Approximately 10% of children in the United States have asthma. Nearly 60% experience an asthma exacerbation annually, leading to 750,000 emergency department visits and 200,000 hospitalizations.
[Photo: Dr. Lynn Gerald]
Recommendations to optimize asthma care in schools emphasize having asthma action plans and quick-relief medication readily available for all students with asthma. The National Asthma Education and Prevention Program guidelines also recommend that schools ensure reliable access to asthma medications. Despite these recommendations, limited access to albuterol remains an important safety issue for schools and for the children with asthma they serve.
A study by researchers at the University of Arizona Mel and Enid Zuckerman College of Public Health and Sunnyside Unified School District (SUSD) in Tucson, Ariz., found stock inhaler programs are feasible, inexpensive, and well-accepted by schools and families. The research was published this month in the journal Annals of the American Thoracic Society.
Dr. Lynn Gerald, a professor of health promotion sciences at the UA Zuckerman College of Public Health and colleagues worked with the SUSD to implement a stock inhaler program. SUSD enrollment includes 17,500 students who attend one of 22 schools. Eighty-two percent of students are Hispanic. Of children younger than 12 years, 58% live in a household with an income below 200% of the federal poverty level. SUSD has a nurse in each school, and the SUSD nurse-to-student ratio is 1:795, which is consistent with the National Association of School Nurses recommendation of 1:750 for healthy populations.
Although SUSD nurses strive to obtain personal inhalers for every student with asthma, they are unable to do so in most cases because parents have difficulty obtaining a second inhaler for school. Students who self-carry may forget their inhaler and lack access when an attack occurs. During the intervention year, a stock inhaler was used to manage 222 discrete events in 55 children. Ninety percent used the stock inhaler one or two times; only 10% used it more than twice.
Despite modest stock inhaler use during the implementation year (222 events across 22 schools), there were 20% fewer 911 calls (P = 0.38) and 40% fewer emergency medical services (EMS) transports (P = 0.20) than during the pre-implementation year. Although neither reached statistical significance, this was not unexpected, given the combination of small sample size and rare event occurrence. These differences, approximately five EMS transports per 1,000 children with asthma, if substantiated, would equal 25,000 fewer EMS transports per year among the 5 million children with asthma in U.S. public schools.
“Our experience indicates a stock inhaler program can be successfully implemented. Program acceptability was high among school nurses, parents, and students. Interviews with all 22 school nurses indicated they felt greater peace of mind and lower job stress for themselves and better asthma outcomes for their students. Telephone interviews with parents and focus groups with students showed they felt the program created a safer school environment,” said Dr. Gerald.
The major barrier to widespread dissemination of stock albuterol policies is ensuring state laws enable stock albuterol use and indemnify good faith use. At this time, there are only five states that have such specific legislation. Supporting legislation is not required to implement a stock inhaler program yet these laws provide specific guidance to school districts, ensure personnel are indemnified for their good faith use, and reassure the public that safe and effective care is being delivered.
“We believe asthma and school health advocates can help accelerate the availability of stock albuterol medication at school by engaging with advocacy organizations, such as the American Lung Association, to enact such laws,” said Dr. Gerald.