Allergic Rhinis

Dr. Larry Smith, MD Allergic Rhinis Definion

— Defined as inflammaon of the nasal mucosa characterized by two or more of the following symptoms: – nasal congeson – anterior/posterior rhinorrhoea – sneezing – itchy nose

Introducon Allergic Rhinis

— occurs when these nasal symptoms are the result of IgE-mediated inflammaon following exposure to an allergen

Prevalence

400 million suffers worldwide > 20% of populaon in US All ages are affected, peaks in teens Boys more affected than girls but equalizes aer puberty ALLERGIC RHINITIS and ASTHMA

• 30% of paents with AR have asthma • The majority of paents with asthma have AR • AR is a major risk factor for poor asthma control • All paents with AR should be assessed for asthma

ALLERGIC RHINITIS AND OTHER COMORBIDITIES • Up to 80% of paents with bilateral chronic sinusis have AR • Os media • Conjuncvis • Lower respiratory tract infecons • Dental problems – malocclusion, discoloraon • 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)

Intermient 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. acvies. Impairment of daily Normal work and acvies, sport, leisure. school. Problems caused at No troublesome school or work. symptoms. Troublesome symptoms.

DIAGNOSIS • History and Examinaon • 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 administraon of an allergen extract to induce a state of immunological tolerance • More effecve in limited spectrum of allergies in parcular seasonal pollen allergy • Severe symptoms failing to respond to usual Px • Subcutaneous injecon/sublingual route • Studies indicate that 3 years therapy necessary

ARIA RECOMMENDATIONS • Topical corcosteroids and oral anhistamines (non-sedang) form the mainstay of treatment • The newer topical steroids e.g. Mometasone furoate and Flucasone propionate were highest recommended • Other drugs should only be considered as second-line treatment • Immunotherapy in selected paents can be highly effecve.

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 combinaon of newer generaon topical and inhaled corcosteroids with low risk of complicaons • Diagnosis in smaller children is difficult as can have up to 6 to 8 colds per year • Small children – oral anhistamines, saline sprays and corcosteroids 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 pialls of diabetes management at school

• Diabetes technology and brief look at future of diabetes management

• Quesons Outline

• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school

• Discuss pearls and pialls of diabetes management at school

• Diabetes technology and brief look at future of diabetes management

• Quesons Diabetes is a team sport

• High burden of disease management placed on child/family

• Requires advanced planning for basic tasks: eang, physical acvity

• Can complicate roune illnesses

• Life experience with diabetes influenced by family dynamics, socioeconomics, coping skills Diabetes at school: Student role

• Depends on developmental stage

• Expect to parcipate 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

• Parcipate in and formulate school care plan with RN • Discuss frequency of BG checks, whether/when parent wants to be nofied, remote monitoring*

• Provide all necessary supplies including low treatments and snacks

• Listen to your feedback Diabetes at school: Medical provider role

• Provide “school orders” direcng the diabetes care of each student

• Update orders as needed

• Be available as resource if orders unclear or do not address situaon

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 navigang the requests of students, parents, school administraon 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 pialls of diabetes management at school

• Diabetes technology and brief look at future of diabetes management

• Quesons Typical schoolday paerns

• 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 geng 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, ketosx, 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, connued

Must a school provide a trained school staff member while students parcipate in field trips and extracurricular acvies? Yes. Failure to provide this care would exclude students from these acvies for safety reasons. Schools are required to provide needed care to ensure a student's full and safe parcipaon in school-sponsored acvies.

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 Associaon 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 regulaons • American Diabetes Associaon clearly supports the training of bus drivers in the basics of diabetes care including glucagon use • Strong legal protecons 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 - connued

• Trace-small • Assess for causes, nofy family • Give water, more frequent BGs/insulin/carbs/ketone checks • May be able to go back to class • Moderate-large • Assess for causes, nofy family • Give water, more frequent BGs/insulin/carbs/ketone checks • Will need extra insulin doses – nofy family; if needed, nofy provider • Probably won’t feel well enough to go back to class (but might) • If voming, 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 +, nofy family (and if needed, nofy provider); will need insulin • If ketones -, have a choice:

