Rachel Lawler RN, MSN, cPNP, AE-C, NPAT
Lucile Packard Children’s Hospital
Pediatric Pulmonary Division
State of Asthma Today
 7 million children have asthma… 1 in 11 in 2010
 In 2009
 8.9 million doctor visits for asthma
 1.9 million ER visits
 479,300 hospitalizations
 1 in 5 children with asthma went to an ER for care in 2009
 1 in 2 children miss at least one day of school each year…
that’s 10.5 million missed school days a year
 3 in 5 people limit their activity due to asthma
 Asthma costs the USA $56 billion a year
http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf
School Challenges
Asthma Action
Plans
No Rescue
Inhalers at
School
Poor Air
Quality
Nurse, Staff,
Teacher
Education
© NAPNAP 2011
Environmental
Triggers
Asthma Knowledge and Asthma Management Behavior in
Urban Elementary School Teachers
JM. Bruzzese, et.al; Journal of Asthma, 2010
 School staff face all the issues of asthma management
that the family faces at home.
 To provide a seamless blanket of care for children with
asthma, school personnel need to
 be educated about asthma,
 take steps to prevent asthma exacerbations
 communicate with parents, medical providers, and each
other
 coordinate care for students with asthma during the
school day
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
© NAPNAP 2011
www.asthmainschools.com
Asthma-Friendly Schools
Initiative Toolkit
http://www.lung.org/assets/documents/lung-disease/asthma/ala-afsi-brochure.pdf
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
www.asthmainschools.com
© NAPNAP 2011
Identifying & Tracking Students with
Asthma
School nurse:
 Receives health intake forms.
 Creates a tracking form for each student with asthma.
 Sends a medication self-carry request and a school
medication form home to the parent.
 Parent brings the medicines, a written asthma action
plan, and the completed medication self-carry request
or a school medication form to the nurse.
 School nurse notes each of the student’s visits to the
nurse to take medication throughout the school year.
http://www.lung.org/assets/documents/afsi-toolkit-2007.pdf
 Notifies the parent, or with permission, the child’s
asthma care provider when student requires quick
relief medication.
 Principal’s office notifies school nurse of any student
with asthma who is absent throughout the year.
 Tracks absenteeism to ensure whether or not student’s
absenteeism warrants case management.
 Generates a year-end asthma report for the principal
that includes:
• total # of children in the school with asthma
• total # of times children came to the nurse for medication
• maximum # of visits by one child
• total # of days absent for kids with asthma
• maximum # of days missed by one child
http://www.lung.org/assets/documents/afsi-toolkit-2007.pdf
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
www.asthmainschools.com
© NAPNAP 2011
Every Student With Asthma Needs a
Rescue Inhaler
© NAPNAP 2011
States that implemented
self-carry law
© NAPNAP 2011
http://www.lung.org/lung-disease/asthma/in-schools/asthma-friendly-schools/about-afsi/asthma-action-plan.pdf
Metered Dose Inhaler with Spacer
1.
2.
3.
4.
5.
6.
7.
8.
Remove cap from inhaler.
Place in end of the valved holding chamber.
Expire all air from lungs.
Insert device into mouth.
Actuate inhaler into chamber.
Inhale as deeply and slowly as possible.
Hold breath for 5-10 seconds.
Rinse mouth.
© NAPNAP 2011
Metered Dose Inhaler with
Spacer and Face Mask
1. Remove cap from inhaler.
2. Place in end of the valved
holding chamber.
3. Place mask over child’s nose and
mouth.
4. Insert device into mouth.
5. Actuate inhaler into chamber.
6. Have child breathe 5 breaths.
7. Rinse mouth.
© NAPNAP 2011
Dry Powder Inhaler Technique:
Diskus
1. Twist Diskus open.
2. Hold parallel.
3. Push lever all the way back.
4. Expire all air from lungs.
5. Insert device into mouth.
6. Inhale as deeply and quickly as
possible.
7. Hold breath for 5-10 seconds.
8. Rinse mouth.
© NAPNAP 2011
Small Volume Nebulizer
 Remove top from the circuit cup.
 Put in prescribed nebulized medication.
 Replace top from the circuit cup.
 Hook tubing to cup and the machine.
 Turn on machine.
 Have child breathe until medication is
finished.
© NAPNAP 2011
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
www.asthmainschools.com
© NAPNAP 2011
Use your Asthma Action Plan!
A plan of care for asthma prevention
and
what to do when it gets worse!
© NAPNAP 2011
Self-Management Plan should:
Provide strategies to improve activities
of daily life




