Fall 2017
Be knowledgeable. Be well. Be healthy.
MEDICATION THE KEY TO ASTHMA CONTROL
COMMON ASTHMA TRIGGERS HIDING IN PLAIN SIGHT
EXERCISE: TREATMENT & TRIGGER ASTHMA ACTION PLAN HEALTHY EATING
Asthma COMMON, BUT CONTROLLABLE
Life.Giving.Breakthroughs.
Physicians at these Brigham Health practices are NOW ACCEPTING NEW PEDIATRIC PATIENTS.
Please call us to schedule an appointment. Appointments are available in English and Spanish
Brigham and Women’s Faulkner Hospital Brigham and Women’s Family Care Associates 1153 Centre Street, Suite 5H, Boston, MA 02130 617-983-7025 Brookside Community Health Center 3297 Washington Street, Jamaica Plain, MA 02130 617-522-4700 Southern Jamaica Plain Health Center 640 Centre Street, Jamaica Plain, MA 02130 617-983-4100
2 Be Healthy | Fall 2017
Publisher Melvin Miller Health Editor Karen Miller Senior Editor Yawu Miller Art Director Daniel Goodwin Production Shannon Owens Proofreader Rachel Reardon For advertising opportunities please contact Karen Miller at (617) 936-7800 or kmiller@bannerpub.com
Be Healthy is published by Banner Publications, Inc. 1100 Washington St., Dorchester, MA 02124 Volume 5 • Number 1 Fall 2017 © 2017 Banner Publications Be Healthy is printed by TC Transcontinental Printing, 1603 Boul. Montarville, Boucherville, Québec, J4B 5Y2 Printed in Canada COVER PHOTO: THINKSTOCKPHOTOS.COM/ STOCKBYTE
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Editor’s note: The information presented in Be Healthy is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate for your age, sex, race and risk factors and make timely visits to your primary care physician.
Asthma
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Medication The key to asthma control
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Exercise: Trigger and treatment
Fall 2017 The issue
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Asthma
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Focus
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Asthma triggers Medication Action plan Asthma at school Patient stories
10 12 13 14 16
Healthy steps
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Nutrition Exercise
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baystatebanner.com/news/be-healthy | Be Healthy 3
The issue: Asthma
Asthma: A fight for breath
Yet often well-controlled TAKE A BREATH IN. LET THE AIR OUT. A simple activity you perform roughly 23,000 times a day. It’s so automatic you don’t give it much thought. But for those with asthma, the process is not so simple. They often have to fight for that breath. It’s known by its telltale wheezing or whistling sound, but it’s the coughing, chest tightness and shortness of breath that often cause concern. In asthma the airways are inflamed and clogged with mucus. The muscles surrounding the airways contract leaving little space for air to enter. Symptoms are often worse at night, resulting in a persistent dry cough, making it hard to get a good night’s sleep. There is no cure, but the news is not all that bleak. With medication asthma can often be well-controlled. Roughly 25 million or 8 percent of people in this country are afflicted, according to the Centers for Disease Control and Prevention. Asthma is the leading chronic disease in children and the top reason for missed school days. In childhood the disease is more common in boys than girls, but in adulthood, the reverse is true. It is more prevalent in those of lower income and strikes the Northeast and Midwest 4 Be Healthy | Fall 2017
more than other sections of the country. For reasons unknown, the prevalence of asthma in black children is almost two times higher than it is in whites, and blacks are three times more likely to be hospitalized for asthma. Studies are underway to investigate the possibility that blacks may respond differently to asthma medications. The impact of asthma on the economy is noteworthy. Yearly visits to emergency departments, physician offices and hospital outpatient departments can exceed 13 million. The total annual cost is estimated to be $56 billion. Recognizing asthma symptoms in your child can be a bit tricky. The symptoms can closely mirror those of allergies or even the common cold. “For young kids in particular you rely on the symptoms and history,” explained Dr. Faye Holder-Niles, the medical director of Primary Care Asthma Programs at Boston
Children’s Hospital. “A parent might say that the child is coughing a lot at night or when running and playing even when they are not sick.” At age six and older the parameters of diagnosis change. In addition to the history and symptoms, asthma can be confirmed by a pulmonary function test called spirometry. This test measures how much and how fast you can move air into and out of the lungs. The National Heart, Lung and Blood Institute has developed a series of guidelines to help diagnose the disease and measure its severity. Asthma ranges from intermittent to severe persistent, and varies by the frequency and seriousness of the symptoms. For instance, those with intermittent asthma may have no interference with normal activities. On the other end of the spectrum a person may experience symptoms throughout the day and have to rely on daily preventive medications. The cause of asthma is unclear. It is probably a combination of environmental as well as genetic factors. Asthma tends to run in families; it is not uncommon for multiple family members to be affected. Additionally, in some cases it is
The issue: Asthma
Faye Holder-Niles, M.D., M.P.H. is the medical director of Primary Care Asthma Programs, Primary Care & Office of Community Health at Boston Children's Hospital.
PHOTO: KATHERINE C. COHEN/BOSTON CHILDREN'S HOSPITAL
baystatebanner.com/news/be-healthy | Be Healthy 5
The issue: Asthma
A CLOSER LOOK
NORMAL AIRWAY
Asthma is an inflammation of the airways that interferes with normal breathing. It affects 7.6 percent of adults in the U.S. and 8.4 percent of children. Its prevalence is on the rise.
