Children’s Project ECHO: School Health · ASTHMA: TAKE ACTION. TAKE CONTROL. WHAT IS ASTHMA? If you have asthma, the tubes that bring air into the tiny air passages in your lungs

Children’s Project ECHO: School Health

Asthma and Food Allergy

Rachel Shirk, RRT, AE-C, Respiratory Care Manager

Mark C. Wilson, MD

Pulmonary, Allergy & Sleep Medicine

Children’s Hospital & Medical Center

November 20, 2019

Presenter Disclosures

Consultant/

Speakers bureaus

Shirk: No Disclosures

Wilson: employed physician seeing asthma and allergy patients

Research funding No Disclosures

Stock ownership

Corporate boards-

employment

No Disclosures

Intellectual property Slide themes used with permission

Mary Hart, Asthma and Allergy Network

Dr. Russell Hopp, Allergy/Immunology, CHMC, UNMC, CUSOM

Off-label uses budesonide/fomoterol as monotherapy and rescue

(new GINA guidelines)

Overview & Learning Objectives

• Understand school nurse challenges (from you) • Define asthma symptoms & triggers for school staff • Review asthma medications and goals of medications • Review the impact of food allergies and top food

allergens • Review the signs and symptoms and treatment of

anaphylaxis • Understand optimal inhaled medication delivery

School nurse: all things to all people

• Loyalties to students, parents, administrators

• Increasing responsibilities with limited resources

• Challenges: fractured families, substance abuse, food insecurity, digital device distraction, obesity, medication explosion, student turnover

• ‘when you can’t breathe, nothing else matters’

On any given day . . .

Riley, a middle school student, tells you that he took his inhaler, but his chest still feels tight

A 2nd grade student

named Bianca appears quieter than usual and you notice hives around her mouth and her lips appear to be swelling

Are you and your school staff prepared to respond

to these emergent situations?

What’s happening in asthma airways?

INFLAMMATION creates

OBSTRUCTION

Airways are swollen

Muscles around airways spasm

Excess mucus blocks airway

Asthma Triggers

Viral respiratory infections, sinusitis

Irritants –smoke, odors, exercise, cold air, weather change

Allergens – mites, dander, roach, mold, pollen, food

Drugs – sulfites, aspirin/NSAIDs, propranolol (beta blockers)

Strong emotions – laughing, anger

Gastric reflux disease – GERD

Goals of Asthma Medications

•Prevent and control asthma symptoms

•Reduce the frequency and severity of asthma flares

•Reverse airflow obstruction

•Prevent the progression of asthma and the development of irreversible airway disease

Asthma medication overview

Short-acting inhaled beta2agonists

SABA

Anticholinergics

ipratropium

tiotropium

Corticosteroids

Inhaler and oral

Long-acting beta2agonists

LABA

Leukotriene modifiers

montelukast LTRA

Biologics

Monoclonal antibodies

Quick Relief Long Acting

Asthma management in school

CHRONIC

• Doctor/provider driven

• Pediatric asthma under-appreciated

• Variable knowledge, interest, education

• Compliance is major deterrent to a calm school year

ACUTE

• Driven by Asthma Action Plan and by Rule 59

• Relies on provider assistance (Rx, plan)

• Relies on parental assistance (Rx, plan)

• Nurse observation & provider relationship helpful

ASTHMA

OBESITY

NORMAL EXERTIONAL

DYSPNEA

VOCAL CORD

DYSFUNCTION

Vaping

Confounding overlapping problems

GER

Pediatric VCD

• Female predominance among children and adolescents.

• Triggered by uncomfortable situation and most commonly exercise

• Inspiratory dyspnea with audible noise

• Confused with exercise-induced asthma.

• Gastric reflux disease (GERD) and psychiatric illness may be associated.

• Often coexists with asthma. Suspect when asthma treatment fails

• Albuterol in some form • Metered dose inhaler (MDI)

and valved holding chamber (VHC) preferred

• Provider/parent responsible for Rx, delivery device, and Asthma/Allergy Action Plan (AAP)

• Fall back to Rule 59 when albuterol not available

Stock albuterol

Saves Lives!

When to seek help

Call Ambulance:

Breathing hard & fast

Having trouble walking or talking

Bluish lip or finger beds

Call Parent:

Unplanned inhaler use

Symptoms near end of school day

Wheezing, repetitive tight cough after inhaler use

Student report that chest feels tight

Whenever you or the student are worried!

