Asthma

Asthma, Respiratory

Discussion: In-depth Resource

This resource provides current and comprehensive health care information for school health nurses in two ways: on this webpage and as a downloadable, In-depth Asthma 27 page pdf document. Related procedures, instructional videos and downloadable skills checklists can be searched by selecting the [More Information] button at the bottom of this web page.

Overview

Asthma is a chronic condition of the airway characterized by inflammation, airway obstruction, and bronchial hyperresponsiveness. Children with asthma have recurrent episodes of wheezing, breathlessness, chest tightness, and cough, especially at night and early morning. The inflammation associated with asthma also causes an increase in bronchial hyperresponsiveness to a variety of stimuli (triggers) (Conlon, 2024).

The following are common asthma triggers:

Respiratory infections (viruses, bacteria)
Allergen exposure (inhalant, food, and occupational)
Inhaled respiratory irritants (including tobacco and cannabis [marijuana] smoke and cold, dry air)
Temperature and weather
Physical activity
Hormonal fluctuations
Medications
Emotional factors (i.e., anxiety, stress)
Comorbidities such as:
- Rhinitis
- Gastroesophageal reflux
- Obesity
- Depression
- Anxiety

(Miller, 2023)

Asthma is classified into four categories, intermittent, mild persistent, moderate persistent, and severe persistent. The categorization of the asthma symptoms assist health care providers in developing a treatment plan (Conlon, 2024). Many health care providers follow a stepwise approach for the management of asthma, prescribing a short-acting beta agonist (SABA) for intermittent symptoms and increasing the dose of the medication or introducing an inhaled corticosteroid when the symptoms increase or worsen (American Academy of Allergy, Asthma & Immunology, 2023; Fanta & Barrett, 2023).

Table: Classification of Asthma- 5-11 years of age

	Level of Asthma
		Persistent
Symptoms	Intermittent	Mild	Moderate	Severe
Daytime symptoms	≤2 days/week	>2 but <7 days/week	Daily symptoms	Symptoms throughout the day
Nocturnal awakenings	≤2 times/month	3 to 4 times/month	>1/week but not daily	Most nights
Short-Acting Beta Agonist (Albuterol)	PRN	PRN	Daily	Several times/day
Interference with activities	None	Minor	Some	Extreme
FEV₁ and FEV₁/FVC (FEV₁is the amount of air a person can force out of their lungs in 1 second) FEV₁/FVC is the ratio of forced expiratory volume in the first one second to the forced vital capacity of the lungs.	Normal	Normal	FEV₁60-80% predicted FEV₁/FVC below normal	FEV₁<60% predicted FEV₁/FVC below normal
Exacerbations treated with oral corticosteroids	≤1/year	≥2/year	≥2/year	≥2/year

Sources: Fanta & Barrett, 2023; National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group, 2020

Table: Classification of Asthma- Adolescent and Adult

	Level of Asthma
		Persistent
Symptoms	Intermittent The presence of all the following symptoms is considered an indicator of intermittent severity	Mild The presence of any of the following is considered an indication of mild severity	Moderate The presence of any of the following is considered an indication of moderate severity	Severe The presence of any of the following is considered an indication of severe severity
Daytime symptoms	≤2 days/week	>2 but <7 days/week	Daily symptoms	Symptoms throughout the day
Nocturnal awakenings	≤2 times/month	3 to 4 times/month	>1/week	Nightly
Short-Acting Beta Agonist (Albuterol)	≤2 days/week	>2 but <7 days/week	Daily	Several times/day
Interference with activities	None	Minor	Some	Extreme
FEV₁ (FEV₁is the amount of air a person can force out of their lungs in 1 second)	≥80% predicted	≥80% predicted	60-80% predicted	<60% predicted
Exacerbations treated with oral corticosteroids	≤1/year	≥2/year	≥2/year	≥2/year

Source: Fanta & Barrett, 2023

Table: Classification of Asthma Control- 5-11 years of age

Components of control	Classification of asthma control (5-11 years of age)
Components of control	Well controlled	Not well controlled	Very poorly controlled
Symptoms	≤2 days/week, but not more than once on each day	>2 days/week or multiple times on ≤2 days/week	Throughout the day
Nighttime awakenings	≤1 time/month	≥2 times/month	≥2 times/week
Interference with normal activity	None	Some limitation	Extremely limited
Short-Acting Beta Agonist (Albuterol)	≤2 days/week	>2 days/week	Several times per day
Lung function
FEV₁or peak flowFEV₁/FVC	>80% predicted/person best>80%	60 to 80% predicted/person best75 to 80%	60% predicted/person best<75%

(Fanta & Barrett, 2023)

Table: Level of Asthma Symptom Control in Adolescents and Adults

Level of Asthma Symptom Control
In the past 4 weeks, has the patient had:	Well controlled	Partly controlled	Uncontrolled
Daytime symptoms more than twice/week	None of these	1 to 2 of these	3 to 4 of these
Night awakening due to asthma
SABA reliever needed more than twice/week
Activity limitations due to asthma

(Fanta & Barrett, 2023)

The goal of asthma treatment is to establish good asthma control. Good asthma control means reducing the intensity and frequency of asthma symptoms and maintaining normal or near normal activity levels. Specific goals for asthma control include:

Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)
Few night-time awakenings (≤2 nights per month) due to asthma
Minimal need (≤2 days per week) for medication for acute relief of asthma symptoms
Optimized lung function
Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise
Satisfaction with asthma care on the part of the student and their parents/guardians (Fanta & Barrett, 2023).

Asthma Exacerbation:

When the student’s asthma is not well controlled it puts them at higher risk of experiencing an asthma exacerbation which can be life threatening.

Symptoms Associated with Asthma Exacerbation:

Hacking, paroxysmal, irritative, nonproductive cough
Dyspnea
Wheezing
Chest tightness
Chest pain
Prodromal itching localized at the front of the neck or over the upper part of the back
Feeling uncomfortable, irritable, or increasingly restless
Headache
Feeling tired
Sitting in tripod position or sitting upright with their shoulders hunched over, hands on a chair, and arms braced to allow them to use their accessory muscles of respiration
Difficulty speaking, only being able to use short, panting, broken phrases (Colon, 2024).

