Asthma

A Presentation on Asthma Management and Prevention

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

 Episodes are usually associated with

widespread, but variable, airflow obstruction
within the lung that is often reversible either
spontaneously or with treatment.
 Pathology of Asthma

Asthma
involves
inflammation of
the airways

Normal Asthma

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma
Created and funded by NIH/NHLBI, 1995
Asthma Prevalence in the United States

June 2014

National Center for Environmental Health

Division of Environmental Hazards and Health Effects
 Introduction
Asthma:
affects 25.7 million people, including 7.0 million children under 18;
is a significant health and economic burden to patients, their
families, and society:
 In 2010, 1.8 million people visited an ED for asthma-related
care and 439,000 people were hospitalized because of
asthma
 Introduction
Asthma prevalence is an estimate of the percentage of the U.S. population with
asthma. Prevalence estimates help us understand the burden of asthma on the
nation.

Asthma “period prevalence” is the percentage of the U.S. population that had
asthma in the previous 12 months.

“Current” asthma prevalence is the percentage of the U.S. population who had
been diagnosed with asthma and had asthma at the time of the survey.

Asthma “period prevalence” was the original prevalence measure (1980-1996).

The survey was redesigned in 1997 and this measure was replaced by lifetime
prevalence (not presented in slides) and asthma episode or attack in the past 12
months. In 2001, another measure was added to assess current asthma prevalence.
Asthma Period Prevalence and Current Asthma Prevalence:
United States, 1980-2010

Current asthma prevalence, 2001-

2010

Asthma period prevalence, 1980-1996

The percentage of the U.S. population with asthma increased from 3.1% in 1980 to 5.5% in 1996
and 7.3% in 2001 to 8.4% in 2010.
Current Asthma Prevalence: United States, 2001-2010

Total number of persons Percent

Year
One in 12 people (about 26 million, or 8% of the U.S. population) had asthma in 2010,
compared with 1 in 14 (about 20 million, or 7%) in 2001.
Current Asthma Prevalence by Race and Ethnicity:
United States, 2001-2010

Blacks are more likely to have asthma than both Whites and Hispanics.
Current Asthma Prevalence by Age Group, Sex, Race and Ethnicity,
Poverty Status, Geographic Region, and Urbanicity: United States,
Average Annual 2008-2010

Children, females, Blacks, and Puerto Ricans are more likely to have asthma.
People with lower annual household income were more likely to have asthma.
Residents of the Northeast and Midwest were more likely to have asthma.
Living in or not in a city did not affect the chances of having asthma.
Child and Adult Current Asthma Prevalence by Age and Sex:
United States, 2006-2010

Among children aged 0-14, boys were more likely than girls to have asthma.
Boys and girls aged 15-17 years had asthma at the same rate..
Among adults women were more likely than men to have asthma.
Asthma Attack Prevalence among Children and Adults with
Current Asthma: United States, 2001-2010

Children aged 0-17 years

Adults aged 18 and over

From 2001 to 2010 both children and adults had fewer asthma attacks.
For children, asthma attacks declined from at least one asthma attack in the previous 12 months for 61.7% of children with asthma in
2001 to 58.3% in 2010.
For adults, asthma attacks declined from at least one asthma attack in the previous 12 months for 53.8% of adults with asthma in
2001, to 49.1% in 2010.
 Asthma Attack Prevalence among Persons with Current Asthma by Age
Group, Sex, Race and Ethnicity, Poverty Status, and Geographic Region:
Unites States, Average Annual 2008-2010

From 2008 to 2010 asthma attacks occurred more often in children and women, among families whose income was below 100% of
the federal poverty threshold, and in the South and West.
Race or ethnicity did not significantly affect asthma attack prevalence.
 Technical Notes
Asthma Period Prevalence and Current Asthma Prevalence: Estimates of asthma prevalence
indicate the percentage of the population with asthma at a given point in time and represent the
burden on the U.S. population.
Asthma prevalence data are self-reported by respondents to the National Health Interview Survey
(NHIS). Asthma period prevalence was the original measure (1980-1996) of U.S. asthma
prevalence and estimated the percentage of the population that had asthma in the previous 12
months. From 1997-2000, a redesign of the NHIS questions resulted in a break in the trend data
as the new questions were not fully comparable to the previous questions. Beginning in 2001,
current asthma prevalence (measured by the question, ‘‘Do you still have asthma?’’ for those
with an asthma diagnosis) was introduced to identify all persons with asthma. Current asthma
prevalence estimates from 2001 onward are point prevalence (previous 12 months) estimates and
therefore are not directly comparable with asthma period prevalence estimates from 1980 to
1996

