environmental protection agency american association for respiratory care
TRANSCRIPT
EnvironmentalProtection Agency
American Association for
Respiratory Care
Asthma Definition - 1997National Asthma Education and Prevention Program - NAEPP
• A disease characterized by the following:A disease characterized by the following:
– Airway inflammationAirway inflammation
• mast cells,eosinophils, T lymphocytes, neutrophils mast cells,eosinophils, T lymphocytes, neutrophils and epithelial cellsand epithelial cells
– Increased airway responsiveness to a variety of Increased airway responsiveness to a variety of stimulistimuli
– Airway obstruction that is reversible (at least to Airway obstruction that is reversible (at least to a significant degree)a significant degree)
Asthma in the United States
• 17.3 million Americans with Asthma17.3 million Americans with Asthma
• 4.8 million children < 18 with Asthma4.8 million children < 18 with Asthma
• Asthma prevalenceAsthma prevalence
– 5.8% of Americans5.8% of Americans
• 75% increase since 198075% increase since 1980
– 6.8% of preschool children 6.8% of preschool children
• 160% increase since 1980160% increase since 1980
Trends in asthma prevalence (1982-1994)
345678
1982
1984
1986
1988
1990
1992
1994
Year
Pre
vale
nce
(%
)
Under 18All Ages
National Health Interview SurveyNational Health Interview Survey
Asthma Prevalence
1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 19920
1
2
3
4
5
6
7
8
Black
White
Pre
vale
nc
e (
%)
Year
Other
Prevalence of Asthma by Race Ages 5-34Prevalence of Asthma by Race Ages 5-34United States, 1982 - 1995United States, 1982 - 1995
Source: National Health Interview SurveySource: National Health Interview Survey
Race and Prevalence
Asthma Morbidity•Approximately 500,000 hospitalizationsApproximately 500,000 hospitalizations
•Approximately 1.9 million ER visitsApproximately 1.9 million ER visits
•10 million missed school days per year10 million missed school days per year
•Loss productivity is estimated at $1 billion Loss productivity is estimated at $1 billion per yearper year
82 83 84 85 86 87 88 89 90 91 920
100
200
300
400
500
600
Hospital Discharge Rates (per 100,000 Population) for Asthma asHospital Discharge Rates (per 100,000 Population) for Asthma as the First Listed Diagnosis, by Race, Age and Year, Age 5-34 Yearsthe First Listed Diagnosis, by Race, Age and Year, Age 5-34 Years
A-A (Age 5 through 14)
Rat
e
Year
A-A (Age 15 through 34)
Cauc. (Age 5 through 14)
Cauc. (Age 15 through 34)
National Hospital Discharge Survey - United States, 1982 - 1992National Hospital Discharge Survey - United States, 1982 - 1992
Morbidity
0
0.1
0.2
0.3
0.4
0.5
0.6
Year
Rat
e/10
0,00
0Asthma Mortality Rate Ages 5-34, Asthma Mortality Rate Ages 5-34,
United States, 1979-1995United States, 1979-1995
Asthma Mortality
0
2
4
6
8
10
12
14
16
18
1979 1981 1983 1985 1987 1989 1991 1993 1995
Year
rate
pe
r m
illi
on
po
pu
lati
on
African-AmericanAfrican-American
CaucasianCaucasian OtherOther
Asthma Annual Mortality Rates by: Race, Ages 5-34, U.S. 1979-1995
0 2 4 6 8 10 12 14 16
Estimated Costs in billions of dollars
1980
1985
1990
1995
2000
Yea
r
1980-1995 Costs of Asthma in the US Projection for the Year 2000
Costs
Smith D et al. AJRCCM 156:787-Smith D et al. AJRCCM 156:787-93,199793,1997
Direct Cost Estimates for Asthma
348(6.8)165(4.7)131(15.6)52(6.5)ED Visits
$ (col%) $ (col%) $ (col%) $ (col%)
5,1473,514(100)839(100)792(100)Total Direct
Cost
2,800(54.4)1,926(54.8)286(34.1)586(74.1)Admissions
1,182(23) 841(23.9)235(28)105(13.4)Ambulatory
