Controlling Controlling Asthma:Asthma:

Preventing Episodes Preventing Episodes BeforeBefore

They Occur They Occur

Is There A Cure For Is There A Cure For Asthma?Asthma?

Asthma cannot be cured, but it Asthma cannot be cured, but it can becan be ControlledControlled

““We should expect nothing less”!We should expect nothing less”!

Goals Of Asthma ControlGoals Of Asthma Control Prevent SymptomsPrevent Symptoms

• No coughing or wheezingNo coughing or wheezing• No shortness of breath or rapid breathingNo shortness of breath or rapid breathing• No waking up at nightNo waking up at night

Maintain normal or near “normal” pulmonary functionMaintain normal or near “normal” pulmonary function Maintain normal activity levels (including exercise and Maintain normal activity levels (including exercise and

other physical activitiesother physical activities Prevent exacerbations of asthma and minimize ER/UC Prevent exacerbations of asthma and minimize ER/UC

and hospital visitsand hospital visits Minimal or no adverse effects from medicationsMinimal or no adverse effects from medications Meet patients/family’s expectations and satisfaction Meet patients/family’s expectations and satisfaction

with asthma carewith asthma careExerts from NAEPP EPR2 Guidelines for Diagnosis and Management of Asthma 1997Exerts from NAEPP EPR2 Guidelines for Diagnosis and Management of Asthma 1997

Asthma ControlAsthma Control Do Most Students Have Do Most Students Have

It?It?

UnfortunatelyUnfortunately NO!NO!Many students who have asthmaMany students who have asthma::• Have poor asthma controlHave poor asthma control• Use “quick relief” medicine (e.g. albuterol) Use “quick relief” medicine (e.g. albuterol)

on a regular basison a regular basis• Cough, experience chest tightness, Cough, experience chest tightness,

wheezing, or shortness of breath regularly wheezing, or shortness of breath regularly • Assume suffering from symptoms are Assume suffering from symptoms are

“normal”“normal”• Remain indoors and cannot fully participate Remain indoors and cannot fully participate

in sports, PE or recessin sports, PE or recess• Miss school due to asthmaMiss school due to asthma

Examples Of Students Whose Examples Of Students Whose Asthma Is Asthma Is NOTNOT Optimally Optimally

ControlledControlled • A 10th grader, says he feels fine except A 10th grader, says he feels fine except

when he runs in PE class, then his chest when he runs in PE class, then his chest hurts. He coughs most mornings and hurts. He coughs most mornings and whenever he gets a cold or virus. He whenever he gets a cold or virus. He often can’t keep up with the other kids often can’t keep up with the other kids and needs to stop and rest. and needs to stop and rest.

• A 12th grader, carries an OTC Primatine A 12th grader, carries an OTC Primatine Mist inhaler & uses it a few times every Mist inhaler & uses it a few times every day. He says he “grew out” of his asthma.day. He says he “grew out” of his asthma.

Examples Of Students Whose Examples Of Students Whose AsthmaAsthma

IS IS Optimally ControlledOptimally Controlled• A 6th grader, doesn’t need his A 6th grader, doesn’t need his

“reliever”(albuterol) since consistently using his “reliever”(albuterol) since consistently using his controller medications twice daily. He now plays controller medications twice daily. He now plays soccer without developing symptoms or having soccer without developing symptoms or having to take pre-exercise albuterol.to take pre-exercise albuterol.

• A kindergartener, no longer coughs or wheezes A kindergartener, no longer coughs or wheezes and easily keeps up with the other kids at and easily keeps up with the other kids at recess. Her dad bought special dust mite proof recess. Her dad bought special dust mite proof covers for her mattresses and pillow. She now covers for her mattresses and pillow. She now takes her controllers daily, uses her Asthma takes her controllers daily, uses her Asthma Action Plan, and sees her health care provider Action Plan, and sees her health care provider every 6 months for a well asthma check-up.every 6 months for a well asthma check-up.

Asthma Severity Level vs Asthma Severity Level vs Asthma ControlAsthma Control

Asthma Severity LevelsAsthma Severity Levels (Mild Intermittent, (Mild Intermittent, Mild Persistent, Moderate Persistent, and Severe Mild Persistent, Moderate Persistent, and Severe Persistent)Persistent)Based on signs and symptoms Based on signs and symptoms beforebefore a a

student starts on controller medicationsstudent starts on controller medicationsLevels can change over timeLevels can change over time

Asthma ControlAsthma Control (or “Current Asthma (or “Current Asthma Severity”)Severity”)Is the students Is the students currentcurrent severity level- severity level-

regardless if they are on medications, regardless if they are on medications,

experiencing symptoms (episodes) and/or experiencing symptoms (episodes) and/or able to be fully activeable to be fully active

Asthma Control Asthma Control Proactive vs ReactiveProactive vs Reactive

• Going from a Going from a reactivereactive to a to a proactive proactive approachapproachInstead of thinkingInstead of thinking--

“ “ How do I treat these symptoms?” How do I treat these symptoms?” e.g. with albuterol after the facte.g. with albuterol after the fact

ThinkThink--“ “ How could have the symptoms have been How could have the symptoms have been

prevented in the first place?”prevented in the first place?” e.g. daily controller medications, pre-exercise e.g. daily controller medications, pre-exercise

meds, asthma action plan, environmental meds, asthma action plan, environmental controlcontrol

Controlling AsthmaControlling Asthma

Medical Medical & &

EnvironmentalEnvironmental ManagementManagement

Controlling Asthma Controlling Asthma Medical Management Medical Management

How To Achieve Good How To Achieve Good Asthma ControlAsthma Control

Have regular asthma check-ups with a primary Have regular asthma check-ups with a primary healthcare provider, even when feeling wellhealthcare provider, even when feeling well• At least every 6 months (more often if having At least every 6 months (more often if having

symptoms)symptoms) Monitor symptoms and peak flow readings dailyMonitor symptoms and peak flow readings daily Ask for and use a personalized Asthma Action Ask for and use a personalized Asthma Action

PlanPlan Know personal green- yellow- red zones, what Know personal green- yellow- red zones, what

each zone feels like and what to do in each zoneeach zone feels like and what to do in each zone

Asthma Control Asthma Control Continued...Continued...

