Rachel Lawler RN, MSN, cPNP, AE-C, NPAT Lucile Packard Children’s Hospital Pediatric Pulmonary Division

Rachel Lawler RN, MSN, cPNP, AE-C, NPAT

Lucile Packard Children’s HospitalPediatric Pulmonary Division

State of Asthma Today7 million children have asthma… 1 in 11 in 2010In 2009

8.9 million doctor visits for asthma1.9 million ER visits479,300 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 asthmaAsthma costs the USA $56 billion a year

http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf

School Challenges

© NAPNAP 2011

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 exacerbationscommunicate 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

© NAPNAP 2011www.asthmainschools.com

Asthma-Friendly Schools Initiative Toolkit

http://www.lung.org/assets/documents/lung-disease/asthma/ala-afsi-brochure.pdf


© NAPNAP 2011

www.asthmainschools.com

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


© 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

© NAPNAP 2011

1. Remove cap from inhaler.2. Place in end of the valved holding

chamber.3. Expire all air from lungs. 4. Insert device into mouth.5. Actuate inhaler into chamber.6. Inhale as deeply and slowly as

possible.7. Hold breath for 5-10 seconds.8. Rinse mouth.

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 NebulizerRemove 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


© NAPNAP 2011


A plan of care for asthma prevention and

what to do when it gets worse!

© NAPNAP 2011

Use your Asthma Action Plan!

Provide strategies to improve activities

of daily life

Minimize school absenteeismMinimize parental work lossDecrease Emergency Room/ urgent care utilizationPromote sports participation

© NAPNAP 2011

Self-Management Plan should:

Emergency plan for worsening asthma:

Yellow zone: Coughing/wheezing/shortness of breathInitiate 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

3210

1. How is your asthma today?

2. How much of a problem is your asthma when you run, exercise or play sports?

3210

3. Do you cough because of your asthma?

4. Do you wake up during the night because of your asthma?

3210Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

It’s a big problem, I can’t do what I want to do. It’s a problem and I don’t like it. It’s a little problem but it’s okay. It’s not a problem

Very bad Bad Good Very Good

00 1 2 33

The Childhood Asthma Control Test for Assessing Control in Patients 4 to 11 Years of Age

© NAPNAP 2011

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?

Score

Patient Total Score

Copyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.

Asthma Control Test, 12 and older

© NAPNAP 2011

Rule of Twos

© NAPNAP 2011

Two doses of albuterol/weekTwo nights of symptoms/month

Two albuterol inhalers/yearTwo urgent clinic visits/yearTwo steroid bursts/year


© NAPNAP 2011www.asthmainschools.com

Environmental Triggersat School

MoldsMolds

GrassesGrasses

TreesTrees

AnimalsAnimals

RodentsRodents

SmokeSmoke

CockroachesCockroaches

PollutionPollution

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 possibleRemove furry pets from classrooms Limit exposure to chalk dustClean classroom well to reduce mold, rodents,

and cockroachesThis may assist in minimizing students’

exposure to allergens throughout the school environment and prevent exacerbations


© NAPNAP 2011


Asthma-Obesity-Inactivity

© NAPNAP 2011

Health Benefits of Exercising for Patients With AsthmaAs 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 Albuterol2 puffs of albuterol with spacer 20-30

minutes prior to intense play or PETrain teachers and coaches to monitor for

signs and symptoms of asthmaCough with or without wheeze Shortness of breathHunched shouldersDifficulty walking or talking

Allow students to have modified PE if asthma is exacerbated


© NAPNAP 2011


Components to include in education sessions with staff and

familiesPathophysiology

Anatomy of airways Bronchospasm Airway inflammation Mucus Production

© NAPNAP 2011

Components to include in education sessions with staff and

families

Common symptomsCoughDyspneaChest tightnessFatigueWheezing

© NAPNAP 2011

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

Components to include in education sessions with staff and familiesMedications

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


© NAPNAP 2011


Teamwork

Use every opportunity to teach and reinforce asthma education!

Family centered, culturally sensitive careObtain Medical documentation including Asthma Action Plan and Self-Medication formsCommunicate with teachers and families often in regards to frequency of symptoms, medication use, physical activity limitations, and absenteeismEstablish communication with the child’s PCP

NAPNAP © 2011

Goal, Goal, Goal. . . .Happy, healthy productive children!

© NAPNAP 2011

References and ResourcesNAPNAP: Pediatric Asthma Education Train-the

Trainer Curriculum Asthma-Friendly School Initiative Toolkit

www.lung.org/lung-disease/asthma/creating-asthma-friendly-environments/asthma-in-schools/asthma-friendly-schools-

initiativePublic Health School Asthma Project, an initiative

of Asthma Plan of Action, Canada www.asthmainschools.com

Environmental Management of Pediatric Asthmawww.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

Documents

Rachel Lawler RN, MSN, cPNP, AE-C, NPAT Lucile Packard Children’s Hospital Pediatric Pulmonary Division