Childhood Asthma: A Complex Condition That Doesn’t Have to Be So Complicated (Recording)
This webinar was recorded on August 21, 2024
Asthma is the most common chronic condition in children and affects nearly 1 in 10 children. It is also the primary reason children miss school – an average of 13.8 million lost days of school each year. Asthma in children can be especially serious because children have smaller airways than adults. In this webinar, learn about childhood asthma, how to work with parents of children with asthma, and how to teach children about using their inhalers properly.
Speaker:
- David Stukus, MD, FACAAI
Professor of Clinical Pediatrics in the Division of Allergy and Immunology.Associate Program Director, Pediatric Allergy/Immunology Fellowship Training Program Director, Food Allergy Treatment CenterNationwide Children’s HospitalColumbus, OH
Dr. Stukus is a Professor of Clinical Pediatrics in the Division of Allergy and Immunology. Prior to becoming the director of the Food Allergy Treatment Center, Dr. Stukus started the Complex Asthma Clinic at Nationwide Children’s Hospital in 2011, treating children with severe or difficult-to-treat asthma. In addition to providing clinical care for children with all types of food allergies, Dr. Stukus participates in clinical research, quality improvement, patient advocacy, and medical education. Dr. Stukus holds multiple leadership positions in the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology and is one of twelve allergists invited as a member of the Joint Task Force for Practice Parameters. In 2018, Dr. Stukus was invited to become the first Social Media Medical Editor for the AAAAI, where he produces and hosts their podcast “Conversations From the World of Allergy”. He has been named a Top Doctor in Pediatric Allergy every year since 2015. Dr. Dave (as his patients call him) has devoted his career to communicating evidence-based medicine and best clinical practice to colleagues, medical professionals of all backgrounds, patients, and the general public. He is very active on social media and uses his popular Twitter and Instagram accounts @AllergyKidsDoc to dispel myths and combat misinformation.
CE is not available for this webinar.
Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Lynda: hello, everyone. Will be starting in just a second here. All righty, hello, everyone. I’m the CEO for allergy and asthma network. Welcome to this afternoon’s webinar. We are in for a real treat today with Dr. Dave Stukus. We have a few details we will go through. First, all participants will be on mute today and we will be recording the webinar and post it on our website within a few days. You can find recorded webinars on our website, just go to our home page, scroll down, and you will see the most recent webinars posted at the bottom of the page. This will be one hour in length, and that includes time for questions. We are hoping to have 10 or 15 minutes at the end of the session for questions. We will take those questions from you, but in the meantime, you can put the questions in the Q&A box at any time. The Q&A box is at the bottom of your screen. We do have someone monitoring the chat also if you have questions and it helped. We will get to as many questions as we can given time constraints. We will not be offering continuing education credits for this webinar, but we do have a certificate of attendance we can offer you. We will put it into the chat, and a few days after the webinar, you will also get a email — and email with some resources related to this chat. Today’s topic is ” Childhood Asthma: A Complicated Condition that Doesn’t Have the So Complicated.” Asthma can be especially serious because children have smaller airways than adults. In this webinar, we talk about childhood asthma, how to work with parents of children with asthma and how to teach children to use inhalers properly. It is my pleasure to introduce Dr. Dave St ukus, professor of clinical pediatrics, division of allergy and immunology and director of the food allergy treatment center. He treats children with severe or difficult to treat asthma. Dr. Stukus Holt — holds audible positions and is one of 12 allergists invited as a member of the joint task force for practice parameters. In 2018, he was invited to become the first social media medical editor of the Academy where he produces and hosts are podcasts, conversations from the world of allergy. He has been named the top Doc of pediatric allergy every year since 2018 and has devoted his career to communicating evidence-based medicine. He is very active on social media, and you can find him online where he is dispelling myths and combating misinformation. Thank you for being here, Dr. Dave.
Dr. Stukus: Thank you so much. Thank you for the kind introduction and thank you for spending part of your afternoon with us. We are going to get into it because I want to be as helpful as possible for all of you. What I want to do today is to make everybody more comfortable recognizing and treating asthma. It is a very complex condition which we are going to talk about, but it does not have to be so complicated. Ultimately, this will improve the lives of students and families and really make your life less stressful. I think with proper education and better understanding, it is not have to be quite so scary.
Why do we need to worry about asthma? This is one of the most common chronic conditions affecting children across the world. About 10% of children have asthma at some point in their lives. It is the leading cause of missed school days, and why I became an allergist in the first place was because I was doing my pediatric residency training and cap asking, why are these children — kept asking, why are all these children getting admitted to the hospital for allergies and asthma? It is the leading cause for ER visits and hospitalizations unfortunately to this day. Disparities are something that we always have to talk about, but it really impacts asthma and other allergic conditions. Asthma is a condition that affects every race, every age, but we know that it absolutely is more common as well as more severe in certain populations such as minority populations, those who have lower SES status, and those who live in urban housing. There’s a variety of reasons for this, but we need to provide resources for those individuals and help those children to the best of our ability. If you take a large population with asthma, it absolutely can affect some a lot more than others.
