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
Adult

Current
12-Month

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

Asthma Prevalence by Sex

United States, 1980-2007

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

Black
White

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

Asthma Prevalence by Race/Ethnicity

United States, 1997-2007
Black NH

Lifetime

White NH
Hispanic

Current

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

Current Asthma Prevalence for Youth

by Race/Ethnicity, Ages 5-17, 2005-2007
10.1% Overall

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

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

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

Females

Males

Adult and Child Asthma Hospital Discharge

Rates
United States, 1996-2006

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

Children

Adults

Asthma Hospital Discharge Rates

by Race
United States, 1980-2006

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

Black

White
Other

Asthma Mortality Rates by Age

United States: 1979-2005
ICD-9

ICD-10

65 +

35-64
5-9

Source: Underlying Cause of Death; CDC National Center for Health Statistics
* Age-adjusted to 2000 U.S. population

Asthma Mortality Rates by Race

United States: 1979-2005
ICD-9

ICD-10

Black
Other

White

Source: Underlying Cause of Death; CDC National Center for Health Statistics
* Age-adjusted to 2000 U.S. population

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

Sufficient evidence of association

None found

Limited or suggestive evidence of

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

Chemical Agents
Sufficient evidence of causal
relationship
None found

Sufficient evidence of association

Environmental Tobacco Smoke
(among pre-school aged children)

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

Sufficient evidence of an association

Dog
Fungus/Molds
Rhinovirus

Limited or suggestive evidence of

association
Domestic birds
Chlamydia and Mycoplasma pneumonia
RSV

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

Sufficient evidence of
association
NO2, NOX (high levels)

Limited or suggestive evidence of

association
Environmental Tobacco Smoke
(among school-aged, older children,
and adults)
Formaldehyde
Fragrances

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
EPR-3)

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 asthma-multifaceted
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 Control
Follow-up Visits

Asthma Action Plan

Asthma Severity

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

Allergen and Irritant

Exposure Control

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

Physical
Education

1. Management &
Support Systems
6. School, Family,
& Community
Efforts

5. Physical
Education &
Activity
Nutrition
Services

Health
Services
2. Health &
Mental Health
Services

Counseling,
Psychological, and
Social Services

3. Asthma
Education
4. Healthy School
Environment

Healthy School
Environment

Health Promotion
For Staff

Health
Education

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