Assessment Findings Associated with Asthma Exacerbation:

Hyperresonance on percussion
Coarse and loud breath sounds
Sonorous crackles throughout lung field
Prolonged expiration
Coarse rhonchi
Generalized inspiratory and expiratory wheezing
With severe spasm or obstruction, breath sounds and crackles may be inaudible (Colon, 2024).

Immediate treatment:

Immediate treatment and medical attention are needed for students who are at high risk for a life-threatening or fatal attack based upon history (see Table: Risk factors for a fatal asthma attack) and/or who have severe symptoms (marked breathlessness, inability to speak more than short phrases, use of accessory muscles, and agitation and drowsiness). School staff should be instructed to immediately administer the student’s albuterol or emergency stock albuterol and call 911 or emergency medical services (EMS) to have the student transported to the emergency department (Sawicki & Haver, 2023a).

Table: Risk factors for a fatal asthma attack

Indicators of severe disease

Previous life-threatening exacerbation

Asthma attack despite current oral glucocorticoid use

Indicators of poor asthma control

More than 1 hospitalization for asthma in the past year

3 or more emergency department visits for asthma in the past year

Use of more than 1 canister of short-acting beta agonist per month

Serious comorbidities

Cardiovascular or chronic lung disease

Illicit drug use or major psychosocial problems

Food allergy

Poor asthma co-management skills

Not taking inhaled glucocorticoids

History of poor adherence with asthma medications and/or written asthma action plan

Difficulty preventing asthma symptoms or severity of exacerbations

(Sawicki & Haver, 2023).

Asthma and Allergies: “Having an allergy is the strongest epidemiological risk factor for asthma morbidity and mortality” (Conlon, 2024, p. 922) and increased consideration needs to be made when caring for a student who has asthma and allergies, especially anaphylactic allergies. For more on anaphylaxis, see the Anaphylaxis page.

Delegation

Delegation of the administration of albuterol is a common practice in the school setting. The American Thoracic Society, Allergy and Asthma Network, the American Lung Association and the National Association of School Nurses state that Unlicensed Assistive Personnel (UAPs) may be designated to administer albuterol (Volerman et al., 2021) and research has shown that “albuterol sulfate can be safely administered by any school staff who have been trained to do so because modern day formulas are safe with a wide-therapeutic index” (Lowe et al., 2022, p. 1-2). Although it is common practice to delegate albuterol administration to UAPs, the school nurse needs to evaluate each situation individually.

Questions to Ask to Inform Safe Delegation: The delegation questions below are based on the American Nurses Association’s Decision Tree for Delegation by Registered Nurses (ANA, 2012) and the National Association of School Nurses’ Emergency Medication Administration Delegation Decision Tree (NASN, 2020a).

Has the school nurse performed an initial assessment of the student to determine their needs? The school nurse should not delegate the procedure to an Unlicensed Assistive Personnel (UAP) until they have completed the initial assessment.
Does school district policy, the school nurse’s job description, and the UAP’s job description allow the delegation of administering albuterol? Although the Missouri Nurse Practice Act allows for registered nurses to delegate administration of albuterol to school staff, the school nurse should ensure that the district does not have policies that prohibit or limit the school nurse’s ability to delegate. Additionally, the school nurse should review their own and the UAP’s job description to confirm that it is appropriate to delegate this procedure.
Is the school nurse competent to perform this procedure or does the school nurse need to acquire some knowledge or skills to be competent in this procedure? If the school nurse does not have the knowledge or skills or does not feel comfortable performing this procedure, they should not delegate this procedure to a UAP. The school nurse must first acquire the necessary knowledge and skill to perform this procedure competently before they can delegate it to someone else.
Does the student have any other health conditions that make their overall health status unstable? The student’s health condition should be stable so that when the albuterol administration is completed by following a set procedure or protocol the student is not at undue risk.
Are the results of the albuterol administration reasonably predictable? If the results of the albuterol administration are not predictable then this procedure should not be delegated.
Does the UAP have the appropriate knowledge, skills, abilities, and willingness to perform the procedure? All these factors need to be considered. Although a UAP may be competent to perform the procedure they may not be willing to do so and in that situation another UAP should be identified and trained. The registered nurse must retain responsibility for the procedure until training is complete.
Is there a procedure and/or protocol in place for this procedure? A delegated nursing procedure must have an established sequence of steps that the UAP can follow. These steps should have a predictable outcome. The steps should be outlined in a written procedure or protocol. If the written procedure/protocol has not been developed, the school nurse should retain responsibility for the procedure until the procedure/protocol is in place.
Is the school nurse able to provide supervision to the UAP (direct or indirect depending on the situation)? If the school nurse is not able to provide supervision, then the procedure should not be delegated. The school nurse will need to assess the situation to determine if direct or indirect supervision is required. The school nurse may also need to reassess the situation if the environment changes, for example, if the procedure is going to be performed during a time that the school nurse is not contracted to provide nursing services (i.e., weekend, summer, or if the school nurse is part-time).
Is the student ready to assume some responsibility for the procedure? The school nurse should resume responsibility for the procedure since the school nurse is the only one who can initiate teaching. The school nurse would also want to observe the student performing the procedure to ensure that the student is competent. Once the school nurse has determined that the student is competent and can safely perform the procedure independently, they can delegate the supervision of the student to a UAP. If at a future date the school nurse is needed to teach the student additional skills, the school nurse would again need to resume responsibility for the procedure until the time in which the school nurse determined the student to be competent.

