Allergic Rhini s
Dr. Larry Smith, MD Allergic Rhini s Defini on
Defined as inflamma on of the nasal mucosa characterized by two or more of the following symptoms: – nasal conges on – anterior/posterior rhinorrhoea – sneezing – itchy nose
Introduc on Allergic Rhini s
occurs when these nasal symptoms are the result of IgE-mediated inflamma on following exposure to an allergen
Prevalence
400 million suffers worldwide > 20% of popula on in US All ages are affected, peaks in teens Boys more affected than girls but equalizes a er puberty ALLERGIC RHINITIS and ASTHMA
• 30% of pa ents with AR have asthma • The majority of pa ents with asthma have AR • AR is a major risk factor for poor asthma control • All pa ents with AR should be assessed for asthma
ALLERGIC RHINITIS AND OTHER COMORBIDITIES • Up to 80% of pa ents with bilateral chronic sinusi s have AR • O s media • Conjunc vi s • Lower respiratory tract infec ons • Dental problems – malocclusion, discolora on • Sleep disorders
ALLERGIC RHINITIS AND ITS IMPACT ON QUALITY OF LIFE In USA 2 million school days lost per year 4 million work days lost per year 28 million impaired work days
ALLERGIC RHINITIS (ARIA)
Intermi ent Persistent symptoms symptoms < 4 days per week > 4 days per week and > 4 weeks Mild Or < 4 weeks Moderate-severe one or more items Normal sleep. Normal daily Abnormal sleep. ac vi es. Impairment of daily Normal work and ac vi es, sport, leisure. school. Problems caused at No troublesome school or work. symptoms. Troublesome symptoms.
DIAGNOSIS • History and Examina on • Skin prick test • Radioallergoabsorbent tests for specific IgE (RAST) • (Nasal allergen challenge)
TREATMENT
• EDUCATION/ALLERGEN AVOIDANCE • PHARMACOTHERAPY • IMMUNOTHERAPY • SURGERY • Others – Nasal douching
IMMUNOTHERAPY • Involves repeated administra on of an allergen extract to induce a state of immunological tolerance • More effec ve in limited spectrum of allergies in par cular seasonal pollen allergy • Severe symptoms failing to respond to usual Px • Subcutaneous injec on/sublingual route • Studies indicate that 3 years therapy necessary
ARIA RECOMMENDATIONS • Topical cor costeroids and oral an histamines (non-seda ng) form the mainstay of treatment • The newer topical steroids e.g. Mometasone furoate and Flu casone propionate were highest recommended • Other drugs should only be considered as second-line treatment • Immunotherapy in selected pa ents can be highly effec ve.
SPECIAL CIRCUMSTANCES PAEDIATRIC ALLERGIC RHINITIS • 4 years and older should be treated as for adults • Children (>4) with AR and Asthma can be treated with combina on of newer genera on topical and inhaled cor costeroids with low risk of complica ons • Diagnosis in smaller children is difficult as can have up to 6 to 8 colds per year • Small children – oral an histamines, saline sprays and cor costeroids if symptoms severe • > 2 years fortunately rare
Bringing Diabetes to School
Regional School Health Conference July 27, 2017
Evan Los, MD East Tennessee State University Pediatric Endocrinology Mountain States Medical Group Disclosures
• No financial conflicts of interest to disclose Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and pi alls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• Ques ons Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and pi alls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• Ques ons Diabetes is a team sport
• High burden of disease management placed on child/family
• Requires advanced planning for basic tasks: ea ng, physical ac vity
• Can complicate rou ne illnesses
• Life experience with diabetes influenced by family dynamics, socioeconomics, coping skills Diabetes at school: Student role
• Depends on developmental stage
• Expect to par cipate in (and contribute to) school care plan
• Take diabetes seriously but don’t use it as an excuse • Show up ready to learn like everyone else • Treat your low and get back to class • If struggling, ask for help Diabetes at school: Family role
• Par cipate in and formulate school care plan with RN • Discuss frequency of BG checks, whether/when parent wants to be no fied, remote monitoring*
• Provide all necessary supplies including low treatments and snacks
• Listen to your feedback Diabetes at school: Medical provider role
• Provide “school orders” direc ng the diabetes care of each student
• Update orders as needed
• Be available as resource if orders unclear or do not address situa on
Diabetes at school: RN role
Diabetes at school: RN role
Use your excellent training to provide and direct the hands-on care of students with diabetes at school while naviga ng the requests of students, parents, school administra on and medical providers. “School orders”
• Please don’t send extra school orders for us to fill out, if possible Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and pi alls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• Ques ons Typical schoolday pa erns
• Arrive at school
• If breakfast at school: check BG, dose insulin, eat
• +/- mid-morning snack
• At lunch: check BG, dose insulin, eat
• +/- extra BG checks per student/family request (PE, before ge ng on bus, etc., and with sx of low BG
• Depart school Supplies
• My preference: Student keeps all supplies with them all the me • BG meter, strips, lancets, ketos x, glucagon, low supplies, insulin, syringes/pens/pump, CGM • Sharps need to be safely disposed of Glucagon
• I think all school nurses, teachers of students with diabetes should know how to give glucagon • Probably PE teachers, recess monitors and sports coaches too Legal stuff (from a non-lawyer)
Tennessee Virginia Can school staff (not medical professionals) administer insulin? Yes Yes Can school staff (not medical professionals) administer glucagon? Yes Yes Can students self-manage diabetes at school? Yes Yes Can students carry all supplies with them at all mes? Yes Yes Legal stuff, con nued
Must a school provide a trained school staff member while students par cipate in field trips and extracurricular ac vi es? Yes. Failure to provide this care would exclude students from these ac vi es for safety reasons. Schools are required to provide needed care to ensure a student's full and safe par cipa on in school-sponsored ac vi es.
Who is responsible for training school staff? The school is responsible for providing appropriate training to school staff.
‘Safe at School’ training materials available on American Diabetes Associa on website. Bus drivers?
