Chair-elect
Cheri Duncan, RRT
(214) 820-9792
cherid@baylorhealth.edu

I hope everyone is having a great summer and enjoying a vacation like no other! The Texas heat has our Pulmonary Rehabilitation Exercise Program back in the pool and cooling down! The patients really enjoy the water. Many have not been in a pool in a number of years. The first day is quite comical, but by the second day, everyone is a pro. It is always rewarding to see them having so much fun while they work so hard. The water program outcomes continue to show significant improvement in quality of life, physical exercise, and activities of daily living. If anyone is interested in finding out more information about a water exercise program for pulmonary patients, please e-mail me.

I recently attended the American Thoracic Society (ATS) meeting, where I found a number of interesting sessions to attend. Lung Volume Reduction Surgery (LVRS) proved to be one of the most interesting. The meeting room was filled with physicians and clinicians waiting to hear the outcome of the trial a year later and how Medicare is reimbursing for the surgery.

I have received a few calls asking how pulmonary rehab programs can bill for their services related to LVRS and how to perform the exercise testing. Our center, Baylor Asthma & Pulmonary Rehabilitation Center, was one of the National Emphysema Treatment Trial (NETT) rehabilitation satellite centers, and Baylor University Medical Center, Dallas, is approved to perform lung transplants and LVRS. We are in the process of setting up the pulmonary rehab process and charge codes.

It would be interesting to find out what others have been doing since LVRS was approved by Medicare. If you have information to share, please e-mail it to me prior to the next Bulletin copy deadline, which is September 10.

Another session that I participated in covered asthma in school-age children. Historically, asthma has been one of the top reasons for absenteeism in school-age children throughout the United States. However, research now suggests the absenteeism rate for asthmatics is decreasing in some cities. I believe this is partly due to the work of respiratory therapists and other health care professionals. In Dallas and the surrounding areas, many health care organizations are working with local school districts to provide asthma education to school nurses, coaches, and PE teachers.

The Baylor Asthma & Pulmonary Rehabilitation Center staff is one example. Our respiratory care specialists (registered respiratory therapists and registered nurses) have, for many years, provided asthma education to the Dallas Independent School District staff and to the children of the district via an asthma day camp called Camp Airways. I am including in this Bulletin a summary of a recent study we conducted showing that asthmatic children miss no more school days than their non-asthmatic classmates.

Yet another hot topic at the ATS meeting was Spiriva (tiotropium bromide). Several abstracts were presented showing positive results for COPD patients using Spiriva. Spiriva is a long-acting bronchodilator for the maintenance treatment of bronchospasm associated with COPD. It is a once daily medication contained in a capsule and administered through the HandiHaler®. Spiriva has been available in Europe and Canada, and has now been approved by the Food and Drug Administration for use in the U.S.

An abstract presented at the ATS by O’Donnell, et al. showed that Spiriva improved symptom-limited exercise tolerance and reduced exertional dyspnea in COPD patients. Another interesting study by this group also showed reduced lung hyperinflation at rest and during exercise in COPD patients using Spiriva. Both abstracts can be found in the American Journal of Respiratory and Critical Care Medicine, Volume 169, Number 7, April 2004.

Another recently approved medication for the treatment of COPD is Advair. The Advair Discus is a specially designed plastic device containing a double-foil blister strip with a powder combination of fluticasone and salmeterol. Advair is intended for oral inhalation only.

It is an exciting time for those of us who have treated COPD patients over the past years. It is nice to report to my patients that COPD is becoming more recognized by the world, and research is moving forward to improve care and treatment for those with this disease.

Please e-mail me your topics of interest for future Bulletin articles, and if you have an article or two that you would enjoy sharing with your fellow members, please don’t hesitate to send it my way. The AARC staff is very supportive and always available to work their magic and make us all look like professional writers.

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Introduction

It is widely believed that children with asthma miss considerably more school than children without asthma. In the 1998 Asthma in America Survey, almost half of families with asthmatic children reported missed school due to asthma symptoms.(1) Data collected by the Dallas Independent School District for the 1998-1999 school year noted that asthma was the leading cause of chronic school absenteeism for health-related reasons.(2) Even so, there is no literature examining the quantitative effect of asthma on school absenteeism in a population including all children with asthma. This study, a cooperative venture of the Baylor Asthma & Pulmonary Rehabilitation Center, the Baylor University Graduate School of Nursing, and the Dallas Independent School District, sought to quantify the effect of asthma upon school absenteeism in the 2002-2003 school year.

