Asthma

A Presentation on Asthma Management and Prevention

What is Asthma?
Chronic disease of the airways that may cause
Wheezing Breathlessness Chest tightness Nighttime or early morning coughing

Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

Pathology of Asthma
Asthma involves inflammation of the airways
Normal Asthma

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

What is Epidemiology?
The study of the distribution and determinants of diseases and injuries in human populations.

Source: Mausner and Kramer, Mausner and Bahn Epidemiology- An Introductory Text, 1985.

Child and Adult Asthma Prevalence United States, 1980-2007 Lifetime Child 14
12

Adult

Prevalence (%)

10 8 6 4 2 0

Current 12-Month

19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06
Source: National Health Interview Survey; CDC National Center for Health Statistics

Year

Asthma Prevalence by Sex United States, 1980-2007

14 12 Prevalence (%) 10 8 6 4 2 0 Year
19 80 19 82 19 88 19 90 20 00 19 84 19 86 19 92 19 94 19 96 19 98 20 02 20 04 20 06

Female Male

Lifetime

12-Month Current

Source: National Health Interview Survey; CDC National Center for Health Statistics

12-Month Asthma Prevalence by Race United States, 1980-1996

12
Prevalence (%)

10 8 6 4 2 0
19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96

Black White

Year

Source: National Health Interview Survey; CDC National Center for Health Statistics

Asthma Prevalence by Race/Ethnicity United States, 1997-2007

18 16 14 12 10 8 6 4 2 0
7 19 9

Prevalence (%)

Lifetime

Black NH White NH Hispanic

Current

19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07

19 9

Year

Source: National Health Interview Survey; National Center for Health Statistics

Current Asthma Prevalence for Youth by Race/Ethnicity, Ages 5-17, 2005-2007

16 14 12 10 8 6 4 2 0
14.2 9.1

10.1% Overall
10 7.1 10.2

NonHispanicWhite

Asian

Centers for Disease Control and Prevention. National Center for Health Statistics. Health Data Interactive. www.cdc.gov/nchs/hdi.htm. [July 15, 2009].

American Indian / Alaska Native

Non-Hispanic Black

Hispanic

Asthma Disparities Among U.S. Children

Low-income populations, minorities, and children living in inner cities experience more ED visits, hospitalizations, and deaths due to asthma than the general population.1 The burden of asthma falls disproportionately on nonHispanic black, American Indian/Alaskan Native and some Hispanic (i.e., Puerto Rican) populations.2, 3

Lieu TA et al. Racial/Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid. Pediatrics 2002; 109:857865. 2 National Center for Health Statistics. Health data for all ages http://www.cdc.gov/nchs/health_data_for_all_ages.htm. 3 Asthma and Allergy Foundation of America and National Pharmaceutical Council. Ethnic Disparities in the Burden and Treatment of Asthma. Reston, 2005.
1

Population Disparities in Asthma

Current asthma prevalence is higher among
children than adults boys than girls women than men

Asthma morbidity and mortality is higher among

African Americans than Caucasians
Source: MMWR 2007;56(No. SS-8):1-54

Asthma* Hospital Discharge Rates# by Sex United States: 1980-2006

24 22

Rate per 10,000

20 18 16 14 12 10
0 2 4 8 0 2 4 6 8 0 2 4 6 6 98 198 198 198 198 199 199 199 199 199 200 200 200 200 1

Females

Males

Year

Source: National Hospital Discharge Survey, CDC National Center for Health Statistics, * First-listed diagnosis, # Age-adjusted to 2000 U.S. population

Adult and Child Asthma Hospital Discharge Rates United States, 1996-2006
35 30

Rate per 10,000

25 20 15 10 5 0
9 19 6 7 8 1 2 3 5 6 9 0 4 99 199 199 200 200 200 200 200 200 200 1

Children

Adults

Year

Source: National Hospital Discharge Survey, CDC National Center for Health Statistics ,* First-listed diagnosis, # Age-adjusted to 2000 U.S. population