Let’s start with some easy definitions. Let’s talk about what is asthma? Asthma is super easy. It is recurrent. It will cause symptoms to come back over and over again. It is not some — not because somebody coughed for six weeks one time because they had an infection. These are symptoms that come back up time. That is what makes it chronic. Everyone has areas of inflammation and side lower airways. Sometimes it is very poorly controlled, sometimes not so severe, but everybody has some element of inflammation. Everybody with asthma also has two key factors. They have hyper responsive airways and reversible airflow restriction, they can close suddenly and also reversed, so those are the hallmarks of symptoms of asthma and while they make it different levels of severity, these are elements that everybody has in common if you have a diagnosis of asthma. When we think about the airflow limitation — I love this picture because it highlights a couple of things. One is you get the squeezing of the muscles around the breathing tube, so those muscles squeeze and constrict the airway. You can also get swelling inside the airway as well, and the mucus people with asthma produce is different than the mucus of people who don’t have asthma. It is a lot stickier and tar-like. So, hopefully, that gives you a sense of why you can have such significant airflow obstruction when someone is having an acute asthma attack situation. Before we get into this any further — you will hear me say this several times because I cannot emphasize it enough. Asthma really is a clinical diagnosis. There is no test we can do that says yes, you have asthma.
There are tests we can do that support a diagnosis of asthma especially in children five years of age and older, but really it has to be established with clinical standards. We know it is often underdiagnosed for many reasons. One is people do not recognize that your child has been coughing or having the symptoms or they just thought it was normal. Or on the physician side of things for the health care professional, sometimes people are afraid to use the big bad a word. I love using the word asthma because that means we can better control what is going on. We know asthma will change over time. It often improves as children go through adolescence, but sometimes it gets worse. We know it is variable throughout the year as well. There are many treatment options available. There is no one-size-fits-all. We absolutely live in the age of personalized care. That’s why I love what I do so much because we absolutely can find an effective treatment for every single person who has asthma. There are different types of asthma. As I mentioned, just because we diagnose asthma does not mean we treat everybody with asthma the exact same way. Some people may get upper respiratory infections only at times of the year. Others may have more chronic conditions that affect them on a daily basis in terms of sleep and ability to work and exercise and stuff like that. There are people with more mild asthma, more moderate asthma, those with less severe asthma. The frequency of symptoms can change, both in the same individual and between different individuals with asthma, and it can present at any age. We know about 40% of all toddlers have reason — wheezing and persistent cough at some point, but only 30% of them develop asthma. Really getting the diagnosis right in terms of impact. I got this question all the time — what’s the cause of asthma? There is no single cause.
It’s a complex, heterogeneous condition. We know parents who have allergies and asthma have a tendency to produce children predisposed to have asthma as well. It is an argument of which came first, the chicken or the egg? Does obesity cause asthma or are people with asthma more likely to be obese? The environment absolutely plays a major role in both developing asthma and contributing to asthma when somebody has that. We no exposure to pollution, people who live within five football fields of a major highway have a significantly increased risk of developing asthma because they are exposed to small particulates in ozone and stuff like that. We know exposure to ozone as well as things in the environment such as tobacco smoke and things like that. Early life infection with RSV — everybody gets infected with the RSV virus by the first two years of life, but not everybody ends up in the hospital for it. There’s infants who end up being hospitalized to absolutely have an increased risk of developing asthma. We don’t know if something actually happened to their physiology and lungs, but regardless, babies are at significantly increased risk of developing asthma. This gives you a sense that there is no single cause of asthma but there are multiple contributing factors. What are the symptoms of asthma? Cough is actually the most common symptom. I know everybody is focused on wheezing, but not everybody with asthma will wheeze. Cough that wakes people from sleep is not cough that interferes with your ability to fall asleep, but if you fall asleep at night and wake up with coughing, that is an indicator that asthma is probably what is causing these symptoms. The second one is if you are causing so hard that it causes you to vomit, if it is mucus or their stomach contents, that’s also a sign could be asthma as well. Can you have other reasons for having this symptoms? Absolutely. I started saying, oh, my gosh, we need to pay attention to this. This could be asthma. Wheezing is just a byproduct of constriction of the airways. It’s a bit of whistling or as air passes through, you will produce the sound of wheezing. Traditionally, you will be able to hear it unless you use a stethoscope to listen to chest walls, but some children have some significant wheezing that you can hear it with your ears. A lot of times people described as someone sitting on their chest or squeezing my chest from the outside. They can have respiratory distress, and what I like to educate health care professionals on, if you are not sure if someone has asthma or not, prescribed albuterol and if that makes them feel better, that’s probably asthma until proven otherwise. Most importantly, this is not the same thing for everybody. It can change over time. Symptoms may be variable. Symptoms may change in the same person over time. It’s not that they are always going to have those symptoms. They will absolutely be different. They can be variable in regards to how long they last four. And everybody is going to respond a little bit differently to therapy. We live in this age of personalized medicine. I love being an allergist for many reasons, but when I see someone with asthma, I’m already thinking about what is causing the inflammation inside their body. The receptors involved and chemicals sending the signals and how we can impact those cascades to make them feel better and stuff like that. This is not a one-size-fits-all diagnosis. When it comes to management, it depends on what type of asthma somebody has.
