Lani: Good afternoon and welcome to the IAQ Tools for Schools Technical Webinar Series. Today's presentation is entitled Managing Asthma in a School Environment. I am Lani Wheeler, a public health pediatrician interested in school based asthma management. Thank you for taking time out of your busy schedule to attend this exciting and interactive webinar. Today's webinar will introduce you to the fundamentals of managing asthma in the school environment. You'll learn best practices and cutting edge strategies to manage asthma in the school environment. You'll discover the wealth of resources offered by a network of experts in the Pediatric Environmental Health Specialty Units. Finally, you'll have an opportunity to have your questions answered by our asthma management experts, Dr. Geller and Dr. Rubin. Let's get started with a few polling questions. Is a healthy and safe indoor environment a priority in your school district? Please select the response that applies to you and then click the submit button. We'll give a few more seconds for your answers. About 75 percent of participants have voted. Let's close the polls. And here are our results: It looks like just over half of you have found that it is an important issue, but funding is a problem. Twenty-three percent feel that it is a top priority; that's great. Others are struggling with other priorities coming first. And a few of you are just beginning to look at this area. Let's look at another polling question. What is your experience with Pediatric Environmental Health Specialty Units? Let us know what your experience has been so we have a sense of what you know about these already. Select your answer and then click submit please. We are going to close the polls. It looks like this is something new to the vast majority of you all. That's great. That's not a problem at all. So, let's start now with a brief overview of Pediatric Environmental Health Specialty Units. They have experts in pediatrics, allergy immunology, neurological development, toxicology, environmental medicine, nursing and more. These units, known as PEHSUs, offer the following services: First community education and outreach that includes raising awareness about environmental conditions that may harm children and providing guidance on preventing exposures. They also provide training for health professionals, including conducting conferences, online education programs and case studies. Lastly, they provide consultation and referral, which includes interpreting diagnostic tests and evaluating toxic exposures. After learning more today about these units from our speakers, perhaps some of you will have more direct experience in the future. I have another polling question for you. What is your experience with the Indoor Air Quality Tools for Schools Program? Again, select you answer, then hit submit. Ok, we are going to close the polls. And here is your response: About a third of you are not familiar with Tools for Schools, so we'll give a little brief review. Another third have a little bit of knowledge. Twenty percent have used the Kit, but still want to learn more, and a small percentage of you are well experienced. Excellent. I want to take a few minutes to review how the Indoor Air Quality Tools for Schools Program got started, its elements and purpose, and how it helps schools manage their indoor environment. The program began in 1995 with the release of the IAQ Tools for Schools Action Kit. The Action Kit is an evolving resource that continues to be a strong foundational element of the program. It provides best practices, walk through checklists, industry guidelines, sample policies and sample IAQ management plans to help schools and school districts take immediate action to implement effective IAQ management programs. The IAQ Tools for Schools Program has been implemented successfully in tens of thousands of schools nationwide. EPA has learned what it takes to create IAQ programs that deliver the remarkable health and environmental results that schools seek. EPA organized that knowledge into a framework of proven solutions, The Framework for Effective School IAQ Management. The Framework provides a common language to describe the drivers of IAQ program success. It offers detailed guidance on the proven strategies, organizational approaches and leadership styles that are fundamental to program effectiveness and presents a clear vision of the pathway to school IAQ excellence. Its highly flexible and adaptable structure allows any school regardless of location, size, budget or condition to use the framework to launch, reinvigorate, and sustain an effective IAQ management program. By applying a cycle of continuous assessment, planning, action and evaluation, the Six Key Drivers work together to deliver effective school IAQ management programs. Here are the Six Key Drivers: organizing your program; communicating with everyone, all of the time; assessing your school IAQ environment and how occupants are doing continuously; planning your short- and long-term actions based on your assessments and other important factors; acting to solve and prevent IAQ problems and address structural, institutional, and behavioral issues; evaluating your results and the impact of your program for continuous improvement. The Six Technical Solutions define the most common issues that schools need to address to effectively manage IAQ risks. When addressing systematically and aggressively, an IAQ program that focuses on the Six Technical Solutions will deliver a healthier school environment. The Six Technical Solutions are: ensuring quality inspection and operation and maintenance of your HVAC system, active, aggressive control of mold and moisture, strong integrated pest management, effective consistence maintenance activities, smart low emitting low toxicity materials selection, and aggressive source control – for example, through anti-idling school bus policies. What does IAQ management have to do with asthma? Asthma and indoor air quality are closely linked. Environmental and indoor air pollutants that are common problems in homes and buildings such as mold, dust mites and cockroach allergens are also known asthma triggers. By managing IAQ, you are already taking an important first step to managing asthma in your school or district. If you are using the IAQ Tools for Schools Program you most likely have the infrastructure in place to address this critical need in a more aggressive, targeted and intentional way. That is what you are going to hear about today. Let's go to another polling question. Does your school currently have an asthma management program in place? Again, click on your selection and then hit the submit button. We are going ahead and closing the polls. It looks like a little over half of you are interested but haven't yet started an asthma management program. There will be lots of information for you. A few have just started. A number of you are looking for improvements and a few of you out there have some really strong programs already in place. Again, you are in the right place so that you will all be learning something more. Let me do one more polling question before I turn it over to our speakers. How confident do you feel in your ability to reduce environmental triggers in your school district or your school? Again, select your choice and then hit the submit button. Ok, let's go ahead and close the polls. Ok, I see a little over a third of you are not feeling very confident but are ready to learn. Another third feel fairly confident. Others of you are interested in learning more strategies. That's perfect because our experts will be giving you lots of information to improve your plan, skill and confidence.. It is my sincere pleasure to introduce our speakers today. Dr. Robert