A sthma and A llergies Pamela Amelung, MD Mini-Med School Fall 2006 University of Maryland School of Medicine

What is asthma? Asthma facts and statistics Who is most at risk to get asthma? Symptoms and triggers, including allergies Management of asthma How to avoid triggers and attacks T opics C overed

What is asthma?

Asthma facts and statistics

Who is most at risk to get asthma?

Symptoms and triggers, including

allergies

Management of asthma

How to avoid triggers and attacks

Chronic inflammatory disorder of the medium and small airways. These airways are hypersensitive to certain “triggers” in the environment. Intermittent and recurrent episodes of... Wheezing Shortness of breath Chest tightness Cough - night, early morning Usually reversible Asthma cannot be cured but its symptoms can be controlled with proper environmental changes and medication. W hat is A sthma ?

Chronic inflammatory disorder of the medium and small airways.

These airways are hypersensitive to certain “triggers” in the environment.

Intermittent and recurrent episodes of...

Wheezing

Shortness of breath

Chest tightness

Cough - night, early morning

Usually reversible

Asthma cannot be cured but its symptoms can be controlled with proper environmental changes and medication.

About 17 million Americans have asthma Most common chronic childhood disease, affecting about 5 million children (6% of children under 18) 14 people die each day from asthma Nearly 2 million emergency room visits each year T he facts about A sthma

About 17 million Americans have asthma

Most common chronic childhood disease, affecting about 5 million children (6% of children under 18)

14 people die each day from asthma

Nearly 2 million emergency room visits each year

H ow many people have A sthma ? The number of Americans diagnosed with asthma has risen. Self-reported prevalence increased 75% Close to 21 million Americans have been diagnosed with asthma in their lifetime. *MMWR December 04, 1998 / 47(47);1022-1025 13.7 17 Millions of individuals diagnosed

The number of Americans diagnosed with asthma has risen.

Self-reported prevalence increased 75%

Close to 21 million Americans have been diagnosed with asthma in their lifetime.

T he cost of A sthma ! Asthma costs billions of dollars each year and the cost is rising. The estimated annual cost of asthma in 2000 was $14.5 billion. * www.cdc.gov 1990 2000 $6.2 billion $ 14.5 billion

Asthma costs billions of dollars each year and the cost is rising.

The estimated annual cost of asthma in 2000 was $14.5 billion.

T he cost of A sthma ! 3 million lost work days 10 million lost school days each year from asthma

3 million lost work days

10 million lost school days each year from asthma

T he cost of A sthma ! Deaths from asthma have increased more than 50% in the past 20 years, and have increased more than 75% in children under 19 *CDC MMWR April 24, 1998 / 47(SS-1);1-28

Deaths from asthma have increased more than 50% in the past 20 years, and have increased more than 75% in children under 19

R ace and asthma M ortality

A sthma M ortality : Female vs. Male

R isk factors for A sthma Allergy / Atopy Family history of asthma/allergy Perinatal exposure to tobacco smoke Viral respiratory infections Low birth weight Male gender - pre-adolescence Low-income, urban residents Obesity

Allergy / Atopy

Family history of asthma/allergy

Perinatal exposure to tobacco smoke

Viral respiratory infections

Low birth weight

Male gender - pre-adolescence

Low-income, urban residents

Obesity

C lassification of A sthma Intermittent - Asthmatics who have symptoms that occur with a cold from time to time. They often grow out of the disease. Persistent - Asthmatics having symptoms at least twice a week during the day and twice a month during the night These asthmatics are further classified as mild, moderate, or severe.

Intermittent -

Asthmatics who have symptoms that occur with a cold from time to time.

They often grow out of the disease.

Persistent -

Asthmatics having symptoms at least twice a week during the day and twice a month during the night

These asthmatics are further classified as mild, moderate, or severe.

Coughing Wheezing Chest tightness Shortness of breath S ymptoms of A sthma

Coughing

Wheezing

Chest tightness

Shortness of breath

A sthma T riggers For people with asthma, exposure to certain substances they are sensitive to can lead to an asthma attack or exacerbation. These substances are known as triggers. Not all people with asthma have the same triggers that will cause an asthma attack.