Delegation Decision Tree and Delegation

The Decision to Delegate:

There may be times when the school nurse and school administrator have conflicting opinions on the delegation of a procedure to a UAP. The school nurse may feel that delegation is not appropriate or the administrator may want the school nurse to delegate a procedure to an UAP that the school nurse feels is not competent. In these situations, the school nurse may need to educate the administrator that the school nurse has a professional and legal responsibility to determine if delegation of a nursing procedure is appropriate and safe (ANA, 2012). See Fact Sheet for School Administrators, Families, and School Personnel: Nursing Delegation Requires the School Nurse and Navigating Delegation in the School Setting (pdf) to assist school nurses communication with the school administration.

School Environment

Proper management of the school environment plays a critical role in the management of asthma and the mitigation and prevention of asthmatic exacerbation. The school environment includes the people within the school (i.e., students, staff, and visitors), the physical environment (i.e., classroom, cafeteria, and playground) and the resources available within the school (i.e., access to stock albuterol, school staff who are educated and trained to respond to asthma exacerbation).

Physical Environment:

Asthma Friendly Schools: The school environment can impact a student’s asthma. Triggers found in the school environment can exacerbate a student’s asthma, such as animal dander, dust, perfume, and car/bus exhaust . The American Lung Association has developed an Asthma Friendly Schools Initiative Toolkit which includes resources on providing a healthy school environment. The Environmental Protection Agency has also developed an Indoor Air Quality Tools for Schools Action Kit.

The Wisconsin Asthma Coalition has developed an asthma walk-through program that includes a school walkthrough checklist.

Access to Albuterol: A prompt and coordinated response to an asthma exacerbation is critical. School staff who have regular interactions with a student with asthma should know where the student’s albuterol is located. If the student self-possesses their albuterol, the student should communicate the location of their albuterol with school staff and the school nurse.

Stock Albuterol: Missouri Statute 167.635 allows schools to maintain a supply of asthma-related rescue medications. When planning for stock albuterol the school nurse should consider the following:

Acquisition of an order for stock albuterol from the school’s medical advisor.
Funding source to cover the cost of initial supply of albuterol and other needed supplies (i.e., individual student spacers or valved holding chambers).
Acquisition of albuterol to maintain adequate stock at each of the school buildings within the district.
Identification of where the stock albuterol will be stored
- It is recommended that stock albuterol be stored in a temperate, dry, and unlocked place that is easily accessible to trained individuals for medication administration (Volerman et al., 2021)
Development of a process to systematically check the expiration date(s) of the stock albuterol.
Development of an albuterol policy, procedure, and protocol.
Training of all school staff on asthma, risk reduction, and response to asthma exacerbation.
Training of designated staff who will be responsible for administering albuterol in response to asthma exacerbation.
Determination if stock albuterol will be available for before and after school events.

An important component of a stock albuterol program is to ensure that there are one-way valved holding chambers or spacers, which can be plastic or cardboard, if necessary for economic reasons. Studies have shown that paperboard spacers can safely last the entire

school year without microbial growth (Volerman et al., 2021, p. 519-20).

It is recommended that a stock albuterol administration protocol include the following:

Signs and symptoms of mild, moderate, and severe respiratory distress
The course of action based on the initial presentation of the student
Specific indications for when to summon emergency medical services
The dose of albuterol to give (i.e., the number of inhaler puffs for initial use and subsequent use for same episode of respiratory distress)
Post incident instructions
Information on the duration that a student’s documentation log shall remain on file with the school (Volerman et al., 2021).

An important treatment consideration for the school nurse to understand is that students who have an Asthma Action Plan but require the administration of stock albuterol (for example, if they do not have their own inhaler at school) is that

Treatment for any child who requires stock albuterol should follow the standardized protocol and prescription instructions specified on the standing medical order, regardless of whether they have an asthma action plan on file at school. An asthma action plan provides school personnel with instructions on how to use a child’s personal medicine, not stock albuterol (Volerman et al., 2021, p. 520).

Ensuring Access to Albuterol in Schools: From Policy to Implementation provides resources and guidance on developing a stock albuterol program and the American Academy of Allergy, Asthma, and Immunology have developed a Stock Albuterol Toolkit. The St. Louis Chapter of the Asthma and Allergy Foundation has the RESCUE Missouri Schools program which offers resources for stock albuterol.

Education and Training:

The American Thoracic Society, Allergy and Asthma Network, the American Lung Association and the National Association of School Nurses recommend that school staff be trained to recognize and respond to a student experiencing asthma symptoms. They state, “at each school, a minimum of two individuals should be trained per building, with consideration given to additional individuals on the basis of asthma prevalence and other school indicators” (Volerman et al, 2021, p. 514) but they recommend to train as many school staff as possible so at least one trained individual is present in the school each day. They recommend that the training include:

Basic asthma pathophysiology and common triggers.
How quick-relief medications work to treat respiratory distress.
Recognizing mild, moderate, and severe respiratory distress.
Demonstration of correct technique to administer treatment by using a metered-dose inhaler with a valved holding chamber.
Determining the course of action for managing respiratory distress events.
Maintenance of stock albuterol devices.
Post incident instructions, including timely documentation and parent/guardian/caregiver contact instructions (Volerman et al., 2021, p. 518).
It is also recommended that all school staff are educated to never send a student, who is experiencing asthma symptoms, to obtain their albuterol on their own (Allergy and Asthma Network, 2023).

Since proper use of the inhaler and administration of the albuterol is key to symptom relief, they state that “opportunities to teach back are particularly important to ensuring proper technique” (Volerman et al., 2021, p. 514).

The American Academy of Allergy, Asthma, and Immunology’s SA³MPRO^TMhas developed additional education and training resources.

