Asthma Health Policies in Schools: Implications for Nurse Practitioners

      Highlights

      • Several organizations provide comprehensive school-based asthma policies.
      • Comprehensive management of asthma is essential to optimal health outcomes.
      • Nurse practitioners should be informed of school-based policy recommendations.
      • Nurse practitioners can advocate for asthma policies within the practice community.

      Abstract

      Asthma is the most common chronic illness of childhood; therefore, detailed school-based policies addressing the specific needs of children with asthma are essential to achieve optimal health and wellness outcomes. Nurse practitioners have a responsibility to support comprehensive school-based asthma policies and should support school personnel in carrying out an in-depth school-based asthma program within their communities. Furthermore, nurse practitioners can focus advocacy efforts toward policy development to close legislative and practice gaps that may inhibit the success of a comprehensive asthma program in schools.

      Keywords

      This activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and other health care providers in evaluating, implementing and advocating for evidence-based asthma health policy recommendations to guide school practices for children with asthma as measured by a score of 70% on the CE evaluation quiz.
      At the conclusion of this activity, the participant will be able to:
      • A.
        Identify the prevalence and impact of asthma on school-age children
      • B.
        Evaluate current asthma-related school health policies that can improve outcomes for children
      • C.
        Apply evidence-based school health policy recommendations for children with asthma to current clinical practice and advocacy actions
      The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment.
      This activity has been awarded 1 Contact Hour of which 0.25 credits are in the area of Pharmacology. The activity is valid for CE credit until July 01, 2022.
      To receive CE credit, read the article and pass the CE test online at www.npjournal.org/cme/home for a $5 fee.
      Asthma is the leading cause of chronic illness in school-age children, resulting in a significant burden for children, parents, schools, and health care systems.
      • Ferrante G.
      • Stefania L.
      The burden of pediatric asthma.
      Asthma is characterized by persistent inflammation, hyperinflation, and hyperreactivity of the airways, resulting in symptoms of wheezing, breathlessness, chest tightness, and coughing. Asthma symptoms often leave children unable to concentrate at school, affecting school performance with possible long-term consequences on academic success. Worse yet, if asthma is not well controlled, symptoms can lead to missed school days, limitations on physical activity and quality of life, increased emergency department (ED) visits, and recurrent hospitalizations.
      • Ferrante G.
      • Stefania L.
      The burden of pediatric asthma.
      ,
      National Heart, Lung, and Blood Institute
      Asthma & Physical Activity in the School: Making a Difference.
      Although asthma can be controlled by accurately following current evidence-based guidelines, it remains uncontrolled in many children.
      • Horak F.
      • Doberer D.
      • Eber E.
      • et al.
      Diagnosis and management of asthma-statement on the 2015 GINA guidelines.
      ,
      Centers for Disease Control and Prevention
      Uncontrolled asthma among children, 2012–2014. July 3, 2019.
      Schools are a primary site where many interventions aimed at improving asthma control can be provided. The Centers for Disease Control and Prevention (CDC), the American Lung Association (ALA), the American Academy of Allergy, Asthma, and Immunology (AAAAI), as well as the National Association of School Nurses (NASN), all support policies that can be implemented directly at school that target asthma outcomes.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      These policies address specific needs such as maintaining individualized asthma action plans (AAPs) for children with asthma, employing registered nurses (RNs) at every school, encouraging physical exercise, addressing air quality, and stocking quick-acting bronchodilators in schools. The purpose of this paper is to provide an overview of current health policies and to discuss methods for advocacy in policy development and implementation of asthma-related guidelines for nurse practitioners (NPs), school nurses, and other school and health care professionals.