Geller assumed the role of PEHSU Director in August of 2005 after being a member of the PEHSU since its inception. He is a pediatrician and medical toxicologist. He is professor of pediatrics at Emory University School of Medicine. He received his undergraduate and medical degrees from Boston University and his pediatrics training at the Medical College of Virginia followed by clinical toxicology training at the University of Virginia. His clinical activities are focused on children's environmental health, toxicology and asthma care. Dr. Leslie Rubin is President and Founder of the Institute for the Study of Disadvantage and disability; is the visiting scholar at the department of pediatrics at the Morehouse School of Medicine and co- director of the Southeast Pediatric Environmental Health Specialty Unit. Dr. Rubin is originally from South Africa, where he trained in pediatrics and then came to the U.S. to specialize in neo-anthology and then developmental pediatrics. After serving at Case Western Reserve University and then the Children's Hospital in Boston and the Harvard Medical School, in July 1994, he moved to Atlanta, Georgia, initially as director of developmental pediatrics at Emory University and then subsequently as a member of the faculty at Morehouse School of Medicine. He currently devotes his time to the care of children who have developmental disabilities and on addressing children living in situations of social and economic disadvantage. We will be starting off today with Dr. Geller. Dr. Geller: Good afternoon and thank you all for spending time with us this afternoon. I'm really optimistic that we will be able to give you some useful information and in order to do that we're going to start with some basic information that some of you probably already know and that some of you may not know. I just want us all to start on the same foundation and then we will all move forward. Let's move to the first slide please. The first slide should be a disclaimer slide. We just wanted to tell you that neither of us has any specific economic difficulties or constraints that I should say and that we are in a position to talk because we have no financial relationships other than the fact that we co-edited a book on school environments. The next slide please. This is an outline of our presentation. First of all we'd like to discuss what is asthma. We'd like to next discuss some current regimens for asthma management as we see its state-of-the-art in the United States. We'd like to discuss the impact of the school environment on asthma. We'd like to talk about some suggested school roles for managing asthma exacerbations and then some suggested roles for managing chronic asthma at the school. And then we're going to talk on some situations that involve managing a child who has special considerations and some other factors that may be applying to the school environment. We will move on to the slide that has the definition of asthma. Asthma is a chronic inflammatory disorder principally of the small airways. By the word chronic we imply that it is a long standing disease that doesn't really go away but it does wax and wane in its severity. By definition, it has to be at least partially reversible on some or all occasions. If a disease is always at the same level of severity and never gets better or worse, that raises the question of if we are really dealing with asthma or if we are dealing with another illness. Next slide. We now have a slide in front of us that discusses the time course of asthma. Asthma is a bi-phasic disease. There is an early phase in which people typically tell us that they feel poorly. We have narrowing of the airway because of bronchospasm. The bronchi, the airways, go into spasm, and the muscles around them shrink and close down. Even if that resolves, we have a late phase that occurs six to 10 hours later or even longer that involves swelling of the airway and increased mucous present in the airway. Each of these, in turn, can cause problems with the situation, with the airflow. Our next slide addresses the goals of maintenance asthma therapy. Ideally what we want is for the patient to have minimal symptoms. Ideally, we would like to have no symptoms. I tell parents that I work with that our goal is for the parent to be in control of what the child does because they are parents, not because the child has asthma. And I would like to see, if we have optimal control, that they manage their children with asthma the same as their children without asthma as long as the child uses their medication. We also, as part of our maintenance goals, want to have minimal asthma attacks or 'asthma exacerbations,' which is the more current term; but my parents always talk about it as asthma attacks. Ideally, we want none of those but certainly we should have less than one a week. They should be mild and not require any medical intervention from a physician. Certainly, ‘no emergency visits' is our goal. We want to minimize the need for quick relief beta two bronchodilators, like Albuterol. We will be talking more about that in a minute. We want to have no limitations on exercise or activities. We want to have near-normal lung function, which we measure in the office in a number of different ways. The best way is probably spirometry. But that's not something that the school would be doing. That's something that a physician's office would be doing. And we obviously want to have no adverse effects from the medications we are using if possible. Our next slide talks about evaluating asthma. The first thing I usually do is ask the child “how are you feeling?” and “how is it going”? I ask them how often they wheeze, how often they get short of breath, how often they cough at night, and how often they have limitations on their activity. A physician, a nurse, another clinician or a respiratory therapist can do basic clinical assessments and get a pretty good feel on how things are going by listening for coughing, wheezing, decreased breath sounds and decreased air flow and looking to see if the child is having increased work of breathing. Increased work of breathing is simply measured by are they taking deeper breaths than normal? Are they breathing faster than normal? Are they having difficulty speaking in full sentences because they can't catch their breath? It's important to recognize that the severity of asthma may be unrecognized and underestimated by the child. I have had many children tell us that they are doing fine, and when you go to examine the child they are nowhere close to fine. The fact that the child tell you, the responsible adult, that they are doing just fine is something that you want to verify with your own observations. Our next slide goes back to talking about rescue therapy or reliever therapy which involves the use of bronchodilators. All of the bronchodilators that we are using in the United States now are classified as beta two agonists. The most commonly used one is referred to generically as Albuterol. Its most common brands are ProAir, Ventolin, and Proventil. There are other brands as well, and I am not trying to endorse any specific brand. comes under the name Xopenex and is principally available for use in a nebulizer. And then Maxair whose generic name is Pirbuterol. All of these work similarly, and all of these when used correctly will work equally well. There are fine difference in how they are delivered and fine differences in how much of the drug and how many adverse effects they may cause in a patient. Basically, they are going to work pretty much the same and they can be interchanged depending on what is available in a situation in which you don't have the child's normal drug. The beta two agonists should be used in all asthmatics if they are complaining of shortness