Get a flu shot every fallGet a flu shot every fall Avoid asthma triggersAvoid asthma triggers Asthma’s not in control? Check in regularly Asthma’s not in control? Check in regularly

at school health office for:at school health office for:• Peak flow check /symptom evaluationPeak flow check /symptom evaluation• Lung sounds / respiratory rate checkLung sounds / respiratory rate check• Pre-exercise and/or controller meds Pre-exercise and/or controller meds • Asthma educationAsthma education• Care coordinationCare coordination

Asthma Action PlanAsthma Action Plan

See MDH Asthma Action PlanSee MDH Asthma Action Plan F1F1

Written Asthma Action Written Asthma Action PlansPlans

Developed by the health care provider for Developed by the health care provider for each individual child with asthmaeach individual child with asthma

Medications are determined by asthma Medications are determined by asthma severity level severity level

Based on symptoms and peak flow rates Based on symptoms and peak flow rates Lists daily & rescue medicationsLists daily & rescue medications Symptom management and emergency Symptom management and emergency

planplan Copies to be shared by clinic, family and Copies to be shared by clinic, family and

school school

Asthma Action Plan Asthma Action Plan ZonesZones

Green ZoneGreen Zone: : All Clear/Breathing All Clear/Breathing Good/Go Good/Go – No asthma symptoms and/or No asthma symptoms and/or – Peak flow 80-100% Predicted or Personal bestPeak flow 80-100% Predicted or Personal best

Yellow ZoneYellow Zone:: Caution/Slow DownCaution/Slow Down– Some asthma symptoms and/orSome asthma symptoms and/or– Peak flow 50-80% Predicted or Personal bestPeak flow 50-80% Predicted or Personal best

Red ZoneRed Zone: : Medical Alert/StopMedical Alert/Stop– Severe asthma symptoms and/or Severe asthma symptoms and/or – Peak flow < 50% Predicted or Personal bestPeak flow < 50% Predicted or Personal best

What Can A Student Do To Stay What Can A Student Do To Stay In The Green Zone?In The Green Zone?

Select The Select The IncorrectIncorrect AnswerAnswerAA. Take their controller (anti-inflammatory) . Take their controller (anti-inflammatory)

medication every daymedication every dayBB. Avoid cigarette smoke and other asthma . Avoid cigarette smoke and other asthma

triggerstriggersC.C. Take their pre-exercise (usually reliever) Take their pre-exercise (usually reliever)

medicine before P.E. or at recessmedicine before P.E. or at recessD.D. Wash their bathroom often with bleach Wash their bathroom often with bleach

to avoid mold and mildew build-upto avoid mold and mildew build-up

What Can A Student Do To Stay What Can A Student Do To Stay In The Green one? In The Green one?

Select The Select The IncorrectIncorrect AnswerAnswerA.A.Take their controller (anti-inflammatory) Take their controller (anti-inflammatory)

medication every daymedication every dayB.B. Avoid cigarette smoke and other Avoid cigarette smoke and other

asthma triggersasthma triggersC. C. Take their pre-exercise (usually Take their pre-exercise (usually

reliever) medicine before P.E. or at reliever) medicine before P.E. or at recessrecess

D. Wash their bathroom often with bleach Wash their bathroom often with bleach to avoidto avoid mold and mildew build-upmold and mildew build-up

If A Student Is In The Yellow Zone, If A Student Is In The Yellow Zone,

TheyThey Should:Should: A.A.Be cautious. Breathing isn’t their Be cautious. Breathing isn’t their

best. Take actionbest. Take actionB.B.Eat a lot of yellow foods such as Eat a lot of yellow foods such as

bananas, which are high in potassiumbananas, which are high in potassiumC.C.Automatically stay home from schoolAutomatically stay home from schoolD.D.Call their doctor or nurse practitioner Call their doctor or nurse practitioner

immediately immediately

If A Student Is In The Yellow If A Student Is In The Yellow Zone, Zone,

They They Should:Should:A.A. Be cautious. Breathing isn’t their best. Take Be cautious. Breathing isn’t their best. Take

actionactionB.B. Eat a lot of yellow foods such as bananas, Eat a lot of yellow foods such as bananas,

which are high in potassiumwhich are high in potassiumC.C. Automatically stay home from school Automatically stay home from schoolD. D. Call their doctor or nurse practitioner Call their doctor or nurse practitioner

immediately immediately (correct answer: call if they aren’t (correct answer: call if they aren’t fully back into the green zone within 48-72 fully back into the green zone within 48-72 hours).hours). R1R1

Which Is One Symptom/ Clinical Which Is One Symptom/ Clinical Indicator Is Indicator Is NOTNOT Associated With Associated With

The Red Zone?The Red Zone?