That’s the most important part. What is your asthma because that’s what your management should be. If you have intermittent asthma with infrequent symptoms, you can get away with as needed therapy. Here is your inhaler. We teach people how and when to use it, and you want to recognize when things are getting worse because we may need to step up therapy. If you get more frequent symptoms, that’s when we start talking about controller therapy. Absolutely want to address comorbid conditions. If people have terrible nasal congestion, postnasal drip, that is going to impact their ability to treat asthma. And we always have to do an environmental assessment. Most importantly, everybody with asthma needs to have a good idea of what is going on inside their body. We need to teach self-management skills. Even people with the most severe asthma, I see them maybe six times a year for 20 or 30 minutes at a time, so I have to empower them, or your team has to empower them. Written treatment plans are extremely important to talk about with caregivers, especially when K — when kids go to school, and we have to have plans that will change over time and really support them in every way we can. It really does take a village, and that’s why I’m happy to be here today. I know all of you are here because you care about children with asthma and want to do the best you can. I love this graphic. These are available online. I think I have a screenshot that will show you the website. This captures the cycle of management. It is not set it and forget it. It’s not I think your child has this type of asthma, here’s management, you are set for life. Let’s see how they are doing after using this and reassess. If they are doing well, maybe they can step things down. If not, we can step things up. The cycle really goes on throughout the year. A lot of times, we step things down and we step things up this time of year when kids are exposed to more triggers. And we can change things over time. Boys tend to get significantly better as they move through childhood and often times, their asthma resolved by the time they are an adolescent. Hopefully, you get the sense, but I really want to imprint upon you that this is going to change.
If a student with asthma comes in and there on one treatment at the start of the school year but their treatment changes throughout the year, that’s good. That means they are receiving proper care and changing therapy according to what level of asthma they have. What are our goals? If you have asthma, you are going to have symptoms. We cannot make symptoms completely go away, but we want to minimize the burden is we can. We want to prevent exacerbations as much as possible. We want people to exercise. If anybody listened to the web and someone with asthma should not exercise because it is bad for their health, that is completely wrong. We want them to exercise. It best thing they can do. If they cannot exercise because of their asthma, their health care provider should know about that, but exercise is something we want to promote. I’m sure we just watched the Olympics that took place. 40% of Olympic athletes have some form of asthma, so it should not hold them back. We also want to monitor adverse effects of treatment. What are our roles and responsibilities? I always try to break this down. If we think about students with asthma going to school, we each have our different responsibilities. The family needs to inform the school their child has asthma. They need to send all medications at the beginning of the school year. My wrist is just about broken because of all the school forms I have been signing the last couple of the weeks. Part of my job, I love it, but it has to be done. We should contact the school nurse for at least a teacher and say they have been having issues lately. What is the school’s responsibility N be receptive to these conversations, have a plan in place to store these medications and be able to access them when students need them, monitor students for overuse of medication, treatment when necessary, and we want the students to learn and thrive and be responsible and let an adult know if they are not feeling well. They have to let somebody know. These are some of the roles and responsibilities electric kind of down — break down. How do we approach this and what kind of things can impact them in school? If you have a child with asthma, they will either be well-controlled or not well-controlled, well-controlled meeting minimal burden of disease. If they are not well-controlled, they are not in a very good place and not feeling well, probably cannot participate in activities like they want to. If they get exposed to triggers, it can cause that hyperactivity we talked about, and you can have both acute symptoms from exposure triggers or more chronic symptoms, especially if you are exposed on a more regular basis. Not everybody with asthma — that’s bad English. Everybody with asthma will have their own individual triggers and those triggers will change over time. Just because we say somebody with asthma does not mean they all share the same triggers. Exercise can be a trigger for a lot of children.
