Keeping Kids with
Asthma in Class
Michael Corjulo APRN, CPNP, AE-C
ACES School System
mcorjulo@aces.org
c.2010
Objectives
• Demonstrate an understanding of common
barriers to successful asthma management
for students in school
• Identify collaborative strategies that
support academic achievement by improving
asthma control for students
• Discuss initiatives to improve asthma
management and control.
Pre-Test
Survey Question
• On a scale of 1 to 10
– 1 being not at all
– 10 being totally satisfied
• How satisfied are you with the
overall asthma management of the
students in your school?
• Write down your biggest issue or barrier
Pediatric Asthma
Based on the National
Institutes of Health
2007 Expert Panel Report 3
National Asthma Education
and Prevention Program
(NAEPP)
Raise the Bar!
Asthma is the #1 cause of
avoidable hospitalization
• Children hospitalized with asthma
very often represent a failure of
ambulatory care management
NAEPP: Components of Asthma
Management
PHARMACOLOGIC
THERAPY
Request for Medication
Refill
EDUCATION
FOR
PARTNERSHIP WITH
FAMILIES
ASSESSMENT
& MONITORING
Symptoms
Medication Use
TRIGGERS &
ALLERGENS
Exposure
Avoidance
Interventions
Based onThe Expert Panel Report 2: Guidelines for the Diagnosis and Management of
Asthma (NHLBI, 1997)
Corjulo, M (2005). Telephone triage for asthma medication refills, Pediatric Nursing,
1(2), 116-120.
Asthma Management 2010
Assessment
Symptoms
Risk /
Impairment
Control
Treatment:
Triggers
Medication
Education
Assessment
The Big Picture
• How many times would a student
needing asthma treatment be seen by
the nurse in one day?
1.
2.
3.
4.
5.
Assess the problem and treat
Re-assess
If not completely resolved – re-assess again
If having to treat again
Re-assess again
» Can’t send a student with acute symptoms
home on a bus!
The Big Picture
• If this happened everyday
– How many visits would this student make
to the nurse’s office in one week?
• Or if symptoms occur 3x/week
• How many in a month?
• a quarter?
• a year?
The Big Picture
• How much time is that out of the
classroom, not learning???
– What else is the student not doing
because of their asthma?
• How much of this is avoidable?
» So what are we going to do about it?
Overcoming Asthma
Management Barriers
… in school
…..and beyond
The Asthma
Action Plan Bridge
CT DPH AAP
Asthma Action Plan: Home, Play, School, & Travel
The
ACES
AAP
Name:
Birth Date:
Date:
Fax #:
Provider Phone #:
Parent/Guardian Phone #s:
□ pets □mold
□ dust □pollen □colds/viruses □exercise □seasons:
other:
Severity: □ Severe Persistent □ Moderate Persistent □ Mild Persistent □Intermittent
Important! Things that make your asthma worse (Triggers): X smoke
GO – You’re Doing Well!
You have all of
these:
 Breathing is good
 No cough or
wheeze
 Sleep through
the night
 Can work
and play
CAUTION – Slow Down!
CAUTION – Slow Down!
You have any of
these:
 First signs of a
cold
 Exposure to
known trigger
 Cough
 Wheeze
 Tight chest
 Coughing at night
DANGER – Get Help!
Your
Asthma is getting
 Coughing
worseatfast
if you have
night
any of these:
 Medicine is not helping
 Breathing is hard and
fast
 Nose opens wide
 Can’t talk well
 Getting nervous
USE THESE MEDICINES EVERYDAY TO PREVENT SYMPTOMS
MEDICINE
HOW MUCH
HOW OFTEN/WHEN
 Inhalers work better with Spacers
MEDICINE
1.