Muscle Airway wall Muscle Airway wall
Airways
Airway cross-section
DURING ASTHMA SYMPTOMS
Inflamed/thickened airway wall
Muscle Narrowed airway (limited air flow) Tightened muscles constrict airway
part of a triad that it shares with allergies and eczema. In asthma the airways maintain a level of inflammation, but exposure to certain substances or conditions called triggers can increase the inflammation, resulting in an attack. Dust mites, mold, rodents and cigarette smoke are examples. Although triggers vary from person to person, one or two invariably are on most lists. One particularly common trigger is change in weather, especially when the weather changes from hot to cool in the fall. September is one of the worse months for asthma attacks, according to Holder-Niles. In the spring there is exposure to seasonal allergies and frequent viruses in the winter. The trick is figuring out just what those triggers are. The best way is to begin a series of queries to find out what 6 Be Healthy | Fall 2017
Inflamed/ thickened airway wall
Mucus
COMMON SYMPTOMS Signs and symptoms of asthma vary widely, but may include the following: n Coughing, which may be worse at night n Wheezing — a whistling sound when exhaling n Chest tightness, which may feel as though something is squeezing your chest n Shortness of breath n Rapid breathing has changed. Did you move into a new apartment? Do you have a pet? Does the attack occur when you go outside? Do they happen when you are running and playing or during gym at school? These are all examples of questions to narrow the source of the offending agent. Boston Children’s Hospital provides home visits to make the home “asthma friendly.” Several medications for asthma are
available. Some reduce inflammation, while others relax the airways. Still others target allergies. The two main categories of medications are preventive, which are taken every day for persistent asthma, and rescue medications for intermittent symptoms during a flare-up. “Even people on daily medication will require rescue medication,” explained Holder-Niles. “At any time a person can
ILLUSTRATION: CALEB OLSON
Lungs
Mucus
The issue: Asthma
HOW ARE YOU DOING?
CONTROLLING YOUR ASTHMA Take an active role in controlling your asthma: 1. Develop a partnership with your primary care provider 2. Learn what asthma is and how it affects your body 3. Create and follow your asthma action plan 4. Identify and avoid triggers 5. Know which medication is which and how to take it correctly
have increased asthma symptoms with coughing, wheezing or chest tightness. It is important to always have your rescue inhaler available for emergencies at home, school and after-care.” Preventive medications are modified according to each person’s response. If symptoms persist, medications can be increased, but they can also be reduced if a person is well-controlled for a period of time. In spite of the availability of these medicines, asthma attacks still persist. The CDC found in its national prevalence of asthma attacks report of 2015, that almost 47 percent of persons with asthma reported having one or more asthma attacks, and over 439,000 were admitted to a hospital. Some people seem to “outgrow” their asthma. It’s not that it’s gone, but it appears to be tamped down. “Once you have asthma, you still have asthma,” said Holder-Niles. “Some adolescents and adults do very well and have few asthma symptoms, but there is still the possibility of an attack, so patients should always be vigilant.” Asthma cannot be prevented, but Holder-Niles offers tips to keep it in check. Most important is to partner with your primary care provider to create your personal asthma action plan. The plan details your prescribed medicine and is color-coded to advise you of the status of your control. Green means you are doing okay. Yellow means caution — that your asthma is getting worse. Red means you are in trouble and require immediate treatment. This plan should be shared with your school nurse, daycare providers and community health worker who
6. Be able to recognize a flare-up and know what to do 7. Exercise regularly and practice precautions to prevent a flare-up 8. Get regular check-ups 9. Don’t smoke or be around people who do 10. Learn to control your stress levels 11. Get a yearly flu shot
“
It is important to always have your rescue inhaler available for emergencies at home, school, after-care or work.” — Dr. Faye Holder-Niles Boston Children’s Hospital
are also part of your child’s team and play an important role in helping to keep your child healthy. Education and pro-active management are key. Learn what your triggers are and avoid them. Understand which medicine is which and how to take it correctly. You need to know the symptoms of asthma, she warned. “If a person is wheezing, and using the abdominal (stomach) muscles to breathe and is unable to speak, that is an emergency,” she explained. “The point is to call before that happens. Call when you are in the yellow phase.” Holder-Niles is trying to put a different face to asthma. Parents should have the attitude that “my child can do anything.” We want to support and empower families to manage their child’s asthma, she explained. That is possible once you feel empowered to control the disease. “You name it; you claim it and then you fight it,” she said.
Daily use of a peak flow meter will help you appraise the status of your asthma. Even without the meter, however, the following symptoms can be used as a guide. Doctors recommend that you contact them when your symptoms fall within the yellow zone to prevent escalation to the red zone. lG reen zone: Your asthma is under control: Breathing is good; No coughing or wheezing; Can work and play; Sleeping well at night lY ellow zone: Caution: Some problems breathing; Coughing, wheezing, or chest tightness; Problems working or playing; Waking at night lR ed zone: Medical alert: Get help now: Lots of problems breathing; Cannot work or play; Getting worse instead of better; Medicine is not helping
COMMON ASTHMA TRIGGERS Triggers are substances or conditions that make asthma worse. They differ from person to person. Examples of triggers are listed below. n Respiratory infections, like colds, flu or sinus infections n Smoke from cigarettes, cigars and fireplaces n Weather, including pollen and air pollution, cold weather n Animals with fur or feathers, such as dogs, cats and birds n Pests, such as rodents, cockroaches n Dust mites n Mold and moisture n Strong odors, such as hairsprays and cleaning products n Medicines, such as aspirin and NSAIDS, beta blockers for heart disease n Medical conditions, such as acid reflux n Exercise n Strong emotions, such as stress, anger, fear baystatebanner.com/news/be-healthy | Be Healthy 7
By the numbers: Asthma
3
rd
Asthma is the third leading cause of hospital stays in children
24% The percentage of Boston high school students who have asthma
25 13%
MILLION
The number of people in this country with asthma
3,615 The number of deaths from asthma in 2015
We’re here for you For adults and children of any age, in Greater Boston and beyond, Dimock's integrated continuum of healthcare and services are here for you every step of the way. Call us today to make an appointment at 617-442-8800 or visit us at www.dimock.org
The percentage of African American children with asthma
56
$
BILLION
The annual cost of asthma
Our health center offers these services: • Adult, Adolescent and Pediatric Care • Obstetrics and Gynecology (OB/GYN) • Eye & Dental Care for Adults & Children • HIV Specialty Care • Behavioral Health Services • Onsite Pharmacy
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Focus: Asthma A better understanding
PHOTO: KATHERINE C. COHEN/BOSTON CHILDREN'S HOSPITAL
» Asthma triggers 10 » Medication 12 » Action Plan 13 » At school 14 » Patient stories 16
“
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My son is still here. He is happy. Asthma is not affecting him. ... If you give up, you’re giving up on your child.” — Sherika Elliott baystatebanner.com/news/be-healthy | Be Healthy 9
FOCUS: Asthma triggers
Right inside your home INDIRA ALVAREZ IS AN INVESTIGATOR OF SORTS, BUT SHE IS NOT TRYING TO FERRET OUT A CRIME. She and her cohorts are looking for the culprits behind a person’s asthma attacks. She does not have to look far. The perpetrators are right in the home. Alvarez is the chief of staff of the City of Boston Inspectional Services Department. In partnership with the Boston Public Health Commission, the department participates in the Breathe Easy at Home program, which helps those with asthma discover and eradicate the triggers of asthma attacks in the home. More than 90 percent of one’s time is spent indoors, according to the Environmental Protection Agency. That means that a person with asthma is confronted with triggers basically all of the time. A trigger is a substance or condition that causes flare-ups in people with asthma. They differ from person to person and in intensity. The department looks for four triggers in particular: mold, signs of moisture, roaches and mice. This choice is understandable. Researchers determined that cockroaches caused flare-ups in up to 60 percent of people with allergic asthma. In another study, scientists from the National Institute of Environmental Health Science found that 82 percent of homes in the United States — whether urban, suburban and rural — had mouse allergens.