of breath, or if they are starting to wheeze, or if they are complaining of chest tightness. In many patients we also recommend that they be used before exercise, so that we give the child more exercise tolerance and better ability to participate. Typically they require five-to--10 minutes to get a typical response and probably 15 minutes to get a maximum response. If we are using them in a preventive mode before exercise, we would like to use them about 15 minutes before P.E. class or before recess starts for example. Our next slide discusses controller therapy. Controller therapy introduces drugs whose intention is to stabilize the airway, reduce the baseline inflammation and reduce airway instability so that the air way doesn't respond as easily to whatever triggering agent or agents are present. Some patients are fine with only one controlling agent. Some need more than one. Some of these agents can be administered once daily, some require more often administration. Most of them are either once daily or twice daily used. There are a few that are still used more often. The role of the school in administering these, if they are once daily drugs, will be less than that of the role of the school with a drug that might possibly need to be given multiple times during the day. Most commonly, I'm on slide Control Therapy 2, most commonly inhaled corticosteroids are the usual first-line agent. Some brands include Flovent, Qvar, Azmacort, Pulmicort and several others. The national guidelines for the management of asthma call for us to be using these as the first line in most patients. In some patients, these are not adequate and those patients require other classes of drugs as well. The most common other drugs would include those patients who are on leukotriene receptor antagonists. The most commonly used drug in this class is Singulair. There are other drugs available in this class. This class works on targeting a different pathway in the body that leads to targeting the asthma symptoms. For some patients that pathway is very important and these drugs are very effective. For other patients that pathway is not important and these drugs contribute very little to their benefit. Some patients do well adding a long-acting bronchodilator to the inhaled corticosteroid. These are almost always administered in combination with the corticosteroid in a mixture with both drugs in the same container. The two most common products that are mixtures like this are Advair and Symbicort. When administering any inhaler, whether it is Albuterol, whether it is an inhaled corticosteroid, they all should be used with a metered dose inhaler spacer. A spacer improves drug delivery substantially by reducing the likelihood that the drug hits the back of the throat and simply bounces out again rather than being inhaled. Because the issue here is that children need to coordinate their inhalation from the spray with the time they press down the trigger in order to get drug delivery appropriately. When the child is poorly coordinated, they will obtain very little relief from the drug. The spacer avoids that problem by putting the drug into a suspension and then when the child does inhale, they pull the drug into the lung, thereby delivering much more drug. Spacers should be used all the time with all metered dose inhalers with only very rare exceptions. I'd estimate that only 5 percent of patients do well without a spacer. Next slide discusses the role of the Asthma Action Plan. The Asthma Action Plan is a document that should be complied frequently for each child describing their current regimen of care. The parent should have a copy of that and the school should have a copy of that. Different people and different places use different asthma action plans, but they all have similar information. The one demonstrated here is courtesy of Children's Health Care of Atlanta, our Health Care Center. In addition to the name of the child and the doctors contact number, there should be information regarding specific patient triggers included. There should be specific information about the drugs being used as controllers for that patient. There should be information about specific patient reliever medicine. Exactly what our intention is as to how they should use their Albuterol, at what dose, and how often. Many schools have forms of their own and those forms may contain similar information. I think it is a particular school's choice as to whether they want to force the use of their own form or if they want to use an Asthma Action Plan that is complete and comprehensive from the physicians managing the child's asthma, but at a minimum you should have that information. Next slide. Let's turn our attention now to factors that exacerbate asthma or things that make asthma worse. There are several classes of these agents; anyone could be a problem, and it varies from patient to patient – child-to-child; adult-to-adult. Some people are very sensitive to inhaled allergens, such as mold, or dust mites, or animal dander or pollen. Some pollens will be more problematic than others to a specific individual. Their sensitivity to these allergens may be contributing more or less to their asthma control at any given season or given day of the week. We also know many people are also sensitive to chemical irritants such as strong odors, strong cleanser odors contribute substantially. It's also important to remember that air pollutants function just that same as these chemical irritants and can be just as substantial a problem. Those of you in cities with high ozone levels --that ozone can be a problem. Ozone starts early in the morning and rises as traffic contributes more ozone. Ozone often peaks in the early afternoon and evening and then tapers off again before repeating the cycle for the next work day. Particulates, such as the emitted from automotive exhaust or power plants or other smoke emitting facilities often follow a different time pattern. They are often more flat during the day, but are often times more irritating to some people. Environmental factors such as heat or cold can be problematic to specific children. As can their ability to participate in exercise I'd like to summarize the school role in exacerbations with four R's. I know these aren't the four R's you usually talk about, but I want to offer you some different R's this time. Recognize. Respond. Reassess. Record. So let's move to the next slide that talks about school recognition. The next slide talks about school recognition. Teachers and others with child contact should be able to recognize shortness of breath, audible wheezing, and similar findings at the non-health professional level. I am not proposing here that we suddenly turn teachers or other staff members with child contact into nurses or doctors. That is not practical. What I am suggesting is that the basic recognition skills should be present so the child can be directed for further care or directed to use their medication if appropriate. Also, all staff should give credence to children reporting systems, unless you know this child consistently has shown to be not dependable. If in doubt, it's always better to let them use their Albuterol one more time than it is to tell them to just not worry about it and go away. Next slide. Response, once you recognize an issue then we want the child to use their bronchodilators they carry. In many states it is legally required that the child carry their own medication if the parent or the health professional requests that to happen. In many states, the child should be carrying their own medication unless there are specific reasons to not have them do that. That's all driven by good reason. That allows the child faster access to their medication rather than having to go somewhere, find