Visits
81(15.9)581(16.5)187(22.3)48(6.1)Prescribed Medicines
Total> 175-170-4Cost
Component
Age in YearsAge in Years
Risk Factors for Asthma• Host - IntrinsicHost - Intrinsic
– genetic: atopy, IgE, BHRgenetic: atopy, IgE, BHR– gender, race, pre-, perinatalgender, race, pre-, perinatal
• EnvironmentalEnvironmental– allergens, diet, air pollution allergens, diet, air pollution – Environmental tobacco smoke (ETS)Environmental tobacco smoke (ETS)– infectionsinfections
Asthma Definition - 1997National Asthma Education and Prevention Program - NAEPP
• A disease characterized by the following:A disease characterized by the following:
– Airway inflammationAirway inflammation• mast cells,eosinophils, T lymphocytes, mast cells,eosinophils, T lymphocytes,
neutrophils and epithelial cellsneutrophils and epithelial cells
– Increased airway responsiveness to a variety Increased airway responsiveness to a variety of stimuliof stimuli
– Airway obstruction that is reversible (at Airway obstruction that is reversible (at least to a significant degree) least to a significant degree)
Expert Panel Report 2:Four Components of Asthma Management
• Measures of Assessment and MonitoringMeasures of Assessment and Monitoring
• Control of Factors Contributing to Control of Factors Contributing to Asthma SeverityAsthma Severity
• Pharmacologic TherapyPharmacologic Therapy
• Education for a Partnership in Asthma CareEducation for a Partnership in Asthma Care
• All of the common asthma triggers are All of the common asthma triggers are found indoorsfound indoors
• Americans spend about 90% time indoorsAmericans spend about 90% time indoors
• Reducing exposure to indoor allergens and Reducing exposure to indoor allergens and irritants can reduce asthma symptomsirritants can reduce asthma symptoms
• Prevention is an important asthma Prevention is an important asthma management toolmanagement tool
What does the Indoor Environment have to do with Asthma?
Indoor Environment in the U.S.
• 8 of 10 people are exposed to mites
• 6 of 10 people are exposed to cat or dog dander
• Clinical studies have demonstrated the prevalence of cockroaches in the inner city, schools and Southern U.S.
What is the Indoor Environment...
• Home EnvironmentHome Environment
– BedroomBedroom
– KitchenKitchen
– BathroomBathroom
– BasementBasement
– Living AreaLiving Area
Triggers Away fron the Home Environment…...
• SchoolSchool
• WorkplaceWorkplace
• Public areasPublic areas
• Second hand smokeSecond hand smoke
* 5 major indoor asthma triggers* 5 major indoor asthma triggers
Common Asthma Triggers• AllergensAllergens
– molds, dust mites, molds, dust mites, cockroaches, animal cockroaches, animal danderdander, pollens,, pollens, foodsfoods
• IrritantsIrritants– secondhand smokesecondhand smoke, ,
strong odors, aerosols, strong odors, aerosols, volatile organic volatile organic compounds, ozone, compounds, ozone, particulate matterparticulate matter
• OtherOther– Viral respiratory infectionsViral respiratory infections
– Changes in weather Changes in weather (cold air, wind, humidity)(cold air, wind, humidity)
– ExerciseExercise
– MedicationMedication
– Endocrine factors Endocrine factors (menstrual period, (menstrual period, pregnancy, thyroid pregnancy, thyroid disease)disease)
Frequency of Positive Skin Tests
38
36
31
24
19
0 5 10 15 20 25 30 35 40
Alternaria
Roach
Mite
Cat
Rat
% Positive Tests
Most Common Indoor Environmental Triggers
Secondhand SmokeSecondhand Smoke
Dust Mites Dust Mites
MoldMold
PetsPets
CockroachesCockroaches
Secondhand Smoke