• Some states have clear policies recognizing bus drivers as school officials who are responsible for providing medical care to students • Most states are either vague or have no specific regula ons • American Diabetes Associa on clearly supports the training of bus drivers in the basics of diabetes care including glucagon use • Strong legal protec ons for school officials who help “in good faith” Ketones
• A sign the body is burning fat instead of carbs for energy • Why? Not enough insulin, not enough carbs, body stress (e.g. illness, menses)
• Some kids get ketones more frequently than others
• Some kids get ketones a lot • Usually this means a student is missing insulin doses on a regular basis Ketones - con nued
• Trace-small • Assess for causes, no fy family • Give water, more frequent BGs/insulin/carbs/ketone checks • May be able to go back to class • Moderate-large • Assess for causes, no fy family • Give water, more frequent BGs/insulin/carbs/ketone checks • Will need extra insulin doses – no fy family; if needed, no fy provider • Probably won’t feel well enough to go back to class (but might) • If vomi ng, heavy breathing, altered mental status; likely need to go to ED Extra insulin/Dose stacking
• Scenario: It’s 10:30am, BG 319 mg/dL, lunch is at 12:00. Tummyache.
• Ask what last BG was. If >300 or unknown, check ketones. • If ketones +, no fy family (and if needed, no fy provider); will need insulin • If ketones -, have a choice:
• Don’t give extra insulin. Check again at lunch, follow usual plan. • Give high BG correc on if >3 hours since last insulin. Check BG at lunch; cover carbs but DON’T give high BG correc on. (<3 hours since last dose)
Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and pi alls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• Ques ons Diabetes technology CGM - now Diabetes technology – what’s coming Technology in school: My recommenda ons
• Student, parent, RN and teachers all need to have same understanding of what technology is present and who’s in charge (include in 504 plan) • CGM: • Lows should be treated based on fingers ck • OK to dose insulin using CGM number if part of school orders; fingers ck preferred • If parents want CGM “trend arrows” to be a part of school orders, they should go through provider • Device problems: • Troubleshoo ng a device is up to the student and parent • If not resolved, contact device helpline • We usually respond in couple hours; device errors usually can’t wait that long Device burden Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and pi alls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• Ques ons Ques ons
MSMG Pediatric Diabetes Evan Los, MD George Ford, MD MS Alexis Duty, FNP Morgan Armentrout, RN CDE Amy Kehely, RN Donna Brookshear, LPN PEGS, G-TUBES & BUTTONS
ALL YOU NEED TO KNOW...
Anjali Malkani M.D. Professor Pediatric Gastroenterology
.....AND WISH YOU HADN’T ASKED!
PEGS, G-TUBES & BUTTONS- GOALS
Indications Methods of placement Types of tubes Care of G- tubes Complications of G- tubes WHAT IS A GASTROSTOMY TUBE?
• A flexible tube or “button”
• Placed into the stomach
• Through an opening in the abdominal wall
Candidates for a G - Tube
IN- Nutrition Medications
OUT- Decompression of gastric contents Indications for G-tubes
FTT cardiac disease CF Swallowing dysfunction neurologically impaired esophageal stricture Administer special formula metabolic disease Crohn’s disease Decompression of stomach motility disorders Purpose of the G-Tube
To ensure : • Normal growth and development
• Maintenance of health and wellness
Types of G-tubes
Conventional Low Profile Devices catheters Balloon-secured MIC MIC-KEY
Foley HIDE-A-PORT MINI-BUTTON Non-balloon secured BARD PEG catheter- AMT including one step G-tube placement
OPEN SURGICAL
ENDOSCOPIC (PEG)
LAPAROSCOPIC Surgical or Open G-tube
Requires laparotomy and general anesthesia Placed under direct vision Sutured into place Low -profile tube can be placed initially Feedings started after post-op ileus resolves (24-48 hours) Can change conventional tube to low profile device sooner than with PEG G tube- Surgical Technique Percutaneous Endoscopic Gastrostomy (PEG) Pull Technique
Guidewire placed in stomach Guidewire brought retrograde through patient’s mouth PEG tube pulled through abdominal wall Percutaneous Endoscopic Gastrostomy placement (PEG)
Based on the principle of sutureless approximation of a hollow viscus to the peritoneum by a catheter Does not require general anesthesia No post-op ileus - feeds started 6 hours after placement Less post-op pain Less expensive with shorter hospital stay Changed to low profile device when track matures - 3 months (except one step PEG) PEG tube – gastric view Immediate post -op care after PEG placement
Decompression of stomach initially Flush tube to ensure patency Rotate and clean tube site with peroxide NSAIDs for pain Start feeds at 6 hours post op. Begin with clears at half maintenance rate and advance to goal by 18 hours after initiation. PEG : Influence on GERD
Wheatley, J Ped Surg,1991 Of 43 MR pts with no GERD pre PEG (UGI &pH probe),14% (6)developed GER 10 mos after PEG placement Anti-reflux procedure not recommended prophylactically if there is no pre PEG GERD. Launay,Pediatrics, 1996 Of 20 pts(50% MR) ,65% had pre-PEG reflux 2/10 GER worsened after PEG ,trted medically 1/10 developed GER after PEG,trted medically
PEG Removal
Removed when indication for placement resolved Changed to low profile Gutbe in 3 months Gastrocutaneous fistula should be mature Removal technique dependent on PEG features PEG change to Low Profile Device
When? 3 months after placement, so track can mature How? Endoscopically: as FB removal under GA Traction: confirm with fluoroscopy Type of tube? Always balloon secured: NEVER “button” which needs obturator for placement Only with 16 Fr or larger PEGs Confirm placement? Fluoroscopy if traction method used PEG Removal
Malleable internal bumper Remove via traction technique Initially rotate tube to disengage from fibrous tract Types of G-tubes