True exercise-based asthma is pretty rare. What happens is children with poorly controlled asthma have trouble exercising. Viruses, number one trigger for children in all ages. Respiratory viruses, there’s about 80 of them. Absolute number one trigger for acute asthma and increased symptoms. Weather can affect it. Some are affected by hot, humid weather. Others affected by colder weather. Older and is very dry. The dryness causes constriction of the airways. They can be exposed to this when they are waiting for their bus or if they go outside during recess. For those that have allergies, and about 40% of children who have asthma also have environmental allergies, they are exposed to cat and dog dander. There is research that shows they can find pet dander on the International Space Station even the pets are not in space. This stuff is everywhere. It’s sticky. He gets on clothing. You can find it in public spaces and community theaters and buses. If somebody has an increase in symptoms, it depends on the situation, but every once in a while, I will find someone sitting next to a student that has six dogs at home and the person is highly allergic to dogs and that is why they are having symptoms exacerbated in a school. Cockroaches, if you have them in buildings are at home, that can be a trigger. Foods rarely cause asthma exacerbations, but obviously, there’s a lot of food allergies. There is one exception where an ingestion of a higher concentration of salt concussed symptoms. Cleaning supplies — anything with smell or aerosol can exacerbate asthma. I talked about small particulates earlier. But if you think you are cleaning and making things more sterile and better, sometimes that perfume or smell can trigger asthma sometimes and emotions can trigger asthma as well. Some students are children are maybe stressed out around test time or part of the reason their asthma accept. I have to put a plug in for this — essential oils are not essential. These do not treat asthma. These absolutely can exacerbate asthma.
If you have poorly controlled asthma or inflammation in your airways or rhinitis, inflammation in your upper respiratory tract, inflation to — exposure to any products. More teachers are using these in school settings to try to help children focus and stay centered, but this absolutely key this could be making students’ asthma worse. What about triggers found after school back in Obviously, if exercise is the trigger, extremes of weather, there’s something called thunderstorm-induced asthma where during pollen season, if someone has allergic rhinitis and a thunderstorm rolled through, it creates microcosms of that pollen that can get inside their airways. When those cold fronts move through our warm fronts, that can exacerbate asthma as well. When we think about allergic rhinitis, depending where you live, pollen season starts at different times and last in different times, but in general, trees pollinate in the spring, grasses and weeds pollinate in the summer and mold spores will typically be during damp and rainy weather, and of course, if they are exposed to tobacco smoke a lot, that can be a trigger as well. We are about to enter into the annual autumn asthma spike. Every single year, approximately 22 days after the start of the school year, this has been demonstrated on multiple continents, we see a huge exacerbation in asthma. That is probably the incubation period for viruses to circulate. We know schools are a great place for viruses to jump from one person to the next. Oftentimes that coincides with weather changes, and for those who have allergies to ragweed or mold, there could be excessive exposure this time of year. We see a second spike in the spring, but it’s generally not quite as high.
That is typically for viruses, changing weather, and tree pollen as well. We have two different categories of medication, so we have our lever — relievers, when symptoms are acute. These work fast and we want people with asthma to always have these available at all times. And controllers are designed to be used on a regular basis, more on a scheduled basis because they work on the long-term. They have to get inside the lungs and decrease inflammation over time. Really understanding differences can be helpful for treatment. What about types of inhalers? This is where it gets really confusing for a couple of reasons. Insurance companies and formularies change every single year. I have patients that are well-controlled on their inhalers for years and years and then it changes because some insurance presence as we don’t want to pay for this. There’s different delivery devices. We have our traditional metered dose inhalers that you press down and it produces the nice mist, but you also have dry powder inhalers and different forms. Dry powder inhalers more like a tube, some are more like a disk. Some you click open, some you twist, so understanding the technique is extremely important. This is something we try to provide education on in our office setting with samples. And we have great resources like this from the allergy and asthma network. What do we want to do when we are treating symptoms? We want to dilate. We need to open up those airways as fast as we can, so short-acting bronchodilators like albuterol are going to be a mainstay for people with asthma. We also have long acting. There are other classes. Some children actually don’t respond well to albuterol and only respond to Atrovent. There’s different ways we can bronchodilators now. Before we go any further, let’s talk about a funeral. As much as we can, let’s not refer to albuterol as an emergency inhaler. This is a reliever, an important part of treatment. We don’t want to wait for an emergency to occur for someone to use albuterol. If someone has asthma, they are going to need albuterol. That is what asthma is. That’s going to be part of the treatment plan. If we teach people this is for emergencies only, that leads to delayed treatment because people only want to wait to use it in an emergency or second, what we see a lot in children’s hospitals, if they use albuterol, they think they have to go to the emergency room, so if we change the way we describe this, we want people to use this sooner rather than later and it will make you feel better. Does acute asthma always cause wheezing?