Asthma Hospital Discharge Rates by Race United States, 1980-2006

45 40

Rate per 10,000

35 30 25 20 15 10 5 0
0 2 4 6 8 0 2 4 6 8 0 2 4 6 9 8 19 8 19 8 19 8 19 8 19 9 19 9 19 9 199 19 9 20 0 200 20 0 200 1

Black

White Other

Year

Source: National Hospital Discharge Survey, CDC National Center for Health Statistics, * First-listed diagnosis, # Age-adjusted to 2000 U.S. population

Asthma Mortality Rates by Sex, United States: 1979-2005

ICD-9
30 Rate per million 25 20 15 10 5 0
19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04
Source: Underlying Cause of Death; National Center for Health Statistics * Age-adjusted to 2000 U.S. population

ICD-10

Female

Male

Year

Asthma Mortality Rates by Age United States: 1979-2005

ICD-9
100 Rate per million 80 60 40 20 0
5-9
19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04
Source: Underlying Cause of Death; CDC National Center for Health Statistics * Age-adjusted to 2000 U.S. population

ICD-10

65 +

35-64

Year

Asthma Mortality Rates by Race United States: 1979-2005

ICD-9
60 Rate per million 50 40 30 20 10 0
19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04
Source: Underlying Cause of Death; CDC National Center for Health Statistics * Age-adjusted to 2000 U.S. population

ICD-10

Black Other

White

Year

Risk Factors for Developing Asthma

Genetic characteristics Occupational exposures Environmental exposures

Risk Factors for Developing Asthma: Genetic Characteristics Atopy

The bodys predisposition to develop an antibody called immunoglobulin E (IgE) in response to exposure to environmental allergens Can be measured in the blood Includes allergic rhinitis, asthma, hay fever, and eczema

Risk Factors for Developing Asthma: Environmental Exposure

Clearing the Air: Asthma and Indoor Air Exposures
http://www.iom.edu (Publications) Institute of Medicine, 2000 Committee on the Assessment of Asthma and Indoor Air Review of current evidence about indoor air exposures and asthma

Clearing the Air: Categories for Associations of Various Elements

Sufficient evidence of a causal relationship Sufficient evidence of an association Limited or suggested evidence of an association Inadequate or insufficient evidence to determine whether an association exists Limited or suggestive evidence of no association

Clearing the Air: Indoor Air Exposures & Asthma Development

Biological Agents
Sufficient evidence of causal relationship
House dust mite

Chemical Agents
Sufficient evidence of causal relationship
None found

Sufficient evidence of association

None found

Sufficient evidence of association

Environmental Tobacco Smoke (among pre-school aged children)

Limited or suggestive evidence of association

Cockroach (among pre-school aged children) Respiratory syncytial virus (RSV)

Limited or suggestive evidence of association

None found

Clearing the Air: Indoor Air Exposures & Asthma Exacerbation

Biological Agents
Sufficient evidence of causal relationship
Cat Cockroach House dust mite

Chemical Agents
Sufficient evidence of causal relationship
Environmental tobacco smoke (among pre-school aged children)

Sufficient evidence of association

NO2, NOX (high levels)

Sufficient evidence of an association Limited or suggestive evidence Dog of association

Fungus/Molds Rhinovirus Environmental Tobacco Smoke (among school-aged, older children, and adults) Formaldehyde Fragrances

Limited or suggestive evidence of association

Domestic birds Chlamydia and Mycoplasma pneumonia RSV

Reducing Exposure to House Dust Mites

Use bedding encasements Wash bed linens weekly Avoid down fillings Limit stuffed animals to those that can be washed Reduce humidity level (between 30% and 50% relative humidity per EPR3)

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Reducing Exposure to Environmental Tobacco Smoke

Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults.

Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.

Reducing Exposure to Cockroaches

Remove as many water and food sources as possible to avoid cockroaches.

Reducing Exposure to Pets People who are allergic to pets should not have them in the house. At a minimum, do not allow pets in the bedroom.

Reducing Exposure to Mold

Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations.

