Let’s Talk about Asthma!

starring the AirBuds Name:______

We want to tell you about ASTHMA and Hi there! what you can do to We’re the AirBuds. TAKE CONTROL! We’re part of your lungs. Are you ready? An Asthma Self-Management Guide for Teens

Developed BY people with asthma FOR people with asthma Jennifer Mammen, MSN FNP & Hyekyun Rhee, PNP PhD University of Rochester School of Nursing, University of Rochester Medical Center Illustrated by Jennifer Mammen & T. Mark Bartley ______CONTENTS Round 1 So what’s it to me? page 1 Pathology and Prevention of Asthma Round 2 Better watch it! page 8 Monitoring of Asthma Symptoms Round 3 Hey, stop it! page 16 Management of Asthma Symptoms Round 4

Let’s Talk about Asthma! page 25 Communication and Social Issues Let’s Talk About Asthma ©

Copyright 2012, Jennifer R. Mammen and Hyekyun Rhee, University of Rochester School of Nursing

Some rights reserved. All content, including printed and electronic materials, may be freely copied, reproduced, shared, and distributed for all non-profit purposes. Modification of content and for profit distribution and sharing is not permitted without written permission from the authors.

If using any portion of these materials, the following citation should be included:

Mammen, JR & Rhee, H. (2012) Let’s Talk About Asthma. University of Rochester School of Nursing. Round 1: So what’s it to me? Pathophysiology and Prevention of Asthma

In this section we’re going to talk about what asthma is, what causes it, and how to prevent it! first, let’s talk about NORMAL BREATHING. During normal breathing, AIR:

moves into your nose and mouth, down into the airways, through the bronchi (the big tubes), into the bronchioles (the smaller tubes) then into the tiny alveoli (the little air sacs at the end).

Your blood collects the oxygen from the alveoli, then moves it around to the rest of your body in red blood cells (kind of like a taxi ride).

ASTHMA. People who have asthma have sensitive lungs. Something irritates your lungs (we don’t always know what). swollen alveoli and That causes SWELLING (inflammation) in your lungs. clogged airways

cross section of airway NORMAL ⟿ INFLAMMED ⟿ AWFUL!!

THIS is what happens during asthma. The airway tubes get swollen (inflammation) and make more mucus. That makes it harder to get air in and out. You start out breathing through a nice big SNORKEL and end up trying to breath through a tiny STRAW!

page 1 The swelling makes your lungs go crazy. Think about it—when you get irritated, what do you want to do?

FREAK OUT! Gasp!

That’s what your lungs do. Irritation makes the muscles surrounding the lungs crazy and “hyper-responsive.”

The muscles SQUEEZE tight around your airways so it’s harder to get air in and out (Broncho-SPASMS). This causes you to cough and make wheezing noises.

NEXT, your lungs turn into mucus making factories, and block up your airway with goo. So now your airway is smaller and OBSTRUCTED with mucus!

The tale of doom continues….the more you Hack! cough, the more you irritate your lungs, the more they swell, the more they spasm, and the more mucus they make. ARGH!!! This weakens your lungs. When your lungs are weak, you get sick more.

Let’s STOP and SUMMARIZE: ! ! ! ! Uncontrolled Asthma causes: uncontrolled Swelling (airways swell up) asthma makes Obstruction (more mucus, smaller spaces) your lungs Spasms (constriction/ bronchospasm) weaker SOS!

page 2 ASTHMA TRIGGERS

Triggers are ANYTHING that causes asthma symptoms.

People with asthma have sensitive lungs, and some things bother us that don’t bother other people—they can cause asthma symptoms!

What are signs that something is triggering your asthma?

PRE-ASTHMA SYMPTOMS ASTHMA SYMPTOMS ALOT of itchy eyes coughing things can sneezing chest tightness trigger asthma tickle in throat wheezing symptoms! getting sick short of breath

YEAH! Look at this. chemicals pests + pets Chemicals Pests: Roaches, Rats, Mice Personal Pets: fur / feathers Care Products consumables Home Cleaners Did you Food know cockroach poop is a HUGE Medicine problem for people exposures with asthma? WHAT’S Cockroaches poop a Cold weather YOUR lot, and when the events poop gets stirred up, Fumes, Exhaust TRIGGER? Exercising/ it floats around in the air. THEN, you Sports Cigarette smoke breath it into your Laughing lungs. YUCK! Next Mold thing you have Stress symptoms! Pollens Catching a cold Dust

The best way to treat asthma is to prevent it! THAT means knowing what your triggers are, so you can avoid them.