Physical Education and Recess:

Some student’s asthma symptoms may be exacerbated by physical activity and exercise and/or by triggers in the outside environment. Physical education teachers should be educated on the signs and symptoms of asthma along with how to respond if a student were exhibiting symptoms. Additionally, physical education teachers should be encouraged to receive education and training on how to administer or assist a student in administering their albuterol (National Heart, Lung, and Blood Institute, 2014). The physical education teacher and any of the student’s coaches should have a copy of the student’s Asthma Action Plan and know what actions the student should take prior to engaging in physical activity. Additionally, the physical education teachers and coaches should ensure that the student has access to their albuterol during physical education class, practice, and/or any sporting events (Allergy and Asthma Network, 2023; Barrett & Moore, 2019). Considering some student’s Asthma Action Plans instruct them to administer their albuterol prior to physical education class or when engaging in exercise, the school nurse should collaborate with the student and their educational team to develop a plan to ensure they receive their medication prior to exercise.

Students

An important first step when caring for a student who is diagnosed with asthma would be to complete a health history and physical assessment, preferably with the student and their parents present.

Health History Questions:

Medical conditions
Does the student have a diagnosis of anaphylaxis?
Medications
Allergies
What triggers the student’s asthma?
Has the student been seen in the emergency department due to asthma exacerbation?
Does the student’s asthma interfere with any activities, such as running or singing?
- How often?
Does the student cough at night?
- If yes, how many nights per week?
During the last month, on average, how many days did the student have asthma symptoms (i.e., coughing, wheezing, shortness of breath, or waking up at night)?
Does the student use a spacer with their inhaler?
- If yes, does the student have a spacer for school and one for home?
Previous hospitalizations
Insurance coverage
Health care provider(s) name and contact information
Preferred hospital, if applicable

(Missouri Department of Health and Senior Services, 2021)

The Missouri Department of Health and Senior Services has developed the School Nurse Chronic Health Assessment Tool and the Colorado Department of Education has developed a Parent Asthma Intake Form and SA³MPRO^TMhas developed a School Nurse Asthma Care Checklist.

Assessment Questions: The school nurse may want to consider asking the student and their parents/guardians the following additional questions:

Does the student have an Asthma Action Plan (EAP)?
Has the student been educated and trained to administer their own albuterol?
Does the student self-carry their albuterol?
How does this health condition impact the student’s daily life?
Does the student know their asthma triggers?
Does the student have strategies to avoid their triggers?
Does the student wear a medical alert bracelet, necklace, watchband?
Has the student shared information about their asthma diagnosis with their peers?
Does the student or parents have any concerns about the student’s health condition?
What challenges does the student face in managing their health condition?
Do you feel the student has been sufficiently supported by school staff in managing their health condition?
Does the student have a 504 Plan or Individualized Education Program (IEP)?
Would the student benefit from evaluations or assessments in any of the following areas: physical therapy, occupational therapy, speech and language therapy, assistive technology, adapted physical education, functional behavior, psychology, hearing and vision?
Would the student benefit from additional academic support and/or modified education (i.e., copies of notes, extra time, reduced workload, simplified instructions, alternative formats for presentation of material, 504/IEP)?
Does the student have an Individualized Health Care Plan (IHCP)?
Is there a need for a specific plan for this student’s individual needs if there is a crisis in the building?
How is the student transported to and from school?
Does the student attend before or after school care?
Does the student participate in school-sponsored clubs or athletics?

(Missouri Department of Health and Senior Services Bureau of Community Health and Wellness, 2021).

Transition Planning:

The school nurse should assess the student’s current and desired level of independence to determine what goals should be established for the student. Additionally, the school nurse should discuss with the student and family what steps have been initiated related to transition planning. The school nurse should consider including goals related to self-management and decision-making skills in the student’s Individualized Health Care Plan (IHCP) (NASN, 2019b) and consider how those goals can be expanded upon each year to support independence, if appropriate.

The Missouri Department of Health and Senior Services has the resource, Asthma in a Minute:

School Nurse Toolkit for Asthma Self-Management Education. The American Lung Association has also developed 4 Steps for Transitioning from Pediatric to Adult Asthma Care.

Transportation:

It is important for the school nurse to determine how the student is transported to and from school. If the student is transported on the school bus the school nurse may be required to educate school bus drivers on asthma and train them on how to administer albuterol. The school nurse should confer with the school administrator to determine who is responsible to provide the training as school bus drivers who are employed by an outside agency may receive their training through their employer.

Communication

Asthma management including exacerbation risk reduction and response requires effective communication with and between multiple stakeholders. At the center are the student and their family. School personnel, such as the school nurse, need to communicate with the family to ensure all the necessary information and documents are available at school, including health care providers order(s), Asthma Action Plan, and contact information. Since a student’s Asthma Action Plan may be frequently updated, the school nurse will want to ensure that they have received the most up to date plan.

The school nurse also needs to ensure that they are communicating with school staff to provide the necessary education and training. School leaders also need to establish effective methods of communicating during an emergency, paying special attention to times when staff are outside of the school building (i.e., during recess) and when students are in transport (i.e., on the bus coming to and from school).

Some families of students with asthma struggle to be able to provide an extra albuterol inhaler to store at school and may rely on the school’s stock albuterol program. It is recommended that the school nurse contact the student’s family and their health care team if the student requires the use of stock albuterol more than once in a school year (Volerman et al., 2021, p. 520).

The school nurse needs to discuss with the student and their family the best way(s) to communicate with them. Does the parents/guardian have a preference (i.e., email, text, telephone call)? Do the parents prefer to have the communications sent to both parents or is there a parent who manages the communication with the school nurse?

The school nurse may want to consider having the parents/guardians complete a Health Insurance Portability and Accountability Act (HIPAA) compliant medical release form to facilitate communication with the student’s health care team. Although HIPAA does not require parental consent to allow the school nurse to discuss the student’s treatment plan, such as medications and nursing procedures, with the student’s health care provider, having a signed consent form would undoubtedly make the process go smoother for all involved parties (U.S. Department of Health and Human Services & U.S. Department of Education, 2008).

