School and asthmaInformation for nurses who manage asthma in the school settingUC San DiegoAAP & CDC Schooled in AsthmaWA Chapter AAP

Asthma: a biggerproblem than everPrevalence in school age children: 5-10%4 5 million children under age 181 2 kids in every 1st grade classEstimated 14 million lost school days/year#1 chronic illness causing school absenteeism

2 or more children are likely to have asthmaIn a classroom of 30 children,

School functioning of US children with asthma10,000 families surveyed5% prevalenceAbsenteeism: 7.6 vs 2.5 days 1.7 x normal risk of learning disabilityLow income families: 2x normal risk of grade failure Fowler et al Pediatrics, 1992

Reasons for school becoming actively involvedIncreased prevalenceNegative learning and social impact on childLoss of fundingNew laws and regulationsLiability issuesPartner with healthcare providerOpportunity to make a differenceSchool based programs

Laws and regulationsSection 504 (of Rehabilitation Act)Americans with Disabilities Act (ADA)Individuals with Disabilities Education Act (IDEA)Individualized Education Program (IEP)

WA StateWashington 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 planconsent/parameters for use of rescue inhalerasthma educationBe accessible to school nurseHave effective rx program in placecontroller therapy if indicated by severity (e.g. inhaled anti-inflammatory medication)proper inhaler technique

Classification of Asthma Severity: Clinical Features Before TreatmentDays With Nights With PEF or PEFSymptoms Symptoms FEV1 VariabilityStep 4 Continuous Frequent 60% 30%SeverePersistentStep 3 Daily 5/month 60%-2/week 3-4/month 80% 20-30%MildPersistentStep 1 2/week 2/month 80% 20%MildIntermittentFootnote: The patients step is determined by the most severe feature.NAEPP. Pediatric Asthma: Promoting Best Practice. 1999. www.aaaai.org.

2002 NIH GuidelinesStepwise Approach to Asthma ManagementConsensus is that if followed correctly should control flare-upsDespite being available, has had little impact on asthma management

Stepwise Approach to Therapy for Adults and Children >Age 5: Maintaining Control Step down if possible Step up if necessaryPatient education and environmental control at every stepRecommend referral to specialist at Step 4; consider referral at Step 3STEP 4: Multiple long-term-control medications, including oral corticosteroids + PRN quick-relief inhalerSTEP 3: > 1 Long-term-control medications + PRN quick-relief inhalerSTEP 2: 1 Long-term-control medication: anti-inflammatory + PRN quick-relief inhalerSTEP 1: Mild Intermittent Quick-relief medication: PRNNAEPP. Pediatric Asthma: Promoting Best Practice. 1999. www.aaaai.org

When Should Controller Medicines be Initiated ?The rule of 2scoughing, wheezing, SOB or chest tightness more than 2 x /weeknocturnal awakening due to asthma more than 2 x /monthThe rule of 6Significant exacerbations more than every 6 weeks

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

Mild Intermittent AsthmaOccasional use of rescue inhaler (

Mild Persistent AsthmaFlare Up >2x/week, less than dailyNeeds Rescue InhalerNeed controller medication (inhaled steroid, leukotriene inhibitor)Definitely needs medication at school formMay need asthma action plan

Moderate Persistent AsthmaRescue Inhaler almost dailyNeeds to be on a controller med (such as long acting beta adrenergic/inhaled steroid)Needs Medication at School FormNeeds Asthma Action PlanMay need Care Plan for Life Threatening Illness

Severe Persistent AsthmaContinuous Asthma IssuesNeeds Rescue Inhaler and Chronic Controller Medications such as high-dose inhaled steroidsRequires Med at School FormRequires Asthma Action PlanRequires Care Plan for Life-Threatening Conditions

Responsibility of classroom teacher, PE teacher, coach:Be aware of:early warning signs of acute asthmatreatment of acute asthma asthma treatment plan for each studentexercise as important trigger of asthmaProvide feedback to school nurse about students asthma symptomsFacilitate MDI prophylaxis before sportsHelp avoid child being singled out as different

Responsibility of school nurseIdentify students with asthmasymptomatic, previously undiagnoseddiagnosed, but asthma not under controlConnect family/child to a medical homeFacilitate a coordinated school health programInterface with classroom teacher/PE teacher/support personnelTrain unlicensed personnel to administer/supervise medicationsWork with other staff to provide healthy school environment

Responsibility of school nurse(cont)Assist/ implement individualized written school asthma planManage exercise-induced asthma Assure easy access to medicationsPrepare for acute emergenciesCheck for proper inhaler techniqueMonitor response to treatment regimenBe on look-out for medication side effectsBe aware of community programsStay current on asthma, asthma management

Identify children with asthma: tip-offsRecurrent, persistent or nightime coughCough, chest pain, or wheeze with exerciseNot fully participating in PE, recessRecurrent wheezy bronchitis or pneumoniaMissing many school days due to respiratory infectionsHistory of rhinitis or eczema

Signs of poorly controlled asthmahigh rate of absenteeism, tardiness avoidance of physical activity; struggling in PE classcough, wheezing, chest tightness or shortness of breath in classroom or with activity/play/sportsfrequent use of rescue inhalerlow peak flow values

Connect family with health care provider (HCP)Preferable: use present HCPKnow local HCPs for referralPediatricians, family practice MDs, NPs, PAsAsthma specialistsCommunity clinics, free clinicsBe aware of health insurance status of familyRequest follow-up/communication with schoolRequest written asthma action plan