page 3 A lot of people CAREFUL with the asthma TRIGGERS!!! with cat allergies think they’re allergic to dog What can you do about it? and cat hair--actually it’s the dead flaky cells pets (fur and feathers):______from the skin (called Avoid pets that trigger your asthma dander) that cause Keep pets out of your bedroom and keep your bedroom door closed. the real problem. Don’t use feather pillows or feather comforters. Use polyester pillows instead and cover them with allergy (dust-mite proof) covers. Ask friends if they have pets you are allergic to BEFORE visiting them. Not pets (Roaches, Bugs, Rats, Mice):______Keep food and garbage in closed containers. Empty the trash every day. Keep food out of your bedroom. Seal cracks in walls and cabinets. Tell your parents if you notice bugs or rats/mice so they can arrange to exterminate them. Use mouse traps or cockroach gels to kill pests. Pesticide sprays can bother your asthma—try using other options for extermination.

Medicine:______Avoid medicine you are allergic to. Ask your parents or healthcare provider if you are not sure. Food:______Avoid foods you are allergic to — these can cause you to have asthma symptoms. People with asthma may be sensitive to foods/medicines that contain sulfites (ex. dried fruit, shrimp). Avoid strong odors and smoke from cooking foods. Exercising and Sports:______Always warm up 5-10 minutes before exercising. Use a quick relief inhaler 15 minutes before exercising, as directed by your provider. Tell coaches and teachers that you have asthma, and when you are having symptoms. If you have asthma symptoms during exercising stop the activity and rest. Use your inhaler as prescribed.

Dust:______Keep your bedroom dust-free. Use washable curtains or window shades. Wash curtains monthly and damp wipe shades weekly. Cover pillows and mattress/bedsprings with allergy (dust-mite proof) covers. Don’t use a bed cover or comforter as a blanket—remove it before you sleep. Getting a COLD Wash pillowcases, sheets, and blankets on your bed in hot water weekly. can make your asthma Keep humidity less than 60% in your home. worse. AND, it takes a Keep stuffed animals off your bed and out of the bedroom. lot longer for all the Vacuum once or twice a week throughout your home. symptoms (like HEPA filtered vacuums are best. Forced air furnace filters should be changed at least every 3 months. coughing) to go away Keep clutter to a minimum—especially in your bedroom. Keep dust collecting items in closed containers or in drawers. Avoid sweeping floors. Use a vacuum instead or damp mop. Dust with a damp clean cloth. Avoid construction areas and remodeling areas due to dust exposure.

page 4 Personal Care Products:______Avoid perfume, cologne, and scented personal care products. Use unscented options. Alert family, teachers, and friends if you are sensitive to the perfume/cologne they are using. Avoid talcum powders, aerosol hair spray, and spray deodorants. Avoid using jewelry cleaner and nail polish remover due to strong odors. Home Cleaners and Products:______Avoid using room fresheners/deodorizers, room sprays, or incense. Avoid using strong smelling cleaners like ammonia and chlorine bleach. Use unscented laundry detergents and avoid using dryer sheets. Use a damp clean cloth to dust - avoid using dusting sprays.

Chemicals:______Avoid chemicals with strong odors, like those found in new clothes, cleaning products, fertilizers, paints, glues, varnishes, and new carpets. Wash new clothing before wearing because many are chemically treated. Avoid exposure to lawn fertilizers/chemicals, pesticides, and household chemicals. Be aware of chemicals used in school science rooms especially in dissection classes.

Things at School:______Tell your teachers that you have asthma so you can work together to avoid things that trigger your symptoms at school. Also talk to your school nurses, science teachers, gym teachers, coaches, bus drivers, and cafeteria staff. It may be helpful to write a letter describing your asthma triggers and symptoms to give to school staff at the beginning of the school year. Mold:______Avoid raking leaves. Avoid moldy books and damp areas. Don’t let people smoke Fix leaky faucets, plumbing, and leaking roof areas. around you. A dehumidifier can dry out damp basements. Throw out spoiled foods and keep refrigerator clean. Second hand smoke is Frequently clean the drip pan under the refrigerator to remove mold. Dry tub and shower areas after using them to decrease mold. one of the biggest Remove carpets from damp areas like the bathroom and basement. asthma triggers. Use a fan in your bathroom if available to prevent mold from growing. Pollens:______Shower and wash hair at night before bed to remove pollens. Pollen counts may be highest during the middle of the day and the afternoon. If you are allergic to pollens your healthcare provider may recommend allergy shots.

Weather:______Cover your mouth and nose with a scarf in cold weather to help warm up the air you are breathing. Cold air can trigger asthma symptoms. Limit outside activities when the weather is extremely cold, hot, windy, humid, or polluted.

