Transcript of NAEPP Webinar: Let's Bench Asthma: Keep Students with Asthma Physically Active and in the Game
June 5, 2012
The following webinar transcript is not an exact representation of the webinar as originally presented. It has been edited to clarify meaning and to update content. The views expressed within this webinar transcript do not necessarily reflect those of the National Heart, Lung, and Blood Institute (NHLBI), the National Institutes of Health, or the U.S. Department of Health and Human Services.
This webinar, hosted by the National Asthma Education and Prevention Program (NAEPP), aims to provide health care providers, school nurses, teachers, coaches, athletic trainers, and others with practical strategies and tools to empower students and their families to follow a written asthma action plan. Asthma action plans can help students control their asthma and participate fully and safely in play, exercise, and other physical activities in preschool, school, afterschool, or community programs. The webinar includes remarks by Rachael Tracy, National Heart, Lung, and Blood Institute, and Stuart Stoloff, M.D., University of Nevada School of Medicine, followed by a question and answer session with Linda Davis–Alldritt, National Association of School Nurses; Sandra Fusco–Walker, Allergy and Asthma Network Mothers of Asthmatics; Barbara Kaplan, American Lung Association; Andrew W. Mead, National Association for Sport and Physical Education; and Jacqui Vok, Asthma and Allergy Foundation of America.
Tracy: Good afternoon, everyone. My name is Rachael Tracy and I am the current acting coordinator for the National Asthma Education and Prevention Program. On behalf of the NAEPP, I would like to welcome everyone to our webinar titled, Let's Bench Asthma: Keep Students with Asthma Physically Active and in the Game. I would also like to welcome and thank all of our presenters for taking time out of their busy schedules to be able to share their valuable experiences and insights on how we can help students keep their asthma under control and be fully active.
I just want you all to know as well that we are very excited to be able to share another announcement. We are releasing a newly revised publication called Asthma & Physical Activity in the School. Some of you might be familiar with this publication. It has been around since about 1995, but we just recently revised it. It is a resource for students, families, health care providers, and especially school personnel. It's filled with valuable tools, information, resources, and guidance for things that school personnel can use in working with health care providers, other school staff, and parents and students with asthma to keep our students active with physical activities and sports. We are so excited that this webinar is occurring at the same time that the publication is ready for dissemination.
If you are interested in ordering the publication, we will have the ordering information for the publication available at the end of the webinar, and you can contact Kate Fink or me if you want a certain number so that it can be shipped to you, and we can work out all of the details. Thank you again, everyone, for joining us for this webinar.
Fink: Thank you, Rachael. We are going to move on to an overview with our moderator today. I am pleased to introduce Dr. Stuart Stoloff, our moderator for today's webinar. He is a clinical professor in the Department of Family and Community Medicine at the University of Nevada School of Medicine. He is also a family medicine practitioner and a member of the NAEPP's Third Expert Panel on the Diagnosis and Management of Asthma. We are so pleased to have him today. Dr. Stoloff, please take it away.
Stoloff: Thank you, Kate. The learning objectives are, basically, six key actions that come out of the NAEPP's Guidelines Implementation Panel Report that we worked on in coordination with the 2007 NAEPP guidelines. These are actionable items, and we are asking you to look to understand what is going on, to recognize worsening asthma, and to have the practical tools available to tackle the issues.
The next thing that we would like you to understand is what is asthma? Well, it is a very heterogeneous disease. It is a chronic disorder. It causes inflammation, and associated with that is narrowing of the airway, which we call bronchoconstriction. What the individual feels is shortness of breath, coughing, wheezing, and chest tightness. We believe that asthma can be well–controlled in the overwhelming majority of the population with asthma, not in 50 or 60%, but actually in 95 to 100% of that population. We believe that with the right therapy, we can diminish or avoid asthma events and attacks and that people should have the ability to live a normal and healthy life. That means having few symptoms, sleeping through the night, and having the ability to be very physically active.
So how common is asthma? Well, it is exceedingly common and, actually, the CDC said that asthma prevalence has continued to go up. The African–American population is really affected. One in 6 black children in 2009 had asthma, and if you look in the classrooms, that number is 3 in 30. So this is very common. For children under the age of 18, it's actually about 1 in 11 to 1 in 9.
What is the impact? Asthma is a leading cause of why kids miss school. If you look at any chronic disease, asthma is a leading cause of why kids end up in emergency rooms; and if you look at the use of those emergency rooms, as you would expect, Latino Americans and African Americans predominate. There is also the risk of death and life–threatening events. About 185 children died from asthma in 2007. The population at the greatest risk of dying from asthma attacks is the elderly population with asthma.
We have available two major reports to help you understand asthma better. So we have the Guidelines Implementation Panel (GIP) Report, which was published in 2008, and the Expert Panel Report 3—Guidelines for the Diagnosis and Management of Asthma published in 2007, of which I was a part. The GIP Report was a follow–up to the Expert Panel Report 3.
So what are the six key actions in the GIP Report? Well, the first is that inhaled corticosteroids are the foundation for chronic care of patients who have persistent asthma. In addition, we believe very strongly that written asthma action plans influence the care of the patients. We also believe that you not only need to assess asthma severity when you initially evaluate asthma, but also, that you need to assess and monitor asthma control. It is about gaining and maintaining control. That involves scheduling regular follow–up well visits as well as looking at the environmental issues that potentially worsen asthma for that individual patient.
How do we use these six key actions in the school? Well, we want people who work in the schools to understand what the medicines do, to assist in obtaining a written asthma action plan for each of their students who has asthma, to identify and have some way to know the initial severity, but more important, to know what is the level of control. One thing you want to know is whether this child's asthma is well–controlled, not well–controlled, or very poorly controlled. You want to remind the student, and especially the family, to get regularly scheduled follow–up care, and you want to look at factors that worsen the child's asthma. Such factors may include exposures to allergens and irritants, especially tobacco smoke.