Other Asthma Triggers

Air pollution Trees, grass, and weed pollen

Clinical Management of Asthma

Expert Panel Report 3 National Asthma Education and Prevention Program National Heart, Lung and Blood Institute, 2007

Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

2007 NAEPP EPR-3

Treatment recommendations based on:
Severity Control Responsiveness

Provide patient self-management education at multiple points of care Reduce exposure to inhaled indoor allergens to control asthmamultifaceted approach
Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

What is GIP?
Guidelines Implementation Panel Report for Expert Panel Report 3 Recommendations and strategies to implement EPR-3 Six key messages

Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf

GIPs Six Key Messages

Inhaled Corticosteroids Asthma Action Plan Asthma Severity Allergen and Irritant Exposure Control Asthma Control Follow-up Visits

Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf

Diagnosing Asthma: Medical History

Symptoms
Coughing Wheezing Shortness of breath Chest tightness

Symptom Patterns Severity Family History

Diagnosing Asthma
Troublesome cough, particularly at night Awakened by coughing Coughing or wheezing after physical activity Breathing problems during particular seasons Coughing, wheezing, or chest tightness after allergen exposure Colds that last more than 10 days Relief when medication is used

Diagnosing Asthma
Wheezing sounds during normal breathing Hyperexpansion of the thorax Increased nasal secretions or nasal polyps Atopic dermatitis, eczema, or other allergic skin conditions

Diagnosing Asthma: Spirometry

Test lung function when diagnosing asthma

Medications to Treat Asthma

Medications come in several forms. Two major categories of medications are:
Long-term control Quick relief

Medications to Treat Asthma: Long-Term Control

Taken daily over a long period of time Used to reduce inflammation, relax airway muscles, and improve symptoms and lung function
Inhaled corticosteroids Long-acting beta2-agonists Leukotriene modifiers

Medications to Treat Asthma: Quick-Relief

Used in acute episodes Generally shortacting beta2agonists

Medications to Treat Asthma: How to Use a Spray Inhaler

The health-care provider should evaluate inhaler technique at each visit.

Source: What You and Your Family Can Do About Asthma by the Global Initiative for Asthma Created and funded by NIH/NHLBI

Medications to Treat Asthma: Inhalers and Spacers

Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication.

Medications to Treat Asthma: Nebulizer

Machine produces a mist of the medication Used for small children or for severe asthma episodes No evidence that it is more effective than an inhaler used with a spacer

Managing Asthma: Asthma Management Goals

Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

Managing Asthma: Asthma Action Plan

Develop with a physician Tailor to meet individual needs Educate patients and families about all aspects of plan
Recognizing symptoms Medication benefits and side effects Proper use of inhalers and Peak Expiratory Flow (PEF) meters

Managing Asthma: Sample Asthma Action Plan

Describes medicines to use and actions to take

National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.

Managing Asthma: Peak Expiratory Flow (PEF) Meters

Allows patient to assess status of his/her asthma Persons who use peak flow meters should do so frequently Many physicians require for all severe patients

Managing Asthma: Peak Flow Chart

People with moderate or severe asthma should take readings:
Every morning Every evening After an exacerbation Before inhaling certain medications
Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma Created and funded by NIH/NHLBI

Managing Asthma: Indications of a Severe Attack

Breathless at rest Hunched forward Speaks in words rather than complete sentences Agitated Peak flow rate less than 60% of normal

Managing Asthma: Things People with Asthma Can Do

Have an individual management plan containing
Your medications (controller and quick-relief) Your asthma triggers What to do when you are having an asthma attack

Educate yourself and others about

Asthma Action Plans Environmental interventions

Seek help from asthma resources Join an asthma support group

A Public Health Response to Asthma

A call to action for organizations and people with an interest in asthma management to work as partners in reducing the burden of asthma within our nations communities.

A Public Health Response to Asthma: Surveillance

Over time
How much asthma does the population have? How severe is asthma across the population? How well controlled is asthma in the population? What is the cost of asthma?

A Public Health Response to Asthma: Uses of Surveillance Data

Basis for planning and targeting intervention activities Evaluating intervention activities

A Public Health Response to Asthma Education

Education programs can be targeted to:
People with asthma Parents of children with asthma Medical care providers School staff Public

A Public Health Response to Asthma: Coalition

Successful asthma campaigns need the cooperation of committed partners.