Continue with Green Zone Medicine and ADD:
CONTINUE WITH GREEN ZONE MEDICINE AND ADD:
Albuterol / Xopenex
HOW MUCH
2 puffs or 1 vial
HOW OFTEN/WHEN
Every _____ Hours
□ Before Exercise as needed
CALL our Office if: You need your ALBUTEROL or XOPENEX SOONER than EVERY 4
HOURS or EVERY 4 HOURS for MORE than 2 days or any questions or concerns
TAKE THESE MEDICINES AND CALL YOUR PROVIDER NOW
CALL YOUR HEALTH CARE PROVIDER FOR HELP, ESPECIALLY IF YOU NEED
MEDICINE
HOW MUCH
OFTEN/WHEN
YOUR ALBUTEROL OR XOPENEX SOONER
THAN 4 HOURSHOW
OR EVERY
4 HOURS
FOR MORE
THAN 2 DAYS
Albuterol
/ Xopenex
NOW!
Get help from a doctor now! Do not be afraid of causing a fuss. It’s
important! If you cannot contact your doctor, go directly to the emergency
room or call 911 and bring this form with you. DO NOT WAIT.
Provider Signature ______________________________________________________
Date______________________
I give permission to the school nurse and my child’s health care provider to exchange information to assist in my child’s asthma management.
Parent/guardian signature __________________________________________________

3/09
Date____________________
Make an appointment with your primary care provider within two days of an ED visit, hospitalization, or for ANY problem
or question with asthma
* Bring asthma meds and spacer to all visits
The
CMG
AAP
Asthma Action Plan: Home, Play, Travel, and School
Name:
Children’s Medical Group
299 Washington Avenue
Phone #: 288-4288
Date:
Fax #: 288-1566
Hamden, CT 06518
Provider:
Your Asthma Triggers / Allergies: X smoke
□ pets □mold □ dust □pollen □ grass
□colds/viruses □exercise □seasons:
other:
Severity: □ Severe Persistent □ Moderate Persistent □ Mild Persistent □Intermittent
GO – You’re Doing Well!
 Inhalers work better with
Spacers
You have all of these:
 Breathing is good
 No cough or wheeze
 Sleep through
the night
 Can work
and play
USE THESE MEDICINES EVERYDAY TO PREVENT SYMPTOMS
MEDICINE
HOW MUCH
1.
_____ puffs
AM / PM
2.
_____ squirt(s) each nostril
AM / PM
3.
AM / PM
4.
AM / PM
CAUTION – Slow Down!
You
have any
these:
CAUTION
– of
Slow
Down!
 First signs of a cold
 Exposure to known
trigger
 Cough
 Wheeze
 Tight chest
 Coughing at night
DANGER – Get
 Coughing
at night
Your
Asthma is
CONTINUE WITH GREEN ZONE MEDICINE AND ADD:
MEDICINE
1.
HOW MUCH
HOW OFTEN/WHEN
CONTINUE WITH GREEN ZONE MEDICINE AND ADD:
Albuterol / Xopenex
2 puffs or 1 vial
Every _____ Hours
□ Before Exercise as needed
2.
 Inhalers work better with Spacers
CALL our Office if: You need your ALBUTEROL or XOPENEX SOONER than EVERY 4
HOURS or EVERY 4 HOURS for MORE than 2 days or any questions or concerns
Help!
getting worse fast:
 Medicine is not
helping
 Breathing is hard
and fast
 Nose opens
wide
 Can’t talk well
 Getting nervous
HOW OFTEN/WHEN
TAKE THESE MEDICINES AND CALL YOUR
MEDICINE
HOW MUCH
Albuterol / Xopenex
4 puffs or 1 vial
PROVIDER NOW
HOW OFTEN/WHEN
NOW! & Call the office
OR
Get help from a doctor now! Do not be afraid of causing a fuss. It’s
important! If you cannot contact your doctor, go directly to the emergency
room or call 911 and bring this form with you. DO NOT WAIT.
Provider Signature _______________________________________________
Date_____________________
I give permission to the school nurse and my child’s health care provider to exchange information to assist in my child’s asthma management.