For people with asthma, exposure to certain substances they are sensitive to can lead to an asthma attack or exacerbation.

These substances are known as triggers.

Not all people with asthma have the same triggers that will cause an asthma attack.

I ndoor air T riggers Environmental tobacco smoke (ETS) Cockroaches Dust mites Animal dander Mold, mildew Strong scented products (perfumes, scented cleaners)

Environmental tobacco smoke (ETS)

Cockroaches

Dust mites

Animal dander

Mold, mildew

Strong scented products (perfumes, scented cleaners)

All of the common asthma triggers are found indoors Americans spend about 90% time indoors Reducing exposure to indoor allergens and irritants can reduce asthma symptoms Prevention is an important asthma management tool W hy i ndoor air is I mportant

All of the common asthma triggers are found indoors

Americans spend about 90% time indoors

Reducing exposure to indoor allergens and irritants can reduce asthma symptoms

Prevention is an important asthma management tool

Contains more than 4,000 substances (over 40 are carcinogenic) Is particularly harmful to young children Can trigger asthma attacks and cause young children to develop asthma S econdhand S moke

Contains more than 4,000 substances (over 40 are carcinogenic)

Is particularly harmful to young children

Can trigger asthma attacks and cause young children to develop asthma

Found in most homes Live in soft bedding Feed on skin flakes Mites and mite droppings can be asthma triggers Most common asthma trigger in adults and kids D ust M ites

Found in most homes

Live in soft bedding

Feed on skin flakes

Mites and mite droppings can be asthma triggers

Most common asthma trigger in adults and kids

Skin flakes, urine and saliva of warm blooded animals can be asthma triggers. Triggers can remain in the home for several months after a pet is removed, even with cleaning. P ets

Skin flakes, urine and saliva of warm blooded animals can be asthma triggers.

Triggers can remain in the home for several months after a pet is removed, even with cleaning.

Can be found almost anywhere. Key to mold control is moisture control. Clean up the mold and get rid of excess water or moisture, this also helps reduce other triggers, such as dust mites and cockroaches. M olds

Can be found almost anywhere.

Key to mold control is moisture control.

Clean up the mold and get rid of excess water or moisture, this also helps reduce other triggers, such as dust mites and cockroaches.

Droppings or body parts can be asthma triggers. Cockroaches likely contribute significantly to asthma problems in inner city area. Asthmatic children allergic to cockroaches are three times more likely to be hospitalized if exposed in the home. C ockroaches and other P ests

Droppings or body parts can be asthma triggers.

Cockroaches likely contribute significantly to asthma problems in inner city area.

Asthmatic children allergic to cockroaches are three times more likely to be hospitalized if exposed in the home.

O utdoor air T riggers Ozone Particulate matter Sulfur dioxide Nitrogen dioxide - vehicle exhaust Outdoor pollens and mold

Ozone

Particulate matter

Sulfur dioxide

Nitrogen dioxide - vehicle exhaust

Outdoor pollens and mold

A dditional T riggers Viral upper respiratory infections Exercise Aggravating conditions - gastric reflux, sinusitis, rhinitis Diet, medication Cold air Changes in weather Menstrual cycle, pregnancy

Viral upper respiratory infections

Exercise

Aggravating conditions - gastric reflux, sinusitis, rhinitis

Diet, medication

Cold air

Changes in weather

Menstrual cycle, pregnancy

W hat causes an A sthma A ttack ? An allergic reaction to triggers or exposures Airways swell and fill with mucus and secretions The muscles around the airways contract and spasm Airways can collapse, causing classic symptoms, even death

An allergic reaction to triggers or exposures

Airways swell and fill with mucus and secretions

The muscles around the airways contract and spasm

Airways can collapse, causing classic symptoms, even death

I ndications of a severe A ttack Breathless at rest Hunched forward Talking in words rather than sentences Agitated Peak flow rate is less than 50% of normal

Breathless at rest

Hunched forward

Talking in words rather than sentences

Agitated

Peak flow rate is less than 50% of normal

M anagement of A sthma Asthma is one condition that, when treated with timely and effective regular outpatient care, prevents hospitalization and ED visits.

