Asthma Awareness. If you answered yes to any of these questions, your child may have asthma. Make an appointment

Transcription

1 Asthma Awareness E1 Does your child: Cough during the day or night? Have hard time breathing or get short of breath? Wheeze (a soft whistling sound while breathing)? Complain of a tight chest or feel a heavy pressure against his/her chest? Get out of breath or cough or wheeze after running, playing or exercising? Have coughing or breathing problems that are sometimes worse at night? If you answered yes to any of these questions, your child may have asthma. Make an appointment with your child s health care provider. Asthma can be well controlled! Your child can live a healthy, active life with asthma. Prevent asthma problems before they start by doing the following things: Find one main doctor or nurse practitioner and go in for asthma check-ups at least every 6 months. Ask for an Asthma Action Plan and use it to help keep asthma well controlled. Talk to the school health office staff about your child s asthma and asthma medications. Avoid things that make asthma worse (smoke, furry animals, dust, mold, chemicals, etc.). Get a flu shot every fall. Your school nurse can help you find the answers. For more information, call your child s school and ask for the school nurse. Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services or

2 Components of Asthma Management in the Health Office E2 Health Service Assistant (HSA) Licensed Practical Nurse (LPN) Licensed School Nurse (LSN) Case Finding Case Finding Case Finding 1. Identify students with asthma by reviewing the following: a. Emergency Referral Cards, Annual Health Information forms 1, Medication forms, Health Problem List, Early Childhood Screening forms, Physical Exams, new Pupil Health Record, and. b. Asthma identified by parent, staff or student report c. ED/hospital admissions due to asthma. 2. Document students seen in the Health Office with symptoms of asthma (frequent cough, wheezing, difficulty breathing) on the Daily Log. 3. Notify LSN of students with asthma or symptoms of asthma following established communication procedure. See activities under Health Service Assistant 1. Conduct case finding for asthma by reviewing data from a variety of sources including the student/ family, health/medical records, information and/or referrals from Health Office staff, school staff, medical and other health providers. 2. Review health data provided by Health Office staff on students with asthma. 3. Record health data in the Pupil Health Record and on the Health Problem List as indicated. 4. Obtain additional history as needed. Delegated Nursing Care/Precedures Delegated Nursing Care/Precedures Nursing Care/Precedures 1. Distribute Parent Guardian Questionnaire (PQ) to: newly diagnosed or newly discovered students with asthma in Pre-K through 5 th grade. any student indicated by the LSN. 2. The PQ may be sent home with the student, mailed or given to the parent/guardian. 3. Document that the PQ was given or sent to parent/guardian on the Daily Log. 1. Administer Student Breathing Questionnaire (SBQ) to any student in Grades 6 12 with asthma: on initial visit with asthma symptoms to the Health Office during the school year, who takes medications on a routine basis, per request of LSN, who is reported to the Health Office staff as absent due to asthma 1-day. 2. Assist student with SBQ if student cannot read at 3 rd grade level or needs interpreter services. 3. Document that SBQ was given to student on the Daily Log. See activities under Health Service Assistant 1. The Parent Guardian Questionnaire (PQ) is a tool used to help the LSN: a. determine if the student s asthma is under control (in grades Pre-K through 5); b. determine severity level, and c. to develop an appropriate plan of care (IHP). 2. The PQ is given to: newly identified or newly discovered students with asthma in Pre-K through 5 th grade. students with asthma where more information is needed. 3. Information from the PQ is summarized in the narrative notes of the pupil health record. 4. The PQ may be sent home with the student, mailed or given to the parent/guardian. 5. Document that the PQ was given or sent to parent/guardian on the Daily Log. See activities under Health Service Assistant 1. The LSN uses the Student Breathing Questionnaire (SBQ) to: a. help determine if student s asthma is under control (for students in grades 6-12); b. help determine the student s severity level, and c. develop a plan of care. 2. Administer SBQ to any student in Grades 6 12 with asthma: on initial visit with asthma symptoms to the Health Office during the school year. who takes medications on a routine basis. who is reported to the Health Office staff as absent due to asthma 1-day. 3. If the student s asthma status appears to be changing, the LSN can repeat the SBQ if indicated (persistent asthma, moderate to severe asthma, out-ofcontrol asthma). 4. Assist student with SBQ if student cannot read at 3 rd grade level or needs interpreter services. 5. Summarize findings in narrative notes of the Pupil Health Record. 6. Document that the SBQ was given to the student on the Daily Log. 1