Parent/guardian signature __________________________________________________
Date____________________
 Make an appointment with your primary care provider within two days of an ED visit, hospitalization, or for ANY problem
or question with asthma
* Bring asthma meds and spacer to all visits
Next Visit:____________________ (At least every 6 months if doing well)
NHLBI AAP
Don’t Have an Action Plan
• Rely on the student’s
recollection of his/her
asthma plan
Have an Action Plan
• Can review written
plan with student
– May not know the names of
meds or when they should
be used
– Have to call the parent,
who also may not be sure
– Makes having a creditable
collaboration with the
provider very difficult
– Seldom results in improved
asthma management
– Discuss control
medication use
• Consistency
• Issues
– Identify knowledge
gaps
– Review plan written by
Provider with parent
– Can result in an office
visit, prescription refill,
or other positive action
The Big Picture
• Not having an Asthma Action Plan
can be like trying to meet IEP goals
that are not written
OR
• Determining if immunizations are
up to date without an immunization
record
Case Example
• 13 y.o. who has had 22 doses of
albuterol in his first 37 days of
school
– Including 1 known ED visit
• Can you call his PCP without a HIPAA
compliant release of information?
HIPPA, FERPA, & ASTHMA
• Yes. The Privacy Rule allows those doctors, nurses,
hospitals, laboratory technicians, and other health
care providers that are covered entities to use or
disclose protected health information, such as Xrays, laboratory and pathology reports, diagnoses,
and other medical information for treatment
purposes without the patient’s authorization. This
includes sharing the information to consult with
other providers, including providers who are not
covered entities, to treat a different patient, or to
refer the patient. See 45 CFR 164.506.
Case Study F/U
• His PCP contacts the family,
schedules an appointment for an
asthma assessment:
– Started on a daily control med
– An Asthma Action Plan copy is sent to
school (as requested)
• How will that have a positive impact?
» BTW, that was approximately 89 visits to the
nurse’s office in that 37 days of school
The Action Plan Request Letter
Dear Fellow Health Care Provider,
Enclosed / attached is a blank
Asthma Action Plan for your patient.
Please return or fax a copy back to
the attention of the school nurse.
This or any 3 zone action plan will be
very helpful, so if you already have an
updated action plan for this student,
a copy of that would be appreciated…
• Thank you for making the effort to
strengthen our collaborative
relationship and improve the asthma
care of children and adolescents in
our community.
• Results?
TEMS (800 students)
• 12/09
– 74 students with asthma medication orders
– 9 AAP (12%)
• Letter mailed to each student’s provider
• 3/10
– 48 AAP (65%)
The “Buy In”
Who’s buying in to what?
The Elephant in
the Room
Compliance
EPR 3 Component 2
• Education for a Partnership in Asthma
Care
• Concepts found in:
– Chronic Care Models
– Family-Centered Care
– Medical Home
The Chronic Care Model
• Use of explicit plans and protocols
• Practice Redesign (sick model doesn’t work)
• Patient Education (self-management behavior change,
on-going support for patients who participate)
• An “expert system” (decision support, provider
education, consultation)
• Supportive information systems (registries, outcomes,
feedback, care planning)
• Which of the following concepts is NOT
found within a Family-Centered Care
framework?
–
–
–
–
Professional as expert model
Screening for non-compliance
Create opportunities to make informed choices
Social work consult for all difficult patients and
families
Family/Professional Collaboration
• Seek mutually-acceptable plans & goals
vs.
Getting hung-up on
COMPLIANCE !

Assess & Negotiate:
Why is this plan not working?
Medication History
• What do assessing for medication
“compliance” and 3rd grade math have
in common?
• 7 x 2 = 14
• Or does it?
EPR 3 Component 2
• Asthma self-management is essential
• Self-management education should be
integrated into all aspects of care
• Involve all members of the health care team
• Occur at all points of care:
»
»
»
»
»
»
Primary Care
Specialty Care
Home
School
Acute Care / ED
Where Else?