Conventional Low Profile Devices catheters Balloon-secured MIC MICKEY
Foley HIDE-A-PORT MINI-BUTTON Non-balloon secured BARD PEG catheter- GENIE (20 FR PEG )
including one step AMT Low Profile G-tubes
Non Balloon Balloon Low Profile Gtubes
Balloon or Non- Balloon Balloon secured tube can be replaced by parent Non-balloon needs obturator- ONLY by physician Length Of shaft In cm Diameter In French Brand “Mickey” “Mini”
“Cubby ” Changing Balloon secured Gtubes
INITIAL CHANGE ONLY BY SURGEON/ GI DOC
Check size of balloon secured tube Length French
Use smaller French if unable to replace Don’t use force Send to ER ASAP as the site can close within 30 mins Insertion of Non-Balloon
Click here for Non- Balloon Insertion G-J tube
Through gastrostomy into jejunum Primary or thru previous Gtube site Interventional Radiology or endoscopy Single or Double lumen Single lumen- only J port Double lumen- G and J port- feed via J and decompress via G Type of tube Always balloon secured Low profile or conventional Size Length of stoma, size of balloon, and length of J tube Gastrostomy Care
Cleaning peroxide for the first week, then daily bath Rotate daily to avoid skin growth and irritation Dry and open to air OK to swim in pool & ocean; avoid lakes and ponds Out of reach “onsie” or pin to diaper if conventional tube G – Tube Site Care
Cleanse site with mild soap and water Keep area clean & dry Observe the site for: Redness Swelling Warmth Drainage/leakage Bleeding Unusual color or odor Check site for granulation tissue Complications of G-tubes
Skin Infection Irritation Granulation tissue
Tube Blockage Leakage Dislodgement Displacement
Complications of G-tubes- Skin
Infection fungal bacterial Granulation tissue Irritation Allergy to soap Irritation by tape Burn
Skin: Infection-Bacterial
Erythema, gradually spreading Tenderness Warmth Foul green/pus +/-T Boil Skin: Infection-Bacterial
Causes Staph/strep Poor hygiene Tight tube Tx Antibiotics Systemic/topical Clean with saline Skin: Infection-Fungal
Red papular rash satellite lesions spreading away from site
Causes Excessive moisture Gtube in deep skin fold Immune suppression, steroids , DM
Tx Anti-fungal Keep area clean and dry
Skin- Irritant Dermatitis
Redness, swelling
Leakage of gastric contents Overuse of cleaners, antibacterial meds
Tx Acid blocking meds Barrier products Proper tube size Water in balloon
Skin- Allergic Dermatitis
Papules, vesicles Crusting Itching
Skin care products Latex New meds or foods touching skin
Tx Remove irritant Barrier cream/powder
Skin-Granulation tissue
Causes Opening too big
Pivoting Excessive moisture, occlusive dressings
Too much hydrogen peroxide
Pink cauliflower like ,beefy tissue Bleeds easily
Yellow brown drainage Granulation Tissue – treatment
Silver nitrate sticks for 3 days Kenalog cream
Stabilise tube Change size of tube
DO NOT leave extensions on when not in use Barrier powder-alum Tube-Blockage of tube
Causes Thick formulas Pill fragments Failure to flush- prevent this!! Defective tubing Tx Try milking tube , check for kinks Push and pull plunger Flushing with diet soda or 1/2 strength vinegar, baking soda, viokase Tube
Dislodgement - migrates into tract traction,seizure,wt gain painful, won’t flush,won’t turn, protrudes Displacement- balloon deflates or falls out Needs to be replaced within 30 mins with any tube If less than 12 weeks since placement call surgeon
Care-giver can use same tube and tape into place if they don’t have replacement tube Refer to ER even if site appears closed Tube -Leakage
Leakage through the center of tube valve broken- change tube
failure to reset valve in button- flush tube Blood through the center of the tube requires medical attention
Leakage around the tube
Water in balloon isn’t enough- check amount Tube too long
Don’t increase Fr of tube- makes stoma bigger
Can leave tube out for 10 mins daily Buried Bumper Syndrome
Excessive traction on PEG tube Overtightening of skin disk Ischemic necrosis of the gastric mucosa Migration of the internal bolster into the gastric or abdominal wall Prevention Confirm some laxity at initial insertion Buried Bumper Syndrome
Findings Resistance to flow PEG tube fixed, with surround subcutaneous erythema Endoscopy Ulceration, mucosal dimpling Nonvisualization internal bumper Buried Bumper Syndrome
Treatment Dissection of the buried appliance from the abdominal wall Replace with new gastrostomy tube Large gastrocutaneous fistula may warrant laparotomy/resection Different Methods of Tube Feeding
• Intermittent gravity -bolus
• Timed intermittent-pump
• Continuous-pump
Farrell Valve Bag
Enteral Gastric Pressure Relief System
A patient suffering from poor gastric motility faces many problems; constant pain and discomfort due to the buildup of fluids and gas, the threat of aspiration pneumonia, and often the inability to tolerate enteral nutrition.
Provides a channel to constantly decompress the stomach, allowing the stomach to empty at its own pace. Mouth Care
Maintain oral hygiene
Brush teeth after each meal Lubricate lips as needed
Dental care as directed Parents/CareGivers ......
Hands on Teaching Handouts/ videos GI nurses - a phone call away Support groups - insideoutsidecare.com
Push Technique
PEG tube advanced via modified Seldinger approach May involve dilators, peel away introducer Push Technique
Advantages Disadvantages Single endoscope Loss of passage pneumoperitoneum Decreased “seeding” May require additional from oropharynx T-fasteners (bacteria, malignant cells w/ head & neck ca.) Relative Contraindications
Coagulopathy Portal hypertension Peritoneal dialysis Large hiatal hernia Fundoplication required for preexisting GERD Another intraabdominal procedure required at the same time PEG: Basics
Gastric insufflation to bring stomach in apposition Placement of catheter into gastric lumen Passage of guidewire into stomach Placement of gastrostomy tube Verification of proper position Factors to consider when selecting an enteral formula.