Assist/implement school asthma action planHCP to providedirectly, or via parentHCPs own form, school-provided formNeeds to cover medications/protocol for:Acute asthma Routine medications at schoolPre-exerciseShould be connected to symptoms and peak-flow

Train unlicensed personnelSchool nurse not always on-premiseHealth aides, office staff relied upon for medication administrationTraining needed in:general asthma knowledgerecognition of acute asthmapeak flowinhaler use

Provide healthy school environmentPotential triggers: dust mold pollen dander tobacco smokechalk odors cleaning solution auto-exhaust Know childs specific triggersCollaborate withparents teacherscustodial staffdistrictto minimize triggers

Advocate for control of asthma triggersExamples:replace carpet with noncarpeted flooringeliminate moisture/mold sourcesestablish tobacco-free schoolminimize odors from cleaning materials, paints, etc in classroomavoid feathered or furry animals in classroomclean air filters regularly schedule pest control and mowing of lawn during off school hours

Interface with parentBeginning of school yearasthma action planchilds triggerspermission for medicationsPermission to exchange information with the HCPThruout school yearvisits to office, use of rescue inhalersymptoms in class, on playgroundexcessive absenteeism

Interface with classroom teacher/PE teacher/coachProvide general asthma educationIdentify specific children with asthmaGo over rescue inhaler arrangement - office - self-carry Encourage reporting of symptomsExplain need to minimize asthma triggersCriteria for referral of student to school nurse

Assure easy access to rescue inhaler (e.g. albuterol)In office readily availablesupervision by nurse, health aid, staffmay need to be used with a spacerSelf-carry (self-administer)older children based on maturityneeds permission from HCP/parentback-up inhaler in-office

Be on look-out for medication side effectsBeta-agonists (e.g. albuterol)StimulationBehavioral changesCorticosteroids (e.g. prednisone)Physical changes (puffy face, wt gain, hirsute)Behavioral changesAntihistamine-decongestants (often used for concomitant allergies)SedationStimulation/behavioral changes

Prepare for acute emergencyAll school staff need familiarity with plan for possibility of acute asthma emergencyAssist student in administration of prescribed medication (e.g. albuterol)Nebulized therapy might be option at certain schoolsAssess and record students responseCall 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 asthmaPE, recess play, sports can pose problemMost common problem activity: long distance running Need effective controller medication programTry warm-up exercisesUse pre-exercise medication (e.g. albuterol, cromolyn)Make med program easy

Asthma and physical educationEvery 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 limitationStrongly avoid permanent PE excuses, or continuously modified PE

Be aware of community programsAsthma campswww.asthmacamps.orgHealth fairsALA, AAFA programs (e.g. Open Airways)Asthma coalitions

Asthma campsusually a week session during summerpromotes self-confidence and an understanding of ways to manage asthma through educationwebsite info on camp directory nationwide: www.asthmacamps.org

Educational WebsitesAsthma and physical activities in school: www.nhlbi.nih.gov/health/public/lung/asthma/phy_asth.pdfAllergy & Asthma Network/ Mothers of Asthmatics: http://www.aanma.org/1997 NAEPP/NIH Asthma guidelines: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htmNational Association of School Nurses: http://www.nasn.org/American Academy of Allergy, Asthma & Immunology http://www.aaaai.orgAmerican Academy of Pediatrics, section on Allergy & Immunol http://www.aap.org1999 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 sportsno coughingno difficulty breathing, wheezing, or chest tightnessno acute episodesno absences from schoolminimal to no use of rescue inhalerno side effects from medicines

Together we can make a differenceasthma-friendly policies and procedureshealthy school environmentasthma education for students and staffopen communication (school, parent, health care provider)

Asthma in school age children is becoming more and more prevalent. It is estimated that every first grade class in this country has at least one child with asthma. Asthma can interfere with a normal experience in school in a number different ways. Aside from the fact that it is number one chronic health condition causing school absenteeism, it creates problems in the classroom, on the playground, and in physical education that have to be dealt with by the school. Many, although not all, studies show that children with asthma do not function or perform the same as other children without asthma. One study by Fowler et al documented an increased number of days of missing school in children with asthma as compared to controls, as well as a 1.7 times risk of having a learning disability. Those children with asthma who came from a low income family had a 2x higher risk of a learning disability. The impact of asthma on school functioning is likely a complex one, and is dependent on a number of factors that interact with each other.According to the ADA, kids with significant asthma problems can be considered handicapped, and have certain rights which make the school need to accommodate their needs. An IEP is a special process, which culminates with a meeting of all involved parties related to the child's education and health while at school, that creates an individualized plan for the student for the school year.Teamwork is the key to success Clinicians roleNAEPP2-NIH 1997 Asthma guidelines

The NAEPP2 has specific therapeutic intervention based on the severity level (4 levels). This is an easy and simplified way on when to initiate controller therapy.Schools nurse plays a humongous role! Schools personal needs to familiarize with signs and symptoms of poorly control asthma. The nurse then, has a moral responsibility to make the parents and/or health care providers aware of students condition.Besides indoor home, and outdoor allergen environmental control measures, we should also paid special attention to potential asthma triggers and opportunity for allergen avoidance in the school setting. Adaptive or full P.E excuse should be avoided. We must work with parents, coaches and school nurses to bring these kids asthma under good control. Asthma can be control, expect nothing less! This questionnaire is readily available at the NIH-NHLBI web page: http://www.nhlbi.nih.gov/health/public/lung/asthma/chc_chk.htmHealth care providers treating asthma patients should have good notion about what good asthma control means. The Goals of asthma control should be shared with our parents, kids, and school personnel.