      Background and Significance of the Problem

      Asthma is a pervasive disease that affects more than 300 million people of all ages and ethnicities.
      • Ferrante G.
      • Stefania L.
      The burden of pediatric asthma.
      ,
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      ,
      • Akinbami L.
      • Moorman J.
      • Bailey C.
      • et al.
      Trends in asthma prevalence, health care use, and mortality in the United States, 2001–2010 (NCHS data brief no. 94).
      Asthma is also the most common chronic medical condition in school-age children, affecting approximately 9 million children in the United States.
      Asthma & Allergy Foundation of America
      Childhood asthma. 2019.
      Asthma disproportionately affects low-income, minority children with higher morbidity and mortality rates among non-Hispanic blacks (22.7%) and other non-Hispanics (8.9%).
      Centers for Disease Control and Prevention
      Most recent national asthma data. May 15, 2018.
      According to the CDC, more than 50% of children diagnosed with asthma are classified as not well-controlled.
      Centers for Disease Control and Prevention
      Uncontrolled asthma among children, 2012–2014. July 3, 2019.
      The classification not well-controlled can be defined as any impairment from asthma symptoms within a 30-day period.
      National Heart, Lung, and Blood Institute
      Expert panel report 3: guidelines for the diagnosis and management of asthma.
      To put these numbers into perspective, an average classroom of 30 children will have 2 or more children who have a diagnosis of asthma and at least 1 plagued by an asthma exacerbation within the past 12 months.
      Asthma & Allergy Foundation of America
      Childhood asthma. 2019.
      ,
      Centers for Disease Control and Prevention
      Asthma attacks among people with current asthma, 2014–2017. December 3, 2019.
      Additionally, asthma is associated with a high socioeconomic burden because asthma exacerbations are a leading cause for ED visits and subsequent hospitalizations for children under 5 years of age.
      • Ferrante G.
      • Stefania L.
      The burden of pediatric asthma.
      ,
      • Woods E.
      • Bhaumik U.
      • Sommer S.
      • Chan E.
      Community asthma initiative to improve health outcomes and reduce disparities among children with asthma.
      Both direct and indirect costs of asthma are estimated to be as high as $56 billion annually related to medications, clinic and ED visits, hospitalizations, and work and school absenteeism.
      • Ferrante G.
      • Stefania L.
      The burden of pediatric asthma.
      ,
      Asthma and Allergy Foundation of America
      Cost of asthma on society.
      Furthermore, asthma carries a significant social impact on children. Children with asthma report being troubled by symptoms such as coughing, shortness of breath, chest tightness, and wheezing; hence they are unable to concentrate at school and experience increased school absences, poor school performance, and low self-esteem due to the inability to participate in physical activities such as recess, physical education (PE), sports, and other extra-curricular activities.
      National Heart, Lung, and Blood Institute
      Asthma & Physical Activity in the School: Making a Difference.
      ,
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.
      Therefore, the benefits of improving asthma control and self-management are essential in improving school achievement, self-esteem, and quality of life.
      Implementing strategic policy initiatives in school settings are vital to the health, growth, and learning of children with asthma.
      American Lung Association
      Improve asthma management in schools. 2019.
      Children spend a considerable part of their day at school where access to care and coordination of services with parents, children, providers, and school staff can be achieved.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      Implementation of evidence-based care and self-management strategies in school settings has been shown to be effective in the management of chronic diseases such as asthma.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      ,
      • Edwards D.
      • Noyes J.
      • Lowes L.
      • Haf Spencer L.
      • Gregory J.W.
      An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings.
      • Buckner E.B.
      • Copeland D.J.
      • Miller K.S.
      • Opt’Holt T.
      School-based interprofessional asthma self-management education program for middle school students: a feasibility trial.
      • Lynn J.
      • Oppenheimer S.
      • Zimmer L.
      Using public policy to improve outcomes for asthmatic children in schools.
      However, school-based services need to be accompanied by public policies that can not only improve outcomes for children but sustain these outcomes.
      • Lynn J.
      • Oppenheimer S.
      • Zimmer L.
      Using public policy to improve outcomes for asthmatic children in schools.

      Current Asthma-Related School Health Policies and Implications for Action

      The CDC, ALA, AAAAI, and NASN recommend specific public policies targeting asthma outcomes that are directly influenced at school (see Table 1 for links to current policy recommendations).
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      ,
      American Lung Association
      Improve asthma management in schools. 2019.
      The American Academy of Pediatrics also emphasizes the importance of school nurses in identifying the unmet needs of children with asthma.
      Council on School Health
      Role of the school nurse in providing school health services.
      Recommendations from these policies can be categorized into 4 themes: (1) providing optimal school health services, (2) enhancing asthma education for students and school staff, (3) providing a healthy school environment, and (4) managing physical activity.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      Adoption of these policies is not widespread, resulting in inequities in access to asthma services.
      • Lynn J.
      • Oppenheimer S.
      • Zimmer L.
      Using public policy to improve outcomes for asthmatic children in schools.
      Yet NPs are in a unique position to bridge this gap by building awareness of the need for school-based asthma policies and advocating for the implementation of policies that support children to lead healthy and active lives.
      Table 1Current Asthma Policy Recommendations for Schools
      American Lung Association (ALA)Practical Guidance for Schools & School Districts: Enhancing School Wellness Policies to Protect Student Lung Health