Mold and moisture Massachusetts law mandates that in 10 Be Healthy | Fall 2017
MAKE IT AT HOME Asthma-friendly all-purpose “green” cleaner 12⁄3 cup baking soda ½ cup liquid Castile or Murphy’s soap ½ cup water 2 tablespoons vinegar
Source: Boston Public Health Commission new construction and updates, bathrooms be equipped with mechanical exhaust fans that prevent the buildup of steam, a precursor to mold. The exhaust fans should vent outdoors. “If there is no proper ventilation, open the window,” advised Alvarez. Inspectors check under sinks, all ceilings, walls and areas where moisture can accumulate, including bathrooms and bedrooms adjacent to bathrooms. Kitchens are another source of moisture if the hood of the stove is not ventilated. Humidity, especially when higher than 50 percent, is the perfect environment for mold to accumulate. Mold is a fungus that can grow rapidly. Its spores travel through the air and are small enough to penetrate the airways.
Roaches Cockroaches are hardy insects. They preceded the dinosaurs, so they’re not going away anytime soon. Unfortunately, their saliva, shell and droppings can trigger an asthma attack. They can get into a home through vents or crevices, warned Alvarez, and have a penchant for stoves and under the sink. More often, however, you unwittingly invite them in through shopping bags and boxes.
Rodents As winter approaches, mice and rats head inside. “They’re trying to find a warm place,” said Alvarez. They’re also very determined. “They can bite through concrete,” she explained. They look for any tiny entrance through which to squeeze. The droppings and dander of rodents can trigger asthma and allergies, and are stronger predictors of asthma symptoms in young children than exposure to roaches, according to a recent study.
Integrated Pest Management To eradicate mold, roaches and mice Alvarez advises Integrated Pest Management, which, according to the Environmental Protection Agency, is an effective and environmentally sensitive approach to pest management. IPM programs develop ways to manage pest control with the least possible hazard to people, property and the environment. For instance, traps are used instead of sprays and poisons. After the inspection tenants and landlords are provided a list of the findings and recommended solutions. A follow-up visit is scheduled. The overall purpose of the program is not only to keep people healthy but also to keep them healthy in their homes.
PHOTO: COURTESY BOSTON INSPECTIONAL SERVICES DEPARTMENT
Triggers: Hiding in plain sight
Indira C. Alvarez, Chief of Staff, Boston Inspectional Services Department
FOCUS: Asthma triggers
COMMON TRIGGERS AND SOLUTIONS Triggers in the home Trigger: MOLD AND MILDEW Source: Bathrooms, kitchens, laundry rooms, basements Solutions: n Run exhaust fan or open window when showering, cooking or using dishwasher. n Clean sinks, tubs and showers with green products, then dry. n Fix leaks quickly. n Use a dehumidifier or air conditioner. n Keep humidity below 50 percent.
Cold Air
old Air
Trigger: COCKROACHES AND RODENTS Source: Preference for dark, damp places, clutter and behind walls Solutions: n Store food in closed containers. n Fix leaks; don’t leave water in sinks or pots and pans. n Clean up crumbs and wipe up spills. n Plug cracks around windows and doors. n Block holes in walls, cabinets and foundation. n Use baits and traps instead of sprays.
Pets/Animals
Pollen
llen
Trigger: SMOKE Source: Cigarettes, pipes, cigars, fireplaces, wood-burning stoves Solutions: n Avoid smoke from all sources. n Don’t smoke. n Call 1-800-QUITNOW for help to stop smoking.
Smoke
Trigger: WEATHER Source: Cold or dry weather Solutions: n Wear a mask or scarf to warm the air you breathe.
Cold Air Dust/Dirt
ILLUSTRATIONS: CALEB OLSON
Pollen
Trigger: DUST MITES Source: In anything made of cloth or fiber: curtains, carpets, upholstered furniture, pillows, stuffed toys, mattresses Solutions: n Use allergy-proof mattress and pillow covers. n Wash sheets and pillow cases in hot water (130°) every week, and dry in clothes dryer. n Remove carpets. n Eliminate clutter. n Dust regularly with a damp cloth.
D
Pets/Animals
Trigger: FURRY OR FEATHERED PETS Source: Animals like dogs, cats, hamsters and birds Solutions: n Keep animals out of the bedroom. n Vacuum weekly with a HEPA vacuum cleaner. n Wash hands after touching animals.
Trigger: STRONG ODORS Source: Cleaners and bleach, pesticides, air fresheners, potpourri, paints, glue, perfume Solutions: n Use “green” products instead of caustic cleaners. n Use an exhaust fan or open window.
r Cold Ai
Pets/A
Smoke
Other triggers
Pollen
Trigger: POLLEN AND AIR POLLUTION Source: Spring: trees, grasses and weeds; Fall: ragweed and weeds; smog, haze, smoke, dust Solutions: n Use air conditioner or keep windows closed. n Check pollen count at www.pollen.com. n Check the air quality at www.airnow.gov.