FERPA HIPAA Consent Sample (NASN)

Medications

Short-Acting Beta Agonists (SABAs):

SABAs such as albuterol (salbutamol) and levalbuterol (levosalbutamol) remain front line treatment for childhood asthma. SABAs relax airway smooth muscle, reducing constriction, which leads to a prompt increase in airflow. SABAs generally provide rapid relief of acute asthma symptoms (i.e., coughing, wheezing, chest tightness, and shortness of breath), with a time to onset of action of approximately 5 to 10 minutes, peak effect beginning within approximately 50 minutes, and duration of action of approximately three to six hours (Sawicki & Haver, 2023b).

Spacers and Valved Holding Chambers: Spacers and Valved Holding Chambers (VHCs) are medical devices approved by the Food and Drug Administration for use with inhaled medications. Both devices are used to improve inhaled medication delivery to the lower airways and decrease potential side effects such as candidiasis (thrush) and dysphonia (hoarseness). Although the word spacer is sometimes used to describe both items, they are different. A spacer is any open tube placed on the mouthpiece of a metered dose inhaler (MDI) used to extend its distance from the mouth (American Academy of Allergy, Asthma & Immunology (AAAI), 2022c). The spacer creates space between the medication and the student’s mouth. The space helps the medicine break into smaller droplets which allows the medication to get further down into the lungs (American Lung Association, 2023). A VHC is also a spacer but it is manufactured with a one-way valve to regulate inspiratory flow and prevent exhalation into the device. The VHC traps and holds the medication in the chamber and allows the student to inhale the medication over several breaths. Many times, the VHC also has a whistle that informs the user when they are inhaling too quickly or forcefully (Schoessler & Winders, 2016). Due to the one-way valve and the whistle feature, VHCs are recommended over spacers by the AAAI (2022c).

Student Possession and Self-Administration of Albuterol: Missouri State Statute 167.627 allows students to possess and self-administer their albuterol. When determining if it is appropriate for a student to possess and self-administer their albuterol the school nurse would want to assess the following:

That the student has an Asthma Action Plan on file
That the student knows:
- What symptoms indicate the need to use their inhaler
- How often to use their inhaler
- When to prime the inhaler
- What to do if their symptoms do not improve
- The difference in their asthma medications (i.e. SABAs and inhaled corticosteroids (ICS))
- How to identify when their inhaler is empty
That the student can demonstrate:
- Proper inhaler use technique (Kimel, 2022)
- Proper use of spacer or valved holding chamber, if applicable
Where the student will store their inhaler
What the student will do if they are in need of their inhaler and do not have access to it (i.e., lost it or cannot find it)
That the student’s health care provider agrees with the plan to allow the student to possess and self-administer their medication
That the student’s parents/guardian have completed a written authorization form that indicates they permit their child to possess and self-administer their albuterol (NASN, 2020b; NASN, 2021).

The National Association of School Nurses has developed a Contract for Student Self-Carry and Self-Administration of Medication that could be used to document the school nurse’s assessment and planning with the student. The Colorado Department of Education has developed an Asthma/Allergy Self-Carry Medication Contract.

Controller Medications:

In addition to SABAs many students are also prescribed controller medications. Controller medications are taken every day to help minimize the likelihood of an asthma exacerbation. The most common controller medications for children under the age of 12 are inhaled glucocorticoids (ICS), plus inhaled long-acting beta agonists (LABAs) or oral leukotriene receptor antagonists (LTRAs) in combination with ICS. Long-acting anticholinergic agents (or long-acting muscarinic antagonists (LAMAs) for children ≥6 years of age) and biologic agents (monoclonal antibodies against immunoglobulin E [IgE] and interleukin [IL] 5, for children ≥6 years of age are used as a stepwise approach (see tables below) in children whose asthma is not well controlled on other medications (Nanda, Russell, & Bingemann, 2021; Sawicki & Haver, 2022).

Inhaled Cocorticoids (ICS): Are anti-inflammatory agents. They reduce bronchial hyperresponsiveness, prevent late asthmatic response, & enhance lung function. ICS are available as MDIs, nebulized medication, & dry powder inhalers (DPI) (Sawicki & Haver, 2022).

Inhaled Long-Acting Beta Agonists (LABAs): LABAs are used in conjunction with ICS and should not be used as monotherapy. LABAs provide long-term control of asthma symptoms with a duration of at least 12 hours. They prevent nocturnal symptoms and exercise-induced bronchoconstriction (Sawicki & Haver, 2022).

Oral Leukotriene Receptor Antagonist (LTRAs): Cysteinyl leukotrienes are potent bronchoconstrictors that also promote the production of mucus and proinflammatory cytokines. LTRAs are medications that block leukotriene receptors. Montelukast is Food and Drug Association (FDA) approved for control of asthma in children ≥12 months of age, and Zafirlukast is approved for children ≥5 years (Sawicki & Haver, 2022).

Long-Acting Muscarinic Antagonists (LAMAs): Tiotropium is an anticholinergic bronchodilator approved by US FDA for long-term maintenance in children ≥6 years of age with severe symptomatic asthma not well controlled on ICS and other maintenance therapies.

Biologic Agents: There are three biologic agents for children ≥6 years of age who have severe asthma and who have not responded to usual therapy. They include Omalizumab, dupilumab, and mepolizumab (Sawicki & Haver, 2022).

Combination Medications:

Some inhaled asthma medication combinations contain both a corticosteroid and a bronchodilator. For more information see American Academy of Allergy, Asthma, and Immunology.

(National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group, 2020, p. 26).

(National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group, 2020, p. 28).

Asthma and Allergies: Some students diagnosed with asthma may also have a diagnosis of anaphylactic allergies and may be prescribed an epinephrine auto-injector. For more information on epinephrine auto-injectors see the Anaphylaxis page.

Health Care Provider Order:

Many times the health care provider’s order for albuterol may be written as an Asthma Action Plan. See the Documentation and Emergency Preparedness sections for more discussion on Emergency Action Plans. If the student does not have an Asthma Action Plan, the health care provider’s order should, at a minimum, contain the following information:

Name of the student
Date of birth
Name of medication
Dose
Route
Time of administration
Reason for administration
- The reasons for administration are typically listed as the symptoms of asthma.