      https://www.lung.org/assets/documents/asthma/practical-guidance.pdf

      Asthma-Friendly Schools Initiative

      https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/asthma-education-advocacy/asthma-friendly-schools-initiative/
      American Academy of Allergy, Asthma, and Immunology and National Association of School Nurses (AAAAI/NASN)School-Based Asthma Management Program (SAMPRO)

      https://www.aaaai.org/conditions-and-treatments/school-tools/SAMPRO
      Centers for Disease Control and Prevention (CDC)Strategies for Addressing Asthma in Schools

      https://www.cdc.gov/asthma/pdfs/strategies_for_addressing_asthma_in_schools_508.pdf
      Environmental Protection AgencyAir Quality Flag Program

      https://www.airnow.gov/index.cfm?action=flag_program.index

      Creating Healthy Indoor Air Quality in Schools

      https://www.epa.gov/iaq-schools
      National Heart, Lung, and Blood InstituteAsthma & Physical Activity in the School: Making a Difference

      https://www.nhlbi.nih.gov/files/docs/public/lung/phy_asth.pdf

      Theme 1: Providing Optimal School Health Services

      The first theme of school-related asthma policies recommended by the CDC, ALA, AAAAI, NASN, and the American Academy of Pediatrics focuses on providing optimal school health services by preparing school health staff to help support and manage students with asthma.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      ,
      American Lung Association
      Improve asthma management in schools. 2019.
      ,
      Council on School Health
      Role of the school nurse in providing school health services.
      Schools must first have a policy in place for identifying and tracking students who are diagnosed with asthma and, once identified, it is necessary to have a documented AAP for each student with asthma. The AAP provides teachers, health care staff, and other school staff with information about the student’s medications, triggers, and emergency management.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      The AAP can also serve as the provider’s authorization for the child with asthma to self-administer their medication at school.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      An additional focus is providing support and access to services such as an individualized health plan or case management services for students with asthma.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      School nurses should also verify that students with asthma have a medical home, provide a medical referral for students with undiagnosed or uncontrolled asthma, and help to ensure that these students have health insurance.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      Likewise, ensuring that every school has a full-time RN who is available to students every day is vital to the implementation of all asthma-related school policies and to ensure that students have access to support services. Innovative ways to link students with asthma to proper medical care and resources can be found in the guideline documents.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      Finally, it is recommended that school districts have a consulting health care provider, such as an NP, to review standardized policies and procedures, provide standing orders for bronchodilators, and assist school nurses in communicating with a student’s health care provider, if needed.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.

      Current Implementation and Implications for Future Advocacy

      Studies show that there are significant discrepancies between schools’ identification of student asthma rates compared with parental reports of asthma rates in the same cohort of students.
      • Volerman A.
      • Ignoffo S.
      • Hull A.
      • et al.
      Identification of students with asthma in Chicago schools: missing the mark.
      Additionally, many school nurses do not have access to student’s AAP, or the plan does not provide all the necessary items recommended by the national guidelines.
      • Gerald J.K.
      • Stroupe N.
      • McClure L.A.
      • Wheeler L.
      • Gerald L.B.
      Availability of asthma quick relief medication in five Alabama school systems.
      The most recent School Health Policies and Practices Study (SHPPS) states that 86.9% of schools in the United States have policies mandating that schools have AAPs documented for each student diagnosed with asthma. However, only 76.2% of US schools have policies in place for identifying students with asthma, and less than 70% have policies for tracking students with asthma.
      US Department of Health and Human Resources Centers for Disease Control
      Results from the school health policies and practices study. 2016.
      Policy recommendations endorse a full-time RN at every school, yet only 33.7% of school districts were following this recommendation, with an additional 18.1% of school districts requiring at least a part-time school nurse.
      US Department of Health and Human Resources Centers for Disease Control
      Results from the school health policies and practices study. 2016.
      School-based policy recommendations also have specific practice implications for the pediatric-focused NP practicing in the primary care setting. The NP can ensure that all children seen in the primary care setting are provided with an AAP for school and home use and can provide education to caregivers of the importance of supplying the school with the AAP.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      NPs comparatively were reported to supply an AAP as often as pediatricians; however, only 20.3% of the NP group reported “almost always” supplying an AAP.

      Akinbami LJ, Salo PM, Cloutier MM, Wilkerson JC, Elward KS, Mazurek JM. Primary care clinician adherence with asthma guidelines: the National Asthma Survey of Physicians [published online ahead of print, 2019]. J Asthma. https://doi.org/10.1080/02770903.2019.1579831.