If you have someone come to your office, do you expect to hear wheezing every time? The answer is no, so don’t wait for wheezing. This two reasons why. One, you typically need a stethoscope to hear it. Two, not everyone really has wheezing when I have asthma. Sometimes it’s just cough and there’s different variations. Sometimes they are so severe you cannot hear wheezing because the airway is so restricted and once they receive treatment, it will open up and they will start wheezing like crazy. When should we give albuterol? When a student with asthma reports an increase in symptoms, so knowing what their symptoms are, if it’s chest tightness, cough, or shortness of breath. What we don’t need is we don’t need to hear wheezing. We don’t need a pulse ox. We don’t want to rely on that. It is a pretty late sign to say that dip below 92% saturation. That is a scary situation. And we don’t need peak flow monitors. We want to treat according to symptoms. Hopefully all of the students, their families have been educated on treating symptoms. Some of these may be ancillary things that may be helpful for monitoring over time, but we don’t want to monitor things that could delay treatment. What about albuterol? How much is enough? One reference here is 17 years ago. Two to six every three to four hours for a day or two. Four to 10 puffs every 20 minutes for the first hour or every three to four hours. A lot of people say that too much albuterol and you will cause the heart to explode. Not at all. This is what we need to do. If someone is having acute symptoms, we need to bronchodilators. We will talk about side effects in a second, but I want you to know that one puff of albuterol is not going to do anything. Two puffs every four hours, that is completely updated. I recognize that oftentimes schools and school nurses are handcuffed by treatment plans, but I want you to be aware that using more albuterol is actually what we are promoting. Maybe you can have a conversation with a student or the family to update that. What about the inhaler versus the nebulizer machine? This has been studied extensively to the point where we have dual clinical trials and studies combined together with thousands of children all having mild to moderate exacerbations and what they find routinely across the board is when you use the metered dosing properly, it is superior to the nebulizer.
They are equally effective, but you have less side effects. So we want to promote this. We don’t want people having to go home to use their nebulizer. Most people will say I feel better after the nebulizer compared to my puffer, and there’s two reasons why. One, they are not using the 4 to six puffs they should be using and two, they are not using the right technique. We always want to promote the use of the spacer. Regardless of age. This has nothing to do with your technique, your age, your ability to use these medications. It’s very simple. See the canister with the inhaler on the screen, that is a liquid. We need to turn that into a mist. It takes about four inches to do that. If you put the inhaler in front of your mouth, there is less space between the teeth and the back of your throat then there is, so most of the medicine stays liquid and gets swallowed and stays in the stomach. This has been well established. It does not matter how old you are. It is a function of the device, and we have to have that spacer. I have seen different things on the package insert that you can hold it for just in front of your space if you don’t have a spacer. I said that’s a good way to get medicine into your eyeballs. I would much rather use a toilet paper roll than nothing. There’s ways you can make your own and use a water bottle and just cut the fat end of it and put the small and a good drink out of into your mouth, and that serves as a good spacer as well, so we want to promote that as much as possible. Dry powder inhalers — my goodness, look at the different forms here. I cannot keep up with it. It makes your head spin. A lot of them you have to activate in some ways. Sometimes you twist it. Oftentimes what is happening is either it is a powder sitting in there that you have to expose to the access chamber or some of them have little capsules you have to burst open that then exposes the powder. Once the powder is out, it can absolutely fall out, so the technique is very different. You cannot use spacers with these. There’s also a breath-actuated albuterol that you cannot use a spacer four. Any dry powder, space is not going to work. How can we help children use these properly? We want to shake it up before use and turn the liquid into an aerosol, slow and deep. With the spacer, you don’t want it to whistle. It’s a little counterintuitive if someone wants to hear the noise. You want it slow, deep breath. These spaces have one-way valves .
Even if they breathe back into it, most of the medicine will stay inside their body. Once they breathe in, you want to hold their breath as long as they can up to 10 seconds. The reason why is gravity. You take a deep breath in, you get the medicine halfway down your airway, you breathe out, the medicine goes back out. If you are not sure they got the dose, do another one. You are not going to hurt them back giving extra puffs. This is — this happens all the time, especially with younger kids not cooperating. Typically, when you go up to the yellow spacer by the time they are one and stay on that until they are seven or eight and then they can transition over to the mouthpiece. What are some tips for the dry powder? We want to hold these upright to prevent spilling the medicine out. I was taught this a long time ago and I love it. You need to have a really fast inhalation rate. You still want to hold your breath again for up to 10 seconds if you can. Younger children cannot do this. This is a problem when I try to prescribe medication and formularies that only cover dry powder, so we fight with insurance companies to get it covered and stuff like that. If you are not sure they got the dose, give another one. You are not going to hurt them, regardless of what medicine it is. Hopefully, that gives you some tips you can use, but they long and short of it is everybody has time. They may not be feeling well and you may feel they need to rush through things. You have time. Take your time. Slow and ready wins the race when it comes to asthma. Take nice, slow breaths. Sometimes people have anxiety provoked by asthma symptoms of what — as well, so have them focus on breathing. Slow, deep inhalation through the nose, out through the mouth, that sort of thing. Albuterol is safe. If you look at evidence surrounding side effects, that concerns people on continuous albuterol delivered in the emergency room. You are not going to cost significant adverse effects by giving inhalers. We want to treat them because it will relieve symptoms, and we want them to breathe. Breathing is good. Side effects are more dose-related, as I mentioned before, you will see increased heart rate. It’s not going to cost are heart to race to the point where you are going to cost problems. It helps activate some of this cells in the heart, but we want them to breathe and we want to open airway’s. These are things that patients of mine have told me that school personnel told them to when they had asthma exacerbation — drinking water is not going to help. It won’t hurt, but it will not treat asthma. Going outside can make it worse depending on the weather and what triggered her symptoms in the first place. One puff of albuterol is not going to do anything. Telling people to lie down — we actually want them to sit upright and we want to use albuterol.