AA. Mild coughing . Mild coughing BB. Peak Flow reading < 50% of personal . Peak Flow reading < 50% of personal

best best C.C. Significant breathing problems Significant breathing problemsD.D. Persistent wheezing or no wheezing at Persistent wheezing or no wheezing at

all indicating severely limited aerationall indicating severely limited aeration

Which Is One Symptom/ Clinical Which Is One Symptom/ Clinical Indicator Is Indicator Is NotNot Associated With Associated With

the Red Zone?the Red Zone?AA.. Mild coughingMild coughing BB. Peak Flow reading < 50% of personal . Peak Flow reading < 50% of personal

best best CC. Significant breathing problems. Significant breathing problemsDD. Persistent wheezing or no wheezing at . Persistent wheezing or no wheezing at

all indicating severely limited aerationall indicating severely limited aeration

ActivityActivityGroup Group Case DiscussionCase Discussion

The first month of school, you are called The first month of school, you are called to an elementary school by a substitute to an elementary school by a substitute teacher. She sent a 3teacher. She sent a 3rdrd grader to the grader to the nurse’s office alone, and told her to lay nurse’s office alone, and told her to lay down.down.

When you arrive, child has neck vein When you arrive, child has neck vein distension, accessory muscle retractions, distension, accessory muscle retractions, dark/dusky color. No inhaler availabledark/dusky color. No inhaler available

Mom is 45 min. away.Mom is 45 min. away. Grandma is in townGrandma is in town WHAT DO YOU DO?WHAT DO YOU DO?

Answer:Answer:Provide emergency care and Provide emergency care and

medication per AAP/ medication per AAP/ Management plan and Management plan and

CALL 911!CALL 911!

Controlling Asthma - Controlling Asthma - Environmental Environmental ManagementManagement

Common Environmental Common Environmental TriggersTriggers At SchoolsAt Schools

• Indoor TriggersIndoor TriggersAnimals with furAnimals with furDust mitesDust mitesMoldMoldPestsPestsSecondhand smokeSecondhand smokeChemicals Chemicals

(e.g. strong smelling (e.g. strong smelling cleaning supplies, cleaning supplies, perfume, air fresheners)perfume, air fresheners)

• Outdoor Outdoor TriggersTriggersOzoneOzoneParticulate matterParticulate matterDiesel exhaustDiesel exhaustChemicalsChemicals

((e.g. re-surfacing the e.g. re-surfacing the playground or roof, playground or roof, etc.)etc.)

AnimalsAnimals• Dander, urine & saliva are triggersDander, urine & saliva are triggers• Triggers remain months after animal pet removedTriggers remain months after animal pet removed• Actions:Actions:

Prohibit/remove animals from schools if ableProhibit/remove animals from schools if able If removal is not possible:If removal is not possible:

» Keep animals in cages or localized areasKeep animals in cages or localized areas» Clean cages oftenClean cages often» Keep animals away from fabric furniture, carpet & Keep animals away from fabric furniture, carpet &

ventilation systemventilation system» Locate sensitive students away from animalsLocate sensitive students away from animals

Pre-notify parents if animals with fur/feathers visitPre-notify parents if animals with fur/feathers visit• Sample Animals in School Guidelines in manualSample Animals in School Guidelines in manual

R1R1

Dust MitesDust Mites• Both cause & trigger asthma; live in pillows, Both cause & trigger asthma; live in pillows,

carpet, fabric-covered furniture, curtains carpet, fabric-covered furniture, curtains • Actions:Actions:

Keep classrooms clutter-freeKeep classrooms clutter-free Make informed decision: presence of carpetMake informed decision: presence of carpet Vacuum often when people with Vacuum often when people with

asthma/allergies are gone (HEPA filter vacuum asthma/allergies are gone (HEPA filter vacuum cleaners may help)cleaners may help)

Pillows/mattress/box spring in dust-mite proof Pillows/mattress/box spring in dust-mite proof zipped coverszipped covers

Wash bedding and stuffed toys weekly in Wash bedding and stuffed toys weekly in HOTHOT water (>130 degrees F)water (>130 degrees F)

Keep room humidity < 50% if possibleKeep room humidity < 50% if possible

MoldMold• Moisture control is keyMoisture control is key• ActionsActions::

Report leaks and wet/moist areas right awayReport leaks and wet/moist areas right away Wash mold off hard surfacesWash mold off hard surfaces Replace moldy porous items such as ceiling Replace moldy porous items such as ceiling

tiles & carpettiles & carpet Avoid carpet in areas with regular moisture Avoid carpet in areas with regular moisture

such as drinking fountains & sinkssuch as drinking fountains & sinksE9E9

PestsPests• Droppings or body parts can trigger asthmaDroppings or body parts can trigger asthma• ActionsActions::

Use integrated pest management (IPM) methodsUse integrated pest management (IPM) methods» Don’t leave food, water or garbage exposedDon’t leave food, water or garbage exposed» Don’t eat or drink in classroomDon’t eat or drink in classroom» Seal entry points for pestsSeal entry points for pests» Use pesticides only as neededUse pesticides only as needed

Parent Right to Know Act: must notify parents & Parent Right to Know Act: must notify parents & employees when using specific pesticidesemployees when using specific pesticides F32, F33, F34F32, F33, F34

Secondhand SmokeSecondhand Smoke• Causes asthma in young children & triggers Causes asthma in young children & triggers

asthma in children & adultsasthma in children & adults• Contains over 4,000 substancesContains over 4,000 substances• State law prohibits tobacco use in K-12 public State law prohibits tobacco use in K-12 public

schoolsschools• ActionsActions::

Enforce smoking bans (for anyone on school Enforce smoking bans (for anyone on school property)property)

