School and asthma

Information for nurses who manage asthma in the school setting

UC San DiegoUC San DiegoAAP & CDC “Schooled in Asthma”AAP & CDC “Schooled in Asthma”WA Chapter AAPWA Chapter AAP

Asthma: a biggerproblem than ever

• Prevalence in school age children: 5-10%

• 4 – 5 million children under age 18

• 1 – 2 kids in every 1st grade class

• Estimated 14 million lost school days/year

• #1 chronic illness causing school absenteeism

2 or more children are likely to have asthma

In a classroom of 30 children,

School functioning of US children with asthma

• 10,000 families surveyed

• 5% prevalence

• Absenteeism: 7.6 vs 2.5 days

• 1.7 x normal risk of learning disability

• Low income families: 2x normal risk of grade failure

Fowler et al Pediatrics, 1992

Reasons for school becoming actively involved

• Increased prevalence• Negative learning and social impact on child• Loss of funding• New laws and regulations• Liability issues• Partner with healthcare provider• Opportunity to make a difference• School based programs

Laws and regulations

• Section 504 (of Rehabilitation Act)

• Americans with Disabilities Act (ADA)

• Individuals with Disabilities Education

Act (IDEA)

• Individualized Education Program (IEP)

WA State

• Washington Asthma Initiative has been present since 1999 (in order to promote NIH guidelines)

• WSMA developing Asthma Intervention Plan (similar to Antibiotic use program)

• State requires Nursing Care Plan for Life Threatening Conditions in place for school enrollment for students with such

School Asthma Team

Student

Parents Health care provider

School nurse, classroom teacher, PE teacher, coach, principal, after-school staff

Responsibility of health care provider

• Provide school with:– clear written asthma plan– consent/parameters for use of rescue inhaler– asthma education

• Be accessible to school nurse• Have effective rx program in place

– controller therapy if indicated by severity (e.g. inhaled anti-inflammatory medication)

– proper inhaler technique

Classification of Asthma Severity: Clinical Features Before Treatment

Days With Nights With PEF or PEF

Symptoms Symptoms FEV1 Variability

Step 4 Continuous Frequent 60% 30%SeverePersistentStep 3 Daily 5/month 60%-<80% 30%ModeratePersistentStep 2 >2/week 3-4/month 80% 20-30%MildPersistentStep 1 2/week 2/month 80% 20%MildIntermittent

Footnote: The patient’s step is determined by the most severe feature.

NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

.

2002 NIH Guidelines

• Stepwise Approach to Asthma Management

• Consensus is that if followed correctly should control flare-ups

• Despite being available, has had little impact on asthma management

Stepwise Approach to Therapy for Adults Stepwise Approach to Therapy for Adults and Children >Age 5: Maintaining and Children >Age 5: Maintaining

ControlControl Step down if Step down if

possiblepossible Step up if Step up if

necessarynecessary Patient education Patient education

and and environmental environmental control at every control at every stepstep

Recommend Recommend referral to referral to specialist atspecialist atStep 4; consider Step 4; consider referral at Step 3referral at Step 3

STEP 4: Multiple long-term-STEP 4: Multiple long-term-control medications, includingcontrol medications, includingoral corticosteroids + PRN quick-oral corticosteroids + PRN quick-relief inhalerrelief inhaler

STEP 3: STEP 3: > > 1 Long-term-control 1 Long-term-control medications + PRN quick-relief inhalermedications + PRN quick-relief inhaler

STEP 2: 1 Long-term-control medication:STEP 2: 1 Long-term-control medication:anti-inflammatory + PRN quick-relief inhaleranti-inflammatory + PRN quick-relief inhaler

STEP 1: Mild IntermittentSTEP 1: Mild Intermittent

Quick-relief medication: PRNQuick-relief medication: PRN

NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

When Should “Controller” Medicines be Initiated ?