      Furthermore, NPs can fulfill this practice gap in primary care to ensure that the school nurse is equipped to discuss asthma care with students (see Table 2 for resources for NPs).
      Integrating students into a medical home is one way NPs can support children with asthma in schools and align care with recommended policies.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.
      Participation in a medical home has been shown to have a significant effect on having received education regarding asthma and an AAP, as well as decreasing the number of exacerbations.
      • Shippee N.D.
      • Finch M.
      • Wholey D.R.
      Assessing medical home mechanisms: certification, asthma education and outcomes.
      Even if exposure to triggers is addressed in schools, triggers must be addressed across the care continuum to ensure optimal outcomes. Children who are publicly insured can qualify for care coordination services that supply home visits and address several aspects of care within the home, such as medication availability, proper use of metered-dose inhalers, and management of suspected environmental triggers.

      Cicutto L, Gleason M, Haas-Howard C, et al. Building bridges for asthma care program: a school-centered program connecting schools, families, and community health-care providers. J Sch Nurs. Published online October 18, 2018. https://doi.org/10.1177/1059840518805824.

      ,
      • Janevic M.R.
      • Baptist A.P.
      • Bryant-Stephens T
      • et al.
      Effects of pediatric asthma care coordination in underserved communities on parent perceptions of care and asthma-management confidence.
      The NP can ensure that children who qualify for these services are receiving the necessary referrals.

      Theme 2: Enhancing Asthma Education for Students and School Staff

      Education of all school staff members who may have any interaction with a child with asthma (ie, teachers, coaches, PE instructors, food-service staff, bus drivers, office staff, playground supervisors) is essential to providing safety for children while at school.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      The suggested frequency of training is every 2 years.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Also, the current policy guidelines advocate for education for all students, whether or not they have asthma, and for parents of children with asthma.
      Centers for Disease Control and Prevention
      Strategies for Addressing Asthma in Schools. 2017.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      Centers for Disease Control and Prevention
      Controlling asthma in schools. May 29, 2015.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      Essential knowledge of asthma management creates a network of capable caregivers in a time of emergency. The ALA recommends training for school staff (Asthma Basics), coaches and PE instructors (Winning With Asthma), school nurses (Asthma Educator Institute), and students (Open Airways for Schools or Kickin’ Asthma).
      American Lung Association
      Asthma-Friendly Schools Initiative.

      Current Implementation and Implications for Future Advocacy

      Recent studies demonstrate the importance of enhanced asthma education. One study demonstrated that although school nurses were aware of policies within their school of how to manage a child with an asthma exacerbation, only 36% of teachers were aware of such policies.
      • Langton C.R.
      • Hollenbach J.P.
      • Simoneau T.
      • Cloutier M.M.
      Asthma management in school: parents’ and school personnel perspectives.
      In addition, less than half of US schools have a policy stating that all students will be taught about asthma, and only 66.5% of schools had policies in place requiring self-management education for students diagnosed with asthma.
      US Department of Health and Human Resources Centers for Disease Control
      Results from the school health policies and practices study. 2016.
      Seventy-five percent of schools offered training to teachers and staff; however, only 50% of schools required specific training on reducing triggers or responding to emergencies for those who teach PE.
      US Department of Health and Human Resources Centers for Disease Control
      Results from the school health policies and practices study. 2016.
      NPs can educate school staff and assist in securing available funding and grants to aid schools in providing education for teachers and school staff. The ALA offers resources available for NPs to use in educating a wide variety of audiences.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.
      Pediatric-focused NPs can also serve as the clinical expert and as a resource for providing education within school systems, as well as assist in linking the school community back to primary care.
      • Kakumanu S.
      • Lemanske Jr., R.F.
      Asthma in schools: how school-based partnerships improve pediatric asthma care.
      The goal of educating school staff can be accomplished by NPs who are either involved directly in the school system, such as in a school-based health center or by NPs serving as certified asthma educators within the school district.