So how would you use a written asthma action plan as a tool? In the guidelines, we have looked at this. In a perfect world, everyone would benefit. However, it is really the population who have moderate to severe persistent asthma—most important, those whose asthma is not well–controlled or is very poorly controlled, that would be frequent flyers to ERs (emergency rooms) for exacerbations. What this one–page asthma action plan should have is information about what medicines the patient is on, when does he or she use a quick–relief inhaler, how often does he or she use it, and most important, what does the patient do if he or she is not getting better? The basis for this document can either be symptoms, peak flow, FEV1 (forced expiratory volume in the first second), or a combination thereof.
And what the key is, and why we emphasize this is, when we look at the population using CDC data, less than one out of every two children have a written asthma action plan. That does not even mean that they understand it, know how to use it, or have used it, just that they have it. And that's less than 50%.
So why use the asthma action plan? What it does is give a process, a pathway for the family and the patient to understand that if I am not doing well, what do I need to do? And it can help guide care for that child, for that student all the way from pre–school until they are an adult. What I do in my practice is I ask the parents to use the written asthma action plan—put one at the school and one usually on the refrigerator—so they know exactly what to do and how to get care for the patient.
We put three sample asthma action plans in the guidelines report in 2007, and you can use them. Your clinicians may have other ones that they use. It really does not matter, as long as it provides pathways for the individual patient to understand what to do when something adverse happens.
So how do we engage students with asthma? What is the key? We are all well aware of obesity in this country. One of the ways to help fight obesity is to keep students engaged in physical activities. How do we do that? We understand that exercise–induced bronchospasm can occur, and many times does occur, in patients with asthma. What we want to do is recognize it in the individual patient with asthma and provide medication in the form of the quick–relief inhaler before the start of the physical activity. This can occur five minutes before the event. Give two puffs with at least 30–second between them five minutes before the exercise. This type of process really diminishes the symptomatology that patients may feel. You also can make sure they warm up before physical activity.
I will also tell you, as someone who practices extensively in this area, if I, or the parent, has to modify the child's physical activity, the child's asthma is not well–controlled. In that case, I need to look at the child's medication, to see whether they are taking their inhaled corticosteroids or other long–term control medication, and I need to ask the parent and child to demonstrate that the child is taking the medication properly. That is how we keep people active.
The Asthma & Physical Activity in the School booklet that Rachael was talking about is now available. I would encourage you to get a copy for your schools and speak with Rachael or Kate about obtaining as many copies as you need.
How do we recognize worsening asthma and what actions do we take? Well, you need to know the signs, namely coughing, wheezing, chest tightness, and shortness of breath. Using a peak flow meter to check lung function is important, but peak flow is effort–dependent, so if the child or young adult does not really want to blow, the number is irrelevant if he or she is not demonstrating symptomatology. So always look for symptoms, such as chest tightness, shortness of breath, coughing, and wheezing.
There was a football coach living 15 miles south of me where there had been a child who, unfortunately, died from an asthma event. The child was not a football player, but this coach was so worried about the kids who played football for him between the freshman and senior year, that he made a belt, a Velcro belt to hold their inhalers and he called me, and I took a picture of him wearing it. This is one action he used. I would not say it is the greatest thing, and I would not recommend it for everybody. It was, however, an action he used to help the kids playing for him to understand the importance of knowing that the medicine is readily available. And twice a year with my help, he made sure they could demonstrate appropriate use of the medication.
So what do we recommend? If the child or student is having difficulty, you've given the child his or her quick–relief inhaler, and after four to six puffs, the child is unable to breathe, talk, or stay awake, that is an emergency. Call 9–1–1, get help, treat the child, and then call the parent.
So how do we access practical tools? What are the practical tools? You can get them from the NHLBI Web site—the NAEPP Asthma Action Plan, Asthma & Physical Activity in the School booklet, Is the Asthma Action Plan Working?—A Tool for School Nurse Assessment, and How Asthma–Friendly Is Your School?.
It's very important to ask how asthma–friendly your school is. We know, for example, that carpets at schools are the number one source for animal dander—from cats and dogs—because kids who have pets come to school and the pet dander is unloaded on the carpets.
How asthma–friendly is your school from tobacco smoke? It is amazing to me to see people in school systems that walk 25 feet away or less, instead of 50 feet, and sit there huffing and puffing, smoking away. It doesn't help anyone.
Should students carry their own asthma medications? Absolutely if the student's doctor and parents believe the child is capable of self–medicating, and that's how it is in 50 states in this country. A similar policy for anaphylaxis medications is in effect in 49 states so students can carry their epinephrine.
Does your school have an emergency action plan, and does each student with asthma have a written asthma action plan? Are students with asthma participating in activities? If you know that a child in your school has been given a release from physical activity, or physical education (PE), it is important that you speak to the parent about having a discussion with a physician and identifying what the issue is so that the child can be helped to participate fully in activities.
In addition, does your school have good indoor air quality? And what about a school nurse on site? Here in northern Nevada we have one nurse for about eight schools, so that is where we are in the economy. Then do you have someone who teaches the educators in the school system—not just the nurses but physical education instructors and everyone—on the appropriate use of the medication and helps them to fully understand so that they can make sure their students use the medicines properly?
Stoloff: To tackle some critical issues, we now go to the panel discussion. What I would like to do at this time is introduce our panelists. We are fortunate to have five well–educated, very knowledgeable people on the panel.
The first panelist is Sandra Fusco–Walker, director of patient advocacy for the Allergy and Asthma Network Mothers of Asthmatics (AANMA), a national patient advocacy organization and a NACI Strategic Partner. AANMA leads the drive for local, state, and national legislation to permit students to carry and use emergency asthma and anaphylaxis medication in schools and school settings.
Next is Barbara Kaplan, director of asthma programs for the American Lung Association (ALA). The ALA provides education, advocacy, and research to improve lung health. ALA recently released its annual State of the Air report and a new Lungtropolis™ interactive Web site for children with asthma ages 5–10 and their parents. ALA also offers an Open Airways for Schools program for elementary school students.
Next is Jacqui Vok. Jacqui is the senior educational programs manager for the Asthma and Allergy Foundation of America (AAFA). AAFA, also a NACI Strategic Partner, uses education, advocacy, and research to improve the quality of life for people with asthma and allergic diseases. On World Asthma Day, May 1, AAFA issued its annual Asthma Capitals ranking. AAFA also compiles a State Honor Roll of Asthma and Allergy School Policies each year and offers a free Asthma Management and Education Online program for allied health professionals.
