Preparing for School Asthma Readiness

Abstract

Children and youth spend a large part of their days in school, so it is critical that schools are asthma-friendly and prepared for students with asthma. According to the American Lung Association, elements of an “asthma-friendly school” broadly include reducing sources of asthma triggers, providing asthma education for students, school staff, and parents and caregivers, and providing appropriate opportunities for physical activity for students with exercise-induced asthma.1 Addressing asthma triggers in schools can include steps such as using air filtration to improve indoor air quality, monitoring outdoor air quality with tools such as www.airnow.gov to guide outdoor activities, and minimizing exposures to diesel exhaust from unnecessary school bus idling. Asthma education can involve providing self-management education and reinforcing appropriate inhaler techniques. Asthma-friendly physical activity strategies can include providing physical education teachers and coaches with training on symptom recognition and appropriate responses.School nurses play a central role in asthma management. This includes monitoring which students have asthma, collecting asthma management plans, dispensing controller medication at school, supervising students’ rescue medications (including single maintenance and reliever medication therapy),2 and maintaining stock albuterol.1 In this issue of Pediatrics, Kenyon et al3 assess whether asthma morbidity experienced during the previous school year (defined as the number of exacerbations involving prescriptions for systemic corticosteroids) is associated with future aspects of asthma readiness in the school setting. Asthma readiness was defined as having the following elements in the school for each student with asthma: documentation of the current asthma diagnosis, a current medication administration form, nonexpired rescue medication, a valved holding chamber, and a current asthma management plan.The authors hypothesized that students with fewer asthma exacerbations in the previous year would be more likely to have the elements of “school asthma readiness” in place in the subsequent school year. In their analysis, Kenyon et al3 found a greater odds of school asthma readiness among students having a greater number of exacerbations in the previous year. Regardless of the past number of exacerbations, Kenyon et al3 report that only 27% of students went to school where all elements of asthma readiness were in place. Of all the elements of school readiness assessed, the most frequently present was school nurse awareness of the asthma diagnosis, at 79%, which makes sense as the other elements presume knowledge of the student’s asthma. Having an up-to-date asthma management plan in the school nurse’s office, potentially the most important element of asthma management in schools, was least likely to be present, at 7%.Of note, Kenyon et al3 found that schools with larger enrollment were less likely to be asthma-ready, which may be a function of the school nurse–to-student ratio. The American Academy of Pediatrics and other professional associations recommend that school buildings each employ one full-time school nurse.4 According to a 2021 National Association of School Nurses survey, 65.7% of schools in the United States have full-time school nurses, with full-time coverage in 70.3% of urban schools and only 56.2% of rural schools.5Having the elements of asthma readiness in place in the school health office is necessary, but perhaps the most important element is having a designated person to implement the asthma response. In most cases, this would be the school nurse; however, for schools without a full-time nurse, it may need to be a trained staff member. In response, the American Association of School Administrators acknowledges that school leadership may need to adopt policies to make sure that “qualified staff members are available to implement asthma action plans and to provide asthma-related health care services.”6With so many resources available for producing “asthma-friendly schools,” why, as Kenyon et al3 have observed, is readiness not closer to 100%? What are the barriers to being prepared for students with asthma? In addition to the previously mentioned school nurse staffing challenges, structural barriers include the lack of school staff training, the lack of availability of medication provided by families to be stored at school, and the limited delivery of asthma action plans to schools, either directly from the family or from the health care provider to school with permission from the family.Other models of school-based health care, including school-based health centers (SBHCs), may be avenues for school-based asthma management that can work in coordination with the school nurse office. SBHCs are typically situated in the school but are distinct from the school nurse offices.7 Staffed by advanced practice clinicians, SBHCs can work with families to create asthma action plans, to share them with the school nurse’s office, and to prescribe medication. SBHCs can address acute asthma symptoms while the student is at school, in addition to providing onsite asthma management. SBHCs may also be able to provide students with direct access to asthma specialists via telehealth.7Asthma-ready schools are vital for asthma management among children and youth. As Kenyon et al3 note, regardless of a student’s history of exacerbations, ensuring asthma readiness requires preparation, optimal school nurse coverage, and collaboration and communication among health care providers, schools, and families.