Methodology

As part of an inner-city school asthma screening and identification project involving 19 schools and funded by the Dallas Asthma Consortium and the Summerfield Roberts Foundation, 3,100 students received screening questionnaires adapted from the Brief Pediatric Asthma Screen.(3) Of the 1,555 students who returned questionnaires, 477 (31% of returned sample) positive “screens” were offered free, school-based testing involving spirometry and a ten-minute, free-run exercise challenge followed by serial spirometry. A positive screen was considered either a 12% post-bronchodilator improvement (≥ 200 mL), or a 10% decline in FEV1 following exercise cessation.

School attendance data was requested at the end of the school year for participating students testing either positive or negative, or with abnormal (but non-diagnostic) spirometry. Comparison was also made with students who had already been identified by school nurses as having asthma, along with attendance data for the entire student bodies of the 19 schools being studied and the district grade-matched attendance rates. Absence rates were calculated by dividing the days of attendance by the days of school enrollment during the 2002-2003 year.

Findings

Surprisingly, there was no significant difference in the school absence rate of children identified with asthma either by exercise challenge, spirometry, or school-nurse identification and the school absence rate in the total population of children attending the 19 study schools or the DISD 4^th, 5^th, and 6^th grades as a whole. On average, the difference between the attendance rates of the different groups with asthma and the total school population was £ 1.75 days. (See Table)

Yearly Absence Rates Among Selected Groups of 4^th — 6^th Grade Students

Discussion

Asthma ranks first (48%) among medical disorders that prohibit or significantly limit children from attending school, followed by neurodevelopment disorders (24%) and learning behavior disorders (12%).(4) In 1990, pediatric asthma in the U.S. was estimated to account for ten million lost school days (mean of 8.7 days missed/year/child), 200,000 hospitalizations, and an estimated $6.2 billion in asthma-related costs.(5) We reported in 2003 significant differences in the school absence rates of control vs. home-based vs. school-based treated asthmatic children who participated in a project targeted at already-diagnosed children.(6) The current data suggest, however, that asthma no longer appears to have such a profound impact upon school attendance rates when compared with non-asthmatic children.

Several factors may help explain this novel observation. In our earlier study (1995), the children in this three-arm study were known asthmatics in whom pre-screen specificity of diagnosis was determined to be >90%, a different population than that identified by a school-wide screen (about 10% of sample population). Then too, in the years between 1995 and 2003 penetration of the National Asthma Education and Prevention Program Guidelines may have improved overall asthma control in school-aged children, which might explain why even the group of asthmatic children identified by school nurses in the current study demonstrated about the same school-absence rate as a control group of non-asthmatic children. Different ways of determining school absence may also have resulted in differences in reported absence rates. Finally, overall school attendance rates in Texas have improved subsequent to implementation of state-mandated competency testing required for promotion to the next grade level.

There is no doubt that individuals with severe asthma suffer significant morbidity from uncontrolled symptoms that in children can include excess school absence. However, our data suggest that, for whatever reason, the overall impact of asthma upon school attendance appears to have lessened when compared to historical figures. Therefore, significant efforts at improving care for identified problematic asthmatic students may be more cost-effective than further investment of limited school district resources in widespread asthma screening.

Conclusions

1. School absence rates may not accurately reflect asthma morbidity in school-aged children identified on mass screening for asthma.
2. Asthma remains a significant cause of school absence and activity limitation in a small population with severe disease.
3. Allocation of limited school resources to school nurse salaries may be more cost-effective than district-wide efforts at screening for asthma.

References

1. Asthma In America™ Survey Project
2. 1998-1999 Annual School Health Services Report, DISD
3. Ann Allergy Asthma Immunol., Vol. 90, No. 5, pp. 500-507; 2003
4. Pediatrics, Vol. 111, pp. 548-554, 2003
5. Am J Public Health, Vol. 82, pp. 364-371; 1992
6. Journal of Asthma, Vol. 40, No. 7, pp.769-776; 2003

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