Next, we have Andrew W. Mead. He is a program manager for the National Association for Sport and Physical Education (NASPE). NASPE works to enhance knowledge, improve professional practice, and increase support for high–quality physical education, sports, and physical activity programs. Before joining NASPE, Mr. Mead played baseball from 2006 to 2008 with the Chicago White Sox organization. He worked one year as an adapted physical educator at Homer Central School District in Central New York and taught health and physical education in the District of Columbia Public Schools system.
Last, but not least, is Linda Davis–Alldritt. She is a registered nurse and is president of the National Association of School Nurses (NASN), which works to advance the specialty practice of school nursing to improve the health and academic success of all students. NASN has issued several briefs and position statements on the role of school nurses in helping students with asthma.
Scenario #1: School/Family/Patient Perspective
Stoloff: What I would like to do now is pose a few questions and scenarios to our panelists that will provide us with some insight to key issues that we all face. I am going to ask Sandra to take a shot at the first one that addresses a school/family/patient perspective.
The school year is approaching, and families, health care providers, and schools are scrambling to get updated health records in place and physicals completed. As a physician, I know how busy this season can get. So who is responsible for making sure that a student with asthma also has a written asthma action plan? And what practical strategies can a school employ to make sure that every student with asthma has an up–to–date asthma action plan on file? In addition, what would you say to a parent whose child has a written asthma action plan but is reluctant to allow their child to participate in physical activity and/or has concerns about the medications prescribed to keep their children’s asthma under control? There is a lot there, but Sandra would you like to take a shot at it?
Fusco–Walker: Sure. Thank you, Stuart. It is a great question with a lot of information, and I know the rest of the panel has some good information to share with us, too. From our perspective, every school should provide parents with the information they need to comply with district policies regarding asthma action plans and the self–carry regulations. These policies need to be posted on the school Web site and in the school handbooks. Parents, working with the student, physician, and school nurse, should be putting this together. Speaking to parents who are reluctant, we get a lot of phone calls from parents that contact AANMA. They really do misunderstand the purpose of the medications their children are prescribed, and we find that it is usually because of the slang terminology used, such as the words “rescue” and “controller.” Rescue implies tossing a life preserver to someone when they drowning. That rescue medications are to be used only when death is imminent. And many patients tell us that albuterol controls their asthma perfectly as it stops it dead in its tracks.
AANMA developed The Language of Asthma that identifies terms that AANMA believes interfere with patients’ learning about asthma. Rather than using slang, AANMA follows the NAEPP guidelines, which reference albuterol as you did earlier, as a quick–relief medication to be used at the first sign of symptoms, before exercise, and during an exacerbation; and long–term control medications, which are to be taken over a length of time to manage inflammation. We also encourage parents to use a tool like AANMA’s Asthma Tracker. Once parents understand how a medication works, they know when to use the appropriate medication and they monitor their child’s progress using a peak flow meter and the AsthmaTracker. They can usually see the plan working, and students will end up participating fully in their education. It is knowledge and understanding of the disease that patients need on a level that they can understand. Thank you.
Stoloff: Thank you. Barbara, would you like to add to this?
Kaplan: Sure. I really believe that open communication is key among the medical home, the school nurse, and the parent or caregiver. The American Lung Association, through our Asthma–Friendly Schools Initiative, provides a resource to schools to establish a comprehensive long–term asthma management plan, and this will ensure that all students can learn in a safe and healthy environment. The four main strategies in the Asthma–Friendly Schools Initiative are maximizing school health services, providing asthma education, creating a healthy school environment, and encouraging physical activity when a child is able. What this could look like in a plan for schools includes tracking students with asthma, collecting asthma action plans, providing professional development for staff, and educating students about asthma, just to name a few. And establishing a school policy or practice on asthma action plans—there are template policies within the Asthma–Friendly Schools Initiative tool kit—can really ensure the health and safety of the students during the school day.
The American Lung Association also offers a tool called the Asthma Incidence Reporter (AIR) database that can be downloaded from our Web site. The AIR database is designed to assist school nurses in identifying and tracking students with asthma in their schools. It includes three quick reports that can give the school nurse a glance at how many days students with asthma have been absent, a detailed individual student report or a school report on the cumulative effects of asthma on a school over a specific timeframe. Reports then can be exported and shared with a child’s health care provider or analyzed to make a case for funding and support for the school. It is understandable for a parent to be concerned about their child’s safety in school, particularly when they have a child with asthma.
Physical activity is important for everyone and is encouraged for children with asthma when they are able. So it is important for the PE instructors to be able to recognize the symptoms and have activity modifications for that child, which could include longer warm–up and cool–down periods. It is important for them to have access to the child’s asthma action plan and understand how to use the plan and what to do in the case of an asthma emergency. I think once the parent knows that the school is prepared to handle their child’s needs, they will be more open to encourage their child to participate in physical activity. And so that is what we have to offer.
Stoloff: Thanks. Jacqui, would you like to add something?
Vok: Sure. Thank you, Dr. Stoloff. Like my colleagues addressing the first question, everyone on the asthma team is really responsible for making sure the student has a written asthma action plan. That would be the child’s health care provider, the school, the parents or caregiver, and even the child can help advocate. We offer two asthma action cards available for free download on AAFA’s Web site. We have one for school–age students and one for childcare–age children. They are a little long, but they are very simple to use. We have another version that also has allergy on it for those folks who have both conditions, which is fairly common.
In regard to the second question, parents really need to speak with their child’s health care provider about any concerns with child’s their asthma. At AAFA, our motto is, “life without limits.” We believe it’s possible to have, as Dr. Stoloff said earlier, a life without limits with proper asthma management. If the parent or the health care provider believes the child has exercise–induced asthma, then reviewing our free program and other materials on our Web site can help educate and inform parents, teachers, and the coaches—if they are shared with them—about exercise–induced asthma.