Include anti-smoking message in curriculumInclude anti-smoking message in curriculum Encourage parents/guardians to quit smoking or to Encourage parents/guardians to quit smoking or to

not smoke not smoke insideinside their home their home

Outdoor AirOutdoor Air• Ozone & fine particles are concerns in Ozone & fine particles are concerns in

MNMN• Staff have little control over outdoor airStaff have little control over outdoor air• ActionsActions::

Sign up for Air Quality Index noticeSign up for Air Quality Index notice» Pollution Control Agency sends e-mail alerts Pollution Control Agency sends e-mail alerts

when they expect poor air quality (regional)when they expect poor air quality (regional)Avoid being outside at high pollen count Avoid being outside at high pollen count

times, especially if students are allergic to times, especially if students are allergic to particular pollen/sparticular pollen/s

Sept. 14, 2000/June 28, Sept. 14, 2000/June 28, 20012001

The AQIThe AQI

Average Number Of Average Number Of AlertsAlerts

6-12 alerts per year in last few 6-12 alerts per year in last few yearsyears

Most due to PM2.5Most due to PM2.5 Not violation of federal air Not violation of federal air

quality standards thus farquality standards thus far Health issues still validHealth issues still valid

2003 – Air Pollution 2003 – Air Pollution Health AlertsHealth Alerts

Expanded AQI to Duluth, St. Expanded AQI to Duluth, St. Cloud, RochesterCloud, Rochester

Detroit Lakes, Marshall coming Detroit Lakes, Marshall coming soonsoon

Expanded media coverage Expanded media coverage (Pioneer Press, TV meteorologists, (Pioneer Press, TV meteorologists, health reporters, others)health reporters, others)

Expanded web & e-mail alert Expanded web & e-mail alert signupsignup

MPCA’s AQI web page 1MPCA’s AQI web page 1

MPCA’s AQI web page 2MPCA’s AQI web page 2

School BusesSchool Buses• State law requiresState law requires::

Reduce unneeded idling in front of Reduce unneeded idling in front of schoolsschools

Reroute bus parking zones away from Reroute bus parking zones away from air intakes, if possibleair intakes, if possible

• Actions:Actions:Post “no idling” signsPost “no idling” signsMaintain bus fleetMaintain bus fleet Invest in cleaner fuelsInvest in cleaner fuelsPurchase newer, cleaner buses over Purchase newer, cleaner buses over

long-termlong-termR2, R3, R4R2, R3, R4

Other Environmental Other Environmental IssuesIssues

• Indoor Air Quality Management PlanIndoor Air Quality Management Plan• Cleaning & cleaning productsCleaning & cleaning products• FlooringFlooring• Air cleanersAir cleaners

R7R7

Home Environment Home Environment ResourcesResources

• US Environmental Protection Agency US Environmental Protection Agency Asthma Home Environment ChecklistAsthma Home Environment Checklist

» 8 page checklist of common asthma triggers8 page checklist of common asthma triggers» Questions to identify triggers & action stepsQuestions to identify triggers & action steps

Clear Your Home of Asthma TriggersClear Your Home of Asthma Triggers fact sheet fact sheet• EPA websiteEPA website www.epa.gov/iaq/asthma/resources.htmlwww.epa.gov/iaq/asthma/resources.html

Communication &Communication &Care CoordinationCare Coordination

Key Communication Key Communication TriadTriad

Child

Health CareHealth Care ProvidersProviders

ParentParent/GuardianGuardian

School HealthSchool HealthOfficeOffice

Care Coordination / Care Coordination / Communication Communication (Health (Health Assistant / Paraprofessional/LPN Assistant / Paraprofessional/LPN Role)Role) Health Assistants / Paraprofessionals / LPNs Health Assistants / Paraprofessionals / LPNs

must alert LSN/PHN/RNs of students who must alert LSN/PHN/RNs of students who come in frequently with asthma type come in frequently with asthma type symptomssymptoms

Monitor students with asthma as directed Monitor students with asthma as directed by LSN/PHN/RNby LSN/PHN/RN

Perform delegated responsibilities once Perform delegated responsibilities once skills have been validated per skills have been validated per district/school policiesdistrict/school policies

Care Coordination Care Coordination /Communication/Communication (LSN/RN/PHN)(LSN/RN/PHN)

• Examples of asthma care Examples of asthma care coordination activitiescoordination activitiesRequest AAPs on studentsRequest AAPs on studentsReview AAP and/or IHP and develop/modify Review AAP and/or IHP and develop/modify

plan for care coordination plan for care coordination Determine medical insurance status and Determine medical insurance status and

connect to appropriate provider(s) connect to appropriate provider(s) Arrange for special transportation (in Arrange for special transportation (in rare rare

cases) prncases) prnConnect to community resourcesConnect to community resources

Care Coordination/ Care Coordination/ CommunicationCommunication

• Communicating with StudentsCommunicating with Students• Educate them toEducate them to::

Follow an individualized Asthma Action PlanFollow an individualized Asthma Action Plan Avoid or control exposure to their triggersAvoid or control exposure to their triggers Use medication appropriatelyUse medication appropriately

• Long-term-control medicineLong-term-control medicine• Quick-relief medicineQuick-relief medicine

Monitor symptoms and response to Monitor symptoms and response to treatmenttreatment

• Understand symptoms and peak flow levelsUnderstand symptoms and peak flow levels• Seek a health care providers help when neededSeek a health care providers help when needed

Communicating w/ StudentsCommunicating w/ Students Continued.. Continued..