Smoke/Fumes/Exhaust:______If you smoke cigarettes talk to your healthcare provider about how to quit. Ask smokers that live in your home to smoke outside, never inside the house, in the car, or around you. Avoid smoke and fumes from heaters (wood-burning, kerosene, gas); fireplaces; campfires; bonfires; and exhaust from cars, trucks, buses, and trains.

page 5

asthma How many asthma Circle the ones you see! triggers can you find? case #1 case Dr. Detective Detective Dr. symptoms. What do you think theWhat could problem? be causing symptoms. Lazair notices that every time he goes over to his cousin Miguel’s house getshe every time goeshe that his cousin notices over to Miguel’s Lazair

page 6 So…What about EXERCISE?

Intense exercise may be a trigger for asthma. BUT, that doesn’t mean you should limit your exercise. In fact, exercising helps to make your lungs STRONGER and decreases inflammation, so that you get fewer symptoms over time. Exercise is an important part of being healthy and controlling asthma.

People with asthma should exercise and be active just like everyone else

The only DIFFERENCE is you may need to take your albuterol inhaler 15 minutes BEFORE exercising, and again (during or after) if you get symptoms.

How many asthma TRIGGERs can you find ? cigarette smoke R E D G D K U Y T R J H G F M N B V G F animals K C A R T L I R E T B C J V I R U S H F laughing G L I N L X N N A Y R O N R L M S I G D dust mites V W D G H S F P M U A L S E I E Q N F P cockroaches F O O D A L L E R G Y D G Z R D L U L O exercise medicine E P D J N R U H M R V A M T B I X S P I stress T N V U I H E X E R C I S E A C N I O B food allergy N E I C M J N T K C D R T K U I E T Y R mold P U J L A F Z B T Q X L R G V N L I B O cold air E M F A L P A C M E B J S E L E L S F N perfume X O D U S T M I T E S D K U B O O H Q C influenza virus C N K G F I O F D R E M U F R E P T W H pollen I I C H L A L C O C K R O A C H E S E I chemical cleaners T A R I D K D L M X P U I K P L H K R T paint E X Y N A Q G C H J P F M C E J M I D I sinusitis M I M G C H E M I C A L C L E A N E R S latex E L N I O G J K W X I W S A I G B E C K pneumonia bronchitis N A A L A T E X O K N N T D R Q D L X H strep throat T O N R P S T R E P T H R O A T C J X S excitement D G J N T O F S V S K O A R T V H U Z A

if you smoke...kick the habit!

page 7 Round 2: Better watch it!! Monitoring symptoms of Asthma

So, last chapter we learned what asthma is, what triggers are, and how to prevent symptoms. Now we’ll talk about how to keep things under control! To control symptoms you need to: Watch how things are going (monitoring) Do something about it (managing)

Let’s start with monitoring. Monitoring asthma is kind of like playing basketball. You don’t just stand around until the other team shoots a hoop-- you try to stop them. You think ahead. You watch the way the game is going. You’re smart, and you stay on top of things.

Well in asthma, you have to watch the way the game is going. You have to be smart enough to spot the little signs. And you have to know how to stop problems before they actually happen. Ignoring your asthma is like standing around on the court and waiting for someone to hit you in the head with a basketball.

Monitoring is for smart people. It means you keep an eye on how things are going, and if something starts to go wrong, you do something about it.

There are two ways you can keep an eye on your asthma everyday: 1. Keeping track of your symptoms I don’t know why my nurse thinks I’m coughing badly-- 2. Peak flow meters I’ve been practicing all night!

page 8 Sometimes people I tell them, No, ask me if it’s hard having asthma... it’s wheezy!

Let’s talk about symptoms What are the symptoms of asthma?

YES cough a frequent cough that is triggered easily or lasts too long

YES mucus / sputum irritated cells in the lungs make more mucus/sputum

YES wheezing sound made by air as it tries to pass through a narrow airway short of breath/ can’t get as much air in and out, so you have to breath faster to YES trouble breathing make up for it. lying down means you work harder to breath, and that makes the cough at night YES symptoms worse.

Fever is not a symptom of asthma--that means something else fever NO! is wrong. chest pain/ working harder to breath--like a band around the chest YES tightness symptoms with asthma symptoms slow you down when you are being active YES exercise

YES clearing throat from too much sputum Red Flags YES tiredness feeling more tired than you should • struggling to breathe YES OTHER: ______• worsening symptoms • trouble talking or walking • using chest muscles to breath • Nostrils open wide Based on YOUR symptoms, how do • lips or fingernails are blue you think your asthma is TODAY? get immediate medical attention !! Circle the box that you think fits you the best. Zero (0) means that you have NO symptoms, and 8 means you’re way out of control!