Field Trips

The school nurse and school personnel should consider the following when planning for a student with asthma to go on a field trip:

Confirm that students on the field trip who have an asthma diagnosis have all the necessary items for the field trip including:
- Health care provider order/Asthma Action Plan
- Albuterol
- Spacer, if available
- Emergency Contact Information
Ensure that the Asthma Action Plan is up-to-date and reviewed to determine if any revisions are needed due to the field trip.
Plan to have emergency plans stored with the medication during the field trip. Consider what steps will need to be taken to ensure health plans remain confidential.
Determine where emergency medication will be stored keeping in mind temperature stability, accessibility, and safety.
- Emergency medication should not be left unattended on the school bus or with a school staff/volunteer who is not with the student.
Identify which students will be allowed to self-carry their emergency medication. Ensure that proper education, training, competency, and documentation has been completed.
Determine how medications administered on the field trip will be documented.
Develop a plan to obtain additional emergency medication, if needed.
Determine locations of emergency departments and hospitals along the route for the field trip and in the vicinity of the final field trip destination.
Determine if any additional staff are needed on the field trip to meet the health care needs of the students.
Identify whether school staff who will be accompanying students on the field trip have the necessary training, education, and competence to perform any emergency procedures such as albuterol administration.
If a field trip will be outdoors or in locations with potential exposure to asthma triggers, plan ahead to reduce potential exposure.
Consider that there may be areas where cellphone reception is limited or not available and plan accordingly.
If the field trip will be occurring out of the state:
- Review the states’ Nurse Practice Acts to confirm that the administration of albuterol can be delegated to an UAP in that state.
- Determine if the states traveled through or visited are a part of the Nurse Licensure Compact.
If the field trip will be occurring out of the country the school nurse should discuss with school administration any applicable laws to determine what additional steps may be needed. In addition, the U.S. Embassy can provide information on points of contact for destination countries.

(Erwin, Clark, & Mercer, 2014; NASN, 2019a; NASN, 2020b; NASN, 2021; Wisconsin Department of Public Instruction, 2019).

It is important to note that the Section 504 of the Rehabilitation Act does not allow for a student with a disability to be excluded from a field trip due to their disability.

Resources for field trip planning: NASN Resource: Field Trip Preparation Checklist

Documentation

The medical management of student’s asthma in the school setting will require the school nurse to acquire and complete numerous forms of documentation.

Health Care Provider Order: Frequently the health care provider’s order for asthma medications are written as an Asthma Action Plan. If the student does not have an Asthma Action Plan then the school nurse will need a health care provider’s order for the medication administration. See the Medication section for more information.

Asthma Action Plan: Many times a student with asthma will have an Asthma Action Plan written (or the template completed) by their health care provider. Several organizations have developed Asthma Action Plan templates including the American Academy of Allergy, Asthma, and Immunology, American Lung Association, Asthma and Allergy Foundation of America, Centers for Disease Control and Prevention, Missouri Department of Health and Senior Services and the National Heart, Lung, and Blood Institute.

SA³MPRO^TMrecommends the Asthma Action Plan contain the following:

Student name
Date of birth
The student’s level of asthma severity (Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent)
An indication if the student has had many or severe asthma attacks
Stop Light Zones: Provide treatment plan for chronic, acute, and emergency situations
Asthma Triggers
An indication if the student should receive their SABA prior to exercise
Which students should be allowed to possess and self-administer their medication
Provider contact information
Parent authorization for the student to communicate with the health care provider
Parent, school nurse, and Health care provider signature

(American Academy of Allergy, Asthma, and Immunology, 2022a, 2022b).

Parent/Guardian Authorization: In addition to the health care provider’s order, the school nurse will also need written authorization from the parents/guardians to administer the albuterol and other asthma medications, as needed (except for when administering stock albuterol for a student exhibiting asthma symptoms). The school nurse should review the Asthma Action Plan template to determine if it has a section for parent/guardian authorization. If the parent authorization is not included or the health care provider just provides an order for the albuterol then the school nurse will want to document the parent/guardian authorization on a separate document.

Self-Possession and Administration: When determining if a student is capable of carrying and self-administering their albuterol the school nurse will want to meet with the student and assess their knowledge, ability, and skills to ensure that it is appropriate for them to self-possess and self-administer their albuterol. Upon completing this assessment the school nurse will want to document their assessment in the student’s health record. The school nurse should also document that the student’s parent/guardian and health care provider agree with the plan of care for the student to self-carry and self-administer their medication. The school nurse should review their school district’s policies, procedures, and/or protocols to determine if the student’s self-administration of medication needs to be documented in the student’s health care record.

Procedures and Medication Administration: Administration of asthma medications will need to be documented, whether they are performed by the school nurse or a UAP. Many times the medication administration is documented in the student’s health record. The school nurse will want to ensure that the documentation is completed for the administration of asthma medications during field trips, before or after school, and/or during any school-sponsored activities.

Staff Competency Validation: If the medication administration is delegated to a UAP the school nurse should document that the UAPs knowledge, abilities, and skills have been assessed. Many times these factors are documented on a skills competency checklist (see Respiratory Just in Time Skills Competency Checklists). There should be a place on the skills competency checklist for the school nurse and UAP to sign to indicate that they feel competent and are willing to perform the procedure. Once the procedure has been delegated the school nurse is responsible for periodic evaluation of the UAP and their competency. The school nurse must determine how often the supervision is needed. After the school nurse has re-evaluated the UAP’s competency, they should document the date of the evaluation (Shannon & Kubelka, 2013; Selekman & Ness, 2019). The school nurse should organize the competency documentation in a way that easily allows them to determine when subsequent evaluation and documentation of competency is needed. For more information on delegation see the Delegation section.