Patient-related factors Formula-related factors 1.Age 1.Caloric density 2.Underlying diagnosis 2.Osmolality 3.Digestive and absorptive capacity of the GI tract 3.Ease of preparation 4.Fluid, nutrient, and 4.Cost caloric needs 5.Food allergies 5.Insurance coverage 6.Route of administration 6.Availability at home Patient Preparation
Bite block May leave NG, feeding tube Can follow tube down esophagus Must take NG off suction to allow for insufflation Upper Endoscopy
Routine flexible fiberoptic upper endoscopy Complete endoscopy recommended 36% incidence of anomalies Some may affect procedure (ulcer, gastric outlet obstruction) Confirm safe position
Transillumination through skin suggests no other viscera interposed Transillumination button (“high beams”) on light source May be difficult in obesity Can assist with digital pressure Confirm Position
Endoscopist watches while assistant indents abdominal wall at proposed insertion Should see simultaneous indentation of gastric mucosa Failure to see Reassess position Intervening viscerae Impossible apposition Inadequate insufflation Site Preparation
PEG kit opened after endoscopic confirmation of entry site Select anticipated PEG insertion site Entry ~2 cm below costal margin Prep left upper quadrant with antiseptic prep of choice May be included in kit Surgical Technique
Kit contains: Local/syringe introducer Prep & drape Guidewire Endoscopic snare Scalpel Hemostat PEG External Bumper Surgical Technique
With area prepped and draped, reconfirm insertion site Inject local anesthetic Skin and SQ Fascia Make incision Alternate: incision after wire placed Endoscopist
Retrieves snare, PEG tube from kit
Advances snare into biopsy channel of endoscope Access
Insert needle/catheter assembly Safe tract technique Continuous aspiration via syringe Return of air without visualization of needle in stomach signifies malposition Remove, retry Endoscopist
While puncture performed, advance snare near intended puncture site Snare the catheter prior to removal of needle to prevent loss Access
Remove syringe/ needle Cover catheter to prevent loss of insufflation Advance guidewire into stomach Incision at insertion site if not placed previously Endoscopist
After wire passed through catheter, endoscopist uses snare to grasp wire Wire advanced Snare/wire pulled out of mouth with endoscope as a unit Endoscopist
Endoscopist secures PEG tube to mouth end of guidewire PEG internal bumper can be snared to allow easy passage of endoscope Assembly passed back into stomach PEG Tube Position
Guidewire pulled through skin incision PEG follows, tract dilated by conical dilator at end of PEG Countertraction at skin level with non- dominant hand facilitates passage PEG Tube Position
PEG tube advanced Two resistance points
GE Junction Final position @ gastric mucosa Usually in position when external marker between 2-4 cm at skin level PEG Tube Position
Guidewire cut at tapered end of tube Skin disk/external bumper applied over introducer and slid to skin surface Bumpers should prevent movement but not blanch skin Endoscopy may confirm no blanching of mucosa Completion of Procedure
Endoscope removed Option: place antibiotic ointment and/or dressing under skin disk Tube cut to appropriate length Adapter secured to cut end of tube Leave to gravity Complications & Pitfalls Complications of PEG
Direct, major complications: 4% Mortality from complications: 25% High mortality attributed to patient population Debilitated Cannot tolerate additional insult Complications of PEG placement
Pneumoperitoneum Peritonitis and sepsis Gastrocolic fistula Other organ injury-liver, small bowel Esophageal injury Wound infection Dislodgement of tube Development of, or worsening GE reflux Pneumoperitoneum after PEG
Expected event Up to 36% Contributing factors Excessive air insufflation Prolonged procedure time Multiple percutaneous needle punctures of the stomach Peritonitis <1% of PEGs ~30% mortality Pneumoperitoneum after PEG
No additional studies warranted unless signs of inflammation, peritonitis Contrast study May detect gross extravasation CT Scan Abdomen Extravasation Lack of apposition with abdominal wall Free fluid, suggestive of visceral perforation, hemorrhage Dislodgement of PEG Tube
Concern when occurs prior to maturation of gastrocutaneous tract Initial Rx Nasogastric suction Broad spectrum antibiotics Surgery Failure to improve Overt peritonitis, sepsis PEG Removal
Rigid internal bumper Mandates repeat endoscopy PEG tube cut at skin Bumper snared endscopically Bumper may be obstructive, must be removed PEG Removal
Secure tube in one hand Continuous steady traction Caution: “spray” of gastric fluids May wrap tube around hand Bumper inverts and PEG removed PEG Removal
Fistula closes within 24 hours Persistent fistula Granulation tissue/inflammation Silver nitrate sticks Anti acid therapy Rarely require resection/operative closure Peristomal Wound Infection
5-30% of cases Prophylactic Antibiotics Single dose 30 minutes before procedure Narrow spectrum (e.g. cefazolin) Skin incision Large enough to easily admit tube Smaller incision allows entrapment of bacteria ⇒ postop infection Necrotizing Fasciitis
Rare, devastating complication 43% mortality Initial presentation with cellulitis Source control essential May mandate surgical closure of PEG site Gastrocolocutaneous Fistula
Early presentation Drainage of feculant material at PEG site Late Detected after tube replacement: diarrhea Colonic interposition during placement Dx: gastrograffin study, CT scan Hemorrhage
2.5% of cases Repeat endoscopy indicated for Dx, possible Rx Often related to gastric ulceration under internal bumper Pressure necrosis Friction Caution in patients with coagulopathy Tube Migration
Inadequate stabilization Proximal migration Vomiting, aspiration Migration into distal stomach Gastric outlet obstruction Distention, vomiting Distal migration (small bowel) Dumping syndrome PEG : Influence on GERD
Andrew, J of Ped Surg,1997 28%(n=39) with no GER pre PEG (onUGI/GES) developed GER; 20% of these required Nissen within 6mos Of 8 with pre PEG GER 25% required Nissen and 25% improved post PEG Current practice for evaluation prior to PEG UGI-R/O anatomical problem eg malrotation pH probe -if symptomatic or neurologically impaired
Postoperative Nursing
Local care to prevent complications Especially important while gastrocutaneous fistula is maturing Allow slack on tubing to prevent pressure/ traction complications Resumption of Enteral Nutrition
Postop “ileus” may be related to degree of insufflation Orders Post PEG placement
Drainage for 4 hours Clamp for 2 hours Pedialyte for 6 hours( ½, then full maint) Formula for 6 hours continuous (1/2 str then full) Hold feeds for 3 hours Give first bolus. Timing of Feeding after PEG placement