0 1 2 3 4 5 6 7 8

Great! Borderline Out of control Way out of control

page 9 Answer these questions to find out how your Try to do question 1 in asthma control is today. the morning, and the rest at Circle the answer that fits you best. bedtime.

1. Did you wake up last night because of asthma? 0 - No, not once 1 - Once 2 - A few times 3 - A lot

2. Did you have any asthma symptoms today? 0 – No, not once 1 – Once ADD all the scores. 2 – A few times The TOTAL number tells you how 3 - A lot good your control is.

3. Did asthma limit your physical activity today? 0 is Great! 0 - No, not once 1 - Once 1 to 3 is Borderline 2 - A few times 3 - A lot 4 to 7 is Out of control 9 or more is Way out of control! 4. Did you use your rescue inhaler today? 0 – No, not once 1- Once 2- A few times 3 - A lot Three strikes, YOU’RE OUT! (A score of 3 on any one question means you’re WAY out of control)

0 1 2 3 4 5 6 7 8 9+

Great! Borderline Out of control Way out of control

page 10 Baby, you’re like asthma... you take my breath away!

Great! (0)

Medication Keep taking prescribed medications. Use rescue inhaler if needed.

Peak Flow Check peak flow 1-2 times a day (morning and/or night).

Activity Keep it up! No limitations (don’t forget to take your inhaler first, if you’re supposed to).

Action Plan Follow your asthma action plan. If you don’t have one--GET ONE!

Reminders Avoid triggers, practice good hand-washing to prevent infection.

Borderline (1 to 3)

Medication You may need to ADJUST medications. Use the action plan, or check with your provider. Use rescue inhaler if needed. If you are borderline more than twice in a week, you need to FOLLOW UP with your provider.

Peak Flow CHECK peak flow 1-2 times a day (morning and night).

Activity Stop activities that cause asthma symptoms--TELL your provider.

Action Plan Follow your asthma action plan. If you don’t have one--GET ONE!

Reminders AVOID triggers, practice good handwashing to prevent infection, WATCH FOR WORSENING SYMPTOMS.

Out of Control (4 to 9+)

Medication Time to ADJUST medications—use your action plan and the ASTHMA ATTACK guide (next page). Use rescue inhaler as directed. If you are out of control more than twice in a week, you need to FOLLOW UP with your provider. If you score 3 in any category or 9+ total, you need to CALL NOW!

Peak Flow CHECK peak flow 1-2 times a day (morning and night).

Activity Stop activities that cause asthma symptoms. Stay sitting up.

Action Plan Follow your asthma action plan. If you don’t have one--GET ONE!

Reminders AVOID triggers, practice good handwashing to prevent infection, WATCH FOR WORSENING SYMPTOMS. page 11 ASTHMA ATTACK!!

1. ! . ! ! !

! oral steroid CALL URGENT instructions. yourdoctor. Follow up with Not urgent today. urgent Not yourDocfurther for START What should you should What do when you have an asthma attack? Follow the steps in this flow sheet to help you decide. YES YES ! ! ! ! NO, it’s less it’s NO, NO, it’s less it’s NO, "! ! "! Is peak Is flow Adapted from Figure Adapted 5-4, National Asthma Guidelines (2007) Is peak Is flow peak Is flow exhausted

" morethan 80% best? of lessthan 50% best?of morethan 50% best? of coughing " NO NO NO ! ! ! ! ! ! symptomsasthma? of essdiscomfort or puffs puffs puffs !

short of breath of short

" ! can’t speak in full sentences full speak can’t in " chesttightn (wait20 minutes) (wait20 minutes) (wait20 minutes) TAKE REPEAT REPEAT NO YES YES YES YES YES wheezing wheezing Do you have ANY ANY Do you have asdirected asdirected asdirected Areyou still having symptoms? Areyou still having symptoms? Albuterolinhaler 2ormore Areyou still having symptoms? Albuterolinhaler 2ormore Albuterolinhaler 2ormore ! can’t catchcan’t breath use of stomachchest or musclesbreatheuseof to Do you have SYMPTOMS of LIFE THREATENING ASTHMA? THREATENING LIFE of have SYMPTOMS you Do go to ER to go CALL 911 911 CALL immediately!! YES ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

page 12 Dr. Detective case #2

You’re the provider

Darth Vader comes to see you because his asthma is really bad. He’s supposed to be taking a daily control medication, but ran out about 2 weeks ago because his underlings never got it refilled. He’s been using his albuterol instead. Now he has a cold, and he feels terrible. He tells you that he has taken 12 puffs of his albuterol in the last hour and is still uncomfortable. He looks (and sounds) out of breath and can’t talk in full sentences. What should you do?

