School and asthma

1. School and asthma Information for nurses who manage asthma in the school setting UC San Diego AAP & CDC “Schooled in Asthma” WA Chapter AAP

2. 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

3. In a classroom of 30 children, 2 or more children are likely to have asthma

4. 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

5. 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

6. Laws and regulations • Section 504 (of Rehabilitation Act) • Americans with Disabilities Act (ADA) • Individuals with Disabilities Education Act (IDEA) • Individualized Education Program (IEP)

7. 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

8. School Asthma Team Student Parents Health care provider School nurse, classroom teacher, PE teacher, coach, principal, after-school staff

9. 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

10. 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% Severe Persistent Step 3Daily 5/month 60%-<80% 30% Moderate Persistent Step 2>2/week 3-4/month 80% 20-30% Mild Persistent Step 12/week 2/month 80% 20% Mild Intermittent Footnote: The patient’s step is determined by the most severe feature. NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org .

11. 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

12. Stepwise Approach to Therapy for Adults and Children >Age 5: Maintaining Control • Step down if possible • Step up if necessary • Patient education and environmental control at every step • Recommend referral to specialist atStep 4; consider referral at Step 3 STEP 4: Multiple long-term-control medications, includingoral corticosteroids + PRN quick-relief inhaler STEP 3: > 1 Long-term-control medications + PRN quick-relief inhaler STEP 2: 1 Long-term-control medication:anti-inflammatory + PRN quick-relief inhaler STEP 1: Mild Intermittent Quick-relief medication: PRN NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

13. 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 /month The “rule of 6” • Significant exacerbations more than every 6 weeks NAEPP. “Pediatric Asthma: Promoting Best Practice”. 1999. www.aaaai.org

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

26. 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

27. Provide healthy school environment • Potential triggers: dust mold pollen dander tobacco smoke chalk odors cleaning solution auto-exhaust • Know child’s specific triggers • Collaborate with • parents • teachers • custodial staff • district to minimize triggers

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Be aware of community programs • Asthma camps • www.asthmacamps.org • Health fairs • ALA, AAFA programs (e.g. Open Airways) • Asthma coalitions

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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)