Trigger: MEDICAL ILLNESSES Source: Colds and viruses, GERD or heartburn Solutions: n Wash hands often. n Avoid people with the flu. n Get a yearly flu shot. n Avoid foods that cause GERD, such as fatty or fried foods.
Trigger: EXERCISE
Source: Sports or gym class or Dust/Dirt Pets/Animals
when running or playing hard Solutions: n Start slowly and cool down. n Breathe through your nose. n Use rescue inhaler if prescribed by your doctor. Other possible triggers are some medicines, strong emotions, such as anger or stress and foods containing sulfites.
Smoke
Source: Asthma and Allergy Foundation of America, Boston Public Health Commission baystatebanner.com/news/be-healthy | Be Healthy 11
FOCUS: Medication
The key to asthma control Teaching … teaching … teaching JHENANE JOSEPH IS A TEACHER, BUT HER MILIEU IS NOT THE CLASSROOM. Nor is she teaching the basics of
One wonders why a nurse has to devote that much time to something that at least with other illnesses is pretty basic. A kid gets sick, takes a pill or gets a shot. With asthma it’s not that easy. Medication for asthma is usually administered through a metered-dose inhaler. The purpose of the inhaler is to deliver a shot of medicine straight to the lungs. The inhaler is composed of a cylinder of medicine, a valve that measures the correct dose and the mouthpiece. The National Heart, Lung and Blood Institute recommends that children younger than five use a spacer or a mask to help direct the medicine more easily into the lungs. Regardless of the method used, inhalers are tricky to master. A study published in the New England Journal of Medicine Journal Watch found that of the 54,000 patients evaluated, only one-third used their inhaler correctly. Poor technique is a common cause of uncontrolled asthma. The proper technique is to breathe slowly and deeply when inhaling the medicine, then hold the breath for 10 seconds to ensure the medicine reaches its target and not stay in the mouth. The most common mistakes mentioned in the study were failure to maintain a full, slow, constant inspiration, and failure to hold one's breath for the required time after the dose of medicine. 12 Be Healthy | Fall 2017
Jhenane Joseph (right), better known as JJ, instructs Brianna Silva, a patient at Codman Square Health Center, in the proper use of an inhaler. Silva is using an inhaler with a spacer and mask.
That’s where JJ steps in. Her patients have not always been properly trained, and have as a consequence gone through a series of medications. “A’s not working. B’s not working — all because education was not given,” she explained. She starts with the basics and explains what asthma is and what it does to the body. Each visit is a teaching session. Then comes the lesson on the inhaler. She has seen her share of the mistakes. Not inhaling is the most common error. Incorrect placement is another. You have to place the inhaler above the tongue under the top teeth and close your lips tightly around the mouthpiece. If you don’t the meds wind up in the air instead of the lungs, she explained. “You’re supposed to feel it,” she said. Once patients do it right they can feel the difference. Some people prefer to use a spacer, a holding chamber for the medicine that attaches to the inhaler. Medicine is sprayed into the spacer instead of directly into the mouth, but you still breathe in slowly and hold your breath for 10 seconds. Sometimes patients don’t know the symptoms of asthma so they don’t know when to take the medicine. Still others are on the opposite spectrum. Some with anxiety go through their inhaler quickly.
They’ve taken all the meds within two to three weeks. “That’s too much,” she explained. In general, one inhaler is enough for 200 puffs of medicine. If the person needs two puffs a day it should last for 100 days. By the fourth visit her patients usually have the technique down pat, but she keeps seeing them until they are comfortable. Age is a factor. Some as young as five can master the technique, but the typical age of expertise is eight or nine. Discharges are rare. “I see them at least every three months,” she explained. JJ said she also relies on peak flow meters, portable hand-held devices used to assess lung function, by measuring how fast a person can push air out of the lungs. ”You have to know your best peak flow,” she said. “It’s a great teaching tool and helps [you] understand the disease.” The measurements on the meter can alert you when your asthma symptoms are worsening. Sometimes changes in your status occur even before you feel them. JJ said she knows she has succeeded when her patients take ownership of their asthma and do their part to keep it under control. She sums up what she does in three words. “Teaching, teaching, teaching,” she said.
PHOTO: SCOTLAND HUBER, CODMAN SQUARE HEALTH CENTER
mathematics or spelling. Joseph, more affectionately known as JJ, is a pediatric nurse at Codman Square Health Center, and her students are kids with asthma. Her role is to teach them to take their medicine correctly.
FOCUS: Action plan
ASTHMA ACTION PLAN Name:
Date:
Doctor:
Medical Record #:
Doctor’s Phone #: Day
Night/Weekend
aafa.org
The colors of a traffic light will help you use your asthma medicines.
Emergency Contact:
GREEN means Go Zone! Use preventive medicine.
Doctor’s Signature:
YELLOW means Caution Zone! Add quick-relief medicine. RED means Danger Zone! Get help from a doctor.
Personal Best Peak Flow: GO You have all of these: • Breathing is good • No cough or wheeze • Sleep through the night • Can work & play
Use these daily preventive anti-inflammatory medicines: MEDICINE
HOW MUCH
HOW OFTEN/WHEN
Peak flow: from to
For asthma with exercise, take:
CAUTION You have any of these: • First signs of a cold • Exposure to known Peak flow: trigger from • Cough • Mild wheeze to • Tight chest • Coughing at night
Continue with green zone medicine and add: MEDICINE
HOW MUCH
HOW OFTEN/ WHEN
CALL YOUR PRIMARY CARE PROVIDER.