Allergies impact the lives of children home and at school

Environmental Allergies Allergic rhinitis – “Hayfever” Dust mites Animal dander Pollen Mold

Insect Venom Allergies May see the first time a child

experiences an insect sting reaction

Can be life-threatening

Medication / Latex Allergies Medications usually given at

home first Latex allergies rare

Food Allergies 1 in 12 children have food

allergies 150 – 200 fatalities per year

from food allergies

Food & anaphylaxis

• Food allergy increasing

• Anaphylaxis estimated 30 cases per 100,000

children per year

Up to 5% of the US population has suffered anaphylaxis.

Independent of race

Boys more common until 15 years

• Morbidity Co-existing asthma can intensify an

anaphylactic event

Most episodes in children with known food allergy (preventable)

Fatal outcome is rare

Fatalities usually away from home

Top 8 Food Allergens + Sesame

Allergy evaluation: skin tests & blood tests

Allergy spectrum: mild to life-threatening

localized reaction one system itching, watery eyes runny nose, sneeze cough, wheeze few hives in one area

child KNOWS something is wrong

sudden onset more than one body

system serious impaired breathing low blood pressure

Mild Reaction Anaphylaxis

Hives vs anaphylaxis

Antihistamine or Epinephrine?

Benadryl, Claritin, etc.

May be given for mild allergies

Often treatment of choice for environmental allergies

The ONLY treatment for anaphylaxis

Epinephrine FIRST, Epinephrine FAST

CALL 911 when epinephrine needed

Antihistamine Epinephrine

Anaphylaxis

May begin in seconds after exposure, may be hours

Lay down

Epinephrine First, Epinephrine FAST!

Delayed epinephrine and non-supine posture associated with fatal outcome

• Use current Action Plans • Download from AIRE

Nebraska Site • http://www.airenebraska.org • Rule 59 (Nebraska)

• Epinephrine in school • Training of staff

• Epinephrine FIRST and FAST • increases blood pressure • bronchodilates

Anaphylaxis plan

School epinephrine by state

State has law/guideline allowing school stock epinephrine

State has law/ guideline requiring school stock epinephrine

State has pending legislation

Avoiding anaphylaxis in school Oral: saliva, food, sharing

No food sharing

No unlabeled food

Non food celebrations

Skin: touch eye/mouth/nose

Read labels for paste/paint/clay

Clean skin with soap & water or wipes. Avoid hand sanitizer

Inhalation: aerosolized protein

Avoid food in classroom

Parental: exposure before school

Allergy shot, med injection

Goals: prevention & appropriate care

We need to be prepared to care for children like Riley & Bianca

We need to work together – Be prepared Know symptoms Have a plan

Be a champion for the

children that you care for!

Emergency Preparedness

Even with best prevention strategies asthma flares & allergy exposures happen

Whole organization needs to be prepared

Nurse/health aide/teacher team

Standard education

Understanding of Rule 59 (Nebraska)

Availability of child records/meds

Plan specific to each student

Summary

• Food allergy is common • 10%

• Anaphylaxis uncommon and rarely fatal

• Rule 59 is well established

• Partnership is key

• Asthma common • 10 to 15%

• Under recognized, under treated, and under estimated by providers, parents, and patients

• Albuterol, when needed is generally effective

• Action plans and Rule 59 have been successful

• Partnership is key

Inhaled asthma medications

Metered dose inhalers (MDI) – preferred for kids

Ozone friendly HFA propellants

Deliver with valved holding chamber (VHC)

Smaller particle size

Rare generics

Breath actuated MDIs emerging, may be more expensive

Dry powdered inhalers

Different inhalation technique

Larger particle size

Nebulizer

Larger particle size

High dose shared with environment

Short acting bronchodilators

• PRN for every asthmatic

• 2 to 4 puffs every 4 hrs prn for cough, wheeze, chest tightness, or as exercise pretreatment

• Call if needed more than a puff an hour

• Rx labeled for school

• albuterol • Ventolin HFA • Ventolin Diskus • Proventil HFA • ProAir HFA • ProAir RespiClick • nebulizer solution

• levalbuterol • Xopenex HFA & nebulizer

• Counter optimal

Inhaled corticosteroids

• Persistent asthmatics

• Long term use to minimize symptoms

• HFA 1 to 2 puffs once or twice a day

• Should be used at home

• fluticasone • Flovent HFA or Diskus

• mometasone • Asmanex HFA or Twisthaler

• budesonide • Pulmicort Flexhaler

• beclomethasone • Qvar HFA or RediHaler

• ciclesonide • Alvesco aerosol

Combination inhalers

• Persistent asthmatics

• Long acting bronchodilator (LABA) and corticosteroid (ICS)