1. What do you think is wrong with Darth? How do you know?

2. What do you want to do for him?

Weird Word Scramble What do you call a pony with a bad cough? (ASHOER) A Little _ _ _ R _ E! page 13 Symptom Diary Give each question a score➤ 0 = No, not once 1 = Once 2 = A few 3 = A lot Did you need your rescue inhaler Did you wake up last wake up you Did fromasthma? night have asthmayou Did symptomstoday? Did asthma limit your asthma Did limit activitytoday? SCORE TOTAL

DAY TIME PEAK FLOW AM PM 1/1 8am G Y R 385 0 1 1 1 3 G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R G Y R It’s hard to rememberG whatY happenedR last week. G Y R Three DIARIES are greatG YwayR to record strikes, symptoms so you don’t forget. YOU’RE OUT! G Y R (A “3” on any one Be sure to bring itG to yourY nextR check up! question means you’re WAY out of control)

0 1 2 3 4 5 6 7 8 9+

page 14 peak flow meters Peak flow meters measure how FAST you can blow air out of your lungs. A peak flow meter tells you what’s going on with your lungs before you even feel it. I think of it as kind of like spying on what your asthma is doing.

Remember what happens with asthma? SOS!

Swelling (from inflammation) Obstruction (more mucus/smaller spaces) Spasms (muscles around lungs spasm and squeeze tight)

SOS makes your airways smaller. A peak flow meter can measure small changes in your SOS before you have symptoms. That way you can prevent things from getting worse and stop symptoms before they happen!! WOW!

How to use a Peak Flow Meter (PFM) 1. Set the slider on the PFM to 0. Stand up straight. 2. BREATH IN. Put the PFM in your mouth. Hold it straight out like a trumpet. 3. BLOW OUT. Take the biggest breath you can, and then blow HARD and FAST. 4. WRITE IT DOWN. Write down the number the slider stopped at. 5. RESET the slider to 0 and try it 2 times more. The best (highest) number is your PEAK FLOW!

Most peak flow meters have a Green-Yellow-Red slider. When you know your personal best, you set the slider to that. GREEN is GOOD because it’s 80-100% of your best, YELLOW is for caution (50-79%), and RED (<50%) is the danger zone! Red means your lungs are constricted and swollen. If you’re RED—call your doctor. GREEN 80-100% ➔ YELLOW 50-79% ➔ RED <50% !! ➔

page 15 Round 3: Hey, STOP it!! Managing symptoms of Asthma

To treat asthma symptoms, you need the right: ✦ Timing It’s easy to take asthma ✦ Amount medications WRONG.… ✦ Kind of medicine but they work better if you ✦ Method of taking it TAK-M-RIGHT!

There are really only 2 kinds of ASTHMA MEDICATION: 1. FASTER “RESCUE” medications 2. SLOWER “CONTROL” medications

Fast Acting “rescue” medications (like albuterol)

Rescue medications treat SPASMS and OBSTRUCTION Control symptoms caused by spasms. Rescue medicine provides relief RIGHT from symptoms like wheezing and coughing in AWAY 5 to 15 minutes. They don’t treat the underlying and they won’t problem. Use them if you have a problem NOW, or get so bad before exercise to prevent symptoms.

Slower “control” medications Control medications stop SWELLING and OBSTRUCTION caused by inflammation and mucus production. Control medications treat the underlying problem—not just the symptoms. They work by preventing symptoms from happening. They take days to weeks to take effect, and you have to take them every day to work. They are NOT for emergencies. Always take the prescribed amount. Taking more can give you side effects. Taking less means it may not work right.

page 16

. . . ! inflammation inflammation short term use.shortterm bronchodialator. How does it work? it does How stopallergy orinflammation. Takes days to weekswork days to Takes weekswork days to Takes weekswork days to Takes usuallyan inhaled steroid, and a stopstheallergic reaction causesthat stopstheallergic reaction causesthat Starts working within 5-15 minutes. within Startsworking Starts working within hours to days. to hours within Startsworking Works same day, but not fast acting. fast acting. not but same day, Works Albuterolrelaxes themuscles squeezethat whenother medications aren’t working. For Thesedrugs are combinations twodrugs,of Helpspreventto bronchospasm, butdoesn’t tightaround thelungs, and letstheair back in Prednisoneisused during bad exacerbations,

! Stops Stops Prevents Prevents Prevents Prevents SPASMS SWELLING, SWELLING, SWELLING & SWELLING & SWELLING & SWELLING What’s it for? it What’s SPASMS FAST SPASMS OBSTRUCTION OBSTRUCTION OBSTRUCTION OBSTRUCTION QUICK FIX NOW PreventsSPASMS

NO! YES meds SLOW “control” “control” ! ! ! !