Werlin ,GI endoscopy,1994 24 pts had feeding started 6 hrs after PEG. All had feeds advanced with no intolerance Malkani,NASPGN,1996 Randomised 52 pts (after successful NG feeds) to early and late feeding groups post PEG No difference in tolerance to feeds or catheter related problems in both groups 90% in early group were ready for discharge at 24 hrs, when the late group were starting feeds. Objectives
Indications and contraindications of PEG Upper flexible fiberoptic gastroscopy Principles Procedures Monitoring, sedation Surgical procedure Contraindications
Inability to perform upper endoscopy Obstructing esophageal tumor Stricture Ascites Inability to appose gastrotomy to anterior abdominal wall Previous subtotal gastric resection Hepatomegaly, esp left lobe Abdominal wall infection or peritonitis Legal Issues in School Health
Regional Nurses Conference Kingsport, Tennessee July 27, 2017 Presenta on by Mike Billingsley, City A orney for Kingsport, Tennessee LEGAL DISCLAIMER
• Nothing in this handout or presenta on cons tutes legal advice. It is for general informa on only, and no a orney-client rela onship is created. • Always contact your a orney should you have any specific ques ons about any legal ma er. • Never rely on this informa on as an alterna ve to legal advice from your a orney. • Do not delay seeking legal advice, commence or discon nue any legal ac on or disregard legal advice, or due to informa on contained in this handout or presenta on. Guidelines for Use of Health Care Professionals And Health Care Procedures in a School Se ng • h p://www.tennessee.gov/assets/en es/educa on/a achments/ csh_guidelines_healthcare_prof_proc.pdf
• A 121 pages documents that is vital for any school nurse to have and use. • It is free and available for prin ng or download at the website set out above.
School Nurses are the Gatekeepers of School Children Health • Do you agree or disagree? Privacy of Student Medical and Treatment Records and the Public School Nurse • What law applies Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family Educa onal Privacy Rights Act (FERPA)? Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family Educa onal Privacy Rights Act (FERPA)
• Joint Guidance on the Applica on of the Family Educa onal Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records
• h ps://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa- guidance.pdf Helpful Informa on
• Dear Colleague Le er to School Officials at Ins tu ons of Higher Educa on issued August 24, 2016
• h p://familypolicy.ed.gov/sites/fpco.ed.gov/files/DCL_Medical %20Records_Final%20Signed_dated_9-2.pdf HIPAA or FERPA
• Does the HIPAA Privacy Rule apply to an elementary or secondary school? • In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered en ty or (2) is a HIPAA covered en ty but maintains health informa on only on students in records that are by defini on “educa on records” under FERPA and, therefore, is not subject to the HIPAA Privacy Rule.
HIPAA and the Public School Nurse
• Generally, a public school is not a HIPAA covered en ty because it does not engage in transac ons covered under HIPAA. • Covered en es are a health plan; a health care clearinghouse; or a health care provider who transmits any health informa on in electronic form in connec on with a transac on pertaining to financial or administra ve ac vi es related to health care transac ons. 45 CFR § 160.103 – defini on of transac on. • Most schools do not engage in any transac ons covered by the defini on of transac on, which includes things such as billing a health plan electronically for payment of service. HIPAA and the Public School Nurse
• A school would be subject to a part of HIPAA (Simplifica on Rules for Transac ons and Code Sets and Iden fiers with respect to its transac ons - 45 C.F.R. part 162 ) if it employs a health care provider that conducts electronic transac ons covered by HIPAA. • However, many schools, even those that are HIPAA covered en es, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are “educa on records” or “treatment records” of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule. Family Educa onal Privacy Rights Act (FERPA)
• FERPA is a Federal law that protects the privacy of a student’s “educa on records.” (See 20 U.S.C. § 1232g; 34 CFR Part 99). FERPA applies to educa onal agencies and ins tu ons that receive funds under any program administered by the U.S. Department of Educa on. This includes virtually all public schools and school districts and most private and public postsecondary ins tu ons, including medical and other professional schools. FERPA Applies to Public School Records
• At the elementary or secondary level, a student’s health records, including immuniza on records, maintained by an educa onal agency or ins tu on, as well as records maintained by a school nurse, are “educa on records” subject to FERPA. In addi on, records that schools maintain on special educa on students, including records on services provided to students under the Individuals with Disabili es Educa on Act (IDEA), are “educa on records” under FERPA. FERPA
• Educa on records include a range of informa on about a student that is maintained in schools in any recorded way, such as handwri ng, print, computer media, video or audio tape, film, microfilm, and microfiche • It prohibits a school from disclosing personally iden fiable informa on from students’ educa on records without the consent of a parent or eligible student (18 or older), unless an excep on to FERPA’s general consent rule applies. • HIPAA specifically excludes educa on records, including shared treatment records, and unshared treatment records. (See 45 C.F.R. 160.103 defini on of "Protected Health Informa on") HIPAA or FERPA
• Even though a school employs school nurses, physicians, psychologists, or other health care providers, the school is not generally a HIPAA covered en ty because the providers do not engage in any of the covered transac ons, such as billing a health plan electronically for their services.
• Where a school does employ a health care provider that conducts one or more covered transac ons electronically, such as electronically transmi ng health care claims to a health plan for payment, the school is a HIPAA covered en ty and must comply with the HIPAA Transac ons and Code Sets and Iden fier Rules with respect to such transac ons. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health informa on only in student health records that are “educa on records” under FERPA and, thus, not “protected health informa on” under HIPAA. HIPAA or FERPA
• The school would have to comply with FERPA’s privacy requirements with respect to its educa on records, including the requirement to obtain parental consent (34 CFR § 99.30) in order to disclose to Medicaid billing informa on about a service provided to a student.