• HFA: 2 puffs twice a day. Use at home

• May have role as rescue

• fluticasone/salmeterol • Advair HFA and Diskus

• budesonide/fomoterol • Symbicort HFA

• mometasone/fomoterol • Dulera HFA

Inhaled Rx delivery

• Asthma meds safer, more effective

• But expensive & few or no generics

• Most use inhaler incorrectly

• One technique desirable for kids

Metered dose inhaler (MDI)

Valved holding chamber (VHC) or ‘spacer’

Valved holding chamber for all

Easier coordination

Traps and maximizes delivered dose

Enhances consistency

Minimizes bad taste

Mask for younger patients

Optimal technique

• Stand

• Shake inhaler and place in VCH

• Breathe in and out and pause

• Actuate inhaler followed by a

• Slow deep breath all the way in over 5 secs

• Hold breath IN for 5 to 10 seconds

• Exhale and relax

• Wait one minute between puffs

• Smaller children Mask

Actuate inhaler. Breathe in and out for 10 to 15 secs OR 6 breathes

Watch for valve to open and close

• Rinse and spit after steroid inhalers

Self injecting adrenaline devices

• Emergency use IM or SQ • Lateral thigh • Can inject through clothes

• Options • EpiPen • Auvi-Q • Adrenaclick

• Twin packs • 0.10 mg up to 15 kg (Auvi-Q) • 0.15 mg up to 30 kg • 0.30 mg over 30 kg

• Repeat in 5 minutes prn • Expensive, outdates

Subcutaneous or intramuscular injection

Self-injecting adrenaline devices

• Train designated staff

• Severe asthma & anaphylaxis

• Rule 59 (Nebraska) • Mandates availability

• Protects staff

Resources

• Asthma Allergy Network. Recommended videos for education and demonstration

https://www.youtube.com/playlist?list=PLC39F35D440D0F155&feature=view_all

• National Jewish Health good videos, good vaping resource

https://www.nationaljewish.org/home

• FARE – Food Allergy Research & Education https://www.foodallergy.org

• AIRE Nebraska Asthma & Anaphylaxis action plans, Rule 59 protocol

http://www.airenebraska.org

• Nebraska asthma coalition website https://nebraskaasthmacoalition.org

• American College of Allergy, Asthma, and Immunology https://acaai.org

• American Academy of Allergy, Asthma, and Immunology https://www.aaaai.org

Messages for Younger Students

What students and staff need to know!

ASTHMA: TAKE ACTION. TAKE CONTROL.WHAT IS ASTHMA?If you have asthma, the tubes that bring air into the tiny air passages in your lungs get too tight, which makes it hard to breathe. When you have trouble breathing, you could be having an asthma fare.

u You feel symptoms of asthma 2+ times a week

u Your asthma wakes you up 2+ times a month

u You run out of quick-relief medicine 2+ times a year

YOUR ASTHMA MIGHT BE DIFFICULT TO CONTROL IF:

To learn more about managing your asthma symptoms, visit chestnet.org/asthma and AllergyAsthmaNetwork.org/asthma

DID YOU KNOW?

A good asthma action plan means you should be able

to do everyday activities without any problems breathing

Walking Sleeping Playing Outside

YOU MIGHT... BECAUSE OF...

Smoke or dirty air

Hard exercise

Allergens in the air

Feeling very happy or very sad

ZZ

ZZ

ZZ

ZZ

ZZ

ZZ

Have trouble breathing

Feel squeezing in your chest

Have coughing or wheezing fts

Feel tired

ZZ

Z

ZZ

Z

ZZ

Z

ZZ

Z

TAKE ACTION Many different triggers can cause an asthma fare. You should learn about the things that make you sick so you can stop an asthma fare before it happens.

TAKE CONTROL

Practice your action plan with your caregivers.

Asthma shouldn’t hold you back! If you still have trouble breathing, talk to your doctor or caregivers.3 41

Your doctor can help you make an Asthma Action Plan so you won’t have as many asthma fares.

Tell your doctor or caregiver when it’s hard to breathe.

2

This asthma awareness campaign is supported in part by grants from Boehringer Ingelheim and GlaxoSmithKline.

Messages for Older Students

Build an empowered student!