Asthma is one condition that, when treated with timely and effective regular outpatient care, prevents hospitalization and ED visits.

Consult with a physician to develop an asthma management plan, which includes: Medication Education: identification of asthma triggers & ways to reduce/avoid exposure to your asthma triggers Peak flow monitoring Emergency plan M anaging A sthma

Consult with a physician to develop an asthma management plan, which includes:

Medication

Education: identification of asthma triggers & ways to reduce/avoid exposure to your asthma triggers

Peak flow monitoring

Emergency plan

G oals of asthma M anagement Control chronic asthma symptoms and asthma attacks during the day and night no sleep disruption due to asthma no missed school or work because of asthma no or minimal need for emergency care or hospitalizations Avoid attacks or exacerbations Maintaining normal activity levels, including exercise and other daily activities Having normal or near-normal lung function Avoid side-effects of medications Prevent asthma mortality

Control chronic asthma symptoms and asthma attacks during the day and night

no sleep disruption due to asthma

no missed school or work because of asthma

no or minimal need for emergency care or hospitalizations

Avoid attacks or exacerbations

Maintaining normal activity levels, including exercise and other daily activities

Having normal or near-normal lung function

Avoid side-effects of medications

Prevent asthma mortality

Choose not to smoke in your home or car and do not allow others to do so either. A voiding secondhand S moke

Choose not to smoke in your home or car and do not allow others to do so either.

Wash sheets and blankets once a week in hot water Choose washable stuffed toys-- keep stuffed toys off beds Cover mattresses and pillows Vacuum often (when asthmatic is not present) Maintain low indoor humidity, ideally between 30-50% A voiding dust M ites

Wash sheets and blankets once a week in hot water

Choose washable stuffed toys-- keep stuffed toys off beds

Cover mattresses and pillows

Vacuum often (when asthmatic is not present)

Maintain low indoor humidity, ideally between 30-50%

Consider keeping pets outdoors or even finding a new home for your pets, if necessary. Keep pets out of the bedroom at all times. Keep pets away from fabric-covered furniture, carpets, and stuffed toys. A voiding pet T riggers

Consider keeping pets outdoors or even finding a new home for your pets, if necessary.

Keep pets out of the bedroom at all times.

Keep pets away from fabric-covered furniture, carpets, and stuffed toys.

Wash mold off hard surfaces and dry completely, absorbent materials (ceiling tiles and carpet) may need to be replaced. Use exhaust fans or open windows in kitchens and bathrooms when showering, cooking, or using the dishwasher. Maintain low indoor humidity (between 30-50% relative humidity). Fix leaky plumbing or other sources of water. Keep drip pans in your air conditioner, refrigerator, and dehumidifier clean and dry Clean bathrooms frequently. A voiding mold T riggers

Wash mold off hard surfaces and dry completely, absorbent materials (ceiling tiles and carpet) may need to be replaced.

Use exhaust fans or open windows in kitchens and bathrooms when showering, cooking, or using the dishwasher.

Maintain low indoor humidity (between 30-50% relative humidity).

Fix leaky plumbing or other sources of water.

Keep drip pans in your air conditioner, refrigerator, and dehumidifier clean and dry

Clean bathrooms frequently.

P est A voidance Free your home of places for pests to hide and sources of food and water Regular, careful cleaning - kitchen Daily trash removal Store food in airtight containers Extermination - baits, gels (not sprays)

Free your home of places for pests to hide and sources of food and water

Regular, careful cleaning - kitchen

Daily trash removal

Store food in airtight containers

Extermination - baits, gels (not sprays)

P revent outdoor T riggers Ozone - advisories, stay indoors Pollens and Molds (if allergic) Close windows, doors Use air conditioners, clean filters regularly Dry clothes indoors Avoid raking leaves, gardening Outside - less breezy, after gentle rain

Ozone - advisories, stay indoors

Pollens and Molds (if allergic)

Close windows, doors

Use air conditioners, clean filters regularly

Dry clothes indoors

Avoid raking leaves, gardening

Outside - less breezy, after gentle rain

P eak expiratory flow (PEF) M eters Allows the patient to assess the status of his or her asthma