Some have had essential oils rubbed on their chest. That is not good for asthma, trust me. And some are still to suck it up in gym class or something, no, we need to listen to these kids and take it seriously. If it gets to the point where a child with asthma is always in the health care office and never participating in gym, their health care professional absolutely needs to know about that. Let’s talk about this awesome new way to treat asthma. It has been around in Europe for 30 years and in the U.S., for five years. Single maintenance and Belieber therapy. Smart therapy. — single maintenance and reliever therapy. Smart therapy. These contain inhaled corticosteroids combined with formoterol. Formoterol is different than Advair. Formoterol is unique because it works as fast as albuterol but last up to 12 hours, so it is like a fast-acting long-lasting bronchodilator. Students are nominally prescribed one inhaler to use as both their controller and reliever or just reliever so they may go to school with one of the state inhalers and the instructions are at the onset of symptoms, stuck two puffs every four hours, so that is something to be aware of. The reason this is such a great therapy is because for most people with asthma, especially children, they don’t have symptoms all the time. It is really intermittent for most people. This is a great way, plus it is very patient-centered and puts them in control of their asthma, and they love it, so it is a great way. Here are the resources I mentioned. This is some of the verbiage. Smart therapy, it just walks to children under the age of four, they can use inhaler for control part rescue therapy. It is all in there. Asthma action plans, as we wind down, this is something everyone with asthma should have right now. It is a way to communicate with other caregivers. Here’s the type of asthma I have. Here is what I do. Green means go. Everybody is doing great. Here is what I do every day. That is easy. To become of it is easy. What happens when you get to the point where you are having exacerbation? The yellow zone is where that’s a little tricky. Everybody may have a different yellow zone. This is where people start to have more symptoms. While this may teeter and get into the red zone if we don’t do something about it, this may change depending on what type of asthma they have. A lot of people ask what happens if you start treatment too early? Great. That’s a great thing. If you start too late, it gets to the point where they have to seek emergency care and you could have prevented that. Don’t worry about false starts. If I have not emphasized it yet, and I think I have, these are safe medicines to use, especially when given through these inhalers, and we want to use them at the onset of symptoms. We don’t want to worry about a false start in situations like this.
There are stock albuterol laws on the books. Not everywhere in the country, which is on what you — which is unfortunate. I was happy to get Ohio to stock albuterol, which is great. Albuterol can be administered to any student without a prescription, and this good Samaritan laws that protect us from all those things. If you are in one of the states that does not have stock albuterol bills, there’s actually playbooks. We will finish talking about self carry. Every state says children’s are allowed to self carry. There’s no magic number. I’ve met 19-year-olds who are not ready to do this and it-year-olds that are. Can they demonstrate that they can use it properly and are they responsible enough that they are not going to lose it? That is what needs to be demonstrated. There is no magic age. Typically, I start having the conversation about 10 or 11. There’s also a difference between self carry versus self-administer. There are some that say allow the child to carry are albuterol but have an adult administer it. What is the benefit of this? They have their inhaler when they need to use it. That’s real life. They don’t have to run to the locker, get an excuse to leave the classroom, and they can treat students quickly. What’s the downside? Maybe they are using their inhaler a ton and not communicating that. That can be a real problem. It could go missing, so if they lose their inhaler, that’s a huge problem. And they may be using it inappropriately. It is a balance, but this is something that is really a partnership between every single family and also with the school as well. As we kind of wrap up, and I’m more than happy — yes, perfect amount of time for questions. We know there are students in everything the school that have asthma to some degree. Sometimes it can be subtle, sometimes intermittent. Everybody is a little different. Really understanding who, when, and how to treat is going to make everybody much safer. I hope I presented some hopefully new information or at least offered a new perspective on some of the information that has already been out there, but I’m happy to take any questions and clarify, so thank you for attending.