AAFA also has a State Honor Roll of Asthma and Allergy School Policies report that Dr. Stoloff mentioned in our introduction, and it ranks each state. There are 18 core policy standards and 15 extra credit indicators in the state honor roll report. We want you to use this report to understand what the laws and policies are in your state. The 2012 report will be released later this summer, and apparently, the 2011 information is available now. We want you to contact your state legislators about meeting all of the core policy standards and all of the extra credit indicators that you can find in the report. In addition, make sure that the school districts in your state implement the policies according to legislation and work with other concerned residents or asthma advocates to ensure the best laws to protect students with asthma are available in your state and in your school district. In regards to this specific question, the report specifically looks at the state policy first, mandating schools to identify and maintain records for students with chronic conditions, including asthma and anaphylaxis. Second, the report recommends the state requiring a procedure of updating health records periodically. Third, the report recommends that state require schools to maintain asthma and allergy incident reports for reactions, attacks, and medications administered. Those are 3 of the 18 policies, and I will address some of those later. Thank you.
Stoloff: Andrew, would you like to chime in?
Mead: Oh, yes, absolutely. Thank you. I would absolutely agree with what the rest of the panelists have said. It is a shared responsibility among the parents, physician, school nurse, and not just the PE teacher or athletic coaches, but really anyone at the school who facilitates physical activity, whether it be before, during, or after school; they really need to be in the loop and be prepared to respond. Specifically from a PE teacher’s or a coach’s perspective, depending on the level at which you teach or coach, you may be the first person to witness the symptoms of asthma. In that instance, it is always important to contact the parent immediately and recommend that they bring their child to see a physician and, pending the diagnosis of asthma, encourage the parent and student to sit down and to create an asthma action plan and then share it with the school nurse. Well, it is also the responsibility of the PE teacher to create a safe and positive environment that is student–centered and is conducive to all students regardless of ability developing the knowledge, confidence, and skills necessary to participate in lifelong physical activity. Creating that environment can sometimes be difficult and may take some time.
But I will give you the example of having a morbidly obese seventh–grade girl in one of your classes. Regardless of how many times she is encouraged by her teachers and by her peers, she is always a little bit reluctant to really engage in an activity. So let us say one day, we are really doing an activity that she enjoys and she starts wheezing, and she starts having difficulty breathing, and the teacher is not aware that she has asthma, and she is not aware of the plan, and she is not prepared to respond at all. All of sudden, class needs to be stopped, the school nurse needs to be called, and a spectacle has been made of this girl. Immediately, she is going to associate that moment of difficulty and embarrassment with PE class and physical activity, and from that point on, it is going to be very difficult to get her to participate again. But let us say we add a different twist on the scenario and say that she has an asthma action plan in place. The teacher is aware and is prepared to respond. The student steps out of the activity, follows the parameters outlined in her plan, takes the time she needs to recover, and hops back into the activity when she is ready. Crisis averted. You can maintain that positive environment you have worked so hard to create and that student will feel confident about participating in physical activity.
Again, preparation is key as a first option there. In order for a teacher to be fully prepared, I recommend that PE teachers schedule a meeting with the school nurse to identify the medical needs of each student, gain access to their management plans, identify the staff in need of their plans and everybody in the school that facilitates physical activity. Not just identify all of them, but also share all of that information with them so that they are prepared. Identify the best and most convenient locations for medications and identify emergency protocol. Then from that point, the teacher can differentiate instruction within each one of their lessons to accommodate each student and carefully avoid asthma triggers. Truly differentiated instruction stems from knowing each and every one of your students and taking into account strengths, weaknesses, likes, dislikes, cultural beliefs and traditions, as well as medical conditions like asthma.
The same can be said for the athletic coach or after–school or before–school physical activity program facilitator—it’s important that they be provided the same resources by the athletic director or school nurse. In this situation, I also recommend the coach schedule a meeting with the school nurse, along with the athletic director and athletic trainer, to identify the same key information that I had mentioned before. And it really is a comprehensive approach that needs to be taken to ensure that asthma management plans are known, executed, and updated as needed.
As far as communicating with the parent, I would be sure to demonstrate to them how I have differentiated my lesson plans to accommodate the needs of their child. I would also inform them that all of the necessary people at school have copies of the asthma action plan on site, we have convenient access to medications at all times, and everybody is prepared to respond in the event of an emergency
Stoloff: Thank you, and last but not least on the first question, Linda Davis–Alldritt. Would you please discuss this?
Davis–Alldritt: Sure. Thank you very much. It’s good to be here. I totally agree with what all the other panelists have said, and I do believe, and the National Association of School Nurses believes, that it is a shared responsibility between the physician and the school nurse to be sure that there is an asthma action plan in place at school for each student that has a diagnosis of asthma. If a student comes to school without an asthma action plan, then the school nurse needs to either ask the parent to bring one in or ask the parent for written permission to contact the physician to ensure that an asthma action plan is coming to school. So through thorough planning for good care, the school nurse can request that every student with asthma has an asthma action plan, and that the student also has access at school to his or her quick–relief inhaler.
If a parent is hesitant to have their child participate in physical activity, then this is a prime educational opportunity and teachable moments where the school nurse can discuss medications and management with the parent that will allow the student full access. That is what school nurses are all about: removing the barriers and providing access so that every child can gain to their fullest ability access to the educational program and have a very positive school experience. This means that kids who have asthma are well–managed, in school, healthy, and ready to learn. So I will give it back to you, Dr. Stoloff.
Scenario #2: School/Family/Patient Perspective
Stoloff: Good. Well, thanks. We are going to go to the next scenario, and Linda, you get to kick it off. So, if in addition to the instructions for daily management of the student’s asthma, the written asthma action plan should describe the specific steps for responding to worsening asthma symptoms, noting which medications need to be taken and when. And medications needed during school activities off–site and off–hours should be known and be available. Really the question is who should have access to the student’s asthma action plan and where should the student’s medications be kept so that they are accessible as needed for worsening asthma symptoms and pre–medication before exercise? If liability is an issue, how should you address this? Linda, will you please lead off?