3 Components of Asthma Management in the Health Office Delegated Nursing Care/Precedures (HSA) [continued] Provide episodic care to students with symptoms of asthma. 1. Document asthma visit on Daily Log and/or Pupil Health Record. 2. Complete Asthma Visit Notification form (AVN) 3 when student is seen in the Health Office with asthma symptoms and/or distress and send home with student. Retain one copy for LSN to review and file. 3. Document that Asthma Visit Notification Form (AVN) was sent to parent/guardian on Daily Log (communication section). 1. Complete or initiate the School Health Office Asthma Record (SHOAR) on all students with asthma medication and/or students who need documentation of Peak Flow or Education. (See instructions under peak flow and SHOAR instructions). 2. The SHOAR is used to: Record asthma medication Record peak flow readings Document asthma symptoms Document education. Delegated Nursing Care/Precedures (LPN) [continued] Provide episodic care to students with symptoms of asthma, which includes physical assessment in the following areas: visual inspection, auscultation of breath sounds (anterior/posterior, skin to skin,), respiratory rate, peak flow. Nursing Care/Precedures (LSN) [continued] 1. Perform assessments 2 on students with symptoms of asthma, which include: Physical Assessment: visual inspection, auscultation of breath sounds (anterior/posterior, skin to skin), respiratory rate, peak flow. School: school performance, ability to function in physical education, sports, socially, and attendance. Resources: insurance status, transportation, finances, access to Health Care Provider (HCP). 2. Assessment can also include the following areas: Emotional/social status: student s reaction to illness, abuse, neglect. Environmental: home and school environment Family support: See activities under Health Service Assistant 1. Document asthma visit on Daily Log and/or Pupil Health Record. 2. Complete Asthma Visit Notification form (AVN) 4 when student is seen in the Health Office with asthma symptoms and/or distress and send home with student. 3. Review and file AVNs completed by Health Office staff. 4. Using the MPS Pathway For School Asthma Care, provide appropriate level of intervention for students with exacerbation of asthma. 5. Phone parent/guardian if student is seen in the Health Office 2 times a week with asthma symptoms. 6. Document that AVN Form was sent to parent/guardian on the Daily Log (communication section). 7. Review AVNs weekly and file in the Pupil Health Record. 8. Determine if additional medical information is needed; request Consent to Release Information from parent/guardian. If AAP includes consent to release information, use AAP as release or Medication Authorization form. See activities under Health Service Assistant. 3. Complete or initiate the School Health Office Asthma Record (SHOAR) on all students with asthma medication and/or students who need documentation of Peak Flow or Education. (See instructions under peak flow and SHOAR instructions). 4. The SHOAR is used to: Record asthma medication Record peak flow readings Document asthma symptoms Document education. 2

4 Components of Asthma Management in the Health Office E2 Delegated Nursing Care/Precedures (HSA) [continued] Delegated Nursing Care/Precedures (LPN) [continued] Nursing Care/Precedures (LSN) [continued] 4. When a student is transported by ambulance to the ED, the AMR form should be sent along with the student. Fax copy to HCP (if known). 5. When a student needs immediate care (based on the MPS Pathway for AcuteAsthma Care) and he/she is going to their primary clinic or urgent care, the LSN should call the HCP to inform them of the referral. The AMR should be sent with the student and faxed to the HCP. 6. For situations not requiring immediate attention, the LSN should fax the AMR to the clinic without calling the clinic. The LSN should call the parent/guardian or send the AVN form home informing parent/guardian of AMR faxed to clinic. 7. The LSN will send the AMR when: Student is seen in the Health Office 2 or more times a week with asthma symptoms. Medication/peak flow meter/spacer are needed at school. There are other questions about medications. Student experiences an acute asthma episode requiring immediate care. Student has missed 5 or more days of school due to asthma within the current school year. 8. Document on the Daily Log and narrative notes of Pupil Health Record that the AMR was sent to the clinic or HCP. File original/copy in the Pupil Health Record. 1. Summarize Health Office asthma visits (intervention and response) at least annually in the narrative notes of the Pupil Health Record. 2. Develop Individual Health Plan IHP for students with moderate to severe asthma who require nursing care (see IHP instructions). 3. Review and modify IHP as needed. obtained, except in the event of an emergency. 3. The AMR should be sent to the HCP only after parent/guardian consent is management concerns. Attach SHOAR if HCP requests. 2. Complete the AMR or contact the HCP when there are asthma control or between the Health Care Provider (HCP) and the LSN. 1. The Asthma Medical Request form (AMR) is used for communication 3