Behavioral Risk Factor Surveillance System (BRFSS): State asthma prevalence rates on the map
come from the BRFSS. The BRFSS is a state-based, random-digit-dialed telephone survey of the
noninstitutionalized civilian population 18 years of age and older. It monitors the prevalence of
the major behavioral risks among adults associated with premature illness and death. Information
from the survey is used to improve the health of the American people. More information about
BRFSS can be found at: http://www.cdc.gov/brfss/.
Sources
Sources (continued)
 What is Epidemiology?

The study of the distribution and

determinants of diseases and
injuries in human populations.

Source: Mausner and Kramer, Mausner and Bahn Epidemiology- An Introductory Text, 1985.
Risk Factors for Developing Asthma

 Genetic characteristics
 Occupational exposures
 Environmental exposures
Risk Factors for Developing Asthma:
Genetic Characteristics

Atopy
 The body’s predisposition to develop an antibody
called immunoglobulin E (IgE) in response to
exposure to environmental allergens
 Can be measured in the blood
 Includes allergic rhinitis, asthma, hay fever, and
eczema
 Risk Factors for Developing Asthma:
Environmental Exposure

Clearing the Air:

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

 Sufficient evidence of a causal relationship

 Sufficient evidence of an association
 Limited or suggested evidence of an
association
 Inadequate or insufficient evidence to
determine whether an association exists
 Limited or suggestive evidence of no
association
 Clearing the Air:
Indoor Air Exposures & Asthma Development
Biological Agents Chemical Agents
 Sufficient evidence of causal  Sufficient evidence of causal
relationship relationship
 None found
 House dust mite

 Sufficient evidence of association

 Sufficient evidence of association
 Environmental Tobacco Smoke
 None found (among pre-school aged children)

 Limited or suggestive evidence of  Limited or suggestive evidence of

association association
 Cockroach (among pre-school aged  None found
children)
 Respiratory syncytial virus (RSV)
 Clearing the Air:
Indoor Air Exposures & Asthma Exacerbation
Biological Agents Chemical Agents
 Sufficient evidence of causal  Sufficient evidence of causal
relationship
relationship  Environmental tobacco smoke
 Cat (among pre-school aged children)
 Cockroach  Sufficient evidence of
 House dust mite
association
 NO2, NOX (high levels)
 Sufficient evidence of an association  Limited or suggestive evidence
 Dog of association
 Fungus/Molds  Environmental Tobacco Smoke
(among school-aged, older children,
 Rhinovirus and adults)
 Limited or suggestive evidence of  Formaldehyde
association  Fragrances
 Domestic birds
 Chlamydia and Mycoplasma pneumonia
 RSV
 Reducing Exposure to House Dust Mites

 Use bedding
encasements
 Wash bed linens weekly
 Avoid down fillings
 Limit stuffed animals to
those that can be washed
 Reduce humidity level
(between 30% and 50%
relative humidity per
EPR-3)

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative
For Asthma Created and funded by NIH/NHLBI, 1995
 Reducing Exposure to
Environmental Tobacco Smoke
Evidence suggests an
association between
environmental tobacco smoke
exposure and exacerbations of
asthma among school-aged,
older children, and adults.

Evidence shows an association

between environmental tobacco
smoke exposure and asthma
development among pre-school
aged children.
Reducing Exposure to Cockroaches

Remove as many water and food sources as

possible to avoid cockroaches.
 Reducing Exposure to Pets

People who are allergic to pets should not

have them in the house.

At a minimum, do not allow pets in the

bedroom.
 Reducing Exposure to Mold

Eliminating mold and the moist conditions that permit

mold growth may help prevent asthma exacerbations.
 Other Asthma Triggers
Air pollution
Trees, grass, and weed pollen
 Clinical Management of Asthma
Expert Panel Report 3
National Asthma Education and Prevention Program
National Heart, Lung and Blood Institute, 2007

Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
 2007 NAEPP EPR-3
 Treatment recommendations based on:
 Severity
 Control
 Responsiveness

 Provide patient self-management

education at multiple points of care

 Reduce exposure to inhaled indoor

allergens to control asthma-multifaceted
approach

Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
 What is GIP?