• Don’t give extra insulin. Check again at lunch, follow usual plan. • Give high BG correcon if >3 hours since last insulin. Check BG at lunch; cover carbs but DON’T give high BG correcon. (<3 hours since last dose)

Outline

• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school

• Discuss pearls and pialls of diabetes management at school

• Diabetes technology and brief look at future of diabetes management

• Quesons Diabetes technology CGM - now Diabetes technology – what’s coming Technology in school: My recommendaons

• 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 fingersck • OK to dose insulin using CGM number if part of school orders; fingersck preferred • If parents want CGM “trend arrows” to be a part of school orders, they should go through provider • Device problems: • Troubleshoong 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 pialls of diabetes management at school

• Diabetes technology and brief look at future of diabetes management

• Quesons Quesons

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

.....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   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 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 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  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  Decreased “seeding”  May require additional from oropharynx T-fasteners (bacteria, malignant cells w/ head & neck ca.) Relative Contraindications

 Coagulopathy   Peritoneal dialysis  Large hiatal  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,  Can follow tube down  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  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  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:  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)  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 Presentaon by Mike Billingsley, City Aorney for Kingsport, Tennessee LEGAL DISCLAIMER

• Nothing in this handout or presentaon constutes legal advice. It is for general informaon only, and no aorney-client relaonship is created. • Always contact your aorney should you have any specific quesons about any legal maer. • Never rely on this informaon as an alternave to legal advice from your aorney. • Do not delay seeking legal advice, commence or disconnue any legal acon or disregard legal advice, or due to informaon contained in this handout or presentaon. Guidelines for Use of Health Care Professionals And Health Care Procedures in a School Seng • hp://www.tennessee.gov/assets/enes/educaon/aachments/ 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 prinng 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 Educaonal Privacy Rights Act (FERPA)? Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family Educaonal Privacy Rights Act (FERPA)

• Joint Guidance on the Applicaon of the Family Educaonal Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records

• hps://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa- guidance.pdf Helpful Informaon

• Dear Colleague Leer to School Officials at Instuons of Higher Educaon issued August 24, 2016

• hp://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 enty or (2) is a HIPAA covered enty but maintains health informaon only on students in records that are by definion “educaon 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 enty because it does not engage in transacons covered under HIPAA. • Covered enes are a health plan; a health care clearinghouse; or a health care provider who transmits any health informaon in electronic form in connecon with a transacon pertaining to financial or administrave acvies related to health care transacons. 45 CFR § 160.103 – definion of transacon. • Most schools do not engage in any transacons covered by the definion of transacon, 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 (Simplificaon Rules for Transacons and Code Sets and Idenfiers with respect to its transacons - 45 C.F.R. part 162 ) if it employs a health care provider that conducts electronic transacons covered by HIPAA. • However, many schools, even those that are HIPAA covered enes, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are “educaon records” or “treatment records” of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule. Family Educaonal Privacy Rights Act (FERPA)

• FERPA is a Federal law that protects the privacy of a student’s “educaon records.” (See 20 U.S.C. § 1232g; 34 CFR Part 99). FERPA applies to educaonal agencies and instuons that receive funds under any program administered by the U.S. Department of Educaon. This includes virtually all public schools and school districts and most private and public postsecondary instuons, including medical and other professional schools. FERPA Applies to Public School Records

• At the elementary or secondary level, a student’s health records, including immunizaon records, maintained by an educaonal agency or instuon, as well as records maintained by a school nurse, are “educaon records” subject to FERPA. In addion, records that schools maintain on special educaon students, including records on services provided to students under the Individuals with Disabilies Educaon Act (IDEA), are “educaon records” under FERPA. FERPA

• Educaon records include a range of informaon about a student that is maintained in schools in any recorded way, such as handwring, print, computer media, video or audio tape, film, microfilm, and microfiche • It prohibits a school from disclosing personally idenfiable informaon from students’ educaon records without the consent of a parent or eligible student (18 or older), unless an excepon to FERPA’s general consent rule applies. • HIPAA specifically excludes educaon records, including shared treatment records, and unshared treatment records. (See 45 C.F.R. 160.103 definion of "Protected Health Informaon") 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 enty because the providers do not engage in any of the covered transacons, 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 transacons electronically, such as electronically transming health care claims to a health plan for payment, the school is a HIPAA covered enty and must comply with the HIPAA Transacons and Code Sets and Idenfier Rules with respect to such transacons. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health informaon only in student health records that are “educaon records” under FERPA and, thus, not “protected health informaon” under HIPAA. HIPAA or FERPA