DANGER Your asthma is getting worse fast: • Medicine is not helping Peak flow: • Breathing is hard & fast reading • Nose opens wide below • Ribs show • Can’t talk well
Take these medicines and call your doctor now. MEDICINE
HOW MUCH
HOW OFTEN/WHEN
GET HELP FROM A DOCTOR NOW! Do not be afraid of causing a fuss. Your doctor will want to see you right away. It’s important! If you cannot contact your doctor, go directly to the emergency room. DO NOT WAIT. Make an appointment with your primary care provider within two days of an ER visit or hospitalization. baystatebanner.com/news/be-healthy | Be Healthy 13
FOCUS: Schools
Keep your child in the classroom And not in the nurse’s office PATRICIA KENNEY SPENDS MUCH OF HER TIME PUTTING OUT FIRES. Some unforeseen event is bound to pop up some-
Kenney is the nurse liaison for Children with Special Health Care Needs in the Boston Public Schools. School nurses see their fair share of asthma. “In 2015-16, we had 10,724 patients with a documented diagnosis of asthma,” she explained. That amounts to almost 19 percent of the student population. Minorities are hit particularly hard, according to “The Facts about Pediatric Asthma in Boston,” a publication of the Massachusetts Department of Public Health. The asthma-related rates for emergency department visits and hospitalizations between 2008 and 2012 for black and Hispanic children were roughly five and four times higher, respectively, than white children. That poses a challenge for school nurses. The School and District Profiles indicate that African Americans and Hispanics make up 73.6 percent of the 2016-2017 enrollment in the Boston Public Schools. Fortunately, the BPS has a protocol in place to help manage asthma in the school setting. Two required signed forms will start the process. The Medication Order signed by a provider lists all prescribed medications and any special instructions, while the Medication Authorization Form signed by the parent allows the nurses to administer the meds. Generally, children younger than nine require assistance. The 14 Be Healthy | Fall 2017
A CRITICAL PARTNERSHIP Share these forms with the school nurse: n The Medication Order that lists the student’s prescribed drugs n The Medication Authorization Form, which gives nurses permission to administer medication n The Medication Self-Administration Form that allows your child to administer the medications without assistance n Asthma action plan
ON THE WEB For more, visit: www.bostonpublicschools.org/healthservices
Medication Self-Administration Form, however, allows students to treat themselves after a nurse has observed and approved their technique. The problem is parents have to set this protocol in motion, but some are unaware of or misunderstand the required procedures. There is a misperception that doctors automatically inform schools that a child has asthma. “That’s not true,” said Mary White, a Parent Asthma Leader and member of Healthy Schools Initiative. “You have to request it.”
Children with asthma can receive treatment at school if parents give permission.
When not notified, nurses often learn about a student’s diagnosis after an attack occurs. “We send for physician orders and medication once we are aware,” explained Kenney. People with asthma — even those whose conditions are well controlled — require rescue inhalers. A Massachusetts law allows students with asthma to carry and use prescription rescue inhalers as needed. School nurses, however, first observe their technique. Errors in use of inhalers is one of the leading causes of asthma attacks. Regardless of precautions taken, flare-ups are bound to happen. Physical exertion from gym class, upper respiratory infections and allergies cause frequent visits to the clinic. At times the school itself is the source of problems. Cleaning agents, dust and rodents are common triggers in the school. MassCOSH (Massachusetts Coalition for Occupational Safety and Health) provides support and strategies to reduce asthma triggers and improve school environmental conditions. Parents entrust the care of their children to school nurses for six hours each weekday. A partnership with that nurse — especially for parents of children with asthma — is the first step to keep your child in the classroom instead of the clinic.
PHOTO: THINKSTOCKPHOTOS.COM/ISTOCK
where. But there is one event she prefers not to see — an unexpected or unanticipated asthma attack.
Asthma Management Checklist
You can take control of your asthma throughout the year by checking all the boxes!
Understand what asthma is and know your child’s triggers
Asthma is a chronic disease of the lungs. It should be taken seriously throughout your life. Controlling asthma helps to prevent emergency room visits, hospitalization and death. Asthma can make it hard for someone to breathe when they participate in certain activities or are exposed to certain “triggers” (such as pets, mice/rodents, cockroaches, chemicals, scents, smoke, pollen, mold, cold/flu and changes in weather).
Get an Asthma Action Plan and share it!
Ask your child’s medical provider for their updated Asthma Action plan (AAP). This provides a roadmap for how to take care of your child when they are well, experiencing asthma symptoms, and in an emergency situation. Share the AAP with all who take care of your child (school nurse, before and after school programs, other caregivers, friends and family).
Know your medications, and take them as prescribed • • • • • •
It is very important to ask the doctor or pharmacist to explain the medications, how and when to use them and to take them as prescribed (with a spacer if it fits with your inhaler). When your child is having an asthma attack, use a reliever medication or “rescue medication”, such as Albuterol, for quick relief. Asthma long term controller medications, such as Flovent, are effective if taken every day, as directed by your child’s doctor. Make sure inhalers are not empty or out of date. Tell your child’s doctor if your child is using their rescue inhaler twice a week or more to control their asthma. See your child’s doctor if you have any concerns. Talk with your child’s school nurse, teacher, or principal about your child keeping asthma medication in their bag with doctor written permission.
Keep active, the safe way
Ask your doctor if your child needs to use their quick relief inhaler before participating in any physical activities.
Talk to your child’s teacher about their health needs • • •
Ensure your child understands the importance of telling a teacher if they are not feeling well. Give your child’s teacher a copy of their asthma action plan and explain any triggers or warning signs they should be aware of. Make sure your child’s school has your emergency contact information.
Get a flu shot! Arm yourself and your family against the flu. According to the Centers for Disease Control and Prevention, respiratory infections such as the flu can affect your lungs, causing an asthma attack. Getting vaccinated is the first and most important step you can take to protect yourself and your loved ones from the flu. WHY is it important to get the flu vaccine? • Much more serious than the common cold, the flu can lead to hospitalization and even death. • Flu symptoms last about 7-10 days, causing kids to miss school and caregivers to miss work. • The flu vaccine is the most effective way to prevent the flu and it can reduce the severeity and length of your illness if you do get sick. • Young children and those with chronic disease like asthma or diabetes are at much greater risk of complications if they get the flu. Note: The flu vaccine will not give you the flu. Possible side effects include soreness, redness, or swelling at the site of injection, a low fever, and/or headaches. These symptoms are usually mild and don’t last long. Families with an egg allergy can still get the flu vaccine. If you have questions or concerns, ask your medical provider.