NO! NO! NO! NO! YES meds ASTHMA MEDICATIONS FAST “rescue” ! drug Qvar Zyflo Advair names Maxair Flovent Flovent Aerobid Ventolin Ventolin Xopenex Accolate Serevent Singulair Singulair Proventil Proventil Common AccuNeb Asmanex Azmacort Pulmicort Pulmicort Symbicort Albuterol Albuterol Combivent Prednisone Type Drugs Inhaled modifier Long acting acting Long Leukotriene Short acting acting Short Combination Combination Oral Steroids Oral Corticosteroid bronchodialator bronchodialator

page 17 Let’s STOP and SUMMARIZE medication treatment:

Remember uncontrolled Asthma causes:

CONTROL Swelling (airways swell up) CONTROL/RESCUE Obstruction (more mucus, smaller spaces) RESCUE Spasms (constriction/ bronchospasm)

SOS? ➔ RESCUE + CONTROL

EVERYONE with asthma needs a rescue inhaler.

Rescue inhalers are good for emergencies. You should always have one with you. It’s like a cell phone. If you woke up in the middle of the night and realized someone was trying to break into your house, you would use your cell phone and call the police. Unless of course you didn’t have a cell phone⎯then you would be out of luck. Remember your inhaler…IT COULD SAVE YOUR LIFE.

Q: what did the corpse say to the doctor? A: this coffin’ is driving me crazy!

Hey! Maybe! But not everyone Wait a sec!! with asthma needs control Does this mean I need medication. It all depends to be on CONTROL on your LEVEL of asthma medication too??? SEVERITY and CONTROL.

How do you tell your asthma control? (turn the page to find out) page 18 ASTHMA Well controlled asthma CONTROL means you have symptoms 2 times a week or LESS. Here’s how providers figure out how well controlled your asthma is. 1. Start with the blue boxes. Next go sideways until you find the level that matches your symptoms. Circle one box for each row. control 2. Find the highest column that has a circle in it. This is your asthma control ➔

OVER THE PAST 4 NOT WELL VERY POORLY WELL CONTROLLED WEEKS CONTROLLED CONTROLLED 2 or LESS 3 or MORE MANY times symptoms start times a week times a week a day

night time wake up 2 or LESS 3 or MORE 4 or MORE for symptoms times a month times a month times a week 2 or LESS 3 or MORE 3 or MORE using rescue inhaler times a week times a week times a day

activity limitations NONE SOME limitation VERY limited

Peak Flow > 80 % of best 60-80% of best <60% of best

adapted from the National Guidelines (2007) Figure 3-4c Now you try it. What kind of symptoms have you had over the last 4 weeks? Circle the answers to the blue boxes that fit you best. Is your asthma well controlled or not?

OVER THE PAST 4 NOT WELL VERY POORLY WELL CONTROLLED WEEKS CONTROLLED CONTROLLED 2 or LESS 3 or MORE MANY times symptoms times a week times a week a day

night time wake up 2 or LESS 3 or MORE 4 or MORE for symptoms times a month times a month times a week 2 or LESS 3 or MORE 3 or MORE using rescue inhaler times a week times a week times a day activity limitations NONE SOME limitation VERY limited

Peak Flow > 80 % of best 60-80% of best <60% of best

adapted from the National Guidelines (2007) Figure 3-4c

page 19 Instructions: Dr. Detective Can you figure it out? Ask the instructor for case #3 more information if you need it.

Ok, you’re the provider.

Shawn is 17. He comes to see you because he’s been coughing every day for about 6 months. It keeps waking him up at night. He hasn’t been able to play sports because he gets too out of breath. He wants to know why his cold won’t go away.

What kinds of questions do you want to ask him so that you can fix his problem? Use the symptoms, severity and medication charts to help you figure out what to do for him.

1. Does it sound like asthma to you? Why? What other information do you need?

2. How bad is it?

• What is his asthma control?

controlled asthma doesn’t slow you down

page 20 REMODELING

The real reason for CONTROL medicine is to prevent DAMAGE Try putting one rubber-band around your fingers. It’s still pretty to your lungs, not just stop easy to open and close them. Now the symptoms. Asthma causes add 2, then 3, 4, 5, and so on. After a while, you can’t move your fingers inflammation. Inflammation anymore. That’s what uncontrolled causes injuries to the lung. When injury asthma does to your lungs. heals up, it leaves a small stiff SCAR behind it. Over time, you get more and more of these scars, which reduces the ability of your lungs to move air in and out. The scars act like rubber bands around the lungs, so that it gets harder and harder to breathe.