• The school would have to comply with FERPA’s privacy requirements with respect to its educaon records, including the requirement to obtain parental consent (34 CFR § 99.30) in order to disclose to Medicaid billing informaon 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 “educaon 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 enty acng 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 educaon 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 “educaon records” under FERPA. See 34 CFR §§ 99.10 – 99.12. • Parents may also seek to amend educaon records believed to be inaccurate; and • Parents may consent to the disclosure of personally idenfiable informaon from educaon records, except as specified by law.

• In addion, these records may not be shared with third pares without wrien parental consent unless the disclosure meets one of the excepons to FERPA’s general consent requirement. Definion of Parent Under FERPA

• Under FERPA, a “parent” means a parent of a student and includes a natural parent, a guardian, or an individual acng as a parent in the absence of a parent or guardian. 34 CFR § 99.3 definion of “Parent.” Addionally, in the case of the divorce or separaon 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 relang to such maers as divorce, separaon, 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 informaon and other “educaon records” to teachers and other school officials, without wrien consent, if these school officials have “legimate educaonal interests” in accordance with school policy. See 34 CFR § 99.31(a)(1). • A school may permit disclosure of educaon records, without consent, to appropriate pares in connecon with an emergency, if knowledge of the informaon 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 authorizaon 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 excepon listed in 34 C.F.R. § 99.31. Disclosure to Medical Providers Under FERPA

• Disclosure may be made to appropriate pares, if the disclosure is in connecon with a health or safety emergency. See 34 CFR §§ 99.31(a)(10) and 99.36. • hps://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 acng on behalf of the educaonal instuon (i.e., third-party health care provider), as long as the informaon is being disclosed only for the purpose of providing treatment to the student. Only allowed as long as the informaon 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 wrien consent before the agency or instuon discloses personally idenfiable informaon ("PII") from the student's educaon records. 34 CFR § 99.30. • FERPA allows a parent to consent to the disclosure of a minor child’s educaonal records, which includes personally idenfiable informaon, to third pares. • Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents • hps://www2.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/ modelform2.html

Disclosures Under FERPA Without Consent (paral list) • Schools are generally prohibited from disclosing personally idenfiable informaon about a student without the parent’s wrien consent. • Excepons to this rule include: • disclosures made to school officials, including teachers, with legimate educaonal interests; • In an emergency "if knowledge of the informaon 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 distribuon list violates FERPA. Disclosures under FERPA

• Can school personnel talk to a student's health care provider without consent?

• Generally, schools must have wrien permission from the parent or eligible student in order to release any informaon from a student's educaon record to outside pares including providers. However, a school nurse may call a student's health care provider to clarify facts surrounding a student's condion or treatment plan. Administraon Of Meds and Procedures

• For the most part, the statutory authorizaons are found in Tennessee Code Annotated (T.C.A.) secon 49-50-1601 et seq.

Administraon of Meds and Procedures - T.C.A. § 49-50-1601 • T.C.A. § 49-50-1601 allows the self-administraon of pancreac enzymes with wrien authorizaon from the healthcare provider and parent. A student with pancreac insufficiency or cysc fibrosis is allowed to carry and self-administer prescribed pancreac enzymes. Administraon Of Meds and Procedures - T.C.A. § 49-50-1602 • T.C.A. § 49-50-1602 requires certain health care procedures, including the administraon of medicaons 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 clarificaon for medical and nursing procedures performed in the school seng. • T.C.A. § 49-50-1602 permits possession and self-administraon of a prescribed, metered dosage, asthma-reliever inhaler by any asthmac student. Administraon Of Meds and Procedures - T.C.A. § 49-50-1602 (connued) • T.C.A. § 49-50-1602 permits “school personnel to volunteer to assist with the care of students with diabetes, excluding the administraon of insulin; • T.C.A. § 49-50-1602 allows school staff, who under no duress, volunteer to be trained in the administraon of an-seizure medicaon, 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 anaphylacc reacon.