Lynda: Terrific, Dr. Dave. It was a great presentation. I saw questions coming in and you work answering them as we were going along, so I think you did a great job of covering some key areas of concern. I have a lot of questions, so I will try to give them to you and see how far we can get. There were a lot of questions about technique issues, so I thought I would leave this to the end and we could run through those. Can we talk about the role of the primary care physician in terms of the asthma action physician? What is all that start?
Dr. Stukus: Hopefully they are heavily involved. Not everybody with asthma needs to be seen by an allergist. There’s not enough of us. Hopefully the primary care physician is filling up a lot of these asthma action plans. That is a whole other story are they feeling comfortable with practicing up-to-date medicine. That’s what we do, help educate and get them up to speed.
Lynda: Can you give any tips to school nurses here about administering the albuterol inhalers when the children have learning disabilities or physical disabilities?
Dr. Stukus: That’s very nuanced because it’s going to be different situations for each of them. I think it goes back to trying to promote calmness as much as possible. It can be difficult depending on the situation you are dealing with. It will simply not work if they are fighting you. As much as we can, we want to avoid the situation where you are restraining somebody to administer education or something like that — to administer medication or something like that. What do you find relaxes your child when they start to get agitated? With asthma, they are probably having a hard time breathing, so either thinks they can be sent to school with for tips — or tips you can offer? Perhaps turning the lights down, playing music. I would try to promote calmness as much as you can before escalating things to restraint or holding them down to give them medication or things like that.
Lynda: There were a couple of questions about where dust permitting mist — primer team missed — primatine mist fit into treatment.
Dr. Stukus: That is not something described by most health care at your that health care professionals. — that is not something typically prescribed by most health care professionals. What we see is someone self treating asthma using it like crazy, and they are just poorly controlled. We can be better. We can help them. I’m all for self-management, all for access to medications, it is an inferior treatment option compared to those that enable evidence-based treatment options. Depending on what kind of medication forms, you may not be aware of it.
Lynda: There’s a question about can you use albuterol if your child has a heart condition?
Dr. Stukus: Hopefully those special circumstances, you have communication with family and from a cardiologist especially. For the vast majority of heart conditions, the answer is yes. Especially in children, a lot of these are more structural. If you are talking about arrhythmia and stuff like that, hopefully school nurses are not the ones that have to determine that. That would be tragic.
Lynda: Absolutely. Somebody wrote in a question and answer that she was or he was informed that HFA inhalers should not need a spacer and it should be placed directly in the mouth.
Dr. Stukus: Interesting. No, spacers really should be used. We used to use — they manufacture is used to use the chlorofluorocarbons, and as we know, those are bad for our ozone layer. It’s just a different kind of propellant that is in the. No, it’s just a propellant that does the medicine out of the canister, but still, you need the space for it to turn into mist. Lynda: We have some new videos we are going to start posting on social about inhaler technique, all the different inhalers. We have respiratory therapists as the educators doing the demonstrations, so we will be showing information about that. There’s just different techniques for every inhaler. Let me see what else — there were questions about smart therapy. We have a great article on our website. Again, do you want to just touch on smart therapy? And do people use smart therapy as a rescue inhaler?
Dr. Stukus: This is interesting. It’s exciting but also complicated and really hard for people to wrap their heads around it first and once you understand it and start using it , it is actually really cool. One inhaler — again, it’s only two specific inhalers. They have to have an inhaled steroid combined with formoterol. It only works with formoterol because of the onset of action. For Motorola’s essentially like albuterol. Any situational use albuterol for, you given formoterol, it’s going to bronchodilator, but you combine that with the inhaled steroid, it will address the inflammation going on as well. Somebody, let’s say they have symptoms only with upper respiratory infections, it works great. Here is your single inhaler. Wait until you get a cold. Start using it at the onset of your illness. If symptoms increase, increase your inhaler to every four hours while you’re awake. That could work really well. Does that work for everybody? No. Is anything we do in medicine work for everybody? No, but it is a great option we have available. You may have people doing it as a in addition to schedule. You may have people who just started at the onset of symptoms, but it is a great way to maintain. I have doing it in other countries for years because it works so well. It just took a while to update the guidelines here in the U.S.
Lynda: Should we wait one minute between puffs of an inhaler?
Dr. Stukus: Quick question. Ideally, yes. Just take slow breaths. Is it wrong if it’s 30 seconds or 75 seconds? No. All these numbers are kind of arbitrary and made up to some extent.
Lynda: Thank you. Should you have kids breathe in and out a number of times while using the spacer or just once and hold their breath?
Dr. Stukus: If it is a mouthpiece, just once, one slow, deep inhalation with no whistle, hold your breath. If it is a face mask, they can brief multiple times because it is a one-way valve. Every breath you take is delivering more medicine into your lungs. For younger children, they just cannot do that long, slow deep breath, which then means you should hold the mask on for at least 10 seconds if you can, make sure they are getting the medicine.