A Public Health Response to Asthma: Advocacy

Asthma needs to be addressed comprehensively by multiple government and non-government agencies.

A Public Health Response to Asthma: Interventions

Medical management Education Environment Schools

A Public Health Response to Asthma: Medical Management Interventions

Ensure people with asthma know about their disease and are empowered to demand appropriate management

A Public Health Response to Asthma: Environmental Interventions

Help people create and maintain healthy home, school, and work environments. Environmental interventions may consist of: Assessments to identify asthma triggers Education on how to remove asthma triggers Remediation to remove asthma triggers

A Public Health Response to Asthma: School Intervention Science-Based Guidance

Management and support systems Health and mental health services Asthma education for students, staff, and parents Healthy school environment Physical education and activity School, family, and community efforts
Source: www.cdc.gov/HealthyYouth/asthma/strategies

Key Aspects
Require team effort Coordinate health, including mental and physical health, education, environment, family, and community efforts Assess needs of school and prioritize (every action step is not feasible to every school or district) Focus on students with frequent asthma symptoms, health room visits, and absenteeism

Family/Community Involvement

1. Management & Support Systems 6. School, Family, & Community Efforts 2. Health & Mental Health Services

Health Services

Physical Education

Counseling, Psychological, and Social Services

5. Physical Education & Activity Nutrition Services 4. Healthy School Environment

3. Asthma Education

Health Education

Healthy School Environment

Health Promotion For Staff

A Public Health Response to Asthma: School

A leading chronic disease cause of school absence Common disease addressed by school nurses Affects teachers, administrators, nurses, coaches, students, bus drivers, after school program staff, maintenance personnel

On average, 3 children in a classroom of 30

are likely to have asthma.*

*

Epidemiology and Statistics Unit. Trends in Asthma Morbidity and Mortality. NYC: ALA, July 2006.

A Public Health Response to Asthma:

What can make asthma worse in the school?
Mold and mildew Animals in classroom Carpeted classrooms Cockroaches Poor air quality

Asthma-Friendly School DVD and Toolkit

Objectives
Personal stories to relate to viewer Aspects of an asthma-friendly school Six strategies for addressing asthma in a coordinated school health program Potential impact of asthmafriendly schools

A Public Health Response to Asthma: School Actions

Establish policies and procedures to support children with asthma. Keep students asthma action plans at the school. Make medications available
During school hours Before physical activity and sports During before- and after-school programs On field trips or when away from campus

Train school staff to recognize signs of an asthma attack and to use appropriate medications.

A Public Health Response to Asthma: Evaluation The systematic investigation of the structure, activities, or outcomes of asthma control programs.
Are we doing the right thing?

Are we doing things right?

Benefits of Program Evaluation

Evaluations help asthma programs
Manage resources and services effectively Understand reasons for current performance Build capacity Plan and implement new activities Demonstrate the value of their efforts Ensure accountability

Using Evaluation to Improve Programs

Highlight effective program components
Recognize achievements Replicate successes

Assess and prioritize needs Target program improvements Advocate for the program

Framework for Program Evaluation

A Public Health Response to Asthma: Summary

Asthma is a complex disease that is not yet preventable or curable. Asthma can be managed with medication, environmental changes, and behavior modifications. By working together, we can ensure that people with asthma enjoy a high quality of life.

Resources
National Asthma Education and Prevention Program
http://www.nhlbi.nih.gov/about/naepp/

Asthma and Allergy Foundation of America

http://www.aafa.org

American Lung Association

http://www.lungusa.org

American Academy of Allergy, Asthma, and Immunology

http://www.aaaai.org

Allergy and Asthma Network/Mothers of Asthmatics, Inc.

http://www.aanma.org

Resources
American College of Allergy, Asthma, and Immunology
http://www.acaai.org

American College of Chest Physicians

http://www.chestnet.org

American Thoracic Society

http://www.thoracic.org

The Centers for Disease Control and Prevention

http://www.cdc.gov/asthma