© NAPNAP 2011
Minimize school absenteeism
Minimize parental work loss
Decrease Emergency Room/
urgent care utilization
Promote sports participation
Emergency plan for worsening asthma:
 Yellow zone:
 Coughing/wheezing/shortness of breath
 Initiate quick-relief agent
 Red zone:
 Retractions, increased respiratory rate, change in color
(pale, blue tinged lips), difficulty finishing sentences
 Call 911, go to Emergency Room
© NAPNAP 2011
Tools for Assessing
Asthma Control
© NAPNAP 2011
The Childhood Asthma Control Test for Assessing Control
in Patients 4 to 11 Years of Age
1. How is your asthma today?
0
Very bad
1
Bad
2
Good
3
Very Good
2. How much of a problem is your asthma when you run, exercise or play sports?
00
It’s a big problem, I can’t do what I want to do.
1
2
It’s a problem and I don’t like it. It’s a little problem but it’s okay.
33
It’s not a problem
3. Do you cough because of your asthma?
0
Yes, all of the time.
1
Yes, most of the time.
2
Yes, some of the time.
3
No, none of the time
4. Do you wake up during the night because of your asthma?
0
Yes, all of the time.
© NAPNAP 2011
1
Yes, most of the time.
2
Yes, some of the time.
3
No, none of the time
Asthma Control Test, 12 and older
1.
In the past 4 weeks, how much of the time did your asthma keep you
from getting as much done at work, school or at home?
2.
During the past 4 weeks, how often have you had shortness
of breath?
3.
During the past 4 weeks, how often did your asthma symptoms
(wheezing, coughing, shortness of breath, chest tightness or pain) wake
you up at night, or earlier than usual in the morning?
4.
During the past 4 weeks, how often have you used your rescue
inhaler or nebulizer medication (such as albuterol)?
5.
How would you rate your asthma control during the past
4 weeks?
Copyright 2002, QualityMetric Incorporated.
Asthma Control Test Is a Trademark of QualityMetric Incorporated.
© NAPNAP 2011
Patient Total Score
Score
Rule of Twos
 Two doses of albuterol/week
 Two nights of symptoms/month
 Two albuterol inhalers/year
 Two urgent clinic visits/year
 Two steroid bursts/year
© NAPNAP 2011
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
© NAPNAP 2011
www.asthmainschools.com
Environmental Triggers
at School
Pollution
Grasses
Molds
Trees
Cockroaches
Rodents
Animals
Smoke
Asthma Knowledge and Asthma Management Behavior in
Urban Elementary School Teachers
Journal of Asthma, 2010
 Help teachers identify and eliminate allergens that
may trigger asthma
 Remove rugs if possible
 Remove furry pets from classrooms
 Limit exposure to chalk dust
 Clean classroom well to reduce mold, rodents, and
cockroaches
 This may assist in minimizing students’ exposure to
allergens throughout the school environment and
prevent exacerbations
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
www.asthmainschools.com
© NAPNAP 2011
Asthma-Obesity-Inactivity
© NAPNAP 2011
Health Benefits of Exercising for
Patients With Asthma
 As tolerance for physical exertion
is built up over time, occurrence
of asthma attacks decreases.
 Exercise helps asthma patients
reduce stress, sleep better, and
feel more energized.
© NAPNAP 2011
Pre-medicate with Albuterol
 2 puffs of albuterol with spacer 20-30 minutes prior to
intense play or PE
 Train teachers and coaches to monitor for signs and
symptoms of asthma
 Cough with or without wheeze
 Shortness of breath
 Hunched shoulders
 Difficulty walking or talking
 Allow students to have modified PE if asthma is
exacerbated
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, HCPs, and school .
www.asthmainschools.com
© NAPNAP 2011
Components to include in education
sessions with staff and families
 Pathophysiology
 Anatomy of airways
 Bronchospasm
 Airway inflammation
 Mucus Production
© NAPNAP 2011
Components to include in education
sessions with staff and families
 Common symptoms
 Cough
 Dyspnea
 Chest tightness
 Fatigue
 Wheezing
© NAPNAP 2011
Components to include in education
sessions with staff and families
 Triggers
 Identification
 Avoidance measures
 Environmental control
 Health department and
poor air quality
 Tobacco exposure
avoidance
 Allergen control in the
home and school
 Premedication philosophy
© NAPNAP 2011
Components to include in education
sessions with staff and families
 Medications
 Prevention



Inhaled Steroids- Qvar, Flovent, Budesonide
Leukotriene Receptor Antagonists- Singulair
Allergy Medications- claritin, zyrtec, flonase, nasonex
 Rescue:

Bronchodilators: Albuterol
 Oral Steroids- Prednisone, Orapred
Asthma Medications
7 Goals for Creating an
Asthma- Friendly School
1
2
3
4
5
6
7
• Establish a process to identify students with asthma
• Allow students to have asthma easy access to inhalers
• Establish a school-wide process for handling worsening asthma.
• Identify and reduce common asthma triggers within the school environment.
• Encourage students with asthma to participate in school activities.
• Provide asthma education for staff, parents and students.
• Collaborate with families, PCPs, and school .
www.asthmainschools.com
© NAPNAP 2011
Teamwork
Use every opportunity to teach and reinforce asthma
education!
 Family centered, culturally sensitive care
 Obtain Medical documentation including Asthma
Action Plan and Self-Medication forms
 Communicate with teachers and families often in
regards to frequency of symptoms, medication use,
physical activity limitations, and absenteeism
 Establish communication with the child’s PCP
NAPNAP © 2011
Goal, Goal, Goal. . . .
 Happy, healthy productive children!
© NAPNAP 2011
References and Resources
 NAPNAP: Pediatric Asthma Education Train-the Trainer
Curriculum
 Asthma-Friendly School Initiative Toolkit
www.lung.org/lung-disease/asthma/creating-asthma-friendlyenvironments/asthma-in-schools/asthma-friendly-schools-initiative
 Public Health School Asthma Project, an initiative of
Asthma Plan of Action, Canada www.asthmainschools.com
 Environmental Management of Pediatric Asthma
www.neefusa.org/health/asthma
 Asthma Knowledge and Asthma Management Behavior in
Urban Elementary School Teachers
JM. Bruzzese, et.al; Journal of Asthma, 2010
 John Mark MD; Clinical Professor of Pediatrics, Stanford University