• If the nurse is hired as a school official (or contractor), the records maintained by the nurse or clinic are “educa on records” subject to FERPA. HIPAA or FERPA
• Does HIPAA or FERPA or apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? • If a person or en ty ac ng on behalf of a school subject to FERPA, such as a school nurse that provides services to students under contract with or otherwise under the direct control of the school, maintains student health records, these records are educa on records under FERPA, just as they would be if the school maintained the records directly. This is the case regardless of whether the health care is provided to students on school grounds or off-site. Disclosure of Records Under FERPA
• Parents have a right under FERPA to inspect and review these health and medical records because they are “educa on records” under FERPA. See 34 CFR §§ 99.10 – 99.12. • Parents may also seek to amend educa on records believed to be inaccurate; and • Parents may consent to the disclosure of personally iden fiable informa on from educa on records, except as specified by law.
• In addi on, these records may not be shared with third par es without wri en parental consent unless the disclosure meets one of the excep ons to FERPA’s general consent requirement. Defini on of Parent Under FERPA
• Under FERPA, a “parent” means a parent of a student and includes a natural parent, a guardian, or an individual ac ng as a parent in the absence of a parent or guardian. 34 CFR § 99.3 defini on of “Parent.” Addi onally, in the case of the divorce or separa on of a student’s parents, schools are required to give full rights under FERPA to either parent, unless the school has been provided with evidence that there is a court order, State statute, or legally binding document rela ng to such ma ers as divorce, separa on, or custody that specifically revokes these rights. 34 CFR § 99.4. Disclosure of Records Under FERPA without Parental Consent • A school may disclose a student’s health and medical informa on and other “educa on records” to teachers and other school officials, without wri en consent, if these school officials have “legi mate educa onal interests” in accordance with school policy. See 34 CFR § 99.31(a)(1). • A school may permit disclosure of educa on records, without consent, to appropriate par es in connec on with an emergency, if knowledge of the informa on is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. Instances of abuse or neglect. • Instances of abuse or neglect. Disclosure to Medical Providers Under FERPA
• The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authoriza on of the student or student’s parent. • Disclosures under FERPA can only be made with the consent of a parent or eligible students or under one of the excep on listed in 34 C.F.R. § 99.31. Disclosure to Medical Providers Under FERPA
• Disclosure may be made to appropriate par es, if the disclosure is in connec on with a health or safety emergency. See 34 CFR §§ 99.31(a)(10) and 99.36. • h ps://www2.ed.gov/policy/gen/guid/fpco/pdf/ferparegs.pdf
• A student’s treatment records may be shared with health care professionals who are providing treatment to the student, including health care professionals who are not part of or not ac ng on behalf of the educa onal ins tu on (i.e., third-party health care provider), as long as the informa on is being disclosed only for the purpose of providing treatment to the student. Only allowed as long as the informa on is being disclosed only for the purpose of providing treatment to the student.
Consent to Disclose Records Under FERPA
• Under FERPA, a parent or eligible student (i.e., a student who has reached 18 years of age) generally must provide a signed and dated wri en consent before the agency or ins tu on discloses personally iden fiable informa on ("PII") from the student's educa on records. 34 CFR § 99.30. • FERPA allows a parent to consent to the disclosure of a minor child’s educa onal records, which includes personally iden fiable informa on, to third par es. • Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents • h ps://www2.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/ modelform2.html
Disclosures Under FERPA Without Consent (par al list) • Schools are generally prohibited from disclosing personally iden fiable informa on about a student without the parent’s wri en consent. • Excep ons to this rule include: • disclosures made to school officials, including teachers, with legi mate educa onal interests; • In an emergency "if knowledge of the informa on is necessary to protect the health or safety of the student or other individuals" (See 34 C.F.R. §99.36(a)).
Disclosures under FERPA
• Can a list of students' health issues be distributed to teachers or other staff?
• A school-wide health concerns distribu on list violates FERPA. Disclosures under FERPA
• Can school personnel talk to a student's health care provider without consent?
• Generally, schools must have wri en permission from the parent or eligible student in order to release any informa on from a student's educa on record to outside par es including providers. However, a school nurse may call a student's health care provider to clarify facts surrounding a student's condi on or treatment plan. Administra on Of Meds and Procedures
• For the most part, the statutory authoriza ons are found in Tennessee Code Annotated (T.C.A.) sec on 49-50-1601 et seq.
Administra on of Meds and Procedures - T.C.A. § 49-50-1601 • T.C.A. § 49-50-1601 allows the self-administra on of pancrea c enzymes with wri en authoriza on from the healthcare provider and parent. A student with pancrea c insufficiency or cys c fibrosis is allowed to carry and self-administer prescribed pancrea c enzymes. Administra on Of Meds and Procedures - T.C.A. § 49-50-1602 • T.C.A. § 49-50-1602 requires certain health care procedures, including the administra on of medica ons during the school day or at related events, to be performed by appropriately licensed health care professionals. • T.C.A. § 50-1602 allows “...school personnel who volunteer under no duress or pressure and who have been properly trained by a registered nurse” to administer Glucagon in the event of a diabetes emergency in the absence of the school nurse. The guidelines were revised to address this change in law and to provide further clarifica on for medical and nursing procedures performed in the school se ng. • T.C.A. § 49-50-1602 permits possession and self-administra on of a prescribed, metered dosage, asthma-reliever inhaler by any asthma c student. Administra on Of Meds and Procedures - T.C.A. § 49-50-1602 (con nued) • T.C.A. § 49-50-1602 permits “school personnel to volunteer to assist with the care of students with diabetes, excluding the administra on of insulin; • T.C.A. § 49-50-1602 allows school staff, who under no duress, volunteer to be trained in the administra on of an -seizure medica on, including diazepam rectal gel as prescribed by a licensed health care provider. • T.C.A. § 49-50-1602 provides that each school is authorized to maintain at least two epinephrine auto-injectors so that epinephrine may be administered to any student believed to be having a life- threatening allergic or anaphylac c reac on.