Davis–Alldritt: Absolutely. And thank you for letting me start this. Ideally, all students who are able to carry their inhaler and self–manage their asthma should be taught to do so. There are going to be some students who, because of physical disabilities or other disabilities, may not be able to be taught, but any student who can be taught needs to be taught to self–manage and permitted to carry their medication. As for school staff, the school nurse can provide them with an emergency care plan for students with asthma so that teachers and other school staff can use those emergency care plans to respond to emergency situations as they arise. The asthma action plan can be reviewed with staff and used to inform the writing of the emergency care plan. We like to put that emergency care plan into lay terms to simplify the school staff actions in the event of worsening symptoms so it is readily available and readily understandable.
As far as medication storage, by the time a student is staying after school for sports or other activities, it is ideal for that student to be able to self–carry and self–manage their medication. If not, then the school nurse needs to assess the building and the staffing situation specific to that student’s experience, and in collaboration with school staff and administration, develop an appropriate plan so that that child is never without medication when it is needed. Liability would be considered in the medication administration plan and because each student, or each situation rather, is unique, the liability situation has to be planned for on an individual basis.
Stoloff: Thank you. Sandra, you have a lot of experience in this one.
Fusco–Walker: Well, we had a lot of experience when schools did not allow students to carry their inhalers and that is why I ended up getting involved in the whole world of asthma. It is really wonderful to hear Linda’s comments because 20 years ago, our kids’ inhalers and auto–injectable epinephrine were locked up and we were losing children at school because they did not have access to their medications. It is nice to see the education that’s happened over the last 20 years and the changes that the schools have made. School nurses have played a big role in that. We promote that every individual with asthma or anaphylaxis has to develop a lifetime habit of carrying their medication on them at all times. No ifs, ands, or buts. They should always have their medications with them.
We work with families and thousands of stakeholders to enact the laws protecting students’ rights to carry and self–administer their asthma and anaphylaxis medications at school. When we started in 2003, you can see that most of the country did not allow students to do so, although we had been working on it for about five years. After the federal legislation went through, we were able to work with so many people from around the nation. Awareness became phenomenal, and here we are today, with only one state left needing the law on anaphylaxis medication. That is New York, and they actually have it pending and if they can adapt it a little bit and make some changes, I think that it will pass this year. However, that is not to say that because states have a law, all schools follow the process. It is still part of the education and the awareness and we all need to be involved in that. If a student is unable to self–administer, what we have found works is for the student to carry their medication and for the teachers, or the coaches, or other trained adults to administer it. Or, in some cases where parents did not want their students at a very young age self–carrying, medication is assigned to the teachers because they are the adults in the school that are with the students throughout the day.
But the goal is to make sure that the medication is at hand because minutes count when an asthma or anaphylactic attack happens, and we all know that we have recently lost some students because life–saving medicine was not at hand. State legislators are now amending laws to make sure that anaphylaxis medication is present and accessible in every school. Medications need to be where they can be used and not locked up anywhere without access. It is unfortunate that we do not have school nurses in every classroom, let alone every building. But students participate in activities during the school day that take them off campus also, so everyone around the student needs to understand an emergency asthma action plan. They need to know the signs and symptoms, and they need to know where the medication is to help the student if the student needs it. Teachers, coaches, band leaders, everybody needs to know what to do in an emergency situation.
As to liability, parents need to sign the appropriate forms because all the schools have policies in place so that school personnel can administer medications. And in many states, legislation included language that limits liability for individuals who, in good faith, administer or do not administer life–saving medication. So I do not think that is a concern as much as it would have been 20 years ago and appreciate everybody that has been working on this. We are almost there with the laws, and I can see the education and awareness ramping up with the efforts of the NAEPP’s National Asthma Control Initiative.
Stoloff: Barbara, would you like to comment on this?
Kaplan: Sure. In my first response, I talked quite a bit about the ALA’s Asthma–Friendly Schools Initiative. One of the recommended components within the Asthma–Friendly Schools Initiative is Asthma 101: What You Need To Know, a professional development course for teachers and coaches to help them understand the asthma action plan, how to use it, and what to do in an emergency. So education for staff and school personnel is very important around this question.
I also think that although the states have self–carrying, self–administrating laws, sometimes the issue comes around whether the parents are aware that this is an option and if the school has clearly communicated the process that is in place to allow a child to self–carry. So educating parents as well is important, and our new program, Lungtropolis™, which we just launched for Asthma Awareness Month, gives an opportunity to empower parents to learn more about asthma and asthma management to feel more confident about sending their child to school.
And then lastly, I would to say it so important to empower students to know what to do in an emergency, to build their confidence in administering their medication and following an asthma action plan, and to recognize triggers through our Open Airways for Schools programs. This is our elementary–age program for children ages 8 to 11, and they can learn all they need to know about asthma. Education really should be a major component of a school’s comprehensive asthma management plan.
Stoloff: Thank you. Jacqui, do you have a comment on this?
Vok: Yes, thank you. I wanted to expand upon Sandra’s comments because she is absolutely right. It is wonderful to see that almost every state has finally passed laws about self–carry and self–administration. But our State Honor Roll report goes a little further with the 18 different full policy standards, and I just wanted to quickly run through them to give folks an understanding of what Sandra and everyone else has said already. There is so much more to those pieces, but those are extremely important pieces and a huge kudos to everyone who has managed to make this happen.
We want each state to recognize the problems of asthma and allergy in schools and begin to address them. That means that we want to see the state require physician–written instructions to be on file to dispense prescription medication to students and that state policy ensures students’ right to self–carry and self–administer asthma and anaphylaxis medication. We want state policy mandating schools to identify and maintain records for students with chronic conditions including asthma and anaphylaxis. We also would like to see the state require procedures for updating health records periodically; require schools to maintain asthma and allergy incident reports for reactions, attacks, and medications administered; require schools to have emergency protocols for asthma; and require schools to have emergency protocols for anaphylaxis. As mentioned earlier, we would like a student to school nurse ratio of at least 1:750 or better. We also would like to see the state mandate that all schools must have an Indoor Air Quality management policy that requires schools to have periodic inspections of their heating ventilation, and air conditioning (HVAC) systems and to address other specific components, like carpeting. In addition, when it comes to outdoor air quality, we would like the state to require schools to notify parents of upcoming pesticide applications. And, when it comes to tobacco policy, that all smoking is prohibited, as you mentioned, Dr. Stoloff, in school buildings and school grounds, on school buses, and at school–related functions, and that tobacco–use prevention be required in the health education curriculum. Those are the 18 core policy standards, and there are another 15 extra credit indicators that we ranked states on as well. There is still more work to be done, but I think we have come a long way—a long, long way. Kudos to all for your effort.