P eak flow C hart People with moderate or severe asthma should take readings — Every morning and 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

People with moderate or severe asthma should take readings —

Every morning and evening

After an exacerbation

Before inhaling certain medications

M anagement of A sthma Quick-relief medications used to treat asthma attacks and acute symptoms “ Relievers” Long-term control medications reduce the airway inflammation that causes these symptoms “ Controllers”

Quick-relief medications used to treat asthma attacks and acute symptoms

“ Relievers”

Long-term control medications reduce the airway inflammation that causes these symptoms

“ Controllers”

A sthma M edications Quick-relief medications Short-acting bronchodilators Relax smooth muscle around the airways Long-term Medications Steroids Inhaled, tablets Anti-inflammatory Long acting bronchodilators Relax smooth muscle Leukotriene inhibitors Anti-inflammatory

Quick-relief medications

Short-acting bronchodilators

Relax smooth muscle around the airways

Long-term Medications

Steroids

Inhaled, tablets

Anti-inflammatory

Long acting bronchodilators

Relax smooth muscle

Leukotriene inhibitors

Anti-inflammatory

A sthma action P lan National Heart, Lung, and Blood Institute

A sthma is I ncreasing Why the increase? Increased recognition, diagnosis-shifting Environmental allergens - indoor, outdoor Energy-efficient buildings, carpet Exposure to mother’s tobacco smoke Psychosocial and socioeconomic factors More time indoors Overcrowding Access to care

Why the increase?

Increased recognition, diagnosis-shifting

Environmental allergens - indoor, outdoor

Energy-efficient buildings, carpet

Exposure to mother’s tobacco smoke

Psychosocial and socioeconomic factors

More time indoors

Overcrowding

Access to care

“ H ygiene H ypothesis” Are we too clean ? Immune Response Th1 Responds to harmless bacteria, dirt, animal droppings after birth Not activated in sterile birth environment Subdues the more hyperactive Th2 Th2 Not as effective as Th1 Fight allergens, cause allergies T0 T2 T1

Immune Response

Th1

Responds to harmless bacteria, dirt, animal droppings after birth

Not activated in sterile birth environment

Subdues the more hyperactive Th2

Th2

Not as effective as Th1

Fight allergens, cause allergies

“ H ygiene H ypothesis” Are we too clean ? Less allergies and asthma: 1990 East vs. West Germany Farm vs. city children Daycare before 6 months of age vs. later Older siblings vs. none Failure to develop balanced immune system Detergents/chlorine, antibiotics, vaccines, antibacterial soaps

Less allergies and asthma:

1990 East vs. West Germany

Farm vs. city children

Daycare before 6 months of age vs. later

Older siblings vs. none

Failure to develop balanced immune system

Detergents/chlorine, antibiotics, vaccines, antibacterial soaps

H ealthy people 2010 Objectives Reduce asthma deaths Reduce hospitalizations for asthma Reduce hospital ED visits for asthma Reduce activity limitations - reduce # of school/work days missed Increase proportion who receive formal patient education Increase proportion who receive appropriate asthma care Establish in  25 states a surveillance system for tracking asthma http://www.health.gov/healthypeople

Reduce asthma deaths

Reduce hospitalizations for asthma

Reduce hospital ED visits for asthma

Reduce activity limitations - reduce # of school/work days missed

Increase proportion who receive formal patient education

Increase proportion who receive appropriate asthma care

Establish in  25 states a surveillance system for tracking asthma

C onclusions Asthma affects 5-10% of the population and the prevalence is rising in developed countries. Allergies often play a key role in asthma and act as triggers for asthma symptoms. Asthma can not be cured but can usually be well controlled in most people. Controlling asthma involves patient education, lung function monitoring, avoidance of triggers, and in many, medications.

Asthma affects 5-10% of the population and the prevalence is rising in developed countries.

Allergies often play a key role in asthma and act as triggers for asthma symptoms.

Asthma can not be cured but can usually be well controlled in most people.

Controlling asthma involves patient education, lung function monitoring, avoidance of triggers, and in many, medications.