For more information, please visit bphc.org/Asthma and childrenshospital.org/.
baystatebanner.com/news/be-healthy | Be Healthy 15
FOCUS: Patient story
An upbeat 6-year-old Even with severe persistent asthma not a doctor, but she has four children with asthma, and has become an expert of sorts. The youngest is 6-year-old T’andre. When at eight months he suffered his first attack, she didn’t miss a beat. She knew exactly what it was, and called her pediatrician to confirm. T’andre had caught a cold and was wheezing and short of breath. The symptoms improved after treatment with a nebulizer. Elliott took no chances, though, and took her son to the emergency department. The doctors, however, did not confirm a diagnosis of asthma. They thought T’andre instead had bronchiolitis, an inflammation of the bronchioles, which are the smallest passageways of air in the respiratory system. Bronchiolitis is common in infants, and is almost always caused by a virus. About two months later, he was admitted to the hospital after another attack, and a diagnosis of asthma was confirmed. That started a series of hospital admissions every two months, lasting two weeks at a time. One admission extended from Thanksgiving to January 24, she explained. Sometimes he was placed on a ventilator not only to give his lungs a rest but also to restore the normal exchange of gases in the body. Some asthma attacks prevent the lungs from breathing in oxygen, the source of energy for cells and organs. This in turn causes a buildup of carbon dioxide, which is poisonous if not expelled. The ventilator allows this exchange to occur with little or no help from the lungs. T’andre has severe persistent asthma, which is often characterized by symptoms throughout the day and frequent nighttime awakening. He takes daily medicine and uses a rescue inhaler when needed. Sometimes that’s often, Elliott said, because he’s quite an active kid, 16 Be Healthy | Fall 2017
T’andre Cephus Harris, 6, (left) and his mother, Sherika Elliott.
She knows his triggers. “He has a small reaction to cigarette smoke,” she explained, “and major reactions to moisture, humidity and cool air.” In the winter he wears a ski mask to help warm the air before it reaches his lungs. His asthma is tricky, Elliott explained. The doctors had to research his condition to properly diagnose and treat him. “He was so little; they couldn’t understand why he was so sick.” He is being followed by an allergist, a pulmonary specialist as well as his regular pediatrician at Boston Children’s Hospital. T’andre is repeating kindergarten because he missed about a month of school last year. Elliott said she relies on the school nurses to make sure he takes his medicine during the school day. All in all, Elliott is not complaining. She said that she has seen improvement in her son’s condition over the years. He used to be hospitalized every two months, then every three to four months. Now the time between admissions is six
months. Also, if she recognizes the symptoms early he responds to his medicine more quickly. In spite of all he’s been through in six short years, T’andre seems to be taking his condition in stride. “He is like no other,” Elliott said. “He is an old soul.” She describes him as a caring, active and silly kid. She recognizes that being constantly on guard has made her life difficult, but she takes it day by day. She relies on the words of her father who advised her that ‘there is someone whose situation is worse than yours.’ She has a consolation. “My son is still here,” she said. “He is happy. Asthma is not affecting him.” Elliott hopes to develop a foundation to help bring asthma to the forefront and provide a source of information for parents going through the same ordeal. Regardless of what happens with the foundation, she will keep fighting. “If you give up, you’re giving up on your child,” she explained.
PHOTO: KATHERINE C. COHEN/BOSTON CHILDREN'S HOSPITAL
IF YOU WANT TO KNOW ANYTHING ABOUT ASTHMA, JUST ASK SHERIKA ELLIOTT. She’s
FOCUS: Patient story
Mold: A most unwelcome intruder The aftermath of the 2014-15 Boston winter MARY WHITE IS NOT ONE TO TAKE THINGS LYING DOWN.
PHOTO: COURTESY BOSTON PUBLIC HEALTH COMMISSION
Especially when it comes to her children. All three have asthma. Years ago they were forced to leave their apartment because of unrelenting triggers that caused multiple flare-ups in her sons. Now, White’s new house was acting up. That terrible winter of 2014-2015 that dumped 110.6 inches of snow in Boston caused roof damage, which resulted in moisture and mold — a trigger in all three sons. “We were back and forth to the emergency room,” she said. It was mold that drove them out before, but not this time. White was referred to the Breathe Easy at Home program, a department within Boston Inspectional Services Department. The program is a joint effort among several players: patients, clinicians, landlords and inspectors from the program. If clinicians suspect something in the home is contributing to multiple flare-ups, emergency department visits or hospitalizations, they can request an appointment. The inspectors look for violations of the state sanitary code for housing. Their targets in particular are moisture, mold, cockroaches and mice, all of which can trigger asthma attacks. The repairs to White’s ceilings were made in two months, but mice posed another temporary setback. That is not unusual. A study found that 82 percent of homes in the United States — regardless of their location — had mouse allergens, which can cause asthma symptoms. The inspector checked all the spots that mice tend to favor
which is favored by the U.S. Environmental Protection Agency, emphasizes prevention techniques and use of cleaners less detrimental to humans and the environment. Rather than sprays and poisons she used copper mesh to seal cracks and holes and door sweeps to block entry under doors. She stores sponges in plastic containers and is quick to clean up crumbs and spills. “Small amounts of water and a crumb are a feast [for a mouse],“ she said. Baking soda and lemon juice to clean counters and stoves have replaced caustic cleaners. The inspection is over but the lessons learned are not. White ticks off a number
Raoul Jacques (left) from the Breathe Easy at Home program discusses the results of a home inspection with Mary White.
GET IN TOUCH For more information: Call (617) 5342485 or email asthma@bphc.org
— behind the refrigerator, behind the stove and in all the cabinets. Mice enter homes through cracks and holes in walls, floors and foundation. Specialists in pest control warn that a hole the size of a dime is all that’s necessary for a mouse to enter. If the head fits the body easily follows. Although cats are nature’s mouse predator, that wasn’t an option for White because of allergies. Her family is allergic to pet dander, or dried flakes of skin that cats shed. She chose instead Integrated Pest Management, an environmentally friendly, common sense approach to controlling pests. IPM,
of tricks. “Keep the vent in the bathroom running a little longer after the shower,” she advised. “It helps absorb the moisture.” She runs the vent over her stove when cooking. Kitchen vents remove fumes, smoke, odors, heat and steam. Vents can remove triggers, but deposit them as well. She cleans them regularly to prevent dust buildup. She traded her carpets for bare floors. She doesn’t use candles or air fresheners. Windows are closed when the pollen count is high. Smoking is not allowed. White, who is a Parent Asthma Leader, said she urges other families with asthma to take a room-by-room assessment to root out triggers. If you can’t do it alone, request an inspection by Inspectional Services, she advised. White is not shy about speaking up. “I listen,” she said. “And then I ask questions.” baystatebanner.com/news/be-healthy | Be Healthy 17
SPONSORED BY NEIGHBORHOOD HEALTH PLAN
Asthma Control Test
If your score is 19 or less, please see your doctor The Asthma Control Test™ was designed to help you and your health care provider determine if your asthma symptoms are well controlled. Take this test if you are 12 years or older. Simply add up the answers to determine your final score. 1.