The “rule of 2’s”• coughing, wheezing, SOB or chest tightness more

than 2 x /week• nocturnal awakening due to asthma more

than 2 x /monthThe “rule of 6”• Significant exacerbations more than every 6 weeks

NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

Mild Intermittent Asthma

• Occasional use of rescue inhaler (<2x/week)

• Needs medication at school form and the actual medication at school

• Office needs to monitor use of inhaler

• Older students, Jr. High or greater may carry inhaler with permission

Mild Persistent Asthma

• Flare Up >2x/week, less than daily

• Needs Rescue Inhaler

• Need controller medication (inhaled steroid, leukotriene inhibitor)

• Definitely needs medication at school form

• May need asthma action plan

Moderate Persistent Asthma

• Rescue Inhaler almost daily

• Needs to be on a controller med (such as long acting beta adrenergic/inhaled steroid)

• Needs Medication at School Form

• Needs Asthma Action Plan

• May need Care Plan for Life Threatening Illness

Severe Persistent Asthma

• Continuous Asthma Issues• Needs Rescue Inhaler and Chronic Controller

Medications such as high-dose inhaled steroids

• Requires Med at School Form• Requires Asthma Action Plan• Requires Care Plan for Life-Threatening

Conditions

Responsibility of classroom teacher, PE teacher, coach:

• Be aware of:– early warning signs of acute asthma

– treatment of acute asthma

– asthma treatment plan for each student

– exercise as important trigger of asthma

• Provide feedback to school nurse about student’s asthma symptoms

• Facilitate MDI prophylaxis before sports• Help avoid child being singled out as different

Responsibility of school nurse

• Identify students with asthma– symptomatic, previously undiagnosed– diagnosed, but asthma not under control

• Connect family/child to a medical home• Facilitate a coordinated school health program• Interface with classroom teacher/PE teacher/support

personnel• Train unlicensed personnel to administer/supervise

medications• Work with other staff to provide healthy school

environment

Responsibility of school nurse(cont)

• Assist/ implement individualized written school asthma plan– Manage exercise-induced asthma – Assure easy access to medications– Prepare for acute emergencies

• Check for proper inhaler technique• Monitor response to treatment regimen• Be on look-out for medication side effects• Be aware of community programs• Stay current on asthma, asthma management

Identify children with asthma: tip-offs

• Recurrent, persistent or nightime cough• Cough, chest pain, or wheeze with exercise• Not fully participating in PE, recess• Recurrent “wheezy bronchitis” or

“pneumonia”• Missing many school days due to

“respiratory infections”• History of rhinitis or eczema

Signs of poorly controlled asthma

• high rate of absenteeism, tardiness • avoidance of physical activity;

struggling in PE class• cough, wheezing, chest tightness or

shortness of breath in classroom or with activity/play/sports

• frequent use of rescue inhaler• low peak flow values

Connect family with health care provider (HCP)

• Preferable: use present HCP• Know local HCP’s for referral

– Pediatricians, family practice MD’s, NP’s, PA’s– Asthma specialists– Community clinics, free clinics

• Be aware of health insurance status of family• Request follow-up/communication with school• Request written asthma action plan

Assist/implement school asthma action plan

• HCP to provide– directly, or via parent

– HCP’s own form, school-provided form

• Needs to cover medications/protocol for:– Acute asthma

– Routine medications at school

– Pre-exercise

• Should be connected to symptoms and peak-flow

Train unlicensed personnel

• School nurse not always on-premise• Health aides, office staff relied upon for

medication administration• Training needed in:

– general asthma knowledge– recognition of acute asthma– peak flow– inhaler use

Provide healthy school environment

• Potential triggers: dust mold pollen dander tobacco smokechalk odors cleaning solution auto-exhaust

• Know child’s specific triggers• Collaborate with

– parents – teachers– custodial staff– district

to minimize triggers

Advocate for control of asthma triggers

Examples:• replace carpet with noncarpeted flooring• eliminate moisture/mold sources• establish tobacco-free school• minimize odors from cleaning materials, paints, etc in

classroom• avoid feathered or furry animals in classroom• clean air filters regularly • schedule pest control and mowing of lawn during off

school hours

Interface with parent• Beginning of school year

– asthma action plan

– child’s triggers

– permission for medications

– Permission to exchange information with the HCP

• Thruout school year– visits to office, use of rescue inhaler

– symptoms in class, on playground

– excessive absenteeism

Interface with classroom teacher/PE teacher/coach

• Provide general asthma education• Identify specific children with asthma• Go over rescue inhaler arrangement