Assessing Asthma
Control
Assessing Asthma Control and Adjusting
Therapy in Children 5 to 11 Years of Age
Not Well
Controlled
Very Poorly
Controlled
>2 days/week or multiple
times on ≤2 days/week
Throughout the day
≤1x/month
≥2x/month
≥2x/week
Interference with normal activity
None
Some limitation
Extremely limited
SABA use for symptom control
(not prevention of EIB)
2 days/week
>2 days/week
Several times per day
60%-80% predicted/
personal best
75%-80%
<60% predicted/
personal best
<75%
Components of Control
Symptoms
Nighttime awakenings
Impairment
Lung function
• FEV1 or peak flow
Risk
• FEV1/FVC
Exacerbations
requiring oral systemic
corticosteroids
Reduction in lung growth
Treatment-related
adverse effects
Recommended Action
for Treatment
Well Controlled
≤2 days/week but not more
than once on each day
>80% predicted/
personal best
>80%
0-1/year
≥2/year
Consider severity and interval since last exacerbation
Evaluation requires long-term follow-up
Medication side effects can vary in intensity from none to very troublesome and
worrisome. The level of intensity does not correlate to specific levels of control but
should be considered in the overall assessment of risk
• Maintain current step
• Step up at least 1 step and • Consider short course of
• Regular follow-up every • Reevaluate in 2 to
oral systemic corticosteroids
1 to 6 months
6 weeks
• Step up 1 or 2 steps, and
• Consider step down if
• For side effects, consider
• Reevaluate in 2 weeks
well controlled for at
alternative treatment
• For side effects, consider
least 3 months
options
alternative treatment options
Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3
2007). U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.
Assessing Asthma Control and Adjusting Therapy in
Youths ≥12 Years of Age and Adults
Components of Control
Impairment
Very Poorly
Controlled
Symptoms
≤2 days/week
>2 days/week
Throughout the day
Nighttime awakenings
≤2x/month
1-3x/week
≥4x/week
Interference with normal activity
None
Some limitation
Extremely limited
SABA use for symptom control
(not prevention of EIB)
≤2 days/week
>2 days/week
Several times per day
FEV1 or peak flow
>80% predicted/
personal best
60%-80% predicted/
personal best
<60% predicted/
personal best
Validated questionnaires
ATAQ
ACQ
ACT
Exacerbations requiring oral
systemic corticosteroids
Risk
Well Controlled
Not Well
Controlled
0
1-2
3-4
≤0.75
≥1.5
N/A
≥20
16-19
≤15
0-1/year
≥2/year
Consider severity and interval since last exacerbation
Progressive loss of lung function
Evaluation requires long-term follow-up
Treatment-related
adverse effects
Medication side effects can vary in intensity from none to very troublesome and
worrisome. The level of intensity does not correlate to specific levels of control but
should be considered in the overall assessment of risk
• Maintain current step
• Step up 1 step and
• Consider short course of
oral systemic corticosteroids
• Regular follow-ups
• Reevaluate in 2 to 6
every 1-6 months to
weeks
• Step up 1-2 steps, and
maintain control
• For side effects, consider • Reevaluate in 2 weeks
• Consider step down if
alternative treatment
• For side effects, consider
well controlled for at
options
alternative treatment options
least 3 months
Recommended Action
for Treatment
Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007).
U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.