Get regular follow-up careGet regular follow-up care Be able to exercise/ play at optimal Be able to exercise/ play at optimal

levelslevels Be responsible for carrying and using Be responsible for carrying and using

their asthma medications per school their asthma medications per school policiespolicies

Ask for help when they need it!Ask for help when they need it!

Care Coordination/ Care Coordination/ CommunicationCommunication

• Communicating with Communicating with parents/guardiansparents/guardians Review parent/guardian and student questionnairesReview parent/guardian and student questionnaires Determine current asthma severity levelsDetermine current asthma severity levels Provide education to family/student as neededProvide education to family/student as needed Encourage questions and give feedback Encourage questions and give feedback Contact parent/guardian every time a student has Contact parent/guardian every time a student has

asthma symptoms and or if having poor asthma asthma symptoms and or if having poor asthma control control

Obtain a signed consent to release/ share information Obtain a signed consent to release/ share information

F11, F14, F3, E1, F7F11, F14, F3, E1, F7

Care Coordination / Care Coordination / CommunicationCommunication

• Communicating with health care Communicating with health care providersproviders Report status changes and re-evaluation needsReport status changes and re-evaluation needsAdvocate for pre-exercise and /or controller Advocate for pre-exercise and /or controller

medications as appropriatemedications as appropriateArrange for asthma education Arrange for asthma education Complete IHP and/or ECP Complete IHP and/or ECP ifif needed neededDocument as appropriate in Pupil Health RecordDocument as appropriate in Pupil Health RecordEvaluate symptoms, lung sounds and peak flow Evaluate symptoms, lung sounds and peak flow

regularly on poorly controlled studentsregularly on poorly controlled students

F17, F18F17, F18

Communicating With School Communicating With School StaffStaff

Share information with staff on a need to Share information with staff on a need to know basis onlyknow basis only

Maintain student confidentialityMaintain student confidentiality Provide general asthma education to staff Provide general asthma education to staff

proactivelyproactively Provide asthma first aid training to staffProvide asthma first aid training to staff Act as a resource to school staff for Act as a resource to school staff for

questions and concernsquestions and concerns

Health Office ScenarioHealth Office Scenario• A 4th grade student who you have not A 4th grade student who you have not

seen in the health office this year for seen in the health office this year for asthma symptoms, has a diagnosis of asthma symptoms, has a diagnosis of asthma in her record, and has albuterol asthma in her record, and has albuterol MDI / orders in the health office at MDI / orders in the health office at school, but no Asthma Action Plan. She school, but no Asthma Action Plan. She comes into the health office with a comes into the health office with a persistent cough.persistent cough.

• What would you do for her?What would you do for her?

Health Office Scenario Health Office Scenario ContinuedContinued......

• ActionsActionsPhysical Assessment Physical Assessment (respiratory rate, (respiratory rate,

breath sounds, severity of symptoms)breath sounds, severity of symptoms)Ask what she was doing before coming Ask what she was doing before coming

into the health office / what may have into the health office / what may have precipitated symptomsprecipitated symptoms

Ask frequency of day / nighttime Ask frequency of day / nighttime symptomssymptoms

Check height/PF chart for predicted PF Check height/PF chart for predicted PF and initiate Asthma Record and initiate Asthma Record

F5 F5

Health Office Scenario Health Office Scenario Continued...Continued...

Check her Peak Flow reading and Check her Peak Flow reading and document in SHOAR document in SHOAR F4F4» Instruct the child how to do a PF reading Instruct the child how to do a PF reading

Give albuterol Give albuterol (observe inhaler technique)(observe inhaler technique) Teach/reinforce proper inhaler technique, use Teach/reinforce proper inhaler technique, use

of spacer or holding chamber with inhaler of spacer or holding chamber with inhaler Monitor her for response to medicationMonitor her for response to medicationSend note home with the child using the Send note home with the child using the

AVN AVN F8F8 andand a PAQa PAQ F11F11

Health Office Scenario Health Office Scenario Continued...Continued...

• Two days later, she returns to the Two days later, she returns to the health office, with cough and shortness health office, with cough and shortness of breathof breath

• What would you do for this 4th grader What would you do for this 4th grader first?first?

• What would be the next steps or what What would be the next steps or what else should you do at this point?else should you do at this point?

Health Office Scenario Health Office Scenario ContinuedContinued……

• What else should you do now?What else should you do now? Re-evaluate her respiratory status and Re-evaluate her respiratory status and

treat as appropriate treat as appropriate Call her parent / guardian to notify, ask for Call her parent / guardian to notify, ask for

parent questionnaire/more info.parent questionnaire/more info.Suggest she see her health care providerSuggest she see her health care providerAsk the child to come see you the next Ask the child to come see you the next

day for a follow up checkday for a follow up checkIf you have consent, fax Asthma Medical If you have consent, fax Asthma Medical

Referral/Request to health care providerReferral/Request to health care provider F9F9

Asthma Management In Asthma Management In The School Health The School Health

OfficeOffice

Sample Forms For Sample Forms For Optimal School Asthma Optimal School Asthma

ManagementManagement

Key Asthma ToolsKey Asthma Tools• Components of Asthma Management in the Components of Asthma Management in the

Health Office Health Office E2, E3E2, E3• Asthma Action Plan w/ imbedded consents, Asthma Action Plan w/ imbedded consents,

parent letter parent letter F1, F2F1, F2• Asthma Visit Notification form Asthma Visit Notification form F7, F8F7, F8• Asthma Medical Request/Referral Asthma Medical Request/Referral F9, F10F9, F10• Pathway for Acute School Asthma Care Pathway for Acute School Asthma Care E6,E6,