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school, or home?
All of the time
1
Most of the time
2
Some of the time
3
A little of the time
4
None of the time
SCORE
5 An Asthma Action Plan outlines your daily treatment for the longterm and for handling worsening asthma, or attacks.
2. During the past 4 weeks, how often have you had shortness of breath? More than once a day
1
Once a day
2
3 to 6 times a week
3
Once or twice a week
4
Not at all
The Importance of an Asthma Action Plan
5
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4 or more nights a week
1
2 or 3 nights a week
2
Once a week
3
Once or twice a week
4
Not at all
5
If your child has asthma, make sure that their written Asthma Action Plan is up-to-date and on file at school or at their daycare center.
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 3 or more times per day
1
1 or 2 times a day
2
2 to 3 times a week
3
Once a week
4
Not at all
5
4
Completely controlled
5
5. How would you rate your asthma control during the past 4 weeks? Not controlled at all
1
Poorly controlled
2
Somewhat controlled
3
Well controlled
If your score is 19 or less, your asthma may not be under control. Talk to your doctor about an Asthma Action Plan.
TOTAL
Asthma Control Test™ (ACT™) © 2002, 2004 QualityMetric Incorporated. All rights reserved. ACT™ is a trademark of QualityMetric Incorporated. The Asthma Control Test is for people with asthma 12 years and older. *Recognized by the National Institutes of Health (NIH) in its 2007 asthma guidelines. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute.
Get the highest quality care Our mission is to promote the health and wellness of our members and to help ensure equitable, affordable health care for the diverse communities we serve. We encourage all people with asthma to seek the care and treatment they need to improve their asthma control and quality of life.
To learn more, visit nhp.org
18 Be Healthy | Fall 2017
Healthy Steps Eat right, stay active, live well
PHOTO: ISTOCKPHOTO.COM/JUPITER IMAGES
» Nutrition 20 » Exercise 22
Still can run
22
Although exercise is a trigger, it is still recommended for children with asthma. Healthy lifestyles are important for overall good health. baystatebanner.com/news/be-healthy | Be Healthy 19
HEALTHY STEPS: Nutrition
A healthy eating plan An integral part of asthma treatment FOR THE MOST PART THERE IS NO FOOD THAT’S TABOO FOR PEOPLE WITH ASTHMA. Just the plain old healthy eating regimen is recommended — fruits, veggies, whole grains and healthy fats. Keep a lid on the sodium and processed foods, and you should be okay. Healthy eating does not necessarily deter asthma attacks, but, especially when combined with regular physical activity, it does improve overall health.
There is one exception, though — sulfites. These are chemicals that are added to foods and drinks as a preservative. Sulfites are triggers for roughly five to 10 percent of people with asthma. The Food and Drug Administration has your back on this one. In 1986, after the incidence of several asthma attacks traced to sulfites, the agency prohibited the use of the chemicals in fresh fruits and vegetables. Fresh potatoes that have been cut for French fries and hash-browns are an exception, however. In addition, food labels must clearly list the presence of sulfites. You have to be careful, though. The label will not always list “sulfites.” It can go by other names, such as sulfur dioxide or potassium bisulfite. It is prudent to become familiar with the different monikers. Even better, look for foods that contain no preservatives. Several foods are high in sulfites. Alcoholic beverages, including beer and wine are high on the list. These beverages actually contain natural sulfites, but some manufacturers add sulfites to preserve freshness. Other examples are dried fruits, such as dried apricots, pickles, fresh and frozen shrimp, jams and jellies.
Vitamin D Vitamin D is considered to play a role in many health conditions, including cancer, heart disease and multiple sclerosis. Recent research has found that diets low in the vitamin may be a factor in controlling asthma flare-ups. In addition to the sun and supplements, Vitamin D can be found in some foods, such as salmon, sardines and egg yolks. The study published last year in the Cochrane Database of Systemic Reviews 20 Be Healthy | Fall 2017
found that people taking vitamin D averaged not only fewer attacks but also less severe attacks, thereby reducing the need for oral steroids and visits to the emergency department or hospitalization. The study suggests that intake of vitamin D should be considered as an adjunct to one’s regular medication for asthma.
The preservative sulfite might be listed under several different names: n Sodium sulfite n Sodium bisulfite n Sodium metabisulfite n Sulfur dioxide n Potassium bisulfite n Potassium metabisulfite
Obesity A higher body mass index, or BMI, is linked to several health conditions: diabetes, heart disease and many types of cancer. Obesity may have an association with asthma as well. A study in the American Journal of Epidemiology found that overweight and obese children had a higher risk of developing asthma and with more severe symptoms than children of normal weight. Another study by Kaiser Permanente found that obese adults with asthma are almost five times more likely to be hospitalized for asthma complications than adults with asthma who are not obese. Inflammation may be the common link. Obesity is associated with low grade chronic inflammation, while asthma is a chronic inflammatory disease. In addition, asthma and obesity share a few conditions. For instance, both groups of people are more likely to experience sleep apnea, in which breathing repeatedly stops and starts while sleeping. Obese individuals often complain of acid reflux, a digestive disorder, which can trigger asthma symptoms. The overall message is that what and how much you eat may be a factor in the control of asthma. You might want to rethink that second piece of cake, or even better — have an apple instead. Reviewed by Kathy Cunningham, M.Ed., R.D., L.D.N.