Scenario #3: Family/Patient Perspective
Stoloff: Thank you, Jacqui.
The third scenario concerns after–school activities. So a coach within an after–school community program is planning a field trip by bus to another state. On the last trip, the coach had to stop the bus on the side of the highway and call an ambulance for a student who was having difficulty breathing due to asthma. The coach has no access to student medications, has no training in administering medications, and does not know what to do in case of a similar event. What would you advise be done?
Andrew, would you like to start?
Mead: Yes, absolutely. I would advise that coach to immediately call 9–1–1 and call the parent and make them aware of the situation, and I would instruct all the students to remain calm and remain seated in their own seats. As for the coach himself, I would recommend that he stay calm, check the area around the person in need, and make sure there is nothing there harmful to them. Then, listen to the 9–1–1 emergency responder for instructions on what to do until the ambulance arrives.
But again, it is really important to remember that situations like these can be avoided by taking a comprehensive approach to creating and sticking to a management plan, and by making sure that students have convenient access to their medications at all times. I would strongly recommend that schools use some types of permission slip before going out on a field trip to collect pertinent medical information as well as identifying an emergency contact. Fortunately, most school districts and most paid athletic associations require PE teachers and coaches to be certified in first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED) administration. What I would like to see would be the state athletic association making a push to really include asthma awareness and asthma management as a part of that first aid certification so that situations like these could be avoided at all costs, and parents and league officials and school administrators could be confident that their coaches are prepared to respond in the event of any emergency.
Stoloff: Thank you. Are there other panelists who would like to chime in on this?
Fusco–Walker: Yes, Stuart. This is Sandra.
Stoloff: Hi, Sandra.
Fusco–Walker: Hi. This is exactly one of the reasons why we encourage kids to carry their inhalers and we encourage the education process. In this situation, it obviously was not there. AANMA has a Fit To Breathe express seminar we have done that has been very successful, and it provides practical information for schools. The AANMA Web site has links to the Language of Asthma and Fit To Breathe. There is a specific article that we did, Winning Strategies for Athletes with Asthma and Allergies, and we used a lot of information from the National Athletic Trainers Association, which provided a position paper just about two years ago, I think. It has some really good information for coaches.
I know that for community coaches who are not in schools—for instance, recreation department coaches and dads like my husband and other people who get involved in coaching soccer—this kind of information is also available to them. We hope that parents that get involved in outside activities like this will take on that little bit of responsibility and go seek information. And maybe we reach out to recreation departments that are in the cities and in the communities and get the information to them because it is basic. It is very similar to what we do at the schools, but it is information that coaches actually need. I know that one of the points they made was making sure to identify patients that have an allergic reaction to aspirin. You know that is something that happens a lot in athletics, and those kinds of things coaches really need to know. I would recommend them visiting Fit To Breathe and especially reading the article, Winning Strategies for Athletes with Asthma and Allergies.
Stoloff: Thank you. That concludes the formal questions and the scenarios that we posed.
Question and Answer Session
Stoloff: And now it is your opportunity to bring forth the questions that you have that you would like the panelists or me to discuss. We already have one that Kate has put up. The question is, and I will put it out to the panelists and see who would like to answer it, “Not all doctors provide a peak flow meter. Where can I get a peak flow meter? My community is also low–income.” I am going to ask whether there is a panelist who would like to answer that question, and then I have something to chime in. So would any of my five esteemed panelists like to give a shot at this?
Davis–Alldritt: Dr. Stoloff, this is Linda Davis–Alldritt, and I would.
Stoloff: Thank you.
Davis–Alldritt: You’re welcome. As a school nurse working in the community, I found that several of our local physicians, allergists in particular, were willing to donate peak flow meters and spacers to schools, especially our low–income schools, and that was really helpful. We were able to train parents, students, and the staff on how to use peak flow meters and what the results meant. Keeping in mind what Dr. Stoloff said, that the symptoms have to go along with results of the peak flow meter. But training the staff and students in the use of peak flow meters was a wonderful thing and that the physicians were willing to donate was great.
Stoloff: Anyone else?
Fusco–Walker: Yes, Stuart. It is Sandra again.
Stoloff: Hi, Sandra.
Fusco–Walker: It is my understanding that you need a prescription for a peak flow meter or you used to in some states. I know for AANMA we have them at our store, but we do require prescriptions. I think they are in the 12–dollar range. But even if you purchased a peak flow meter by yourself, you still need your provider, school nurse, or somebody to teach you how to use it. It is not something we recommend patients try to figure out on their own. We really do encourage patients to work with their provider or their school nurse so they can understand how to use a peak flow meter and then to chart the numbers they get when using it so they can find out their personal best. From there, they may be better equipped to know when something is going wrong or be able to use their peak flow meter after they use their medications to see whether the medications are working.
Stoloff: Thank you. I am going to add to this, but I am going to step back a little. We discussed through this webinar a lot about a written asthma action plan. It is not just a piece of paper. It cannot be handed to a parent or to a patient or an older student and say, this is what you do. This has to be a cooperative discussion. It has to be written so the person can understand it. It has to be a guidepost. So basically, it says that if you are doing well, you continue to do what you are doing. But if you begin to having symptoms, what do you do? And that is where the quick–relief inhaler comes in. And then if that quick–relief inhaler does not work, whom do I call, where do I go? That information should be on that page. That is one item.