      Theme 3: Providing a Healthy School Environment

      Management of environmental triggers is essential to asthma control and reducing exacerbations while at school. Schools can enact several policies that are aimed at providing a healthy school environment.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      ,
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      The goal of these policy initiatives is to ensure healthy indoor air quality (IAQ) and that school personnel, caregivers, and students are familiar with federal regulations that protect children with asthma. Current policy recommendations include having policies and procedures in place for fieldtrips, reducing bus idling and treating the bus as an indoor environment, use of asthma-friendly cleaning products, and the incorporation of integrated pest management within the school.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      The Environmental Protection Agency (EPA) has an IAQ program that can be used to evaluate and enhance current practices and also recommends hanging no idling signs across school campuses to remind buses and personal vehicles not to idle.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.
      ,
      Environmental Protection Agency
      Clean school bus idle reduction.
      Schools should ensure that a tobacco-free campus policy is in place, and the outdoor air quality index should be monitored and accommodations made for students with asthma on high outdoor air pollution days. The Air Quality Flag program allows schools to display different-colored flags in coordination with the EPA’s Air Quality Index to alert school officials and students when the outdoor air quality may be a threat to students with asthma.
      Environmental Protection Agency
      Air quality flag program: know your air quality to protect your health.

      Current Implementation and Implications for Future Advocacy

      Poor air quality, both indoor and outdoor, can contribute to asthma morbidity.
      • Huffaker M.
      • Phipantanakul W.
      Introducing an environmental assessment and intervention program in inner-city schools.
      ,
      • Esty B.
      • Permaul P.
      • DeLoreto K.
      • Baxi S.N.
      • Phipatanakul W.
      Asthma and allergies in the school environment.
      Recent studies have shown that a child’s school environment often contains more indoor allergens compared with the home environment.
      • Huffaker M.
      • Phipantanakul W.
      Introducing an environmental assessment and intervention program in inner-city schools.
      The CDC found that only 48.9% of US schools have a formal IAQ management program in place.
      US Department of Health and Human Resources Centers for Disease Control
      Results from the school health policies and practices study. 2016.
      Whereas 54.6% of schools have a policy in place for handling mold problems, 49.2% of schools have an engine idling reduction program for school buses, and only 33.9% of schools have a policy in place for purchasing low-emitting products for cleaning the school grounds.
      US Department of Health and Human Resources Centers for Disease Control
      Results from the school health policies and practices study. 2016.
      Although the connection between air quality and asthma management are known, much work needs to be done in implementing policies to create a healthy school environment.
      • Esty B.
      • Permaul P.
      • DeLoreto K.
      • Baxi S.N.
      • Phipatanakul W.
      Asthma and allergies in the school environment.
      The NP can assist school health professionals in addressing indoor and outdoor air quality and reducing environmental triggers for children with asthma while at school.
      • Esty B.
      • Permaul P.
      • DeLoreto K.
      • Baxi S.N.
      • Phipatanakul W.
      Asthma and allergies in the school environment.
      • Abramson S.L.
      Reducing environmental allergic triggers: policy issues.
      • Permaul P.
      • Phipatanakul W.
      School environmental intervention programs.
      These outcomes can be accomplished through state, regional, and federal grant programs. NPs can also work within an advocacy organization to formulate state-level legislation that targets outdoor emissions due to bus idling, nearby industry, approved cleaning chemicals in schools, and other known triggers.
      American Lung Association
      Asthma-Friendly Schools Initiative.

      Theme 4: Managing Activity and Physical Education

      The Asthma Friendly Schools Initiative, as well as other policy documents, aim to maximize participation in physical exercise for students with asthma and to provide alternative activities for students whose asthma is not well-controlled.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.
      This approach requires that PE teachers are knowledgeable about exercise benefits and asthma management for the child with asthma. It is recommended that students with asthma participate fully in PE and recess when they are asymptomatic and within their green peak flow zone.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      Each student should have an AAP in place that will guide teachers and coaches on what to do if the child begins to experience symptoms during activity.
      All 50 states have laws that allow for students to self-carry and self-administer prescribed medications for asthma.
      Allergy & Asthma Network
      School stock albuterol and asthma management.
      Therefore, NPs can ensure that students who have exercise-triggered asthma premedicate before physical activity and that all students have access to their quick- relief medications. For those who do not self-carry their medications, PE teachers or coaches should be trained on how to help a student who is experiencing asthma symptoms. If an emergent situation should occur, it is also recommended that schools have a standardized emergency procedure in place. Current policies recommend that schools have stock bronchodilator guidelines or legislation to ensure that students have access to medications if their inhaler is unavailable; however, only 13 states have enacted stock bronchodilator laws or guidelines.
      Allergy & Asthma Network
      School stock albuterol and asthma management.
      Model stock bronchodilator policies state that school nurses or other trained school personnel should be available at all times to administer the stock bronchodilator if needed.
      American Lung Association
      Model policy for school districts: stock bronchodilators.
      Even though physical activity can trigger asthma symptoms, it is also beneficial to lung health and quality of life in children with asthma.
      • McClelland Q.
      • Avalos M.
      • Reznik M.
      Asthma management in New York City schools: a physical education teacher perspective.
      For children, much of the physical activity during the day occurs in schools, namely during recess, PE, or during sports practice. Therefore, PE teachers and coaches can play a vital role in asthma management during physical activity.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.
      Even when a student is outside of their “green zone,” it is essential to provide modified activities. Exercise modifications can be outlined in the student’s AAP and can include premedication, less intense aerobic activities, or an extended warm-up and cool-down period. Finally, if outdoor air quality has high air pollution on a given day, children with asthma should be offered modified activities.
      American Lung Association
      Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health.
      ,
      American Lung Association
      Asthma-Friendly Schools Initiative.