E7E7• Emergency Care Plan - Asthma Emergency Care Plan - Asthma F18F18 • Individualized Health Plan - Asthma Individualized Health Plan - Asthma F17F17

Key Asthma ToolsKey Asthma Tools• Parent/Guardian Breathing/Asthma Parent/Guardian Breathing/Asthma

Questionnaire Questionnaire F11, F12, F13F11, F12, F13• Student Breathing/Asthma Questionnaire Student Breathing/Asthma Questionnaire F14, F14,

F15, F16F15, F16• School Health Office Asthma Record School Health Office Asthma Record F4, F5, F4, F5,

F6F6• Self-administration Asthma Medication Self-administration Asthma Medication

Authorization Authorization F19, F20F19, F20• First Aid for Asthma poster / pocket cardsFirst Aid for Asthma poster / pocket cards E4, E4,

E5E5• Asthma Green/Yellow Zone Update Asthma Green/Yellow Zone Update F23, F24F23, F24• Permanent Health Office Pass Permanent Health Office Pass F25 F25

Components Of Asthma Components Of Asthma Management In School Health Management In School Health

OfficeOffice Two Models Provided in School Asthma Two Models Provided in School Asthma

ManualManual• LSN + Health Assistant LSN + Health Assistant (Mpls. Public Schools model)(Mpls. Public Schools model) E2E2• LSN + Secretary LSN + Secretary (St. Paul Public Schools model) (St. Paul Public Schools model) E3E3

Purpose:Purpose: Provides job specific instructions for Provides job specific instructions for providing quality asthma care in the school health providing quality asthma care in the school health office office • Licensed School Nurse, Public Health Nurse, Licensed School Nurse, Public Health Nurse,

Registered NurseRegistered Nurse• Licensed Practical NurseLicensed Practical Nurse• Health Aid/Service Assistant / ParaprofessionalHealth Aid/Service Assistant / Paraprofessional• Secretary / Administrative AssistantSecretary / Administrative Assistant

Asthma Screening Asthma Screening QuestionsQuestions

Include these 3 questions into your Include these 3 questions into your existing student health existing student health

questionnairequestionnaire1.1. Does your child have asthma or other Does your child have asthma or other

breathing problems?breathing problems?2.2. Has your child ever been diagnosed by a Has your child ever been diagnosed by a

doctor as having asthma?doctor as having asthma?3.3. Has your child had episode(s) of wheezing Has your child had episode(s) of wheezing

(whistling in the chest) in the last 12 (whistling in the chest) in the last 12 months? months?

Asthma Action Plan (AAP) Asthma Action Plan (AAP) • PurposPurposee Provides a plan to guide the asthma Provides a plan to guide the asthma

management of individual studentsmanagement of individual studentsIncludes imbedded consents:Includes imbedded consents:

» Allow parents/guardians and providers to give Allow parents/guardians and providers to give permission for medications to be given at school permission for medications to be given at school

» Allow for sharing/release of information between Allow for sharing/release of information between school, clinic, hospital, child care provider and school, clinic, hospital, child care provider and home care home care

• Available in English and SpanishAvailable in English and Spanish

Asthma Visit Asthma Visit Notification Form (AVN)Notification Form (AVN)

• PurposePurpose Increases communication between the Increases communication between the

school health office, parents/guardians, school health office, parents/guardians, and primary care/asthma care providersand primary care/asthma care providersFill out and send home whenever the student Fill out and send home whenever the student

is in the health office with asthma symptomsis in the health office with asthma symptomsOr when delegated by the LSN/PHN/RNOr when delegated by the LSN/PHN/RN

F7,F8F7,F8

Asthma Medical Asthma Medical Request (AMRRequest (AMR))

• PurposePurpose To facilitate communication and care To facilitate communication and care

coordination between the health care coordination between the health care provider and the school nurse about the provider and the school nurse about the student’s asthma status/managementstudent’s asthma status/management Fill out and fax, mail to health care providersFill out and fax, mail to health care providers You must have the parents written consent to You must have the parents written consent to

collect medical information firstcollect medical information firstF9, F10F9, F10

Pathway for Acute Pathway for Acute School Asthma CareSchool Asthma Care

• PurposePurpose Assists school nurses in making decisions Assists school nurses in making decisions

regarding the provision of acute asthma regarding the provision of acute asthma care in the school health office or other care in the school health office or other school settingschool setting Designed to be used for students experiencing Designed to be used for students experiencing

mild, moderate or severe asthma symptomsmild, moderate or severe asthma symptoms

E6, E7E6, E7

Asthma Emergency Care Asthma Emergency Care Plan Plan

(ECP) (ECP) • PurposePurpose

Provides special instructions to selected Provides special instructions to selected school staff on howschool staff on how to respond to an to respond to an asthma emergencyasthma emergencyUsed with students with severe or labile Used with students with severe or labile

asthmaasthmaIndividualized for each student with asthmaIndividualized for each student with asthma

F18F18

Asthma Individualized Asthma Individualized Health Plan (IHP)Health Plan (IHP)

• PurposePurpose Provides a Nursing Plan of Care and promotes Provides a Nursing Plan of Care and promotes

care coordination and communication between care coordination and communication between the school nurse and health office staff regarding the school nurse and health office staff regarding students whose asthma is not in good controlstudents whose asthma is not in good control

• Also used to document special Also used to document special education nursing serviceseducation nursing services

F17F17

Parent / Guardian Asthma Parent / Guardian Asthma QuestionnaireQuestionnaire (PQ) (PQ)