Secondly, on peak flow meters. In 1997, as part of the second Expert Panel Report, of which I was a part, we had advised that everyone should have a peak flow meter. This is not correct. Even if we wanted everyone in the world to have a peak flow meter, it is not correct. The reason is a peak flow meter has to be directly attached to an action, that action has to be based upon knowledge, and that knowledge has to be based upon an understanding of what you have and what you do to respond to the symptoms you may have. So a peak flow meter, just as Sandra said, cannot just be picked and used. Each peak flow meter brand has different resistance, has different norms, and the norm is basically irrelevant. It is the number that a person normally blows when they are well that they really need to know. And then, when they have symptoms, they need to identify what the number means, and the value of the decrease, and what action they must take according to their asthma action plan. So just having peak flow meters at school does not help because if a student has never used one or it is not the brand that he or she has used, then it does not help. Peak flow meters also must meet the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) standards for cleanliness. The 2007 guidelines recommend a peak flow meter for individuals with moderate to severe persistent asthma; especially those whose asthma is not well-controlled, a peak flow meter may have value. I would say that if the person can afford something better, we now have digitalized FEV1 meters, and there are six brands on the market. These devices have results better correlated to airway obstruction, because that is what they are specifically measuring.
Kaplan: Dr. Stoloff, this is Barbara Kaplan.
Stoloff: Go ahead.
Kaplan: I actually would like to add to your response, because I agree. I think where peak flow meters are very helpful is when you have a child who cannot really communicate his symptoms to you so it is sometimes a tool that can help. I very much agree that there is a learning process that needs to take place between the child, parent, and the health care provider.
Stoloff: Thank you. Kate, do we have another question?
Fink: Yes. One question came in that said, “Are there concerns or safeguards that need to be taken into consideration related to the Health Insurance Portability and Accountability Act (HIPAA) or Family Educational Rights and Privacy Act (FERPA), and what safeguards need to be in place to protect students’ privacy?”
Stoloff: I can speak to that, and actually, you maintain HIPAA privacy by having asthma action plans for students. The information is for the health care needs of the individual, so it does not break HIPAA regulations to have a written asthma action plan on file or to respond appropriately. This is not an issue with this document.
Davis–Alldritt: Dr. Stoloff, if I could jump in for a second. This is Linda.
Stoloff: Linda, please.
Davis–Alldritt: The question also included the Family Educational Rights and Privacy Act (FERPA), which governs the protection of school records, which includes health records and student health records at school. In order to share information, given FERPA, it is important that people remember that information is shared on a need–to–know basis and typically as the information affects the child’s educational outcomes, and that includes sharing with school staff, with coaches, with teachers, with principals, and so on. The school nurse has an obligation, as does anyone else who controls the health record, to protect that confidentiality. So in the case of a child with asthma, or who has a quick–relief inhaler, has epinephrine, or any other medication at school, it is important to keep FERPA in mind. It is much more impactful on the school than HIPAA. Typically, HIPAA applies to those schools that fall under this act that because they have a health clinic or something else where they are doing electronic record sharing.
Stoloff: Thank you, Linda. The next question is, “I am already overwhelmed with school physicals. How can I provide written asthma action plans and explain them in the course of a visit? Plus, I give the asthma action plan to the parent who never takes it to the school.”
This is basically a two–part answer. I would not have an asthma action plan discussed or written during a school physical. Asthma action plans should be completed during a well visit for asthma. For all of you who take care of children with asthma, I encourage you to schedule an appointment for that child about a month or at least a couple of weeks before school starts for a well asthma visit. The reason being what we call the “September epidemic,” and studies have shown that in the fall, human rhinovirus hits in the school at about two to four weeks before school starts. Human rhinovirus is the number one cause of asthma exacerbations in the school–age child, even those of preschool age. So you want to make sure during the well asthma visit that the child is on his or her long–term control medication, if indicated, and knows how to use it, as well as how to use his or her quick–relief inhaler.
A well asthma visit is also the time a written asthma action plan can be discussed and provided. As far as providing copies, I would give two copies of the asthma action plan to the child and caregiver or parent and say that the second one goes to the school. I think that this process enhances the probability that the asthma action plan gets to the school. You should also have a copy for your medical records of what you provided that child or student so that if necessary, you can quickly make a copy of the asthma action plan and provide it to the school.
Ok, the next question is, and this is one that I have not faced, “In our area, we hear that physicians are charging their patients to complete a written asthma action plan. This is a barrier for some of our families and they are not getting them completed. Are there any suggestions?”
As I stated, my recommendation is that a written asthma action plan should not be something that is done in lieu of a well asthma visit. It should not be done during an exacerbation of asthma or an unscheduled visit where the patient is not feeling well because you will overwhelm them. So number one, I do not charge for a written asthma action plan. Anything that you put in front of the patient that creates an economic barrier to the quality of the care is inappropriate, especially with asthma. I don’t have another answer to it. I keep getting these forms that patients want for work or something else. We charge the fee for that if it is not directly related to the care of the patient or if someone else, an outside organization, is asking for a form. A written asthma action plan is directly related and linked to the ongoing care of that patient and it is not initiated by anything other than good care. So there should be no charge for a written asthma action plan. Would anyone else like to answer?
Fusco–Walker: Yes, Stuart. This is Sandra. Years ago, I was on the New York Childhood Asthma Initiative, and charging for asthma action plans was proposed as a way for providers to cover their costs. At the time, the committee and providers we were speaking with came to the conclusion that an asthma action plan is basically a prescription for your patients, and it is a prescription that changes sometimes as a child grows and as we move through the different stages of life. But it is a prescription, and you do not charge for prescriptions. It is essential that patients are provided the information they need to be able to leave the office and care for themselves, and follow the plan that they and their asthma provider have put together.
Stoloff: Thank you. The next question is about very young children, especially those in elementary school: “What do you advise regarding self–carry for young kids?”
Many school staff don’t feel comfortable because the children lose their medication or they hand it to the other kids to play with it. For very young children who are of school age, those medications are kept at the school, and they should move with the child as he proceeds through his day. Now the difficulty, of course, occurs if the school happens to be one where the child is being seen by multiple teachers. In the very young age group, that really does not happen very often, so I recommend that the medication be kept in the child’s classroom by his or her teacher. Additionally, what I do, and I am not telling other people to do it, is that a minimum of twice a year, I go to the schools in the area where I live, and I spend time in the morning with placebo medications and review with nurses and other school staff how to use inhalers. And I also provide these tools to the schools, because I can get valved holding chambers with masks that can be used in the very young population, so this alleviates a lot of the difficulty of administering the medication in young children. But I fully support the fact that if there is concern that the child is going to lose his or her medication or that it is going to be shared with someone, then that child is not ready to self–carry or administer that medication because the possibility of appropriate use of that medication is less than acceptable. Would anyone else like to answer that?
