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Management of Asthma Exacerbations: School Treatment

Suggested Emergency Nursing Protocol for Students with Asthma Who Don't Have a Personal Asthma Action Plan

A student with asthma symptoms should be placed in an area where he/she can be closely observed. Never send a student to the health room alone or leave a student alone. Limit moving a student who is in severe distress. Go to the student instead.

See list of Possible Observations/Symptoms at bottom of the page.


Acronyms Used in the Text

ED:  emergency department
ICU:  intensive care unit
MDI:  metered-dose inhaler
PEF:  peak expiratory flow
SABA:  short-acting beta2-agonist (quick-relief inhaler)


Immediate Assessment:

  • Is the exacerbation severe? — Marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness OR
  • Is the student at High Risk of a fatal attack? — Risk factors for a fatal attack (see bottom of the page)*.

If YES (exacerbation severe or student at High Risk):

  • Take Immediate Actions
    • Treat with inhaled SABA.
    • Call 911 (student to ED)
    • Contact parent/guardian.
  • IF NO RESPONSE
    • Consider epinephrine for life-threatening attack only.** (see bottom of the page).

If NO (exacerbation not severe and student not at High Risk):  Continue


If available, measure PEF:  Is PEF <50% of predicted or personal best?

If YES (PEF <50% of predicted or personal best):

  • Take Immediate Actions
    • Treat with inhaled SABA.
    • Call 911 (student to ED)
    • Contact parent/guardian.
  • IF NO RESPONSE
    • Consider epinephrine for life-threatening attack only.** (see bottom of the page).

If NO (PEF not <50% of predicted or personal best):  Continue


Check and record respirations, pulse, and PEF rate.



Initial Treatment

  • Inhaled SABA: Up to two treatments 20 minutes apart of 2-6 puffs by MDI or nebulizer treatments (Note: medication must be authorized by a personal physician order or standing protocol signed by the school physician or public health physician).
  • Restrict physical activity. Allow student to rest.
  • Administer oxygen (if appropriate and available).
  • Contact parent/guardian.
  • Assess response after 10 minutes.

Response

  • Good Response: (PEF ≥80% and no wheezing or dyspnea.)

    • Reassess after 3-4 hours.
    • Follow school protocol for returning to class.
  • Incomplete Response: (PEF 50-79% or persistent wheezing or dyspnea.)

    • Repeat inhaled SABA.
    • Reassess after about 10 minutes.
    • Call parent immediately if response remains incomplete.
  • Poor Response>: (PEF <50% or marked wheezing and dyspnea.)

    • Repeat inhaled SABA.
    • Call 911 (Student to ED)
    • Contact parent/guardian.
    • Consider epinephrine for life-threatening attack only.** (see bottom of page)

With parental permission, send a copy of the health room encounter report to the student's physician. Obtain a personal asthma action plan.

Updated August 2011


Reprinted from the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007

Possible Observations/Symptoms (May include one or more of the following):

  • Coughing, wheezing, noisy breathing, whistling in the chest.
  • Difficulty or discomfort when breathing, tightness in chest, shortness of breath, chest pain, breathing hard and/or fast.
  • Nasal flaring (nostril opens wide to get in more air).
  • Can only speak in short phrases or not able to speak.
  • Blueness around the lips or fingernails.

Risk Factors for Death from Asthma

Asthma history

  • Previous severe exacerbation (e.g., intubation or ICU admission for asthma).
  • Two or more hospitalizations for asthma in the past year.
  • Three or more ED visits for asthma in the past year.
  • Hospitalization or ED visit for asthma in the past month.
  • Using >2 canisters of SABA per month.
  • Difficulty perceiving asthma symptoms or severity of exacerbations.
  • Other risk factors:  lack of a written asthma action plan, sensitivity to Alternaria.

Social history

  • Low socioeconomic status or inner-city residence.
  • Illicit drug use.
  • Major psychosocial problems.

Comorbidities

  • Cardiovascular disease.
  • Other chronic lung disease.
  • Chronic psychiatric disease.

ED: emergency department
ICU: intensive care unit
SABA: short-acting beta2-agonist

Updated August 2011

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