somebody, find where there medication is, and the like. I strongly encourage all of you to consider how you can allow the child to carry their own medications and have access to them at all times. That doesn't relieve the need to provide supervision. Ideally a staff member who is trained to supervise medication use needs to be available at all times students are on the premises. In some states, licensing rules and standards and practices may require this to be a nurse, physician or respiratory therapist and other states may not require that they be present. I recognize that not every school has such a person available at all times. That doesn't replace having this as our goal to work for. It is further about the school response; if the symptoms appear severe they should use their Albuterol and someone should simultaneously call 911for EMS assistance. If the symptoms are not so severe and the patient makes a good recovery and seems to be back at their baseline, we need a recording of the fact that the medication was used, the circumstances that dictated the usage, and to keep that information in some appropriate place. Some people might have a separate health record for the child or some might have it in with the child's other records, but that is a school decision. It is important to have this information as you periodically meet with parents; you can share this information with parents. Parents may not realize their child is having a lot of trouble with their asthma in school. Being giving that information, they can take further action to address needs with physicians and address needs for control. We are now turning our attention to school reassessment and the question here is after the child user their medication has the child returned to their asymptomatic state? If they remain symptomatic after about 15 minutes, I think you can give a second dose of the reliever drug and reassess again after 10 minutes. If the child has not returned to asymptomatic after two doses of their reliever they need to be taken for medical care. You then have the decision as to if you are going to call the parent or call the EMS unit to take them to the emergency department. That will likely be driven by local constraints such as if the parent can be reached and if the child is in severe distress or not in severe distress. The next slide talks about recording. It is important to record the information of what you did and why you did it. It is important to use this information to advise the parents and to advise your individual educational plan for this student if that is appropriate. This is also in case of the rare event in which someone challenges the school as to why they did a certain thing and you then have information to support the school's actions. Next slide. We are now on the school environment and how that plays into this question of asthma. The school environment is actually a much broader set of circumstances and things to consider than just the air quality in and around the school, even though we are talking a lot about the air quality in and about the school today. I'd urge you to consider the entire physical environment of the school and what toxic hazards might be in the school in terms of chemicals used and other products used in the school. School environment includes things such as food safety in the school, sports at school, and how students get to and from school. So the school role in chronic management of asthma includes trying to minimize triggers in the school environment. Some of you, perhaps most of you, might say “gee, how am I going to do that? I don't have much of a budget to do that, particularly in this current economy. How in the world am I going to do this?” I would like to point out that there are many things you can do here that cost either no money or almost no money. First of all think of humidity in the school. Your goal is to keep humidity in the range of 40 to 60 percent. If humidity rises above 60 percent, the conditions will favor mold growth and that is a potential problem for both students with asthma and other students in general. If you encounter plumbing leaks, it doesn't make any sense to wait to fix them, you are going to have to fix them anyway, and they can contribute to humidity and mold overgrowth. As the school chooses what cleansers are going to be used to keep the facility clean, what paints and markers are going to be used on the white boards, in art class, in shop class, in theatre class and the like, choose those that emit less fumes and are substances that emit less odor. Activities that involve using strong cleaners such as waxing floors, stripping floors, and using other compound that produce strong odors can be scheduled for use after students and staff leave for the day or on weekends or school holidays. Remember that areas that are under renovation have many, many triggers present. Areas that are under renovation should have restricted access so that students and staff are entering them only when absolutely necessary and they should not be sharing a stairwell with people painting the railings and otherwise emitting fumes and compounds. Some other triggers you may have not considered include the vehicles. Vehicle exhaust fumes are not good for children or the adults either, frankly. Allowing the carpool line to sit next to the entry to the school and having the vehicles idling there is clearly putting bad exhaust fumes into what should be a good air zone. We want to keep vehicles away from the site at which the children will be exiting and entering and we want to avoid idling. Many schools are implementing anti-idling policies and if yours is not one of them, I would strongly encourage you to considering this policy. Also, remember the school bus. There is a substantial body of data that suggests that school buses often have very bad air quality inside of the school bus when it is in operation. As a consequence, those children who have asthma and who have irritable airways have more difficulty on the school bus. Part of this issue can be solved by good maintenance of the school bus, but for those buses that are older, diesel retrofitting is an effective and cost-effective solution to reducing substantially how much air pollutant is emitted by that diesel. It is much cheaper than buying a new bus and it often has federal subsidies available. The school district itself may not need to lay out lots of cash to accomplish this. In thinking further about the schools role in management of chronic asthma, I would like to talk about scheduling outdoor activities at this point. Outdoor activities would be best scheduled on days with good air quality. On days with bad air quality, they should be scheduled at the times in which air quality is better. Given that this data is often available early in the day, you can check the air quality monitoring data and predication for that day. This is generally available either through sources on the internet or other similar sources. If you know this is a bad time for air quality, a bad season for air quality I should say, and you know that typically ozone and other pollutants are going to be peaking later in the day, then it is appropriate to use late afternoon practice times for indoor activities because usually ozone is much lower inside a building than outside a building. If you are in a particularly bad air quality circumstance, then you may wish to entirely reschedule outdoor activities for a different day. We talked about this before, but I am going back to it to emphasize this, I think it is important to allow the child to carry their own medication as appropriate to their age, development and level of responsibility. I think that is part of the school's role in chronic management, to not only allow them to carry it in