      Current Implementation and Implications for Future Advocacy

      PE teachers are often unaware or have misperceptions of asthma symptoms and management. One study found that PE teachers felt unprepared to handle asthma symptoms and acute situations and that they were unaware of the school’s written procedures for asthma management. PE teachers also perceived that asthma limits a student’s participation in physical activity due to varying PE class times and a lack of access to medication.
      • McClelland Q.
      • Avalos M.
      • Reznik M.
      Asthma management in New York City schools: a physical education teacher perspective.
      Pediatric-focused NPs practicing in primary care should serve as the resource for education on asthma control, trigger reduction, and exercise modification based upon the level of asthma control. Physical activity should be addressed at each office visit, and the NP should adjust the AAP accordingly to keep the school informed of any activity limitations. Further, children should have medications and delivery devices available to maximize their function at school and participation in PE.
      American Lung Association
      Asthma-Friendly Schools Initiative.
      ,
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      NPs can ensure that children with asthma have prescribed medication and an appropriate delivery device (ie, spacers) for home and school use and guarantee that children and parents are well-versed on medication delivery technique.
      • Lemanske R.
      • Kakumanu S.
      • Shanovich K.
      • et al.
      Creation and implementation of SAMPRO™: A school-based asthma management program.
      In examining the call for medication access and the use of standardized emergency protocols, access to medication at school remains problematic. Although all 50 states allow children to self-carry, only 13 states have stock access to quick-acting bronchodilators for children who may not have their inhaler at school.
      Allergy & Asthma Network
      School stock albuterol and asthma management.
      This policy change can be accomplished by implementing new legislation or through NPs spearheading and supporting state-level legislation to enact stock, quick-acting bronchodilator laws within their states.
      • Pappalardo A.A.
      • Gerald L.B.
      Let them breathe: a plea to pediatricians to advocate for stock inhaler policies at school.
      NPs also serve as a resource to parents and families to ensure that they are aware that students may self-carry medications. Several studies indicate that despite these laws, students are still not self-carrying their medication due to a knowledge deficit regarding the medication, variance in policy application between schools, and various other factors limiting access to the medication while at school.
      • Gerald J.K.
      • Stroupe N.
      • McClure L.A.
      • Wheeler L.
      • Gerald L.B.
      Availability of asthma quick relief medication in five Alabama school systems.
      ,

      Volerman A, Kim TY, Sridharan G. A mixed-methods study examining inhaler carry and use among children at school. J Asthma. Published online July 16, 2019. https://doi.org/10.1080/02770903.2019.1640729.

      Conclusion

      Asthma remains the most prevalent chronic condition of childhood. Furthermore, schools comprise a significant role in access to care, education, and environmental triggers that all contribute to the overall level of control for children with asthma. Specific strategies are needed to target asthma control in the school setting. NPs are in a pivotal role to advocate for comprehensive policies addressing school-based asthma care. Likewise, these policies should complement and inform the practice of pediatric-focused NPs to ensure they are providing families with the knowledge and resources to manage this chronic disease and its exacerbations.

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      Biography

      Ashleigh F. Bowman, DNP, CPNP-AC, is an assistant professor, University of South Alabama College of Nursing, Mobile, AL and a Nurse Practitioner in the Pediatric Emergency Department, USA Health Children’s & Women’s Hospital, Mobile, AL. She can be contacted at [email protected]
      Donna J. Copeland, DNP, RN, NE-BC, CPN, AE-C, is an assistant professor, University of South Alabama College of Nursing, Mobile, AL and an Inservice Specialist, USA Health Children’s & Women’s Hospital, Mobile, AL.
      Kristina S. Miller, DNP, PCNS-BC, CNE, is an assistant professor, University of South Alabama College of Nursing, Mobile, AL.