise suggests EIB.

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Co-morbid ConditionsIf a patient’s asthma cannot be well controlled, evaluate for the presence of co-morbid conditions.

Evidence suggests that appropriately treated co-morbid conditions can improve asthma control.

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Allergic broncopulmonary Aspergillosis*A Suspect this condition in patients with asthma and a history of pulmonary infiltrates or evidence of IgE sensitization

.

Gastroesophageal reflux disease*

B

Suspect this condition in patients with poorly controlled asthma, particularly at night, even without other suggestive symptoms.

Co-morbid Conditions

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10/21/201345

GASTROESOPHAGEAL

REFLUX DISEASE (GERD)

Present in 50-70% of chronic asthma patients

Proposed trigger mechanisms:

microaspiration

&

vagally

mediated bronchospasm

An asthma episode may be the trigger for GERD - change in pleural pressure gradients, thoracic distension and air trapping

Other triggers for GERD: abdominal obesity, obstructive sleep apnea, asthma meds, exercise, cough

Silent reflux - especially in diabetes

Symptoms: cough, wheezing, sob, water brash, heartburn, chest tightness

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Obesity*B Suggest to asthma patients who are overweight or obese that weight loss may improve asthma control, in addition to improving overall health.

Obstructive sleep apnea*

D

Suggest to asthma patients who are overweight or obese that weight loss may improve asthma control, in addition to improving overall health.

Co-morbid Conditions

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10/21/201347OBESITY IN ASTHMA

Asthma mimic and risk factor for asthma

Lung effects: decreased functional residual capacity (FRC) and expiratory reserve volume (ERV) - decreased airway caliber, increased airway resistance, possible increased airway hyperresponsiveness - overall effect is dyspnea

Pro-inflammatory state that may contribute to lung inflammation and asthma

Necessary to evaluate symptoms with complete PFT, bronchoprovocation studies, IgE levels, etc

Obese patients with asthma require more drugs, are more symptomatic, have an increased risk of ER visits

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10/21/201348

RHINOSINUSITIS

IN ASTHMA

Most common comorbidity associated with asthma -occurs in 78% asthma patients compared to 20% general population

Allergic rhinitis (AR) is a risk factor for asthma, it

’

s presence before 7

yrs

old predicts asthma onset

“

The allergic march

”

progression of allergic disease from nose/sinuses to lung airways

Complications: nasal polyps, sleep apnea, recurrent

rhinosinusitis

,

anosomia

, more severe asthma

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Rhinitis/sinusitis*B Suspect these conditions in patients with asthma; evaluate the possible presence of symptoms.

Stress, depression and psychosocial factors*

D

Suspect these conditions in patients with asthma that is not well controlled. Ask about the potential role of chronic stress or depression in complicating their asthma management .

Pregnancy

Co-morbid Conditions

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10/21/201350

P

REGNANCY

IN

ASTHMA

Rule of 1/3

’

s

Uncontrolled asthma during pregnancy can cause preeclampsia, cesarean delivery, placenta previa, preterm labor, vaginal hemorrhage .Fetus increased risk of low birth weight, intrauterine growth retardation and death

Other pregnancy issues - obesity, gerd, rhinitis

Aggressive Rx of asthma during pregnancy is important

Medications -

- Category B Budesonide, Singulair, Cromolyn, Xolair

Category C - Albuterol, other inhaled CTS, Theophylline, combination products

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10/21/201351 Vocal Cord Disorder

Presents as acute upper airway obstruction with dyspnea, throat tightness, anxiety, wheezing, inspiratory stridor, dysphonia, hoarseness, respiratory distress (retractions may be present), +/or choking

Mimics asthma, but does not respond to asthma meds

May coexist with asthma

Occurs in up to 40% of patients being evaluated for asthma, more freq in females, can occur in conjunction with asthma

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10/21/201352

SUMMARY

OF TRIGGERS

Inhalant Allergies - pollens, molds

Irritants - chemical exposures, cold

air, stomach acid with GERD

School /Occupational Triggers

Respiratory Infections - viral

Food - mostly in children peanuts, sulfites

Drugs - nonselective beta blockers,

ACE inhibitors, ASA, NSAIDS

Strong Emotions

Hormones - premenstrual,

pregnancy???

Strenuous Exercise

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CO-MORBID CONDITION SUMMARYOBESITYGASTROESOPHAGEAL REFLUX DISEASE (GERD)OBSTRUCTIVE SLEEP APNEAVOCAL CORD DYSFUNCTION (VCD)CHRONIC RHINITIS/SINUSITIS

STRESS, DEPRESSION, PSYCHOSOCIAL CONDITIONS

PREGNANCY

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)

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25 yr old Yongcha has been recently seen in the ER for an asthma exacerbation. She has since been diagnosed with moderate persistent asthma and is on appropriate medications for her severity level. She is still experiencing poor asthma control and her provider has referred her to you, the asthma educator to discuss trigger reduction.Yongcha works at a childcare center in downtown Albuquerque and commutes via bus. She recently moved in with her boyfriend. Recently diagnosed, she has a poor understanding of trigger exposure. She is not taking prescription meds for allergies or other comorbid conditions.

Case Study

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Divide into 2 groups. Discuss as a group what information a first meeting would entail. Role play the meetin with one person being the asthma eduucator and the other being Yongcha.Practice describing factors in simple English and determining priorities for intervention.

Case Study Directions

Yongcha

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Acknowledgements Beverly Stewart American Lung Association in Oregon

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