Administraon Of Meds and Procedures - T.C.A. § 49-50-1602 (connued) • 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 clarificaon for medical and nursing procedures performed in the school seng. Administraon Of Meds and Procedures - T.C.A. § 49-50-1603 • T.C.A. § 49-50-1603 (2017 Public Chapter 84) - State Board of Educaon will adopt rules for the administraon of adrenal insufficiency medicaon by school personnel if the healthcare provider is not immediately available. The school system is only required train personnel if nofied by a parent/guardian that a student has the condion. The school system must adopt a policy. Removes liability when administering the medicaon. Effecve July 1, 2017.

• hp://publicaons.tnsosfiles.com/acts/110/pub/pc0084.pdf

Administraon 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 Educaon will develop guidelines for the administraon of an opioid antagonist for students experiencing an opioid overdose. The prescripon will be held in the name of the school system. The school nurse, SRO, or other trained personnel may administer the medicaon. There are provisions removing liability if a student is injured due to the administraon of the medicaon. This is effecve July 1, 2017.

• hp://publicaons.tnsosfiles.com/acts/110/pub/pc0256.pdf Administraon Of Meds and Procedures – Related Statutes • T.C.A. § 49-5-414 encourages LEAs to have CPR - cerfied 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 cerficaon consistent with the guidelines of the American Heart Associaon • 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 relaonship to reporng immunizaon status for a child. Health care professionals shall provide a copy of the report or form to the parents or guardians indicang the need to seek appropriate follow up.

Other Legislaon – Telehealth Services

• Changes made by Public Chapter 130 to T.C.A. § 56-7-1002 - Telehealth services • (ii) The paent is at a qualified site or at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunicaons described in this secon; and equipped to engage in the telecommunicaons described in this secon; and, or at a public elementary or secondary school staffed by a healthcare services provider and Proposed Legislaon Sll Under Consideraon

• 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 posion for each three thousand (3,000) seven hundred fiy (750) students or one (1) full-me posion for each LEA, whichever is greater. Proposed Legislaon Sll Under Consideraon

• Changes by proposed SB1055/HB1099 would amend T.C.A. § 68-55-501 - Part definions.

• (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 praconer with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician. Proposed Legislaon Sll Under Consideraon

• Changes by Proposed SB190/HB145 would amend T.C.A. § 68-11-313 - Authencaon of verbal orders.

• (d) For the purposes of this secon, 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 Obstrucve Sleep Apnea. 3. Idenfy treatment opons 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. Acvated EEG (similar to wake) with decreased or no muscle tone 2. Alternates with NREM every 90-100 minutes with progressive lengthening in the laer 1/3 on the night

American Thoracic Society defines OSA

• A disorder of breathing during sleep characterized by prolonged paral airway obstrucon and/or intermient complete obstrucon that disrupts normal venlaon during sleep and normal sleep paerns. 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 populaon

3. More likely to be seen in boys versus girls Risk Factors for OSA

1. Adenotonsillar Hypertrophy 2. Obesity 3. Craniofacial Anomalies 4. Familial Predisposion 5. Ethnicity 6. Prematurity Nocturnal Symptoms

1. Snoring 2. Paradoxical Breathing Most sensive and 3. Witnessed Apnea specific

4. Restless Sleep 5. Frequent Awakenings 6. Nocturnal Enuresis 7. Night Sweang Dayme Symptoms

1. Abnormal Dayme Funconing - Less than 15% report dayme sleepiness - May present in children as irritability, nervousness, and aggressiveness. - Impaired cognive funcon 2. ADHD 3. Poor School Performance Dayme Symptoms – other consideraons

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 resulng from intermient hypoxia, sleep fragmentaon, and inflammaon.

1. RV and LV dysfunction 2. Systemic Hypertension 3. Pulmonary Hypertension 4. Poor Growth 5. Behavioral and Cognitive Impairment 6. ADHD

Evaluaon

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 classificaon 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 contribung risk factors.

1. Mild OSA –AHI 1-4.9 2. Moderate OSA – AHI 5-9.9 3. Severe OSA – AHI >10 Obstrucve Sleep Apnea • Treatment Opons • Tonsillectomy and Adenoidectomy • CPAP (connuous posive airway pressure) • “Watchful Waing?” Obstrucve 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

Obstrucve 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

Obstrucve 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.