Individualized Health Care Plan (IHCP): Another document that the school nurse may develop for a student with asthma is an Individualized Health Care Plan (IHCP). The IHCP outlines the plan of care for the student, including but not limited to:

Actions taken by the school nurse to support the student’s educational attainment.
The education and training that will be provided to school personnel.
The education and training the school nurse will provide to the student to assist them in being able to self-possess and self-administer their albuterol.
The education the school nurse will provide to the student to assist them in being able to reduce their risk of an asthma exacerbation.
The development of Asthma Action Plans, including steps to be taken in case of an evacuation.
And the accompanying expected outcomes for each of the nursing interventions (NASN, 2020d).

Prior to completing the IHCP, the school nurse should complete a health history and physical assessment of the student. For more information on health history see the Student section.

The Texas School Nurse Association has developed a sample Asthma IHP.

Section 504 Plan: Students with asthma may qualify for a Section 504 Plan since their health condition may impact a major life activity (breathing). If the student has been identified as qualifying for a 504 Plan, the school nurse may be involved in identifying appropriate accommodations and writing the plan. Once developed, the school nurse will want to frequently review, update, and document in the 504 Plan (NASN, 2020d). For more information on Section 504 Plans see Legal Issues section.

Emergency Preparedness

Shelter-in-Place and Other Emergency Events:

In addition to ensuring that all students with asthma have an Asthma Action Plan (see Documentation) and that all school staff have been educated on the signs and symptoms of asthma and how to respond to an emergency (see School Environment); the school nurse should also collaborate with school administration and the student’s education team to plan for other potential emergencies such as shelter-in-place, lockdowns, and emergency evacuations. The emergency planning should include discussion and planning on where the student’s medication will be stored. The emergency plan should also address access to medication during a school evacuation considering exposure to outdoor elements could trigger asthma symptoms.

For more information on emergency planning see Missouri School Boards’ Association’s Emergency Planning Guide for Students and Staff with Special and Functional Needs within Schools.

Legal Issues

There are currently two Missouri State Statutes that relate to asthma management in the school setting. They are:

Section 504 Plan:

Students with asthma may qualify for a Section 504 Plan. Section 504 of the Rehabilitation Act of 1973 as amended through the Americans with Disabilities Amendment Act (ADAA) in 2008 ensures that students who have disabilities have access to a free and appropriate public education (FAPE) (U.S. Department of Education, 2023). FAPE provides a student with a physical or mental impairment that impacts one or more major life activities (including breathing) with related services and accommodations in the general education classroom (U.S. Department of Education, 2023; NASN, 2023). If the student does not have a 504 Plan the school nurse should determine if an evaluation is indicated (see Students section for questions to ask student and family to determine if 504 evaluation is indicated). If it is determined that the student qualifies for a Section 504 Plan, the school nurse may want to consider the appropriateness of the following accommodations (this list is not all inclusive):

Allowing the student to carry their quick-relief asthma medication at all times during school hours and school-sponsored activities.
Allowing the student to self-administer their quick-relief asthma medication with or without assistance, as appropriate.
Developing physical education class modifications as needed.
Allowing the student to self-monitor their activity level with rest periods as needed, including during physical education class.
Allowing the student to have unlimited access to the restroom and access to water for hydration as needed.
Not allowing fur/feather bearing animals in the student’s classroom.
Planning for weather related triggers (i.e., accommodations related to outdoor recess/physical education class during hot/cold weather, windows opened in the classroom).
Development of an Asthma Action Plan.
Education to school staff regarding how to respond to student who is experiencing an asthma exacerbation.
The student will have access to trained transportation staff who know how to respond to an asthma exacerbation.
The types and methods of cleaning that are appropriate to prevent triggering asthma symptoms.
Steps that the school needs to implement to ensure a healthy indoor air quality in the student’s classroom.
The student will not be excluded from field trips or the ability to participate in extracurricular activities.

(Asthma and Allergy Foundation of America, 2023; Chicago Asthma Consortium’s School Working Group, n.d.)

Resources

Allergy and Asthma Network Back to School Checklist for School Nurses

American Lung Association: Asthma Resources

Asthma and Allergy Foundation of American: Asthma Resources

Asthma Ready

CDC: Asthma Resources

Environmental Protection Agency: Asthma Resources

Missouri Department of Health and Senior Services: Asthma Prevention and Control

Show-Me ECHO’s Asthma ECHO

NASN: Asthma Resources

NASN: Allergy & Anaphylaxis: Clinical Practice Guidelines and Toolkit for School Nurses

References

Allergy and Asthma Network. (2023). Managing asthma in school: A guide for schools. Available at: https://allergyasthmanetwork.org/allergies-and-asthma-at-school/managing-asthma-a-guide-for-schools/

American Academy of Allergy, Asthma & Immunology. (2022a, September 29). Asthma action plan for home and school. Available at: https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Tools%20for%20the%20Public/School%20Tools/04-Component-1-2-English.pdf

American Academy of Allergy, Asthma & Immunology. (2022b, September 29). Essential features of a school-related Asthma Action Plan. Available at: https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Tools%20for%20the%20Public/School%20Tools/04-Component-1-5-English.pdf

American Academy of Allergy, Asthma & Immunology. (2022c, April 12). Spacers and valved holding chambers (VHCs) for use with metered dose inhalers (MDIs). Available at: https://www.aaaai.org/tools-for-the-public/conditions-library/asthma/spacers-and-valved-holding-chambers-(vhcs)-for-use

American Academy of Allergy, Asthma & Immunology. (2023a). Follow the stepwise approach for asthma control. Available at: https://www.aaaai.org/tools-for-the-public/conditions-library/asthma/follow-the-stepwise-approach-for-asthma-control

American Lung Association. (2023). Valved holding chambers and spacers. Available at: https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/treatment/devices/chambers-spacers

American Nurses Association. (2012). Principles of delegation. Available at: https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf

Asthma and Allergy Foundation of America. (2023). 504 plans for asthma. Available at: https://aafa.org/asthma/living-with-asthma/504-plans-for-asthma/

Barrett, M. & Moore, C.M. (2019). Students with chronic respiratory conditions: Asthma and cystic fibrosis. In J. Selekman, Shannon, R.A., Yonkaitis, C.F. (Eds.). School nursing, a comprehensive text (3rd ed., pp. 523-548). Philadelphia PA.: F.A. Davis Co.