• PurposePurposeUsed To:Used To: Gather baseline information about the child’s Gather baseline information about the child’s

asthma symptoms asthma symptoms Determine the child’s asthma severity level Determine the child’s asthma severity level Determine if the child’s asthma is under controlDetermine if the child’s asthma is under control Develop an appropriate plan of careDevelop an appropriate plan of care

• Typically used for students in 5th grade or Typically used for students in 5th grade or lowerlower

F11, F12, F13F11, F12, F13

Student Breathing Student Breathing Questionnaire (SBQ)Questionnaire (SBQ)

• PurposePurpose Used to: Used to:

Determine the student’s asthma severity levelDetermine the student’s asthma severity levelDetermine if the student’s asthma is under Determine if the student’s asthma is under

controlcontrolDevelop an appropriate plan of care Develop an appropriate plan of care Determine student’s familiarity of their meds, Determine student’s familiarity of their meds,

triggers, symptoms etc. triggers, symptoms etc.• Used with students in grades 6th grade or Used with students in grades 6th grade or

higherhigher

F14, F15F14, F15

School Health Office Asthma School Health Office Asthma Record (SHOAR)Record (SHOAR)

• PurposePurpose Provides a user-friendly document on which Provides a user-friendly document on which

to record many aspects of a student’sto record many aspects of a student’s asthma care asthma care

• Allows health office staff to:Allows health office staff to: Record Asthma Medication Record Asthma Medication Record Peak Flow ReadingsRecord Peak Flow Readings Document Asthma SymptomsDocument Asthma Symptoms Document EducationDocument Education

F4, F5F4, F5

Self-Administration Of Asthma Self-Administration Of Asthma Medication Authorization / Medication Authorization /

AgreementAgreement• PurposePurpose To systematize practice regarding self-To systematize practice regarding self-

carrying of asthma medications carrying of asthma medications between schoolsbetween schoolsPromotes strong asthma self care skills in Promotes strong asthma self care skills in

studentsstudentsAgreement between student and school Agreement between student and school

nursenurse Used in conjunction with an Asthma Action Used in conjunction with an Asthma Action

Plan or may stand alonePlan or may stand alone F19, F20F19, F20

First Aid For Asthma First Aid For Asthma Poster / Pocket CardsPoster / Pocket Cards

• PurposePurpose Provides basic first aid care for asthma Provides basic first aid care for asthma

and asthma symptoms with directions and asthma symptoms with directions when to call 911when to call 911Place posters in locations in the school where Place posters in locations in the school where

students and staff are usually presentstudents and staff are usually presentPocket cards may be given to physical education Pocket cards may be given to physical education

teachers or coaches or other staff as neededteachers or coaches or other staff as needed E4, E5E4, E5

Prioritizing In A Busy Prioritizing In A Busy School Health OfficeSchool Health Office

There’s Never Enough There’s Never Enough Time, Time, What Can I Do? What Can I Do?• It isn’t possible for school health office It isn’t possible for school health office

staff to get deeply involved with every staff to get deeply involved with every student who has asthma so -student who has asthma so -

• Prioritization is essential!Prioritization is essential!Determine which students seem to be Determine which students seem to be

having the most difficulty, and focus on having the most difficulty, and focus on them firstthem first

How Do I Prioritize?How Do I Prioritize?1.1. Prioritize by “current asthma control / Prioritize by “current asthma control /

severity level”severity level”2.2. Focus first on students with the poorest Focus first on students with the poorest

asthma control regardless of severity asthma control regardless of severity levellevel

3.3. Start working with students whose Start working with students whose asthma is poorly controlled in the asthma is poorly controlled in the moderate to severe persistent asthma moderate to severe persistent asthma levelslevels

Which Of These Students Which Of These Students With Asthma Would You With Asthma Would You

Focus On FirstFocus On First??1.1. A boy with diagnosed moderate persistent A boy with diagnosed moderate persistent

asthma who can run, play, attend school asthma who can run, play, attend school without symptoms and rarely uses his albuterolwithout symptoms and rarely uses his albuterol

2.2. A girl with current mild persistent asthma who A girl with current mild persistent asthma who is unable to fully participate in PE classis unable to fully participate in PE class

3.3. A girl who’s original severity level was severe A girl who’s original severity level was severe persistent but whose “current asthma severity persistent but whose “current asthma severity level” (control) is moderate persistent. She can level” (control) is moderate persistent. She can play outside better than originally, but still play outside better than originally, but still needs albuterol for symptoms 3-4 times a week needs albuterol for symptoms 3-4 times a week at schoolat school

Which Of These Students Which Of These Students With Asthma Would You With Asthma Would You

Focus On FirstFocus On First??3.3. A boy with diagnosed moderate persistent A boy with diagnosed moderate persistent

asthma who can run, play, attend school asthma who can run, play, attend school without symptoms and rarely uses his without symptoms and rarely uses his albuterol.albuterol.

2.2. A girl with current mild persistent asthma A girl with current mild persistent asthma who is unable to fully participate in PE class.who is unable to fully participate in PE class.

11.. A girl who’s original severity level was A girl who’s original severity level was severe persistent but whose “current severe persistent but whose “current asthma severity level” (control) is moderate asthma severity level” (control) is moderate persistent. She can play outside better than persistent. She can play outside better than originally, but still needs albuterol for originally, but still needs albuterol for symptoms 3-4 times a week at school.symptoms 3-4 times a week at school.

