Albuterol inhaler without spacer

Pursuant to 167.627. Possession and self-administration of medication in school — requirements. Each board of education and its employees and agents in this state shall grant any pupil in the school authorization for the possession and self-administration of medication to treat such pupil’s chronic health condition, including but not limited to asthma or anaphylaxis if:

(1) A licensed physician prescribed or ordered such medication for use by the pupil and

instructed such pupil in the correct and responsible use of such medication;

(2) The pupil has demonstrated to the pupil’s licensed physician or the licensed physician’s designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered;

(3) The pupil’s physician has approved and signed a written treatment plan for managing the pupil’s chronic health condition, including asthma or anaphylaxis episodes and for medication for use by the pupil. Such plan shall include a statement that the pupil is capable of self-administering the medication under the treatment plan;

(4) The pupil’s parent or guardian has completed and submitted to the school any written

documentation required by the school, including the treatment plan required under subdivision (3) of this subsection and the liability statement required under subdivision (5) of this subsection; and (5) The pupil’s parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the pupil or the administration of such medication by school staff. Such statement shall not be construed to release the school district and its employees or agents from liability for negligence.

3. An authorization granted under subsection 2 of this section shall:

(1) Permit such pupil to possess and self-administer such pupil’s medication while in school, at a school-sponsored activity, and in transit to or from school or school-sponsored activity; and

(2) Be effective only for the same school and school year for which it is granted. Such

authorization shall be renewed by the pupil’s parent or guardian each subsequent school year in accordance with this section.

4. Any current duplicate prescription medication, if provided by a pupil’s parent or guardian or by the school, shall be kept at a pupil’s school in a location at which the pupil or school staff has immediate access in the event of an asthma or anaphylaxis emergency.

5. The information described in subdivisions (3) and (4) of subsection 2 of this section shall be kept on file at the pupil’s school in a location easily accessible in the event of an emergency.

Considerations:

• Attempt to provide the student with as much privacy as possible, given the urgency of the situation.
• For children the use of a valved holding chamber (spacer) is optimal to ensure proper medication delivery.
• The school nurse should develop a plan to systematically check the expiration date on the medication to ensure the medication has not expired.

Supplies:

• Inhaler
• Student’s Individualized Health Care Plan (IHCP) and Asthma Action Plan/health care provider’s order
• Parent/Guardian authorization form
  

Instructions for inhaler administration without spacer:

1. Gather needed supplies and place on a clean surface
2. Position student, providing as much privacy as possible
3. Wash hands
4. If the student will be administering medication, have the student wash hands
5. Check for authorization forms or records. Review the medication administration form, the medical provider form, and the parent/guardian consent form
6. Review the six rights of medication administration to be sure it is:  

1. The right student
2. The right medication
3. The right dose
4. Being given at the right time
5. Being given by the right route
6. Being given for the right reason

7. Check medication expiration date
8. Review the student’s allergy status
9. Ensure proper documentation of parent/guardian authorization to administer medication
10. Make sure the inhaler is free of foreign objects
11. Shake the inhaler for 5 seconds to mix the medicine
12. Remove the cap from the inhaler mouthpiece
13. Prime the inhaler if indicated (if the inhaler is new or has not been used in the past 7 days or if it has been dropped)
    1. When the inhaler is brand new or has not been used for a while, the medication may separate from the other ingredients in the canister and the metering chamber. Shaking the inhaler will mix the ingredients in the drug reservoir but may not produce enough turbulence to re-blend the ingredients in the metering chamber. Priming, or releasing one or more sprays into the air, ensures your next dose will contain the labeled amount of medication
14. Review the six rights of medication administration again to be sure it is:
15. The right student
16. The right medication
17. The right dose
18. Being given at the right time
19. Being given by the right route
20. Being given for the right reason

15. Hold the inhaler between your index finger and thumb
16. Have the student stand up and take a deep breath in and breathe out
17. Have the student tip their head back slightly toward the ceiling
18. Have the student put the inhaler in their mouth, between their teeth and above their tongue
19. Have the student close their lips around the inhaler
20. Press down on the top of the inhaler once as the student breathes in very slowly until they have taken a full breath
21. Instruct the student to hold their breath for 10 seconds
22. Instruct the student to breathe out slowly through their mouth
23. Wait 1 minute before having the student take a second puff, if ordered
24. Repeat previous steps if taking a second puff
25. Have the student rinse out their mouth with water and spit
26. Wash hands
27. Document medication administration in student’s medication administration log
28. Follow up, as needed, with parents or guardian and health care provider

