16-02 Annex B - Asthma
Cadet Administrative and Training Orders (CATOs)
1. Asthma is a frequently occurring medical condition present in up to 5% to 10% of the general Canadian population. Asthma can be responsible for a significant level of morbidity and mortality. In the last decade, statistics have shown an increase in deaths related to asthma in Canada and in the majority of developed countries.
2. In Canada the first guidelines for the management of asthma were established. In 1989 and have been updated regularly. In 1999, the Canadian Asthma Consensus Report was issued which provides the basis for the current guidelines for the diagnosis and management of asthma. Their last update was in June 2003.
3. Past experience at cadet camps has shown that many young cadets take anti-asthmatic medication without having had the benefit of a proper medical investigation confirming the diagnosis of asthma. Hence the diagnosis can be suspect. Personnel must be very careful before concluding that a cadet presents an asthmatic condition based solely on a medication profile included in the medical questionnaire (CF 51).
4. The diagnosis of asthma remains descriptive and it is characterized by paroxysmal or persistent symptoms identified such as:
- cough;
- wheezing;
- shortness of breath;
- chest tightness; and
- sputum production.
5. When further questioning confirms that the above symptoms vary in intensity, present themselves at night or early morning, are initiated by stimuli like cold air or physical activity, or are initiated by precipitants and/or allergens, then the diagnosis becomes more probable. Finally, response to bronchodilator anti-asthmatic medication helps confirm the diagnosis of asthma. It is interesting to note that a physical exam might exclude other medical conditions but it will not contribute to establishing the final diagnosis. To that end, pulmonary function tests may help to establish a diagnosis of asthma.
6. However, in the context of the medical selection process, confirming the diagnosis of asthma is not the most important factor, if asthma is probable IAW paragraph 4, it is the severity of the asthmatic condition that is considered.
7. The concept of control of asthma should be differentiated from severity of asthma. Optimal control of asthma refers to the absence of respiratory symptoms, the lack of the requirement for use of rescue bronchodilator medications, and normal pulmonary function tests. However, optimal control is difficult to achieve with many asthmatics, thus the concept of acceptable asthma control is more appropriate as the base for treatment requirement.
8. Asthma control is determined by the following criteria and should be included in the medical history when applying for camps in order to classify the level of asthma:
- daytime symptoms;
- night-time symptoms;
- physical activity capability;
- frequents of exacerbations;
- absence from school due to Asthma;
- need for b- agonist;
- peak flow results and diurnal variability;
- date and reason of last medical follow-up; and
- the severity of an asthmatic condition, which is based on 3 factors;
- frequency and duration of respiratory symptoms;
- presence of persistent airflow limitation; and
- medication required to maintain control.
9. In well-controlled asthma, the level of severity can be established by the treatment required to achieve an acceptable asthma control level.
10. Medications used to treat asthma are generally divided into 2 main categories, which either relieve or control symptoms. ‘Relievers’ are best represented by short acting beta-2 agonists such as salbutamol. They are quick- acting bronchodilators which relieve the acute symptoms: they are used only on-demand and always at a minimum required dose and frequency. ‘Controllers’ include anti-inflammatory medications such as inhaled and oral corticocosteroids, leukotriene receptor antagonists, and long acting beta-2 agonists. These medications control the symptoms of asthma, prevent exacerbations and decrease the requirement for the short acting rescue medications such as Ventolin (salbutamol).
11. Ideally, severity is determined by all three factors it is not critical. Since the evaluation is established in view of a selection process and not for therapeutic purposes, determining severity based on information presented in sub paragraphs 8a and 8c is usually adequate. Positive questionnaires (CF 51) of probable asthmatic cadets will be followed by the Formation Surgeon or the on‑site medical team with an evaluation of the acceptability of the asthma control in moderate and severe asthmatic cadets.
12. Again, in the context of the medical selection process, severity of an asthmatic condition can be identified according to three categories:
- Mild asthma. More than one‑half of asthmatic cadets will fall into this category. Often symptoms are precipitated only by respiratory infections and there may be complete symptom‑free episodes. This group also includes cadets who have primarily exercise-induced broncho-spasm, who present only with cough, and who have fewer than two or three mild non-life threatening acute asthmatic episodes per year. These individuals generally require at most intermittent medications, and symptoms are well controlled with occasional use of short acting B2 adrenergic agonists (i.e. Ventolin/salbutamol, Aeromir) or equivalent. These cadets are capable of self-administering anti-asthmatic medication. Consequently no restriction nor any specific medical support is required;
- Moderate asthma. Approximately 20% of asthmatic cadets will present with moderate asthma. These individuals have a history of occasional exacerbations of their condition, which prevents them from participating in physical activities for a specific period of time. If they require short acting rescue medications more than three days per week, they may take regular or continuous medications such as inhaled corticosteroids to control or prevent their symptoms. These include low dose inhaled steroids (i.e.: Flovent), which may be offered alone or in combination with long acting bronchodilators. Newer medications such as leukotriene receptor blockers (i.e. Singulair) are available in pill form and are used by some individuals for symptom control. Acute exacerbations are still managed with the short acting inhaled bronchodilators such as salbutamol. If there is a seasonal pattern to the asthma, there may be times when less intensive therapy is adequate to control symptoms. For these individuals the following restrictions would normally apply:
(1) requires easy access to medical and physician services. Requires ready access to medication at all times. Anti‑asthmatic treatment regimen should be readily available. A written asthma treatment plan from his/her personal physician is highly recommended,
(2) no underwater activity,
(3) no heavy exertion at high altitudes, and
(4) if an offending agent is known that precipitates exacerbations of the asthmatic condition, it must be easily controllable in the cadet camp environment; and - Severe asthma. Asthmatic cadets with severe asthma live with continuous symptoms and/or experience frequent asthma attacks. These asthmatics must change their lifestyle to accommodate the condition. Overall activity levels are affected, and they have nocturnal symptoms or may have frequent admission to the emergency department or recent admission to hospital. Anti‑asthmatic medications include drugs already mentioned, but taken more frequently and usually at higher dosage, plus regular use of oral corticosteroids. They often need regular follow-up with a specialist in a tertiary care facility. Because of the level of care needed and the frequent constraints concerning physical activities, cadets presenting with controlled severe asthma would normally require the following restrictions:
(1) requires immediate access to physician services in a hospital setting readily available. Requires immediate access to medication at all times,
(2) no underwater activities,
(3) no heavy exertion at altitude and activities otherwise as tolerated only,
(4) if allergy is a high precipitating agent, allergy testing should be done prior to camp and known allergens that lead to exacerbations of the asthmatic condition must be easily controllable in the cadet camp environment,
(5) must be cleared by a pediatrician, respiratologist or internist with a PEF or FEV1 > 60% predicted prior to endorsement to attend camp, and
(6) no recent hospitalization for asthma.
13. Poorly controlled Asthma: Signs of poorly controlled asthma include the occurrence of a prior near-fatal episode (loss of consciousness, (intubation), recent hospitalization or emergency room visit, night time symptoms, limitation of daily activities, need for inhaled beta2-agonist several times per day or at night, and forced expiratory volume (FEV1) or peak expiratory flow (PEF) less than 60% predicted. Cadets with poorly controlled asthma are at high risk of needing emergency medical care, and are not suitable for cadet camp.
14. Formation Surgeon’s assisted by RCMLO will evaluate each asthmatic cadet accordingly.
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