Transcript School and asthma

School and asthma
Information for nurses who manage
asthma in the school setting
UC San Diego
AAP & CDC “Schooled in Asthma”
WA Chapter AAP
Asthma: a bigger
problem 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
In a classroom of 30 children,
2 or more children are likely to have asthma
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
Step 4
Days With
Symptoms
Nights With
Symptoms
Continuous
Frequent
PEF or
FEV1
60%
PEF
Variability
30%
Severe
Persistent
Step 3
Daily
5/month
60%-<80%
>2/week
3-4/month
80%
2/week
2/month
30%
Moderate
Persistent
Step 2
20-30%
Mild
Persistent
Step 1
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
2002 NIH Guidelines
• Stepwise Approach to
Asthma Management
• Consensus is that if
followed correctly
should control flareups
• Despite being
available, has had little
impact on asthma
management
Stepwise Approach to Therapy for Adults
and Children >Age 5: Maintaining
Control
STEP 4: Multiple long-termcontrol medications, including
oral corticosteroids + PRN quickrelief 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
Step down if
possible

Step up if
necessary
 Patient education
and
environmental
control at every
step
 Recommend
referral to
specialist at
Step 4; consider
referral at Step 3

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 /month
The “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 smoke
chalk 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)