• Contains more than 4,000 substances Contains more than 4,000 substances (over 40 are carcinogenic)(over 40 are carcinogenic)
• Is particularly harmful to young childrenIs particularly harmful to young children
• Can trigger asthma attacks and cause Can trigger asthma attacks and cause young children to develop asthmayoung children to develop asthma
Avoiding Secondhand SmokeChoose not to smoke in your Choose not to smoke in your
home or car and do not allow home or car and do not allow others to do so eitherothers to do so either
Tobacco Smoke
• Secondhand smoke is classified by the EPA Secondhand smoke is classified by the EPA as a known cause of lung canceras a known cause of lung cancer
• Is a serious asthma triggerIs a serious asthma trigger
• EPA estimates that between 200,000 - EPA estimates that between 200,000 - 1,000,000 asthmatic children are affected1,000,000 asthmatic children are affected
Smoking Interventions
• Stop smokingStop smoking
• Smoke outsideSmoke outside
• Enforce smoking bans on school propertyEnforce smoking bans on school property
• Enroll in a smoking cessation programEnroll in a smoking cessation program
• Get help from physicianGet help from physician
• Take the Smoke-Free PledgeTake the Smoke-Free Pledge
It’s Okay to Let People Know Smoking Around People with Asthma Is Not Cool
Remember Other Sources of Secondhand Smoke
Dust Mites
• Found in most homesFound in most homes
• Live in soft beddingLive in soft bedding
• Feed on skin flakesFeed on skin flakes
• Mites and mite Mites and mite droppings can be droppings can be asthma triggersasthma triggers
• Can cause children to Can cause children to develop asthmadevelop asthma
Dust Mites
• Evidence suggests that Evidence suggests that avoidance can effectively avoidance can effectively reduce allergic symptomsreduce allergic symptoms
• Dust mites feed on skin Dust mites feed on skin scales and organic scales and organic materials found in homesmaterials found in homes
• Need RH of 55% or moreNeed RH of 55% or more
NCICAS - Hospitalization, Allergy, Exposure
0
0.05
0.1
0.15
0.2
0.25
1. (-) low 2. (-) high 3. (+) low 4. (+) high
Rosenstreich et al. NEJM 1997; 336: 1556Rosenstreich et al. NEJM 1997; 336: 1556
p = 0.88p = 0.88
Dust Mites
Avoiding Dust Mite Triggers
• Wash sheets and Wash sheets and blankets once a week in blankets once a week in hot waterhot water
• Cover mattresses and Cover mattresses and pillows in dust-proof pillows in dust-proof (allergen-impermeable) (allergen-impermeable) zippered coverszippered covers
Avoiding Dust Mite Triggers
• Choose washable Choose washable stuffed toys, wash stuffed toys, wash them often in hot them often in hot water, and dry water, and dry thoroughly -- keep thoroughly -- keep stuffed toys off bedsstuffed toys off beds
– Freezing soft toys Freezing soft toys and small itemsand small items
Avoiding Dust Mite Triggers• Vacuum often (when Vacuum often (when
asthmatic is not present)asthmatic is not present)
• Maintain low indoor humidity, Maintain low indoor humidity, ideally between 30-50% ideally between 30-50%
• Replace carpets, draperies, Replace carpets, draperies, and upholsteryand upholstery
Pets• Skin flakes, urine, and Skin flakes, urine, and
saliva of warm blooded saliva of warm blooded animals can be asthma animals can be asthma triggerstriggers
• Triggers can remain in the Triggers can remain in the home for several months home for several months after a pet is removed, even after a pet is removed, even with cleaningwith cleaning
Warm Blooded Animals Includes….