Lynda: OK. There’s a question about essential oils and cultural preferences like families and as a school nurse, how to handle the conversation with the families regarding a child who has asthma Dr. Stukus:.
Dr. Stukus: Yeah, those are hard conversations sometimes but important ones. It is not just have to do with essential oils. It could be incense or certain perfumes. If there is something that somebody is doing as a practice that is causing symptoms for somebody else that has to be exposed to them, that conversation has to take place. It may just be separating those two students in the classroom. It may just be a case by case scenario, but it gets into, can you tell somebody not to do these things? That is a whole different conversation. Our daughter started school. She is in sixth grade, and her teacher sent in a melted everybody said she is extremely sensitive to perfumes, so if we could prevent students from wearing perfumes or clones to school, she would really appreciate it. Happy to do so. Thanks for communicating. Not a problem. Have the conversation first.
Lynda: This is another question. I’ve seen the question — a commercial for certain medication. Is that something we could see coming to schools as well?
Dr. Stukus: That is the newest version. It is not quite smart therapy, but the version you may see in school as well.
Lynda: Think we answered that question. Since the news just came out within the past 10 days, do you want to comment on Nephi?
Dr. Stukus: We have the first FDA-approved nasal epinephrine spray to treat anaphylaxis. Everyone who has epinephrine autoinjector’s, we now have a new option that will be available in pharmacies in coming weeks. Just got approval a few days ago. It is approved down to 66 pounds that it delivers one two-Milliken — two-milligram dose. One pleasure, Windows, and it will be sold, the studies that were done — there are no randomized control trials , but what they do is they do studies looking at pharmacokinetic and pharmacodynamic data, so they look at basically you take volunteers. You can spare the medicine in your notes and measure epinephrine in your bloodstream or how fast does it peak, how long does it pick, how fast it compares to epinephrine given by syringe. It’s pretty good. And how it affects heart rate and blood pressure. It has an effect. They went back and did an extra study on people specifically with allergic rhinitis symptoms. The question I had was how this works on all medications. They can probably be more permeable if you have environmental allergies. This is going to be a great option. You may be seeing students sent to school with it once it is available probably in the next few weeks, but, yeah, we need to come up with even more teaching and add that to action plans. Epinephrine is epinephrine. It is the same as all autoinjector’s with regards to use. It is just a different way than typical.
Lynda: I have an exercise-induced asthma question out. If it requires pretreatment for the plan, what if the child is having multiple, say, recesses or activities during the day that would require treatment?
Dr. Stukus: That’s fine. Ideally, we do it at least 15 minutes prior to exercise. If that were my patient, I would have a conversation with the family. This is really exercise-induced asthma, they really need it, should we put them on a control cap I would approach that. That’s fine to give that way.
Lynda: OK, great. I don’t think we have time for this, could you please demonstrate proper technique for administering inhalers? Since there are so many with different techniques, we have to save that until another time, but we will have videos out soon, so you can check to see which one you might want to watch. Let me see. Trying to go through. There’s, like so many questions.
Dr. Stukus: Yeah, that’s great.
Lynda: Can pet dander become an allergen after having a pet for a long time?
Dr. Stukus: Yes. Especially kids born into homes that have those pets, they are kind of desensitized to their own pets but may have symptoms around other people’s pets, which is fascinating. There’s a cool syndrome called Thanksgiving syndrome. Teenagers who have asthma and allergies and are allergic to cats and dogs but they live in a house with cats and dogs and they go to college for the first time and are gone from their home environment for three months and come home for Thanksgiving, and their pet now causes them to itch and sneeze. It may just be that your own pet you are OK with. Can you develop new symptoms to a pet you have had a long time? It’s possible, but I always question, is there something different now going on?
Lynda: Let’s see. What do I tell patients what the difference is between a controller for the nebulizer and the MDI since controllers are long-term, but nebulizer solutions are for a short period.
Dr. Stukus: I guess it goes back to what is the type of medicine. Very few controllers are given through the nebulizer. Nebulizers, hopefully — we don’t really need to use as much as we used to. I think it goes back to just can we update and better communicate as to what these medicines are and how to use them.
Lynda: OK. Well, it is 5:00, so I think we will go ahead and wrap up. Thank you so much, Dr. Dave. Learned so much. I want to kind of tell you what our upcoming webinars are. Seasonal allergies, optimizing treatment for each patient for August 27, and will talk about updates to atopic dermatitis treatment options. That should be a good one, too. There were questions about links to smart therapy and these other things I mentioned. We will include them in follow-up to emails, so we will get back to you on that. Thank you again from all of us here at allergy and asthma network. Join us as we work every day to help everyone breathe better. Have a good night, everybody. Thank you again.
Dr. Stukus: Thank you so much.