the school, but to encourage the parents to have the child carrying it as well. It is appropriate to work with the parents about asthma control so the parents are aware of the frequency of symptoms, because frequency of symptoms means frequency of control plan failure. If the control plan is failing, then the parents need to work with the physicians to obtain a better plan. Also, It is appropriate that when the physician wants to work with the school, that this is a natural partnership that should be encouraged, but unfortunately all too often that partnership never matures into a workable relationship. Steps you can take in that direction would be very helpful. Next slide. One of the problems that I've often encountered and tried to figure out is what is the school's role in administering medications? Not to medications that treat an exacerbation, but the routine medications. In some schools, for some patients, it may be appropriate for the school to be doing that. I think it depends on the school's ability to do it and the family's ability to do it on their own. If the school is going to be doing this, the parent needs to be involved. Where special equipment such as a nebulizer is involved, or a spacer is required, the parent has to make sure that the equipment is available at the school. I think most parents should be responsible for their child's medication and not relying on the school to do that. There are some children for whom this will make a major difference in their asthma control because the unreliable parent will be relived of this responsibility in favor of the school which will be much more reliable. We are going to stop here and try to try and answer some questions. Michele: We have quite a few questions. The first one is: At what age is it appropriate to be using a spacer? Dr Geller: That is a very good question, the spacer with a facemask, which goes under multiple trade names, but it has a facemask, often called an aero chamber with facemask or an aero chamber plus, but there are other brands. Don't stick to my endorsement or lack of endorsement, there are other brands. These can typically be used in children six months of age or older, sometimes younger. When a child gets to be older, usually around six or seven years of age, you can switch to a mouthpiece based spacer, which would not require covering the nose and face. But usually all ages above six months, I would feel very comfortable using a spacer. Michele: Another question is about a highschooler using a spacer – is there an age at which they would outgrow the need for a space? Dr. Geller: The best answer I can give you is this: about 90 percent of adults use metered inhalers incorrectly without a spacer. I'm going to assume adolescents won't be much better about using inhalers than adults. We encourage them for all patients, unless the specific patient has specifically shown to not need a spacer. In my practice I only have a handful of those out of the several hundred patients we see. Michele: Just so everyone knows, this is just a mid-presentation break for questions in-between speakers. Our next question is about the use of rescue inhalers and rescue inhalers; so it is a two-part question. Can the person have a rescue inhaler and a controller medication at the same time? The second part is it possible to overuse your rescue inhaler? Dr. Geller: The first question is, the rescue inhaler and the controller medication are used for different purposes. People who are using controllers always need to have a rescue inhaler as well. Normally, the controller drug can stay at home if the school is not giving it. The only thing they are carrying typically is the rescue inhaler. In terms of can people over use the rescue inhaler? Absolutely. If they get more than the number of doses called for in their action plan – which is typically two doses of whatever their action plan calls for – they need to get further care because they need more management than you are going to give them in a school setting, unless you have a medical care facility based within a school setting. Typically I would vote for two uses of the inhalers and then seeking further care. Tracey: As a follow-up to that, there was a question about using the inhaler everyday and if it is acceptable to use a rescue inhaler everyday at school. I'll let you answer, but my thought is this may be someone using it before PE class. Dr. Geller: This is exactly the distinction we want to make. Someone is using the rescue inhaler on a scheduled basis before P.E. class that may be part of their daily management plan. This is true for many patients. On the other hand, if they are using it frequently to control symptoms because they are out of control, they are short of breath, they are wheezing, they are unable to talk – and then that is inappropriate and requires some refinement of their Asthma Action Plan on a chronic basis because they are inadequately controlled. It all depends on the circumstance and the reason why they are doing that. Michele: Thank you for that clarification. We have one last question – in your presentation you listed several asthma triggers, and we had several questions about the asthma triggers. For example, we had a question about temperature and secondhand smoke. What is your recommendation on identifying and addressing specific asthma triggers? Dr. Geller: That's an interesting question, and it really comes down to different people having different triggers. We know that certain triggers are very common. We know that secondhand smoke is going to be a trigger for most people with asthma. Some people respond to certain pollens, some people respond to others. Some people have difficulty when they become very upset, for other people their emotions are not really playing a role in exacerbating their asthma. I think the pediatrician, the asthma specialist, the parent, the child ought to work together to identify those triggers but in a general school setting where you are dealing with all of the children I think you've got to try to control the ones that are causing the most problems as much as possible. Since that may be different for different kids, it may become difficult to prioritize. My suggestion is to tackle the ones that you can reasonably control. You can change what cleaning products are used. You can change when they are used. You can control humidity to some extent, but in an older school building the heating and ventilation system just may not be up to that task. In that case you do as much as you can until the time at which you can actually renovate the school. That may be something you're going to have to do a little less well on. While I'm thinking of it, let me mention something that I didn't put in the presentation. Many teachers, or custodial staff, or other people mean well, but they go and use chemicals that contain fragrances that try to mask odors, or they use small room based air filters and neither of these strategies is very successful in actually reducing the irritant load presented to the lung. If you are going to do filtration, you need to do it in a much larger and more effective manner than a desktop air purifying or a chemical that you can spray in the room. It may reduce the nasty odor, but it's not really reducing the irritant load to the lung. So, just throwing that out there. Michele: Great. Thank you very much. I'm going to make two quick announcements and then we are going to continue on with our presentation. The first is that the slides will be available following the presentation. You will receive an e-mail with the slides and the slides will also be available with the combination with the audio on our website in a few weeks. We will also provide a question and answer document from all of the wonderful questions that