#1
• Appreciate the Chronic &
Inflammatory nature of the
disease
A Key to Control
 Inhaled Steroids have become the
pharmacological key to long-term asthma
control. Daily use can:
Minimize the need for systemic steroids
 Decrease ED use and Hospitalization
 Decrease the potential for symptoms & acute
exacerbations
 Improve exercise and activity tolerance
Classifying Asthma Severity and Initiating Treatment in
Youths ≥12 Years of Age and Adults
Persistent
Components of Severity
Impairment
Normal FEV1/FVC:
8-19 yr
85%
20-39 yr
80%
40-59 yr
75%
60-80 yr
70%
Mild
Moderate
Severe
Symptoms
2 days/week
Nighttime awakenings
2x/month
3-4x/month
>1x/week but
not nightly
Often 7x/week
2 days/week
>2 days/week
but not daily and not
more than 1x on any day
Daily
Several times
per day
None
Minor limitation
Some limitation
Extremely limited
• FEV1 >80% predicted
• FEV1/FVC normal
• FEV1 >60% but
<80% predicted
• FEV1/FVC
reduced 5%
• FEV1 <60%
predicted
• FEV1/FVC
reduced >5%
SABA use for symptom
control (not prevention
of EIB)
Interference with
normal activity
Lung Function
Risk
Intermittent
Exacerbations
requiring oral
systemic
corticosteroids
• Normal FEV1
between
exacerbations
• FEV1 >80%
predicted
• FEV1/FVC normal
Daily
Throughout the day
≥2/year
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
0-1/year
Relative annual risk of exacerbations may be related to FEV1
Step 1
Recommended Step
for Initiating Treatment
>2 days/week but not daily
Step 2
Step 3
Step 4 or 5
and consider short course of oral
systemic corticosteroids
In 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly
EIB = exercise-induced bronchospasm; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity.
Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). U.S. Department of Health and
Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.
Asthma Control Report: For Family and Health Care Provider
Student/ Child’s
Name:
Age:
Home Town/City:
Grade:
School:
Date:
PART 1
School Nurse or asthma educator can assist the student or family in understanding the questions in a developmentally and culturally
appropriate manner in order to obtain objective and accurate information. Circle the correct response
YES
1.
Does your asthma get in the way or stop you from doing an activity in school, at home, during play or a sport?
If YES:
Rarely
(less than once a month)
Sometimes
(less than once a week)
NO
Frequently
(at least once a week)
2. In the past 4 weeks, how many times did you wheeze, cough, feel tight in the chest, or have trouble breathing?
Rarely
(2 or less times a month)
Sometimes
(3 – 8 times a month)
Frequently
( at least 3 times a week)
3. In the past 4 weeks, how many times did your asthma wake you up at night or make it hard to sleep?
Rarely
(2 or less times a month)
Sometimes
(2 – 4 times a month)
Frequently
( at least 4 times a month)
4. In the past 4 weeks, how many times did you have to use your rescue inhaler or nebulizer (albuterol or xopenex)?
Rarely
(2 or less times a month)
Sometimes
(3 – 8 times a month)
Frequently
( at least 3 times a week)
5. How many days of school have you missed this year because of your asthma?
PART 2
On a scale of 1 – 10: “1 being your asthma never really bothers you; and 10 being your asthma is so bad you should be in
the hospital” ,
What is your asthma number?
Yes
No
 Do you have a spacer to use with your inhaler?
o

If yes, how often do you use it?
Never
Sometimes
Always
Is there an Asthma Action Plan for this student at the school or in the
home?
Yes
No:
(blank
enclosed)
o If yes, most recent date:
PART 3
Known frequency of Albuterol or Xopenex use in: school or home (circle one). Can tally to keep track (IIII II = 7)
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
June
Planned
(Pre-Ex)
Acute
Sx’s
Any additional information you think would be helpful for this student’s health care provider or family to know:
Nurse or Assessor’s Printed Name:
Phone Number:
July
August
ACES Student Asthma Control Report: For Family and Health Care Provider
Part B: Compare how the student’s asthma control rates according to the 2007 National Asthma Guidelines
In the past 4 weeks:
Well Controlled
Not Well
Controlled
Very Poorly
Controlled
1.
How many times did your asthma get in the way or stop you from
doing an activity in school, at home, during play or a sport?
None
Sometimes
Frequently
2.
How many times did you wheeze, cough, feel tight in the chest, or
have trouble breathing?
2 or less
3-8
Every day
3.
How many times did your asthma wake you up at night or make it
hard to sleep?
2 or less
2-4
More than 4
4.
How many times did you have to use your rescue inhaler or
nebulizer (albuterol or xopenex)?
8 or less
More than 8
Answers in these
boxes should
indicate good
asthma control 
Any answers in
these sections
could indicate the
need for an
asthma visit
Usually
every day
Any answers in
these boxes
indicates the
need to call for
an asthma visit
Your Quality Asthma Management Checklist:
Is your asthma well controlled?