 Guidelines Implementation Panel Report for

Expert Panel Report 3

 Recommendations and strategies to

implement EPR-3

 Six key messages

Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf
 GIP’s Six Key Messages

 Inhaled  Asthma Control

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

Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf
 Diagnosing Asthma:
Medical History

 Symptoms
 Coughing
 Wheezing
 Shortness of breath
 Chest tightness
 Symptom Patterns
 Severity
 Family History
 Diagnosing Asthma
 Troublesome cough, particularly at night
 Awakened by coughing
 Coughing or wheezing after physical
activity
 Breathing problems during particular
seasons
 Coughing, wheezing, or chest tightness
after allergen exposure
 Colds that last more than 10 days
 Relief when medication is used
 Diagnosing Asthma

 Wheezing sounds during normal breathing

 Hyperexpansion of the thorax

 Increased nasal secretions or nasal polyps

 Atopic dermatitis, eczema, or other allergic

skin conditions
 Diagnosing Asthma:
Spirometry

Test lung function when diagnosing asthma

 Medications to Treat Asthma

 Medications
come in several
forms.

 Two major
categories of
medications are:
 Long-term control
 Quick relief
 Medications to Treat Asthma:
Long-Term Control
 Taken daily over a long period of time

 Used to reduce inflammation, relax airway

muscles, and improve symptoms and lung
function
 Inhaled corticosteroids
 Long-acting beta2-agonists
 Leukotriene modifiers
Medications to Treat Asthma:
Quick-Relief

 Used in acute
episodes

 Generally short-
acting beta2agonists
 Medications to Treat Asthma:
How to Use a Spray Inhaler

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

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative for
Asthma Created and funded by NIH/NHLBI
Medications to Treat Asthma:
Inhalers and Spacers

Spacers can help patients who

have difficulty with inhaler use
and can reduce potential for
adverse effects from
medication.
 Medications to Treat Asthma:
Nebulizer
 Machine produces a mist of
the medication

 Used for small children or

for severe asthma episodes

 No evidence that it is more

effective than an inhaler
used with a spacer
 Managing Asthma:
Asthma Management Goals
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including
exercise
 Maintain pulmonary function as close to
normal levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma
medications
 Prevent asthma mortality
 Managing Asthma:
Asthma Action Plan
 Develop with a physician

 Tailor to meet individual needs

 Educate patients and families about all aspects of

plan
 Recognizing symptoms
 Medication benefits and side effects
 Proper use of inhalers and Peak Expiratory Flow (PEF)
meters
 Managing Asthma:
Sample Asthma Action Plan

Describes medicines
to use and actions to
take

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

 Allows patient to assess status of his/her asthma

 Persons who use peak flow meters should do so frequently

 Many physicians require for all severe patients

 Managing Asthma:
Peak Flow Chart
People with
moderate or
severe asthma
should take
readings:
 Every morning
 Every evening
 After an
exacerbation
 Before inhaling
certain medications

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For
Asthma Created and funded by NIH/NHLBI
 Managing Asthma:
Indications of a Severe Attack

 Breathless at rest
 Hunched forward
 Speaks in words rather than complete sentences
 Agitated
 Peak flow rate less than 60% of normal
 Managing Asthma:
Things People with Asthma Can Do

 Have an individual management plan containing

 Your medications (controller and quick-relief)
 Your asthma triggers
 What to do when you are having an asthma attack
 Educate yourself and others about
 Asthma Action Plans
 Environmental interventions
 Seek help from asthma resources
 Join an asthma support group
A Public Health Response to Asthma

A call to action for organizations and people with

an interest in asthma management to work as
partners in reducing the burden of asthma within
our nation’s communities.
A Public Health Response to Asthma:
Surveillance
Over time…
 How much asthma does the population have?
 How severe is asthma across the population?
 How well controlled is asthma in the population?
 What is the cost of asthma?
A Public Health Response to Asthma:
Uses of Surveillance Data

 Basis for planning and

targeting intervention
activities

 Evaluating
intervention activities
 A Public Health Response
to Asthma Education

Education programs can be targeted to:

 People with asthma
 Parents of children with asthma
 Medical care providers
 School staff
 Public
A Public Health Response to Asthma:
Coalition
Successful asthma campaigns need the
cooperation of committed partners.
A Public Health Response to Asthma:
Advocacy