you submit. We are sorry we won't be able to get to all of them, but we will try our best to get to a few more at the end of the webinar. We may not get to all, but we will try to answer as many of them in a document that will be available on the website in a few weeks following the webinar. With that, we will continue on. Dr. Geller thank you so much for a fantastic presentation. I'm going to turn it over to Dr. Lani Wheeler. Lani: Thanks, Michele. We are moving on now to the part of our presentation from Dr. Rubin. Dr. Rubin? Dr. Rubin: Hello, everyone. I know you don't have to say hello to me, but I say hello to you – all of you out there in cyberspace. Thank you for this opportunity. What I'm going to tell you about, as you'll see on your screen, are children who are representative of unique populations --A different populations. They are those children who have developmental disabilities or other kinds of disabilities, either physical or behavioral. And there are those children who grow up in circumstances of social and economic disadvantage. I will first tell you about children with cerebral palsy. cerebral palsy is defined by the children having difficulty with movement or posture that affects their ability to function. Sometimes the child has a motor disability and difficulty with walking, writing or a more complicated picture like orthopedic problems or seizure disorders for which they need to be on medication. Some children have feeding difficulties, and some children have respirator y difficulties. Often the more complicated the children are, the more likely they are to have multiple doctors. For example, there will be the doctor dealing with the muscles and the bones and the joints – that's the orthopedic doctor. There are the doctors who deal with the seizure disorders, usually neurologists. When children have a seizure disorder they may very likely require medication. These medications may make them drowsy or give them other side effects, but they are given to prevent seizures, but like any medication there is the potential for a side effect. Probably most significant on a day-to-day classroom basis is not so much the seizure disorder, which happens periodically, it's the children who have feeding difficulties. Children may have feeding difficulties in chewing or they may have difficulty in swallowing. The difficulty in swallowing is the part that we need to address in the context of respiratory problems, or lung disease, or even asthma. What happens when children have feeding difficulties and they don't swallow as well as they should, they may aspirate. Aspirate means that some of the food, and it may be a very small amount either liquid or solid, is that it may go into the lungs and if it does that it can either cause some problems with the airways of the lungs and in which case it may present as an asthma. Many children who have feeding difficulties due to cerebral palsy may also have a diagnosis of asthma and may be on the same medications as other children who are otherwise quite typical who have asthma can have. They will be using Flovent and the all the other medications that Dr. Geller has told you about. And just as the other children as sensitive to the air and the environment, the indoor air, these children are even more sensitive. They are more sensitive as their lungs are a little more “ticklish”. When you tickle someone who is very ticklish and therefore more likely to react and respond, the lungs of children with cerebral palsy who have had problems with aspiration may be more ticklish so the slightest irritant may cause a significant problem with breathing. I bring this particular set of children's cases to you so that when do you see children with cerebral palsy you'll be aware that they may have multiple complex medical problems, such as orthopedic problems, seizures, feeding difficulties and respiratory problem. They will have multiple doctors. They will have multiple medications often for their breathing, for their feeding, and for their seizures. They will often require many doctor visits and they may not be in school as regularly as other children. If they are ill they may be out of school, and they also require hospitalization or surgery. This particular group of children are probably physically the most involved group that we'll see. Because of this complexity it will interfere with their overall health and their day-to-day life and well being. The next group of children I want to discuss with you are children with autism. I hope that those of you who are listening know that when I say autism in this particular context, I'm talking about a condition that we call the autism spectrum. Some children may have classic autism where they will not speak, they will not relate, they will not interact, they may engage in repetitive self-stimulating behaviors, and they may also have dramatic emotional reactions and responses where they might have tantrums. They might hurt themselves. They might hurt others. They might break furniture. And all the way across the spectrum to children who have Asperger's Syndrome. For those of you who don't know, children with Asperger's Syndrome tend to be very bright children and these children do have some difficulties, some sensitivities that may interfere with their ability to learn, with their ability to interact and relate to other children. One of the difficulties is that they are not able to express their emotions very well. They might be able to tell you what's going on, they might be very bright academically, but they have difficulty expressing their emotions and their feelings. On the one end of the spectrum we have the condition called autism, at the other end of the spectrum we have the condition which we call Asperger's Syndrome, and in the middle between the two is a condition we call Pervasive Developmental Disorder, or PDD - sometimes called PDD NOS – which is Pervasive Development Disorder Not Otherwise Specified. That means it's not autism, it's not Asperger's Syndrome, but it's somewhere in the middle. These children may have some of the characteristics of classis autism, or at the other end of PDD they may look more like they have Asperger's Syndrome. These children are very sensitive to the environment – not only the air in the environment, but the ambience including sounds, noise and light. They are very sensitive to noise and may be very bothered by noise to the point that it may be a trigger for them to cause them to have tantrums. As I say in point number four, if they do have any disturbances like sound, noise, changes in teachers, a new schedule, or the fire alarm, they may overreact or react dramatically and they may have these tantrums and hurt themselves, hurt others or break some furniture. We need to be very cognizant and very careful with children on the autism spectrum. They need to have a lot of structure, a lot of predictability, and they respond much better to calm, quiet comfort. If they are having tantrums its best to speak with them calmly, remove them from their environment and put them in a place where they can feel a little more relaxed and calm down. Some children are on medication, and some children may have asthma, and they may have a reaction they may not be able to tell you about. You, as teachers or anybody taking care of children who are on the autism spectrum, need to know what kind of conditions these children have and how can I best ensure that this child does not have any complications or any problems. Next slide. Michele: Dr. Rubin, this is fantastic information. I just wanted to give you to give you a time check. It is about 2:15, and we are looking to finish up around 2:30. Dr. Rubin: Alright. Good. I think we can do it. The next slide shows you obesity, and I think many of you have