Chicago Asthma Consortium’s School Working Group. (n.d.). Section 504 plan request for a child with asthma. Available at: https://chicagoasthma.org/resources/Documents/Resources/504-Parent-Updated-4.pdf

Conlon, P. (2024). The child with respiratory dysfunction. In Hockenberry, Duffy, & Gibbs (Eds). Wong’s nursing care of infants and children (12th Ed., pp. 871-948).

Erwin, K., Clark, S., & Mercer, S.E. (2014). Providing health services for children with special health care needs on out-of-state field trips. NASN School Nurse, 29(2), 84-8. doi: 10.1177/1942602X13517005

Fanta, C.H. & Barrett, N.A. (2023, August 3). An overview of asthma management. UpToDate. Available at:https://www.uptodate.com/contents/an-overview-of-asthma-management

Kimel, L.S. (2022). Assisting students with asthma inhaler technique and knowledge. NASN School Nurse, (Print), 37(3), 127–131. https://doi.org/10.1177/1942602X211073747

Lowe, A. A., Gerald, J. K., Clemens, C., & Gerald, L. B. (2022). Compliance to a standardized protocol for stock albuterol medication among school staff. The Journal of School Nursing. Advance online publication. https://doi.org/10.1177/10598405221128053

Miller, R.L. (2023, November 14). Trigger control to enhance asthma management. UpToDate. Available at: https://www.uptodate.com/contents/trigger-control-to-enhance-asthma-management

Missouri Department of Health and Senior Services Bureau of Community Health and Wellness. (2021). SN chat. School nurse chronic health assessment tool. Available at: https://health.mo.gov/living/families/schoolhealth/pdf/sn-chat.pdf

Missouri Revised Statute: 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

Nanda, A., Russell, A.F., & Bingemann, T. A. (2021). Pharmacology update. Emergency and controller medications for treatment of asthma. NASN School Nurse, (Print), 37(1), 31–35. https://doi.org/10.1177/1942602X211036933

National Association of School Nurses. (2019a). School-sponsored trips -The role of the school nurse (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses. (2019b). Transition planning for students with healthcare needs (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses. (2020a). Emergency medication administration delegation. Decision tree. Available at: https://learn.nasn.org/courses/25694

National Association of School Nurses. (2020b). Emergency medication toolkit. Available at: https://learn.nasn.org/courses/25694

National Association of School Nurses. (2020c). Understanding student health and education plans. Available at: https://learn.nasn.org/courses/25340

National Association of School Nurses. (2021). School nursing evidence-based clinical practice guideline: Medication administration in schools implementation toolkit. Available at: https://learn.nasn.org/courses/36927

National Association of School Nurses. (2023). IDEIA and Section 504 Teams – The school nurse as an essential team member (Position Statement). Author.

National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. (2020). Focused updates to the asthma management guidelines. Available at: https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines

National Heart, Lung, and Blood Institute. (2014). Managing asthma. A guide for schools. Available at: https://www.nhlbi.nih.gov/files/docs/resources/lung/NACI_ManagingAsthma-508%20FINAL.pdf

Sawicki, G. & Haver, K. (2022, November 15). Asthma in children younger than 12 years: Management of persistent asthma with controller therapies. UpToDate. Available at: https://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-management-of-persistent-asthma-with-controller-therapies

Sawicki, G. & Haver, K. (2023a, April 10). Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment. UpToDate. Available at: https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-younger-than-12-years-overview-of-home-office-management-and-severity-assessment

Sawicki, G. & Haver, K. (2023b, March 28). Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms. UpToDate. Available at: https://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-quick-relief-rescue-treatment-for-acute-symptoms

Schoessler, S., & Winders, T. (2016). Enhancing asthma medication delivery: Spacers and valved holding chambers. NASN School Nurse (Print), 31(4), 200–201. https://doi.org/10.1177/1942602X16646593

Selekman, J. & Ness, M. (2019). Students with chronic conditions. In J. Selekman, R.A. Shannon, C.F. Yonkaitis, (Eds.). School nursing, a comprehensive text (3rd ed., p 493). Philadelphia PA.: F. A. Davis Co.

Shannon, R. A., & Kubelka, S. (2013). Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, Part 2. NASN School Nurse (Print), 28(5), 222–226. https://doi.org/10.1177/1942602X13490030

U.S. Department of Education. (2023). Frequently asked questions about Section 504 and the education of children with disabilities. Available at: https://www2.ed.gov/about/offices/list/ocr/504faq.html

U.S. Department of Health and Human Services & U.S. Department of Education. (2008). Joint guidance on the application of the Family Educational Rights and Privacy Act (FERPA) the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to student health records. Available at: https://studentprivacy.ed.gov/resources/joint-guidance-application-ferpa-and-hipaa-student-health-records

Volerman, A., Lowe, A. A., Pappalardo, A. A., Anderson, C. M. C., Blake, K. V., Bryant-Stephens, T., Carr, T., Carter, H., Cicutto, L., Gerald, J. K., Miller, T., Moore, N. S., Phan, H., Sadreameli, S. C., Tanner, A., Winders, T. A., & Gerald, L. B. (2021). Ensuring access to albuterol in schools: From policy to implementation. An official ATS/AANMA/ALA/NASN policy statement. American Journal of Respiratory and Critical Care Medicine, 204(5), 508–522. https://doi.org/10.1164/rccm.202106-1550ST

Wisconsin Department of Public Instruction. (2019). Meeting student health needs while on field trips. Tool kit for Wisconsin schools. Available at: https://dpi.wi.gov/sites/default/files/imce/sspw/pdf/Meeting_Student_Health_Needs_While_on_Field_Trips_Tool_Kit.pdf

Reviewers

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

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

More Information