Rescue inhalers make your symptoms go away, but don’t stop the SCARRING

This process is called REMODELING — it permanently scars your lungs.

SO…Treating asthma isn’t just about making you feel good now. It’s about the future. Everyday you don’t treat your asthma puts you one step closer to a really serious breathing problem.

Let’s face it. Treating asthma is a pain in the butt…..But then so is walking around with an oxygen tank.

That’s why we use control medications—because they stop REMODELING, make your asthma easier to control, AND prevent symptoms. Control medications prevent asthma from getting in the way of what you want to do. You don’t want asthma to slow you down—so STOP it!!

SEVERITY: MILD MILD MODERATE SEVERE INTERMITTENT PERSISTENT PERSISTENT PERSISTENT

WELL CONTROL: NOT WELL CONTROLLED & POORLY CONTROLLED CONTROLLED

What kind of Rescue medicine You need CONTROL medicine medicine? (ex. Albuterol) and RESCUE medicine

page 21 What’s up, doc? Can you figure out what’s going on? Dr. Detective HINT: Use the information from pages 11, 18-19, case #4 21-22, 24, to answer the questions.

Maca is 14. She has had asthma for 5 years. She says things are great and that she only has her normal symptoms. She treats it with an albuterol inhaler, which easily gets rid of the symptoms. She’s coming to see you because she needs a refill of her albuterol inhaler.

You’re the provider. 1. What are Maca’s asthma symptoms? What other information do you need?

2. What’s her asthma control?

3. Is she taking the right medications? Why or Why not?

if you have symptoms of

4. What else does she need? Why? asthma more than TWICE A WEEK, it’s NOT NORMAL

KEY POINT: People with persistent asthma need CONTROL + RESCUE medication.

page 22 Now that we know what medications to take, let’s

make sure we’re taking them RIGHT!

How to take inhalers (correctly) because ANYONE can do it wrong. 1. Stand up. 2. Shake the inhaler. 3. Breath OUT. (Blow out all the air in your lungs.) 4. Hold the inhaler up right, start breathing in, puff the inhaler as you start. 5. Keep breathing in slowly, the biggest breath you can. 6. Hold it for 10 seconds, then breath out. 7. Wait 1 minute and repeat if needed. 8. Remember to rinse your inhaler at least once a week so it doesn’t get clogged up.

MAKE SURE YOU RINSE YOUR MOUTH AFTER TAKING STEROID INHALERS. (otherwise you can get a yeast infection in your mouth.)

Don’t forget to use a Spacer! 1. Shake the inhaler and attach it to the spacer 2. Breath OUT 3. Put the spacer mouth piece in your mouth, squirt in one puff into the chamber, and then inhale slowly through your mouth 4. Hold for 10 seconds 5. Wait 1 minute and repeat as directed 6. Clean your spacer as directed by the manufacturer

Spacers (chambers) are little plastic tubes that help more medicine get to your lungs. When you use your inhaler with out a spacer a lot of the medicine just stays in your mouth.

Use a spacer whenever you can.

page 23 Round 4: Let’s Talk about Asthma! Communication & Social Issues

So now we know all sorts of stuff about asthma. But what about all those other people out there who don’t? Like friends, and teachers, and the people you live with? Sometimes they don’t know what causes asthma, or what the triggers are. What do we do about that? Let’s Talk about Asthma!

what do people need to know about us? I gotta remember to tell my doc how often I have symptoms! Sometimes I forget to talk about my healthcare provider NORMAL symptoms. s coach friends teacher parents

I want the NURSE to know that sister brother just because she can’t SEE my asthma symptoms doesn’t mean I don’t have them. I want her to believe grandparents me!

If I use an inhaler, will people make fun of me? school nurse

page 24 What kind of problems do you have in dealing with other people? Check the boxes that fit you. ✓ Problems with Friends ✓ Problems at home My friends smoke. No one fills my inhalers on time My friends have pets I’m allergic to. People smoke in my house. People smoke or do drugs at parties and I My house is dusty and dirty. don’t know how to handle it. My friends don’t know I have asthma. We have pets, and I’m allergic. I’m embarrassed to carry an inhaler. I have too much stress. I’m allergic to things, and I’m embarrased to My parents don’t seem to care. tell people about it. I don’t like taking my inhaler where people My parents are too protective. can see me. My friends worry about my asthma too My problem is... much. I feel left out of things because of my ✓ Problems with Healthcare Providers asthma. I feel pressured to do things I don’t want to I keep forgetting to say what my symptoms do. are My problem is... I don’t think I’m getting the right medicine.