SAMPLE OF FOODS THAT MAY CONTAIN SULFITES n Alcoholic beverages, such as beer and wine n Condiments and relishes, such as pickles and olives n Fish and shellfish, such as shrimp, scallops n Jams and jellies n Snack foods, such as trail mixes, dried fruit snacks n Instant tea n French fries n Dried soup mixes n Gravies and sauces
PHOTO: THINKSTOCKPHOTOS.COM/PURESTOCK
Sulfites
WHAT’S IN A NAME?
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HEALTHY STEPS: Exercise
An unusual dichotomy Exercise can be both an asthma trigger and a treatment center, no barbells to hoist. After all, as many as 90 percent of all people who have asthma will experience symptoms during exercise, according to the Asthma and Allergy Foundation of America. For some, exercise may even be the most common cause of asthma symptoms. Yet, asthma has not sidelined several well-known athletes. Jackie Joyner-Kersee won six Olympic medals for track. Former Pittsburgh Steeler and Super Bowl champion, Jerome Bettis, was diagnosed with asthma at the age of 15. Greg Louganis, regarded as one of the best male divers in history, won five Olympic medals. During exercise the body demands more oxygen. In response you breathe more deeply and faster — and usually through the mouth. That’s what causes the problem. Normal breathing is through the nose, which moisturizes, cleans and warms the air before it reaches the throat and lungs. Mouth breathing on the other hand increases the intake of dry, cooler air, which triggers the airways to narrow, thus obstructing air flow. This condition is often called exercise-induced asthma, but is more accurately termed exercise-induced bronchoconstriction, according to the Mayo Clinic. Exercise induces the narrowing of airways, but is not a root cause of asthma. Symptoms of coughing, wheezing, shortness of breath and tightness in the chest may begin several minutes into exercise and can continue another 30 minutes or more after stopping exercise. In spite of these potential problems, exercise does not get a stay. Health professionals recommend it for overall good health and to improve the function of the heart and lungs. Studies have shown that exacerbations or flare-ups are less in people with asthma who are more active. 22 Be Healthy | Fall 2017
Dirk Bovell (center standing) heads Boston Children’s Hospital Boston Asthma Swim Program at DotHouse Health.
BANNER PHOTOS
YOU MIGHT THINK THAT PEOPLE WITH ASTHMA HAVE A LEGITIMATE EXEMPTION FROM EXERCISE. No gym class, no fitness
HEALTHY STEPS: Exercise Dirk Bovell instructs a student in the Boston Asthma Swim Program.
TIPS TO PREVENT A FLARE-UP DURING EXERCISE n Warm up before exercising and cool down afterwards n Start gradually n Wear a face mask or scarf when exercising in cold or dry weather. This warms the air you breathe. n Breathe through the nose instead of the mouth n Stay hydrated n Avoid strenuous exercise if you have a respiratory infection n Take medicine before exercise if recommended by your doctor
A recent study published in BMJ Open Respiratory Research found that adult study participants who engaged in the most amount of exercise — roughly 30 minutes most days of the week — were almost 2.5 times more likely to have their asthma under control compared to those who did not exercise at all. Certain physical activities are more likely to trigger symptoms. Cold-weather sports like ice hockey and skiing are examples. In addition, sports that require constant activity, such as soccer and long-distance running, are more prone to trigger an attack. On the other hand, activities, such as baseball and gymnastics, which are demanding only in spurts, tend to cause fewer problems. Walking, hiking and biking are good sports activities for those with asthma, according to the American Academy of Allergy Asthma & Immunology. Regardless of the activity chosen, there are measures one can take to prevent a flare-up. Stay hydrated; warm up before exercising and cool down afterwards; wear a face mask or scarf when exercising in cool, dry weather; breathe through the noise instead of the mouth. Most important is to take medications before exercise if recommended by your doctor.
Swimming Swimming is actually one of the best exercises recommended for those with
asthma. The wetness and warmth of the water can prevent the cascade of events leading to an attack. You don’t have to explain that to Dirk Bovell. He has asthma and learned to swim in elementary school. Although he admits that football was his first love, the weather was too cold for him, and caused him to resort to his asthma pump. Swimming, however, increased his lung capacity, he explained. As a youth he said he was discouraged from sports because of his asthma. It’s a good thing he didn’t listen. The water is Bovell’s domain. He is a certified lifeguard, a lifeguard instructor and an American Red Cross instructor. He is the aquatic coordinator and head swim coach at DotHouse Health in Dorchester. But on Saturdays, his second calling comes into play. Bovell is the program manager of the Boston Asthma Swim Program for Boston Children’s Hospital. Each session lasts for 10 weeks and can accommodate 15 kids between the ages of 8 and 12. The program has two parts. First is the classroom. Bovell teaches the students and their parents about asthma, its medications and triggers — all to help them understand the disease better. Then comes the fun part — finally getting into the pool. For some, however, initially it’s not that much fun. “They might have had a bad experience,” he explained,
ON THE WEB For more about the Asthma Swim Program, email: asthmaswimprogram @gmail.com
and are fearful of the water. “Emotion is a trigger. The brain can take you to the yellow zone,” he said, referring to a period of increased symptoms. The yellow zone is a warning that, without a remedy, the situation can become an emergency. Several of the participants use rescue inhalers before the class to prevent an attack. If they need help with their inhaler, Bovell can assist. He has had personal experience. The program has many successes. The kids learn to control their asthma; they overcome their fear and learn to swim. No one has ever suffered an attack while in the water. Some of the students excel in swimming to the point that they join the DotHouse Health Stingrays, a USA registered swim team in the New England Swimming LSC. Each Local Swimming Committee is a member of USA Swimming, which is charged with selecting the United States Olympic Swim team. Who knows? There might be another Greg Louganis in the making. The program’s success has one downside, though. “Now the problem is getting the kids out of the water,” Bovell said. baystatebanner.com/news/be-healthy | Be Healthy 23
ACTIVE STRONG INDEPENDENT Take control of your health at the Y. An active lifestyle can help reduce asthma symptoms, improve breathing and reduce stress.
From aqua fitness to Zumba, and yoga to personal training, the Y offers many programs and classes to help you enjoy a healthy lifestyle and prevent chronic disease. • Locations in your community • Convenient class times • Financial aid available to those who qualify • A place where everyone belongs
Visit ymcaboston.org/join to learn more.
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