Education In The School Education In The School Health OfficeHealth Office

Components Of StudentComponents Of Student& Family Education& Family Education

Concept of asthma controlConcept of asthma control Pathophysiology of asthmaPathophysiology of asthma Environmental control and triggersEnvironmental control and triggers Controller vs. reliever medications Controller vs. reliever medications

and refilling medicationsand refilling medications Use of Asthma Action Plan and Use of Asthma Action Plan and

treatment of episodestreatment of episodes Peak flow meter usePeak flow meter use

Components Of StudentComponents Of Student& Family Education Cont…& Family Education Cont…

Signs and symptoms of respiratory Signs and symptoms of respiratory distress and when to seek helpdistress and when to seek help

MDI with spacer / DPI techniqueMDI with spacer / DPI technique Nebulizer use and technique (prn)Nebulizer use and technique (prn) Importance of relationship with Importance of relationship with

provider and well-asthma check-upsprovider and well-asthma check-ups Flu shot every fallFlu shot every fall Self-care, especially for students as Self-care, especially for students as

they get olderthey get older

Strategies To Educate Strategies To Educate When Time Is LimitedWhen Time Is Limited

Give short asthma education Give short asthma education messages when meeting with with messages when meeting with with studentsstudents

Use innovative / interactive asthma Use innovative / interactive asthma education tools (computerized education tools (computerized asthma games, internet-based asthma games, internet-based asthma control tools, videos) with asthma control tools, videos) with students / families students / families

The Best Laid PlansThe Best Laid Plans.... You can increase the likelihood of You can increase the likelihood of

asthma management success asthma management success (compliance) by:(compliance) by:

1.1. Reviewing Asthma Action Plan and making Reviewing Asthma Action Plan and making sure student understands how to use it sure student understands how to use it

2.2. Ask how controller medications fit into the Ask how controller medications fit into the student’s daily routine (can they handle it?)student’s daily routine (can they handle it?)

3.3. Identify obstacles or barriers to the Identify obstacles or barriers to the student/family carrying out the plan as student/family carrying out the plan as prescribedprescribed

““I Can’t Manage This By I Can’t Manage This By Myself.Myself.

Who Else Should Be Who Else Should Be Involved”?Involved”?

Referring To Community Referring To Community Resources For Education Resources For Education And Case ManagementAnd Case Management

LSN/PHN/RNs can utilize case managers, LSN/PHN/RNs can utilize case managers, home visiting professionals, and asthma home visiting professionals, and asthma educators from health plans, hospitals, educators from health plans, hospitals, clinics, public health, to help educate and/or clinics, public health, to help educate and/or case manage students whose asthma is case manage students whose asthma is poorly controlledpoorly controlled

Connect students/family to community Connect students/family to community education, asthma camp, other community education, asthma camp, other community resources resources

Coordinated School Coordinated School Health:Health: Partnering For Partnering For

Optimal Asthma Optimal Asthma Management In SchoolsManagement In Schools

CDC’s Strategies For Addressing CDC’s Strategies For Addressing Asthma Within A Coordinated Asthma Within A Coordinated

School Health ProgramSchool Health ProgramSix StrategiesSix Strategies

1.1. Establish management and support Establish management and support systems for asthma-friendly schoolssystems for asthma-friendly schools

2.2. Provide appropriate school health and Provide appropriate school health and mental health services for students with mental health services for students with asthmaasthma

3.3. Provide asthma education and Provide asthma education and awareness programs for students and awareness programs for students and school staffschool staff

Strategies Continued…Strategies Continued…4.4. Provide a safe and healthy school Provide a safe and healthy school

environment to reduce asthma triggersenvironment to reduce asthma triggers5.5. Provide safe, enjoyable physical Provide safe, enjoyable physical

education and activity opportunities for education and activity opportunities for students with asthmastudents with asthma

6.6. Coordinate school, family, and Coordinate school, family, and community efforts to better manage community efforts to better manage asthma symptoms and reduce school asthma symptoms and reduce school absences among students with asthmaabsences among students with asthma

Asthma Goals For Asthma Goals For SchoolSchoolHealthHealth

Healthy school environmentHealthy school environment Health services in schoolHealth services in school Asthma educationAsthma education Supportive policiesSupportive policies Sound communicationSound communication

1997 National Asthma Education and Prevention Program (NAEPP)1997 National Asthma Education and Prevention Program (NAEPP)

Spearheading School-wide Spearheading School-wide Asthma Best Practices At Your Asthma Best Practices At Your

SchoolSchool See Checklist in manual for suggestionsSee Checklist in manual for suggestions Create a multi-disciplinary plan for Create a multi-disciplinary plan for

improving asthma management in your improving asthma management in your health office, school and/or districthealth office, school and/or district

Improve own practiceImprove own practice Educate other school staffEducate other school staff Involve all disciplines within the school Involve all disciplines within the school

settingsetting

Community Community InvolvementInvolvement

Get involved with the Minnesota Get involved with the Minnesota Asthma Coalition, and/or the regional Asthma Coalition, and/or the regional Asthma Coalition in your area Asthma Coalition in your area

Contact your legislators and insist on Contact your legislators and insist on legislation to support asthma-friendly legislation to support asthma-friendly policiespoliciesAnti-smoking lawsAnti-smoking lawsHealthy housing initiativesHealthy housing initiativesSupporting Clean Indoor actSupporting Clean Indoor actSupport stricter pollution control measuresSupport stricter pollution control measures

ConclusionConclusion Asthma is a big challenge for Asthma is a big challenge for

MinnesotaMinnesota Working together with parents and Working together with parents and

health care providers, we have the health care providers, we have the ability to positively and dramatically ability to positively and dramatically impact the health of children who impact the health of children who have asthma!have asthma!