seen in newspapers, listened to the radio, watched TV, the crisis of obesity in this country is a very big one and if you just have a look at the bottom of this slide you'll see that 16.9 percent of children ages 2-19 are described as obese. That's about three times what it was about 30 years ago. The rate of obesity has dramatically increased. Children with obesity have a lot of medical complications. What's of concern is that they tend to have high blood pressure and diabetes, which is a big problem as they get older. They also are much more likely to have asthma. Children who are overweight and have asthma are less likely to be active. They are more likely to be sedentary, they are more likely to eat, and the eating and inactivity result in a vicious cycle of gaining weight without losing weight. Some of these children can be very, very big. The other problem with breathing is that during the night they may have some problems with what's called sleep apnea. It interferes with the pattern of sleep and if they don't have enough good sleep during the night because of obstructive sleep apnea, they are more likely to be sleepy in the classroom which will interfere with their learning and will interfere with their participating with other children. This is very likely to have social and emotional consequences and can affect their education. Education is critical to their developing their skills which will enable them to get good jobs after school, to earn a good living, and to live where they want to. This is a very big problem with children, and if you saw the last slide, 16 percent are described as obese with 30 percent described as being overweight. I see we can go back, so let's go forward. These are two photographs I took. The first with the Cokes, Fruitopias and snacks was at a high school. If you think about what's causing obesity, it's the foods that the kids eat. The foods and the environment. Coca Cola has a tremendous amount of sugar in it. Fruitopia gives you the illusion that you are drinking fruit, but you are drinking a lot of sugar. The snacks are high in fat, high in sugar, and high in salt. This article from the newspaper “Fast food profits tempt schools.” So many schools to save on developing food programs and food for cafeterias are relying on fast food companies such as McDonald's and Burger King to provide the food for the kids. It's very tasty and the kids eat it. Why is it tasty? It's got a lot of sugar, a lot of fat, and a lot of salt. All are things that help us enjoy our foods. We've got to be careful about all of these foods in school, particularly to prevent obesity. I also wanted to talk to you, and this is the last section I will discuss, about social and economic circumstances under which children live. These are children who will be coming to school but may live in dilapidated situations like houses that are in the state of disrepair. They could be living in complicated, big urban situations that could be regarding as slums, living close to each other in stressed circumstances. Or, on the bottom left, they could be living in a single family house in the suburbs with a nice green around it and going to a very nice school where kids wear uniforms and their school is well kept. Now, what‘s the difference is that children who live in poor environments particular when the school is in a state of disrepair, on the left hand side of the screen, is that kids need some school lunch, go to schools, on the right hand side of the screen, that are much more likely to be in need of repair and renovation. The school conditions are much poorer. If you go back to Dr. Geller's presentation, where he spoke about mold and indoor air control, you can tell that schools that are in a less good state of repair, they are more likely to be triggers for asthma, such as allergies, mold and problems with the air. Next slide please. This slide shows the prevalence of asthma compared to household income. Along the left you will see the income of poorer people, $0 to less than $20,000 a year, versus greater than $70,000 on the right, and the height of those columns reflects the prevalence of asthma. Looking at it you can see that the poorer families are much more likely to have a prevalence of asthma versus those families who are more well off. In fact, they are almost twice as likely to have asthma. Asthma is not just a condition where kids have some problems with indoor air or they have some respiratory disease, but those children who grow up in poorer environments are much more likely to have asthma and go to schools where the triggers are greater. Not only are children who are poor more likely to have asthma and go to schools that are more likely to have environments that trigger asthma, or not be as safe and secure, but if you look at these columns, the difference between children who are poor versus children who are not poor is quite dramatic. Children who are poor are much more likely to have developmental delays, learning disability, and twice as likely to be retained in their grade. They are twice as likely to be expelled or suspended from school. More than twice as likely to dropout and to not be employed once they leave school. Can I have the next slide please? When we take this whole picture into consideration we say that children, if you look on the right hand side of the screen, children who live in older houses where there are adverse environmental factors, increased social factors, with increased toxins and stresses, are much more likely to have health and emotional problems. The health problems are asthma and allergies and also obesity and hypertension because there are many more fast food places in the lower income neighborhoods than there are in the more affluent neighborhoods. They are also more likely to be depressed, to engage in substance abuse and violence. They are more likely to drop out of school. In addition to their environment, if you go about 10 o'clock, they have limited educational services, limited health care services, and limited social capital. Therefore if they have limited education, if you have limited employment, limited income, you have limited options as to where you can live and you have to live in the poorer areas. We developed a project called Break the Cycle. Break The Cycle invites students in different universities to develop projects that allow them to break the cycle. We have concluded one such project this past week. One student from the School of Social Work at Clark Atlanta University looked at the social and economic disadvantages and health. Next one please. A student from Duke University Center for Environmental Health looked at the impact of the built environment on birth weight. Next one please. A student from the School of Public Health at the University of Florida looked at toxic waste sites and mercury exposure. Next one please. A student from the Georgia State University in the School of Law looked at laws and the built environment. By the way, the built environment is the area we live in including buildings, roads, store, restaurants and things. A student from the University of North Carolina looked at healthy homes and lead in homes. . Students from Mercer University School of Health looked at environmental factors and obesity, particularly pesticides. A medical student from the George Washington University in Washington D.C., looked at second hand smoke as effecting particularly children with asthma and brought to our attention the concept of third hand smoke. If you aren't familiar with that it's the smell of smoke on someone's clothing that can trigger asthma. And the last slide; a student from the School of Architecture at the Georgia Institute of Technology looked at improving education and improving the quality of schools through