• DogsDogs
• CatsCats
• BirdsBirds
• CowsCows
• HorsesHorses
• RodentsRodents
Pet Interventions• Consider keeping pets outdoors or even finding Consider keeping pets outdoors or even finding
a new home for your pets, if necessarya new home for your pets, if necessary
• Wash weeklyWash weekly
Pet Interventions
• Keep out of Keep out of bedroombedroom
• Restrict to one Restrict to one areaarea
Pet Interventions
• Remove carpetingRemove carpeting
• Vacuum carpetingVacuum carpeting
• Use high-efficiency Use high-efficiency air cleanersair cleaners
Avoiding Pet Triggers• Keep pets away Keep pets away
from fabric-covered from fabric-covered furniture, carpets, furniture, carpets, and stuffed toysand stuffed toys
• If you remove an If you remove an animal from the animal from the home, clean the home, clean the home thoroughlyhome thoroughly
Molds
• Molds grow on damp materialsMolds grow on damp materials
• Found in basements, bathrooms, kitchens, Found in basements, bathrooms, kitchens, outdoorsoutdoors
Molds• Can be found almost anywhere and can grow on Can be found almost anywhere and can grow on
virtually any damp substancevirtually any damp substance• Key to mold control is moisture controlKey to mold control is moisture control• Clean up the mold Clean up the mold andand get rid of excess water or get rid of excess water or
moisturemoisture• Reducing moisture also helps reduce other Reducing moisture also helps reduce other
triggers, such as dust mites and cockroachestriggers, such as dust mites and cockroaches
Mold Intervention
• Use dehumidifiersUse dehumidifiers
• Provide adequate Provide adequate
ventilationventilation
• Use exhaust fans when Use exhaust fans when
cookingcooking
• No carpeting over No carpeting over
cement flooringcement flooring
Mold Intervention• Vent showersVent showers
• Do allow standing Do allow standing
waterwater
• Frequent inspections Frequent inspections
for moldfor mold
Avoiding Mold Triggers• Wash mold off hard surfaces Wash mold off hard surfaces
and dry completelyand dry completely
• Absorbent materials (ceiling Absorbent materials (ceiling tiles and carpet) may need to tiles and carpet) may need to be replacedbe replaced
• Fix leaky plumbing or other Fix leaky plumbing or other sources of watersources of water
• Keep drip pans in your air Keep drip pans in your air conditioner, refrigerator, and conditioner, refrigerator, and dehumidifier clean and drydehumidifier clean and dry
• Use exhaust fans or open Use exhaust fans or open windows in kitchens and windows in kitchens and bathrooms when showering, bathrooms when showering, cooking, or using the cooking, or using the dishwasherdishwasher
• Vent clothes dryers to the Vent clothes dryers to the outsideoutside
• Maintain low indoor Maintain low indoor humidity (between 30-50% humidity (between 30-50% relative humidity)relative humidity)
Cockroaches• Require a water/food sourceRequire a water/food source
• Over 3500 different speciesOver 3500 different species
• An inner city problem (85% of homes with An inner city problem (85% of homes with
children)children)
• Inner city schools also a concern (Baltimore Inner city schools also a concern (Baltimore
69% of dust samples)69% of dust samples)
• Become airborne (similar to dust mites)Become airborne (similar to dust mites)
Cockroaches
• Droppings or body parts of Droppings or body parts of cockroaches can be asthma triggerscockroaches can be asthma triggers
• Cockroaches likely contribute Cockroaches likely contribute significantly to asthma problems in significantly to asthma problems in inner city areainner city area
• Free your home of places for pests to Free your home of places for pests to hide and sources of food and waterhide and sources of food and water
NCICAS - Asthma Morbidity - ED Visits
0
0.5
1
1.5
2
2.5
1. (-) low 2. (-) high 3. (+) low 4. (+) high
p < 0.001p < 0.001
CockroachCockroach
Rosenstreich et al. NEJM 1997; 336: 1556Rosenstreich et al. NEJM 1997; 336: 1556
NCICAS - Hospitalization, Allergy, Exposure
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
1. (-) low 2. (-) high 3. (+) low 4. (+) high
Rosenstreich et al. NEJM 1997; 336: 1556Rosenstreich et al. NEJM 1997; 336: 1556
p = 0.001p = 0.001
CockroachCockroach
Relations Among Skin Test and Morbidity
• Children with sensitization and high Children with sensitization and high exposure to cockroach have:exposure to cockroach have:– More symptomatic daysMore symptomatic days– More nights of lost sleepMore nights of lost sleep– More school days missedMore school days missed– More days of caregiver change in plansMore days of caregiver change in plans
Cockroach Intervention• Education that emphasizes:Education that emphasizes:
– Do not leave food or garbage Do not leave food or garbage out out
• Place trash outside Place trash outside
– Store food in airtight Store food in airtight containerscontainers
– Clean all food crumbs or Clean all food crumbs or spilled liquids right away spilled liquids right away
– Washing dishes dailyWashing dishes daily
– Seal off ports of entrySeal off ports of entry
– Remove standing waterRemove standing water
Cockroaches Eradication• Try using poison baits, boric acid,
or traps first before using pesticide sprays
• If sprays are used:
• Limit the spray to infested area
• Carefully follow instructions on the label
• Make sure there is plenty of fresh air when you spray, and keep the person with asthma out of the room
Allergen Exposure Sources• SchoolsSchools
– Cockroach allergenCockroach allergen• detectable in 69% of samples from 4 urban schools detectable in 69% of samples from 4 urban schools
(Sarpong, et al. JACI 1997; 99:486)(Sarpong, et al. JACI 1997; 99:486)
• elevated in mostelevated in most
– CatCat– Dust mite ??Dust mite ??