Asthma needs to be addressed

comprehensively by multiple government and
non-government agencies.
A Public Health Response to Asthma:
Interventions
 Medical management
 Education
 Environment
 Schools
A Public Health Response to Asthma:
Medical Management Interventions
Ensure people with asthma
know about their disease and
are empowered to demand
appropriate management
 A Public Health Response to Asthma:
Environmental Interventions
 Help people create and
maintain healthy home, school,
and work environments.
 Environmental interventions
may consist of:
 Assessments to identify
asthma triggers
 Education on how to remove
asthma triggers
 Remediation to remove
asthma triggers
 A Public Health Response to Asthma:
School Intervention Science-Based Guidance
 Management and support
systems
 Health and mental health
services
 Asthma education for
students, staff, and parents
 Healthy school environment
 Physical education and
activity
 School, family, and
community efforts

Source: www.cdc.gov/HealthyYouth/asthma/strategies
 Key Aspects
 Require team effort
 Coordinate health, including mental and physical
health, education, environment, family, and
community efforts
 Assess needs of school and prioritize (every
action step is not feasible to every school or
district)
 Focus on students with frequent asthma
symptoms, health room visits, and absenteeism
 Health
Family/Community
1. Management & Services
Involvement
Support Systems

6. School, Family, 2. Health &

& Community Mental Health Counseling,
Physical Efforts Services Psychological, and
Social Services
Education

5. Physical 3. Asthma
Education & Education Health
Activity Education
4. Healthy School
Nutrition Environment
Services

Health Promotion
For Staff
Healthy School
Environment
 A Public Health Response to Asthma:
School
 A leading chronic disease cause of school absence

 Common disease addressed by school nurses

 Affects teachers, administrators, nurses, coaches,

students, bus drivers, after school program staff,
maintenance personnel
 On average, 3 children in a classroom of 30

are likely to have asthma.*

*
Epidemiology and Statistics Unit. Trends in Asthma Morbidity and Mortality. NYC: ALA, July
2006.
 A Public Health Response to
Asthma:
What can make asthma worse in the school?

 Mold and mildew

 Animals in classroom
 Carpeted classrooms
 Cockroaches
 Poor air quality
 Asthma-Friendly School
DVD and Toolkit
Objectives
Personal stories to relate to
viewer
Aspects of an asthma-friendly
school
Six strategies for addressing
asthma in a coordinated school
health program
Potential impact of asthma-
friendly schools
 A Public Health Response to Asthma:
School Actions
 Establish policies and procedures to support children with
asthma.
 Keep students’ asthma action plans at the school.
 Make medications available
 During school hours
 Before physical activity and sports
 During before- and after-school programs
 On field trips or when away from campus
 Train school staff to recognize signs of an asthma attack
and to use appropriate medications.
A Public Health Response to Asthma:
Evaluation
The systematic investigation of the
structure, activities, or outcomes of
asthma control programs.
 Are we doing the right thing?

 Are we doing things right?

 Benefits of Program Evaluation
Evaluations help asthma programs
 Manage resources and services effectively
 Understand reasons for current performance
 Build capacity
 Plan and implement new activities
 Demonstrate the value of their efforts
 Ensure accountability
Using Evaluation to Improve Programs

 Highlight effective program components

 Recognize achievements
 Replicate successes

 Assess and prioritize needs

 Target program improvements

 Advocate for the program

Framework for Program Evaluation
 A Public Health Response to Asthma:
Summary
 Asthma is a complex disease that is not yet preventable or curable.

 Asthma can be managed with medication, environmental changes, and behavior

modifications.

 By working together, we can ensure that people with asthma enjoy a high quality of life.
 Resources
 National Asthma Education and Prevention Program
 http://www.nhlbi.nih.gov/about/naepp/
 Asthma and Allergy Foundation of America
 http://www.aafa.org
 American Lung Association
 http://www.lungusa.org
 American Academy of Allergy, Asthma, and Immunology
 http://www.aaaai.org
 Allergy and Asthma Network/Mothers of Asthmatics, Inc.
 http://www.aanma.org
 Resources

 American College of Allergy, Asthma, and

Immunology
 http://www.acaai.org
 American College of Chest Physicians
 http://www.chestnet.org
 American Thoracic Society
 http://www.thoracic.org
 The Centers for Disease Control and Prevention
 http://www.cdc.gov/asthma