Administra on Of Meds and Procedures - T.C.A. § 49-50-1602 (con nued) • T.C.A. § 49-50-1602 allows “...school personnel who volunteer under no duress or pressure and who have been properly trained by a registered nurse” to administer daily insulin to a student based on the student’s individual health plan in the absence of the school nurse. The guidelines were revised to address this change in law and to provide further clarifica on for medical and nursing procedures performed in the school se ng. Administra on Of Meds and Procedures - T.C.A. § 49-50-1603 • T.C.A. § 49-50-1603 (2017 Public Chapter 84) - State Board of Educa on will adopt rules for the administra on of adrenal insufficiency medica on by school personnel if the healthcare provider is not immediately available. The school system is only required train personnel if no fied by a parent/guardian that a student has the condi on. The school system must adopt a policy. Removes liability when administering the medica on. Effec ve July 1, 2017.
• h p://publica ons.tnsosfiles.com/acts/110/pub/pc0084.pdf
Administra on Of Meds and Procedures – 2017 Public Chapter 256 • 2017 Public Chapter 256 (likely to be added as T.C.A. § 49-50-1604) - State Board of Educa on will develop guidelines for the administra on of an opioid antagonist for students experiencing an opioid overdose. The prescrip on will be held in the name of the school system. The school nurse, SRO, or other trained personnel may administer the medica on. There are provisions removing liability if a student is injured due to the administra on of the medica on. This is effec ve July 1, 2017.
• h p://publica ons.tnsosfiles.com/acts/110/pub/pc0256.pdf Administra on Of Meds and Procedures – Related Statutes • T.C.A. § 49-5-414 encourages LEAs to have CPR - cer fied individuals in their employment or as a volunteer. • T.C.A. § 49-3-359(b)(2) each public school nurse employed or contracted by an LEA will maintain current CPR cer fica on consistent with the guidelines of the American Heart Associa on • T.C.A. § 49-6-5004 authorizes health care professionals to indicate the need for a dental or vision screening on any report or form used in rela onship to repor ng immuniza on status for a child. Health care professionals shall provide a copy of the report or form to the parents or guardians indica ng the need to seek appropriate follow up.
Other Legisla on – Telehealth Services
• Changes made by Public Chapter 130 to T.C.A. § 56-7-1002 - Telehealth services • (ii) The pa ent is at a qualified site or at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunica ons described in this sec on; and equipped to engage in the telecommunica ons described in this sec on; and, or at a public elementary or secondary school staffed by a healthcare services provider and Proposed Legisla on S ll Under Considera on
• Changes by proposed SB534/HB503 would amend T.C.A. § 49-3-359 - BEP funding for teacher's supplies, duty-free lunch periods, and school nurses.
• There is included in the Tennessee BEP an amount of money sufficient to fund one (1) full- me public school nurse posi on for each three thousand (3,000) seven hundred fi y (750) students or one (1) full- me posi on for each LEA, whichever is greater. Proposed Legisla on S ll Under Considera on
• Changes by proposed SB1055/HB1099 would amend T.C.A. § 68-55-501 - Part defini ons.
• (3) "Health care provider" means a Tennessee licensed medical doctor (M.D.), osteopathic physician (D.O.), clinical neuropsychologist with concussion training, or physician assistant (P.A.) with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician; or nurse prac oner with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician. Proposed Legisla on S ll Under Considera on
• Changes by Proposed SB190/HB145 would amend T.C.A. § 68-11-313 - Authen ca on of verbal orders.
• (d) For the purposes of this sec on, telephone orders and orders by electronic means are considered verbal orders. Pediatric Sleep Apnea
Kelly Hare, FNP-BC Indian Path Center for Sleep Disorders July 27, 2017 Objectives:
1. Review Pediatric sleep architecture norms. 2. Define and describe Pediatric Obstruc ve Sleep Apnea. 3. Iden fy treatment op ons for Pediatric OSA. 4. Detail “CHAT” study findings. 5. Case Studies
Sleep Architecture
A. NREM Sleep 1. Includes Stages 1, 2, SWS 2. Occupies 75% of TST B. REM Sleep 1. Ac vated EEG (similar to wake) with decreased or no muscle tone 2. Alternates with NREM every 90-100 minutes with progressive lengthening in the la er 1/3 on the night
American Thoracic Society defines OSA
• A disorder of breathing during sleep characterized by prolonged par al airway obstruc on and/or intermi ent complete obstruc on that disrupts normal ven la on during sleep and normal sleep pa erns. Pediatric OSA Incidence and Prevalence
1. Occurs in all ages with peak between 2-8 years
2. Occurs in 1-4% of the general pediatric popula on
3. More likely to be seen in boys versus girls Risk Factors for OSA
1. Adenotonsillar Hypertrophy 2. Obesity 3. Craniofacial Anomalies 4. Familial Predisposi on 5. Ethnicity 6. Prematurity Nocturnal Symptoms
1. Snoring 2. Paradoxical Breathing Most sensi ve and 3. Witnessed Apnea specific
4. Restless Sleep 5. Frequent Awakenings 6. Nocturnal Enuresis 7. Night Swea ng Day me Symptoms
1. Abnormal Day me Func oning - Less than 15% report day me sleepiness - May present in children as irritability, nervousness, and aggressiveness. - Impaired cogni ve func on 2. ADHD 3. Poor School Performance Day me Symptoms – other considera ons
1. Mouth breathing due to hypertrophied tonsils and adenoids. 2. Recurrent URI 3. Hearing and speech difficulties 4. Morning headaches much less common than adults but may be reported.
Clinical Consequences – likely resul ng from intermi ent hypoxia, sleep fragmenta on, and inflamma on.