• Infestation/TransportedInfestation/Transported
Targeting the Indoor Environment...
• Home EnvironmentHome Environment
– BedroomBedroom
– KitchenKitchen
– BathroomBathroom
– BasementBasement
– Living AreaLiving Area
Bedroom
•Access to animalsAccess to animals
•Pillow and beddingPillow and bedding
•Stuffed animalsStuffed animals
•DustDust
Bathroom / Kitchen
• Moldy surfacesMoldy surfaces
• Standing garbageStanding garbage
• Food containers left Food containers left
unopenedunopened
• Venting of cooking Venting of cooking
fumes/vaporfumes/vapor
Living Area
• Sofa and upholstered Sofa and upholstered
chairschairs
• CarpetingCarpeting
• FireplaceFireplace
Basement
• Moldy surfacesMoldy surfaces
• Carpeting over Carpeting over
cement floorcement floor
• Filtering at furnaceFiltering at furnace
Outdoor Environment
• GrassesGrasses
• PollensPollens
• PollutionPollution
• Time of dayTime of day
• TemperatureTemperature
Respiratory Therapist Interventions
• Symptom assessmentSymptom assessment
• Asthma historyAsthma history
• Scoring of symptoms and triggersScoring of symptoms and triggers
• Environmental assessmentEnvironmental assessment
• Skill/knowledge assessmentSkill/knowledge assessment
• Patient focused educationPatient focused education
• Action planAction plan
Resources and InformationEnvironmental Protection Agency Asthma Website
www.epa.gov/iaq/asthma
EPA Indoor Air Quality Information Clearinghouse (800) 438-4318
Allergy and Asthma Network/Mothers of Asthmatics (800) 878-4403 www.aanma.org
American Academy of Allergy, Asthma and Immunology (800) 822-2762 www.aaaai.org
American Lung Association (800) LUNG-USA
www.lungusa.org
Asthma and Allergy Foundation of America (800) 7-ASTHMA www.aafa.org
American Association for Respiratory Care (972) 243-2272
www.aarc.org
REPORTS
Clearing the Air: Asthma and Indoor Air Exposures, National Academy of Sciences http://books.nap.edu/books/0309064961/html
Guidelines for the Diagnosis and Management of Asthma, 1997, National Asthma Education and Prevention Program
(301) 592-8573
Getting Others To Take Action
• Take the recommended actions, and encourage others to do Take the recommended actions, and encourage others to do
so tooso too
• Smoke-Free Home Pledge (800) 513-1157Smoke-Free Home Pledge (800) 513-1157
• Indoor Air Quality Tools For Schools (800) 438-4318Indoor Air Quality Tools For Schools (800) 438-4318
• Secondhand Smoke Community Action Kit (800) 438-4318Secondhand Smoke Community Action Kit (800) 438-4318
• ALA ALA Open AirwaysOpen Airways for schools (800) LUNG-USA for schools (800) LUNG-USA
• ALA ALA A is for AsthmaA is for Asthma in local Headstart or daycare center in local Headstart or daycare center
• AAFA Childcare trainingAAFA Childcare training
US Environmental
Protection Agency
Indoor Air Quality
Clearinghouse
www.epa.gov/asthma
800-438-4318
US Environmental
Protection Agency
Indoor Air Quality
Clearinghouse
www.epa.gov/asthma
800-438-4318
American Association For
Respiratory Care
www.aarc.org
972 243-2272
American Association For
Respiratory Care
www.aarc.org
972 243-2272