- office - self-carry

• Encourage reporting of symptoms• Explain need to minimize asthma triggers• Criteria for referral of student to school

nurse

Assure easy access to rescue inhaler (e.g. albuterol)

• In office – readily available– supervision by nurse, health aid, staff– may need to be used with a spacer

• Self-carry (self-administer)– older children based on maturity– needs permission from HCP/parent– back-up inhaler in-office

Be on look-out for medication side effects

• Beta-agonists (e.g. albuterol)– Stimulation– Behavioral changes

• Corticosteroids (e.g. prednisone)– Physical changes (puffy face, wt gain, hirsute)– Behavioral changes

• Antihistamine-decongestants (often used for concomitant allergies)– Sedation– Stimulation/behavioral changes

Prepare for acute emergency

• All school staff need familiarity with plan for possibility of acute asthma emergency– Assist student in administration of prescribed medication (e.g.

albuterol)– Nebulized therapy might be option at certain schools– Assess and record student’s response– Call EMS/911 if not responding

Quality Nursing Interventions in the School Setting: Procedures, models, guidelines. National Association of School Nurses Publication. 1996

Manage exercise-induced asthma

• PE, recess play, sports can pose problem• Most common problem activity: long distance

running • Need effective controller medication program• Try warm-up exercises• Use pre-exercise medication (e.g. albuterol,

cromolyn)• Make med program easy

Asthma and physical education

• Every effort should be made to keep the child in regular P.E.

• Allow temporary curtailment of activities during flare-ups:

- specify type and length of any

limitation• Strongly avoid permanent PE excuses, or

continuously modified PE

Be aware of community programs

• Asthma camps– www.asthmacamps.org

• Health fairs

• ALA, AAFA programs (e.g. Open Airways)

• Asthma coalitions

Asthma camps

• usually a week session during summer

• promotes self-confidence and an understanding of ways to manage asthma through education

• website info on camp directory nationwide: www.asthmacamps.org

Educational Websites• Asthma and physical activities in school: www.nhlbi.nih.gov/health/public/lung/asthma/phy_asth.pdf• Allergy & Asthma Network/ Mother’s of Asthmatics:

http://www.aanma.org/• 1997 NAEPP/NIH Asthma guidelines:

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm• National Association of School Nurses: http://www.nasn.org/• American Academy of Allergy, Asthma & Immunology http://www.aaaai.org• American Academy of Pediatrics, section on Allergy & Immunol http://www.aap.org• 1999 Pediatric Asthma guidelines http://www.aaaai.org

How asthma friendly is your school?

1. Is your school free of tobacco smoke?

2. Does your school maintain good indoor air quality?

e.g., reduce or eliminate allergens and

irritants that can make asthma worse?

3. Is there a school nurse in your school all day,

everyday? Is a nurse regularly available to write

plans and give guidance?

NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

How asthma friendly is your school? (cont.)

4. Can children take medicines as recommended by their doctors and parents? May children carry their own medicines?

5. Does your school have an emergency plan for kids with severe asthma attack?

6. Does someone teach school staff about asthma care plan ? Does someone teach all students about asthma?

7. Do students have good options for P.E. class and recess?

If the answer to any question is no, students may be facing obstacles to asthma control.

NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

What is good asthma control in the school setting?

• full participation in most sports• no coughing• no difficulty breathing, wheezing, or chest

tightness• no acute episodes• no absences from school• minimal to no use of rescue inhaler• no side effects from medicines

Together we can make a difference

• asthma-friendly policies and procedures

• healthy school environment

• asthma education for students and staff

• open communication (school, parent, health care provider)