✓ Problems with other people They treat me like a little kid. People don’t seem to care that I have They aren’t very friendly. asthma. People worry too much that I have asthma I don’t trust them. My coach thinks I’m being a wimp if I ask to I don’t understand what they’re saying rest during practice. Sometimes people won’t let me take an They don’t explain things to me. inhaler when I need to. My problem is... I think they’re too busy to talk to me about asthma treatment. My problem is...

So, what do we do? You as-th-Ma! What do you do Let’s TALK if dad says no? about ways to solve the problems.

page 25 Dr. Detective What are reasons why people don’t want to use inhalers? case #5

Keisha is 16. She has had asthma for 1 year. She coughs off and on every day, and wheezes once in a while, but it doesn’t bother her very much. She doesn’t wake up at night. She has to be a little careful with sport and gym. She only uses her inhaler at home because she’s embarassed to take it to school. You told her she needs to start taking an inhaled steroid every day, AND carry her albuterol with her, but she doesn’t want to. She heard in health class that taking steroids is bad for you. What are you going to do?

1. How is Keisha’s asthma control? controller medications make your lungs 2. What are the reasons she should take a controller STRONGER medication? (what do steroid inhalers do?) because they STOP inflammation

3. What are her risks if she doesn’t take a controller medication?

4. Why should she carry her rescue inhaler?

5. How can you help her?

Some people worry about the side effects of taking medications. NOT treating asthma is far more dangerous than side effects. If the idea of side effects worries you, you should talk to your provider about it.

page 26 Fact or Fiction?

1. Asthma is something you grow out of. Fiction. You don’t grow out of asthma. However, the kinds of symptoms you have may change, depending on where you live and what your exposed to. Also, as kids get older, their airway gets bigger, so the swelling and inflammation that happens in the lungs may not be as noticeable as in smaller airways. 2. Taking my inhaled steroids will make me hairy with big muscles. Fiction. No way, Jose. There’s only a little bit of steroid, and most of that stays on the surface of your lungs—it’s just not enough to cause those kinds of side effects. That myth come from stories about people (like some athletes) using steroids to “bulk up.” Any one who wants big muscles is going to have to do it the old fashioned way—working out. 3. Taking steroids can give you osteoporosis. Fact. Taking prednisone for long periods of time can weaken your bones. That’s why it’s so important to take the inhaled corticosteroids regularly--so you won’t have to take the prednisone (pills). Most of the inhaled steroids stays on the surface of your lungs--only a tiny amount goes into your system. That’s why it doesn’t have the same problems that the prednisone pills do. The risks from taking steroid inhalors are really, really low--much lower than the risk of NOT taking them and permanently damaging your lungs from uncontrolled inflammation. 4. If you take inhalers too much, you can get addicted. Fiction. You don’t get hooked on inhalers. You don’t even get cravings for them. In fact, the people I know only take inhalers because they know it’s the SMART thing to do--not because they’re addicted. So don’t worry about turning into an inhaler junkie. 5. Having asthma means you can’t be as active as other people. Fiction. If your asthma is under control, there is no reason why you can’t be as active as everyone else. The only time asthma slows you down is when it is poorly controlled. So the take home message is--control your asthma, don’t let asthma control YOU!

page 27 ANSWER KEY

CROSSWORD PUZZLE page 9 Page 15 Weird word scramble: What do you call a pony C I C V I R U S with a bad cough? I N O M I G F L E N Answer: A little HOARSE! F O O D A L L E R G Y D R D U P N R U A T I S N I E X E R C I S E C N I B E M N T R I E T R U L A Z T N L U O E M A L A E E L S N X O D U S T M I T E S O C C N G O E M U F R E P H I I H L C O C K R O A C H E S I T A I D T E N P I M G C H E M I C A L C L E A N E R S E I N L A T E X N T S T R E P T H R O A T

REFERENCES:

American Lung Association. (2009) Kickin’ Asthma Student Workbook. Retrieved from https://lungne.app.box.com/s/hnpwq6spultwhuto9waq7ucbvh5gyj6l Current Asthma Population Estimates. (2010). 2010 National Health Interview Survey Data, from http://www.cdc.gov/asthma/nhis/2010/table3-1.htm Mammen, J., Rhee, H., 2012. Adolescent asthma self-management: a concept analysis and operational definition. Pediatric Allergy, Immunology, and Pulmonology 25 (4), 180-189. National Asthma Education and Prevention Program (National Heart Lung and Blood Institute). (2007). Expert Panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Institutes of Health. National Heart, Lung, and Blood Institute.

a Broncho-spasm! oooooh! What do Bad pun! you call a rodeo horse having a seizure? page 28