Kaplan: Sure. This is Barbara. I’ll jump in and just say our Open Airways for Schools program targets children who are between the ages of 8 and 11. We started with 8 years old because it is typically at that age where we’ll see children can take action and be responsible for their medication, not to suggest that a child younger than that could not. But I think that it could be important if it is a very young child for it to just be in the classroom and for a teacher or a school staff member to be educated on how to use it. That is what I would add.
Stoloff: Thank you.
Mead: This is Andrew. I would just like to step in and add that especially at a really young age—pre–K and kindergarten age—students’ school days are very structured. I would just like to echo what you guys said that it would be a very good idea for the teacher to have the medication in the classroom on–site, but also anybody that facilitates physical activity throughout the day, whether it be somebody else that facilitates recess, or classroom break, or physical education class, I would also recommend that they have it on–site as well.
Stoloff: Thank you.
Fusco–Walker: Stuart, it is Sandra. I just wanted to jump in and say that it is not just young children. Sometimes children who are teenagers are irresponsible with their medications. I think that you have to look at the specific student and as Barbara and Andrew said, address the issue on an individual level.
Stoloff: Thank you. So the next question posed from the audience was, “Peak flow meters are effort–dependent. Some students know this, and they can get out of physical education. What do you suggest when this is suspected?”
I do not want any kids out of physical education so I am going to answer this. Yes, peak flow meters are effort–dependent, so here’s what I encourage if someone is actually asymptomatic, and their numbers are low, even when they are showing slight symptoms, and their numbers are totally abnormal: Number one, they have to demonstrate how they use the peak flow meter in front of me. Number two, I am going to many times disregard the results from the peak flow meter, especially if they are asymptomatic because I know they are—I use the term—“shucking and jiving”—and the numbers are irrelevant. A peak flow meter is a device that can help, especially for those who are poor perceivers of symptoms or who are having difficulty. But you can fake it, you can stick your tongue in it and change the resistance and blow the numbers out the roof. So I do not allow a peak flow result alone to determine the continuation or discontinuation of physical exercise. And if there is any question, I would encourage the parent or the appropriate responsible party within the school to refer that child back to their physician with the request that if this child’s asthma is so poorly controlled that he or she is unable to participate in physical activity at school that the physician please help to get the child’s asthma under better control.
Mead: Sure. I would just like to jump in and add another point. As a former physical educator, we want PE to be for everybody. I agree with you that I do not think that anybody should sit out. But we do know that students make up excuses and there really is no way of ignoring that. In that instance, the teacher should know the student and if it appears that there may potentially be a deeper reason for that student not wanting to participate in physical education, I would recommend that the teacher have a meeting with the student, maybe bring in a parent, a nurse, or school administrator and touch base with that student and really encourage them. As one of the panelists mentioned earlier, that is an opportunity to educate a student and a parent about the importance of being physically active and getting everyone on board. One potential solution is to take a look at your curriculum and see what you are doing and try to figure out why that student may or may not want to participate. See the program; see how you can make it more fun, safe and positive environment for that student to want to participate. As a former physical educator, that is what I would recommend.
Stoloff: Thanks, Andrew. The next question is, “What is the recommendation regarding the use of spacers? It seems to be becoming passé. When administering quick–relief inhalers, do you put it in the mouth or is it away from the mouth?”
I am going to start with the second question. All current quick–relief inhalers now have wrapped around them a propellant called hydroflouoroalkane (HFA). It requires that the inhaler be put directly in the mouth. If you put the inhaler one centimeter away from the mouth, some estimates are that you reduce by at least 50 percent the amount of medicine getting into the airways. A spacer may also be used with the inhaler. One kind of spacer, the valved holding chamber, is especially useful for the very young child, for example a preschool– or kindergarten–age child, who has difficulty manipulating a metered–dose inhaler. In which case, especially for the metered dose inhalers, a valved holding chamber with or without a mask may be acceptable. Hopefully, the valved holding chamber is used with just the mouthpiece, but if it is not, especially in the preschool era, then with a mask. The mask needs to be tightly fit. If the child is screaming, if the child is exhaling, little to no medicine gets in the airway. I use valved holding chambers a lot with very young children. I will also look to use them when compared to using a nebulizer, depending upon the need, the affordability, and the site where the parent or caregiver will be, because the portable nebulizers are substantially more expensive than those that need to be plugged into an electrical outlet.
I will add one more thing. One of the difficulties with valved holding chambers is cost. They are a durable medical good and, unfortunately, many of the insurance plans in this country pass on the cost of that durable medical good to the patient. So what you want to see is whether your clinician has available valved holding chambers or if the nebulizer is better. Budesonide is the only nebulized long–term control medicine available presently that you could use.
Are there any other comments, or did I ramble on too much?
Kaplan: No, you said it well.
Stoloff: Kate, are there any other questions?
Fink: There is one more here that just came in. This can be our final question. It says, “In Charlotte, and I think it’s the Charlotte–Mecklenburg Schools, they contract with a respiratory therapist on–site for children with poorly managed asthma. Is anybody else doing that?”
Stoloff: I am going to ask if anyone on the panel would like to answer this because I am not familiar with any school having sufficient money to be able to afford that luxury. Would any of the other panelists have information to answer this?
I guess not. I am not aware of it, Kate. I have used respiratory therapists at my own cost, and sometimes I can get them to come with me for free to help do the education for people when I do the school teaching program, but other than that, I am not aware of having that type of economic situation available.
And if there are no other questions, I am going to pass it back over to you, Kate.
Fink: OK, great. Well, thank you so much. Just wanted to thank everyone today: the National Asthma Education and Prevention Program and the National Heart, Lung, and Blood Institute, who hosted this webinar today. I would also like to thank Rachael Tracy from the NHLBI, our moderator, Dr. Stuart Stoloff, as well as our five panelists. We really appreciate your time today. We also thank the audience for listening and for your questions. I think this was a great discussion. We will be sending a follow–up email very shortly with a link to a webinar feedback form. We would appreciate your response. Thank you to everyone.
(End of webinar)
Last Updated December 2012