Have you had a planned asthma visit (not for an acute attack or exacerbation) in the past 6 months?
Are you sure that you know what your asthma allergies are?
Do you know how to avoid your asthma triggers and allergies?
Do you have a copy of an Asthma Action Plan that you understand and know how to use?
If you are able to check off the whole list – Great!

If not, or if you have any questions about asthma or medications, call your provider for an asthma visit
This project is in accordance with the CT Department of Public Health Collaborative Effort for Addressing Asthma in Connecticut:
2009-2014; The Yale New Haven Community Medical Group Pediatric Asthma Sub-Committee; and the ACES Students with Asthma
Quality Improvement Program
Any questions, please contact:
The Missing Links
Broad Categories of Why
Asthma Management Fails
Diagnosis
Treatment
Fixing what
doesn’t work
?
• MDI’s work better with Spacers!
• You should request a spacer to use
with all MDI orders
» Stop Laughing (again)
Teaching Moment:
Why a Spacer
Demonstrate what a puff of an MDI
looks like in the air and point out how
hard it is to make sure it is not
squirted on the tongue or back of
throat and how hard it is to breathe
in at exactly the right second
So Jimmy, do you
have a spacer to
use with that
inhaler?
Why a Spacer:
Sample Dialogue
• When discussing the use of an inhaler without
a spacer ask:
“Did you ever puff it so it felt like you
got it down in your lungs…. (yes)….
“Well did you ever miss a little and get it
on your tongue or the back of your
throat”
…(yes)…. “that’s medicine that doesn’t do
any good, it doesn’t help your asthma”
Useful Analogies:
Inhaled Asthma Meds only work if you
get them in your lungs
• Like taking 2
Tylenol for your
headache and
throwing one over
your shoulder
 You’re still going
to have a
headache
• Like eating pizza or
ice cream and
spitting it out or
like throwing
popcorn up in the
air and missing it
 You’re still going
to be hungry
• Identifying and avoiding allergens &
triggers is at least as important as
medication
• How much of the $12 billion that
asthma costs can we save if we stop
throwing fuel on the fire?
Allergy / Trigger
Medication
The Chronic Inflammation of Asthma
Medication
Allergy /
Trigger
The Chronic Inflammation of Asthma
Keys to Successful Asthma
Management for Students
• Just call it ASTHMA!
– Need a diagnosis
• Assess Control
• Obtain an Asthma Action Plan
– Use it to communicate and educate
• Focus on inhaled medication technique
• Improve environmental interventions
»Including your school’s IAQ
Your IAQ Program
• Does your school/district have one
• How active is it?
• How involved are you in it?
• Do you want to learn more about it?
IAQ Contacts
CT
http://csiert.tfsiaq.com
Karen_DeSimone@whps.org
mcorjulo@aces.org
Everywhere Else
http://www.epa.gov/iaq/whereyoulive.html
Sample Summary of Successful Asthma
Programs and Initiatives in CT
• In 2008 the ACES school system increased the number of
Asthma Action Plans from 12 to 164 in one SY
• The Yale Community Medical Group is standardizing
asthma management with all Yale-affiliated PCPs
• The CCMC based Easy Breathing Program has significantly
improved the number of children diagnosed with asthma
and decreased hospitalization
• The DPH has regional programs that will do in-home
asthma trigger evaluations and teaching
– And they accept school nurse referrals
Sample Summary of Successful Asthma
Programs and Initiatives in CT
• CT DPH has a lot of information about
statewide initiatives and resources
http://www.ct.gov/dph/cwp/view.asp?a=3137&
q=387872
Home
Schools
ED &
Hospitals
Community
Health Centers
Community
Educators
and SBHC
Communication
T
e
c
h
n
o
l
o
g
y
The Primary Care
Medical Home
Model
Coordination
Pulmonologists
and Allergists
F
u
n
d
i
n
g
Local Health
Departments
Home
Care and
VNA
Post-Test