a program called KIPP. KIPP is Knowledge Is Power Programs. I would urge you to look up the KIPP Schools on the internet. It's a program that was started in Texas. These are programs that improve the school's environment to ensure the kids are healthier and learn better. And if you do the next slide, you there is will be an opportunity to ask questions, but we wanted to say that this work was supported by Pediatric Environmental Health Specialty Units, of which there are 12 in the country. If you look on the map you will see which one will be the one that will serve your community. Thank you very much. Dr Geller: I think we will have questions in a moment. I just wanted to point out that schools, just like we learned in the survey at the beginning, that there's a lot of variation between the various participants and where the stand now. There is a lot of difference between our schools nationally, this is a CDC survey from just a few years ago showing that there's a wide range of how schools are handling asthma, what services they have available, whether they had asthma action plans, and if they had teachers who had received staff development. I think there is a lot of opportunity to improve all of these numbers. As we look at what are we going to do about this and what can we do about this as a group, I'd encourage you to solicit input and communication all the time with everybody, I think that's a key piece. The EPA Tools for Schools Kits that we talked about earlier can help identify and address indoor air quality and environmental issues. I think that after having this session and having dialogue with your various constituencies, the parents, the students, the staff and the like, hopefully you'll be able to take a fresh look at the issues in your school that affect you. When we were putting this talk together we were asked, so what have you been doing? A lot of what we presenting to you today is a short version of what we had complied in our process of co-editing a book on safe and healthy school environments. We are trying to disseminate that information, we've created some video modules about the school environment that each of you that you can use. They are available on the internet for free for non-commercial use. They are aimed at lay audiences, they are not technical. They are at least a starting point to start a dialogue. There is an overview video. There is one specifically about indoor air quality. There is one specifically about playgrounds. There is one about sports environments itself, one about nutrition at schools, and one about emergency preparedness. There are others as well that I have not given you pictures of. At this point I think we can open the floor for questions for either of us. We have put up our specific PEHSU's phone numbers. We also have some websites that you can copy down the addresses. I'd like to ask our people to leave this slide up while we take questions. Michele: Great, thank you so much Dr Rubin and Dr Geller for this wonderful presentation. We're going to take a few questions and then close out with resources. A question we will go forward with is, once obesity is reduced or your child's weight is back to a normal weight, does their asthma go away, or does it improve? Dr. Geller: That's a great question. Remember that obesity makes asthma more difficult to control and typically makes it worse, the obesity is not necessarily the only reason they have irritable airways. You may have to control multiple factors. Typically, if you can make the obesity better, the body doesn't have to lift as much of a weight every time you take a breath and make the chest swell. Therefore that tends to make things better. Michele: And then our last question is, how can a local PESHU help with managing our disadvantaged children's asthma in school? What are some resources that they can go to for help? Dr. Rubin: I think the answer for that is quite complicated. In each region there are PEHSUs located in various cities who would very likely know the resources in the particular town and city where the school is. If that town or city where the school is can contact their local clinics, local pediatrics department, and public health centers I think that much can be done. I'll tell you also that often you might not find resources in your community to answer your questions. If that's the case, I'll urge those of you who are concerned citizens, whether you are teachers or nurses or social workers or parents to see what you can do or develop in your environment. You are welcome to contact us for help. What we showed you was a program called Break the Cycle, and even though it doesn't make a very big difference in the big part of the world, each project makes a small difference in a small area and each of those projects can grow. I think that when we think about doing something we think about doing it to its absolute conclusion and perfection, but in the end in life things don't always go to conclusion and perfection. My parting proverb for you is that even though each one of us may not be able to achieve the desired outcome of our initiatives and projects we are nevertheless compelled to take these projects because if we don't undertake them nobody else will. It is incumbent upon each one of us regardless of what our situation is to see what difference we can make for an individual in setting up a new kind of program for our community that will make a difference and in that way we can encourage and inspire the community participants who will then take that and make it bigger and better than we could ourselves. Lani: Thank you Dr. Rubin we'd like to leave you now with a few additional resources to help answer some of your questions. First is the IAQ Tools for Schools update e-mail newsletter. These bring the hot topics and best practices right to your inbox. To subscribe you can send an e-mail to this address with “subscribe” in the subject line. You can also join the Schools Connector Listserv. This listserv allows you to connect directly with your peers in the IAQ Tools for Schools national network to share information and resources and communicate by e-mail and on the web. You can join by sending a blank e-mail to schools_iaq_connector-subscribe@lists.epa.gov and you see that address on your screen. You're also invited to attend the National Asthma Forum next month from June 17th -18th in Washington D.C., where you can network with national asthma care experts and discover the latest strategies in building successful asthma control networks in your communities. This year's Forum contains several sessions discussing the strategies and tools needed to effectively provide asthma care in schools. You can also continue the conversation with peers and experts after the Forum on AsthmaCommunityNetwork.org, an online network that provides members access to tools and resources that facilitate problem solving, collaboration and knowledge sharing. We want to thank you again for your participation today and to remind you that this entire webinar as well as the answers to questions that we answered and those that were sent in and haven't yet been answered will be archived on the website, we believe we will have that address posted momentarily. It is under the IAQ Tools for Schools Webinar Resources link at the bottom. Michele, is there anything else before we sign off? Michele: No, that's it. Thank you so much everyone who attended. We will be e-mailing everyone the presentation and other materials. Please read through all of the questions and answers. You will find even more resources in there. Again, thank you again for your time and taking time out of your busy schedules to participate today. IAQ Tools for Schools Webinar Transcription – Managing Asthma in the School Environment May 27, 2010 1