Children's Project ECHO: School Health - ECHO ID#SH2019-003

School Nurse or Provider Information Name Ashley DeBrie BSN, RN, NCSN School/Clinic/Facility Name Lincoln Public Schools ECHO ID#SH2019-003 Age 13 Gender Female Patient Race White Patient Ethnicity NOT Hispanic or Latino Current medications and allergies: Dulera - 2 puffs BID Spiriva - 2 puffs once/day Asmanex - 2 puffs once/day Zyrtec - once/day Singulair - once/day Combivent - 2 puffs q 4 h prn Auvi-Q - prn anaphylactic reaction What is your concern or goal for this case presentation? The goal of this presentation is to highlight the importance of Care Coordination, part of the framework for 21st Century School Nursing Practice by the National Association of School Nurses, and the specific facets of Care Coordination and how they play a role in this student's chronic illness and overall health. History History of presenting problem: Student transferred from another middle school within district. In reviewing file, student has diagnoses of severe persistent asthma, multiple food allergies, including anaphylaxis. Upon receiving health record, it was noted that student had a self-carry contract on file for her inhaler. A self-carry in our district means that a student may keep their necessary medication with them after a signed agreement is made between the student, parent, medical provider, school nurse, and teacher/principal. The student also had a written physicians order to be out of physical education indefinitely.

Children's Project ECHO: School Health - ECHO ID#SH2019-003

The student also has a medical statement for a prescribed diet to avoid milk/dairy and egg, but these foods are not deemed to be life-threatening. Parent states that she is letting student self-monitor the intake of these foods and "if she does not feel well because of it, she will learn". In continuing to review the file, the previous school nurse had revoked the self-carry due to concerns that student was having a hard time understanding how often to use inhaler and used or requested it too often. To-date the student has been in the health office at least 49 times with breathing problems during her middle school career. On the second day of school, I sat down for health counseling with the student to 1) establish a relationship and 2) assess how well the asthma has been controlled. The first two weeks of school this year, the student needed rescue inhaler four times, one time in which parent came to pick up due to no relief from inhaler. Upon one of my first assessments when student had breathing issues, she presented with bilateral wheezes heard on both inspiration and expiration and verbalized chest tightness. She did not appear to be in distress but appeared anxious. As student went to use the Combivent inhaler, we utilized a disposable spacer. Verbal instruction and demonstration was done prior to the student using her inhaler. The student continued to struggle with the inhaler and spacer technique. Continued assessments of mine when the student was requesting her inhaler most of the time revealed either wheezes and/or decreased air movement. Typically the right side of her chest either had more wheezes or decreased lung sounds when it was present. The student has needed her rescue inhaler 13 times during first quarter and had 21 health office visits, or the equivalent of almost one school day. During second quarter, student has only needed inhaler two times in last month of school. I have had multiple contacts with mother at this time, highlighting the importance of student needing to take her daily medications, concern about right side always sounding worse than left, and multiple requests for mom to complete release of information to partner with the medical provider. Student reports that she was only taking her daily preventative medications when she was having problems with her asthma. Between her IEP manager, parent, and myself, we created a system with student's academic planner where mom had to sign off that student took her daily medications in the AM and the PM and then she could pick rewards in the teacher's classroom. The student was also seeking out the health office during class time for other various reasons throughout the day. Using our district-wide and school's multi-tiered systems of support, the student began to do informal check-ins in the health office daily before school and at noon. We worked on relationship building and could also provide education and reinforcement of daily asthma medications. The student also developed a positive peer relationship through this. As a member of student's interdisciplinary team, we discussed at her recent IEP meeting this month the goal for her to become independent in using her inhaler successfully with a spacer, without cues, as she is getting ready to transition to high school next year. She will be in a bigger building and the self-carry contract will be essential for her to have. Pertinent past medical history: Severe-Persistent Asthma. Different rescue medications tried and failed for asthma, including albuterol inhaler that at one time was prescribed to be given 2 puffs every 20 minutes if needed.

Children's Project ECHO: School Health - ECHO ID#SH2019-003

History of food allergies including: carrots, peanut, tree nuts, squash, green bean, dairy, barley, soy, bananas, egg. Risk for anaphylaxis. Eczema. Student-School Information Current school grade 8 School Performance Acceptable Is the student on any of the following individual plans? Allergy-anaphylaxis plan Asthma action plan IEP Family History Primary caregiver Biological mother With whom does the patient live? Mother and siblings Previous Trauma Older sibling sent to separate behavior school out of home. Is there anything else the HUB team should know to provide feedback and considerations? I want to highlight the pillar of care coordination from the NASN Framework for the 21st Century School Nursing Practice. I feel like this particular case study demonstrates many of the facets within care coordination including: case management, chronic disease management, collaborative communication, direct care, education, interdisciplinary teams, motivational interviewing/counseling, student care plans, student-center care, student self-empowerment, and transition planning.