Cleaning the inhaler:

1. Remove the canister from the actuator
2. Run warm water through the top and bottom of the plastic actuator (do not boil or place the actuator in the dishwasher)
3. Shake off the excess water
4. Allow the actuator to air dry on a clean surface prior to putting the canister back in

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References: 

American Lung Association. (2019, April). How to use your inhaler and spacer. Retrieved May 24, 2023, from https://www.lung.org/getmedia/21c7dabe-795c-4576-9bbc-6f6bb9fcad06/ala-how-to-inhaler-v4.pdf

American Lung Association. (2022, September). How to use a metered-dose inhaler without a valved holding chamber or spacer. Retrieved May 24, 2023, from https://www.lung.org/getmedia/1aa45911-f79f-44ef-a348-08e089e1a57c/MDI-one-pager.pdf?ext=.pdf

American Lung Association. (2022). How to use a metered dose inhaler . Retrieved May 24, 2023, from https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/treatment/devices/metered-dose-inhaler

American Lung Association. (2022, November 17). How to use a metered-dose inhaler with a spacer or valved holding chamber . Retrieved May 24, 2023, from  https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/treatment/devices/metered-dose-inhaler-chamber-spacer

Butler, S.M., Boucher, E.A., Tobison, J., & Phan, H. (2020). Medication use in schools: Current trends, challenges, and best practices. J Pediatr Pharmacol Ther., 25(1): 7–24. doi: 10.5863/1551-6776-25.1.7

Centers for Disease Control and Prevention. (n.d.). Know how to use your asthma inhaler using a metered dose inhaler: Using a metered dose inhaler (inhaler in mouth). Retrieved May 24, 2023, from  https://www.cdc.gov/asthma/pdfs/Inhaler_in_Mouth_FactSheet.pdf

Centers for Disease Control and Prevention. (n.d.). Know how to use your asthma inhaler using a metered dose inhaler: Using a metered dose inhaler with spacer. Retrieved May 24, 2023, from https://www.cdc.gov/asthma/pdfs/Inhaler_Spacer_FactSheet.pdf

Centers for Disease Control and Prevention. (2022, December 12). Using a metered dose   

inhaler with spacer . Retrieved May 24, 2023, from https://www.cdc.gov/asthma/inhaler_video/default.htm                                                                       

Center for Disease Control and Prevention. (2022, December 12). Using a metered dose inhaler (inhaler in mouth) . Retrieved May 24, 2023, from https://www.cdc.gov/asthma/inhaler_video/default.htm

Children’s Hospital St. Louis. (n.d.). For kids: How to use a metered-dose inhaler (closed-mouth). . Retrieved June 7, 2023, from https://stlouischildrens.staywellsolutionsonline.com/MultimediaRoom/VideoLibrary/?e=0#player:138,K1991

Fanta, C.H., Barrett, N.A. (2023, April 4). An overview of asthma management. In a R.A. Wood and B.S. Bochner (Ed.), UpToDate. Retrieved: May 24, 2023, from https://www.uptodate.com/contents/an-overview-of-asthma-management

Lynn, P. (2019). Administering medication via a metered-dose-inhaler (MDI) In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 116-118).

Missouri Revised Statutes: 167.627.1 RSMo. (2010). Possession and self-administration of medication in school—requirements. Retrieved June 20, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=167.627

Missouri Revised Statutes: 167.635 RSMo. (2010). Asthma-related rescue medications, school nurse may be authorized by school board to maintain, procedure. Retrieved June 7, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=167.635

Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Nonparenteral medications. In Clinical nursing skills and techniques. (10th ed.). (pp. 637-640). St. Louis, MO: Elsevier.

Prescribers’ Drug Reference (PDR). (2023). Albuterol sulfate – drug summary. Retrieved May 24, 2023, from https://www.pdr.net/drug-summary/Albuterol-Sulfate-Inhalation-Solution-0-083-albuterol-sulfate-1427

Possession and self-administration of medication in school—requirements, Missouri State Statute Chapter 167: Pupils and Special Services: Section 167.627.1 RSMo. (2010). https://revisor.mo.gov/main/OneSection.aspx?section=167.627
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Page last updated on February 20, 2024
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Acknowledgement of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

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