1. RV and LV dysfunction 2. Systemic Hypertension 3. Pulmonary Hypertension 4. Poor Growth 5. Behavioral and Cognitive Impairment 6. ADHD
Evalua on
1. Sleep Consultation -focused sleep history -physical exam including detailed exam of oropharynx
2. Polysomnography- the “Gold Standard” for diagnosis of OSA. The only tool capable of definitively identifying obstructive events and quantifying severity of OSA, including gas exchange abnormalities and sleep disruption. Polysomnography
1. Nasal and oral airflow sensors 2. Snore microphone 3. Respiratory impedance plethysmography (RIP Belts) 4. Pulse oximetry 5. EKG 6. Capnography 7. EEG 8. Body position 9. Muscle tone (chin and lower extremities)
Diagnosis
1. Clinical Criteria – one or more of the following: snoring, labored, paradoxical, or obstructed breathing in sleep
WITH
2. Polysomnographic criteria – one obstructive apnea, mixed apnea or hypopnea per hour of sleep and/or obstructive hypoventilation with at least 25% TST with hypercapnia (PaCO2>50mmHg) with snoring, flattening of the nasal pressure waveform, paradoxical thoracoabdominal motion.
Assessment of Severity – no clear cut classifica on of OSA in children has gained uniform acceptance. PSG findings should be interpreted by a Sleep Medicine Physician using all the PSG parameters and in the context of the child’s symptoms and contribu ng risk factors.
1. Mild OSA –AHI 1-4.9 2. Moderate OSA – AHI 5-9.9 3. Severe OSA – AHI >10 Obstruc ve Sleep Apnea • Treatment Op ons • Tonsillectomy and Adenoidectomy • CPAP (con nuous posi ve airway pressure) • “Watchful Wai ng?” Obstruc ve Sleep Apnea • The Childhood Adenotonsillectomy Trial (CHAT) 2013 – Hypothesis: In children with OSA without prolonged oxyhemoglobin desaturation, early AT, as compared to “watchful waiting” would result in improved outcomes. – Multi-center, single blind, randomized, controlled trial – 464 children ages 5-9 – Excluded for Severe OSA and/or oxyhemoglobin saturations <90% for 2% TST or longer, recurrent tonsillitis, meds for ADHD, and z score based on BMI of 3 or greater – PSG and cognitive/behavioral testing at baseline and then again at 7 months. Caregiver surveys and behavioral assessments from teachers also collected
Obstruc ve Sleep Apnea
• The Childhood Adenotonsillectomy Trial (CHAT) 2013
Early AT group: improvements in symptoms, behavior, QOL, and PSG findings
Effect size: moderate to large indicating clinical significance
Obstruc ve Sleep Apnea
BUT- No significant improvements in attention or executive function and no decline in the “watchful waiting” group.
SO- Medical management and reassessment after a period of observation may be a valid therapeutic option.
CASE STUDY 1
Case Studies
B.M. 3y/o male
CC: “He stops breathing in the middle of the night.”
Case Studies Hx: Little witness to sleep until moved into grandparents home in a shared bedroom with mom in his own bed. Snores in all sleep positions. Sleeps with mouth open. +Sleeptalking Mom questions effort to breathe. Breathes “funny.” Bedtime 9p/10p weekend Rise time 0615 / 1000 weekend
Case Studies Social history:
Headstart No behavioral problems Behind in learning for age Grandparents smoke “outside” Case Studies Past Medical History:
Abnormal chromosome analysis Microcephaly RAD Small Stature Speech Delay Case Studies FH: Sleep apnea in 1 cousin
Meds: None
PE: BP 100/65 HR 123 O2 sats 98% Ht: 38in Wt: 26lbs
Case Studies PSG Findings
Sleep Eff: 88.4% N1: 0.1% N2: 33.4% SWS: 56.6% REM: 9.8%
Arousals: 27.4/hr
Case Studies PSG Findings
OH: 113 OA: 5 CA: 32 MA: 7 **AHI: 23.1 REM AHI: 69 Supine AHI: 17.9
Case Studies PSG Findings
PLMS: 1.6 EKG: NSR/SA Capnography: WNL Lsat 50% Sat<88% 50min TST
PLAN: ENT evaluation for T&A
CASE STUDY 2 Case Studies A.L. 7 y/o male
-Referred by ENT for snores -Snores in all sleeping positions -Oral breathing in sleep and wake -Restless in sleep/moves frequently -Whines and whimpers in sleep -Rare bedwetting Case Studies
-Bedtime 830p/10p on weekends -LSO 30 minutes -Uses tablet and TV before bed -Shares bedroom with 14y/o brother -Rise time 7a/8a weekend – difficult to wake -No problems at school -FT/no delivery complications Case Studies PMH
-PE Tubes -ADHD -Obesity -New onset absence seizures
FH
-RLS – Aunt, GGM. -OSA - GF Case Studies SOC -Mom deceased/Grandmother with custody -2nd grade -No tobacco exposure
MEDS -Keppra -Loratadine -Fluticasone Case Studies EXAM BP: 112/67 HR: 98 Pulse Ox: 99% Ht: 56.5in Wt: 140lbs
Remainder of exam unremarkable except for 3+ tonsils Case Studies PSG
SE 91% OH 118 MA 12 OA 1 CA 82
Case Studies PSG
AHI 33 LSAT 86% 2% TST with CO2 56-60mmHg
PLMI 2/hr No arrhythmia No seizure activity Case Studies
PLAN: Referred to ENT for T & A.
Repeat PSG: AHI 5.2 CO2 never above 50mmHg
Plan: CPAP at 5cm with full face mask
Sleeping better, Likes cpap, No snores on therapy, No restlessness, Easier to wake
Pediatric Sleep Disorders
References:
www.uptodate.com
www.aasmnet.org American Academy of Sleep Medicine
www.sleepfoundation.org National Sleep Foundation
Principles and Practice of Pediatric Sleep Medicine. 2nd ed. Sheldon, DO FAAP, Stephen H.
“A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea.” Carol L. Marcus, et al. NEJM 2013; 368; 2366-76.