5 Components of Asthma Management in the Health Office Delegated Nursing Care/Precedures (HSA) [continued] Request Asthma Action Plan (AAP) and/or Release of Medical Information or Medication Authorization form per LSN request (see form letter in Asthma Manual). Send AAP form and explanatory cover letter home with request. The AAP form serves as a medication consent and release of information consent when signed by Health Care Provider and parent. AAPs will be faxed to HRS who will fax them directly to the student s school. HSA and LPN will notify LSN of new AAPs. Place AAPs in medication book behind SHOAR form. File copy in chart. If student returns with symptoms a second time Peak Flow Rate For Healthy Children. predicted peak flow using the table: Average student s personal best or calculate student s available, calculate the values based upon the is used to document the peak flow (If AAP is not monitoring, the following adjacent vertical column on that same date and requires repeat peak flow Check peak flow: on students with asthma symptoms, to determine if medication is needed per AAP on students designated by the LSN Document peak flow readings, signs, symptoms and medications given on SHOAR form 6 : o = peak flow reading before medication, x = peak flow after prn medication. Record actual PF number above o or x on graph section of SHOAR. Delegated Nursing Care/Precedures (LPN) [continued] Nursing Care/Precedures (LSN) [continued] medical referrals as needed). Summarize visits at least annually in the Pupil Health Record and modify care plan if needed. Develop or modify nursing care interventions as needed.. (I.e. Initiate Review asthma visits on the daily log on a weekly basis) See activities under Health Service Assistant. 1. Send request for AAP on students: whose asthma is out of control, with mild, moderate and severe persistent asthma, who take asthma medications at school on a daily basis, with ED or hospital visits within the last year. 2. Review new AAPs on a weekly basis. 3. Place AAPs in medication book behind SHOAR form. File copy in chart. 1. Review PQ, SBQ, AVN Form, and AAP to determine student s current level of control 5 and/or severity. 2. Determine control and/or severity level on any student who comes into the health office with problems related to asthma. 3. Document in Pupil Health Record and on Health Problem List. Update severity level on Health Problem List. See activities under Health Service Assistant Check peak flow on students: with persistent asthma with asthma symptoms to determine if medication is needed per AAP. Document peak flow readings, signs, symptoms and medications given on SHOAR form 7 : o = peak flow reading before medication, x = peak flow after prn medication. Record actual PF number above o or x on graph section of SHOAR. If student returns with symptoms a second time on that same date and requires repeat peak flow monitoring, the following adjacent vertical column is used to document the peak flow (If AAP is not available, calculate the values based upon the student s personal best or calculate student s predicted peak flow using the table: Average Peak Flow Rate For Healthy Children. 4

6 Components of Asthma Management in the Health Office E2 1. Administer medications per AAP or Health Care Provider (HCP) order. Document medication in the same vertical column, that peak flow is recorded on the SHOAR form, in the first available box corresponding to the medication given. 8 If student returns with symptoms a second time on that same date and receives PRN medication and/or requires peak flow monitoring, the following adjacent vertical column is used to document the peak flow and medication given (use one line only for PRN medication). Use one line for each medication unless a medication is routinely given twice during the each school day. In this case, use a separate line for each administration time. See activities under Health Service Assistant 1. Assess, monitor, and/or administer medications. Document medication in the same vertical column, that peak flow is recorded on the SHOAR form, in the first available box corresponding to the medication given. If student returns with symptoms a second time on that same date and receives PRN medication and/or requires peak flow monitoring, the following adjacent vertical column is used to document the peak flow and medication given (use one line only for PRN medication). Use one line for each medication unless a medication is routinely given twice during the each school day. In this case, use a separate line for each administration time. Summarize triggers, significant history, education and progress toward Provide ongoing support and monitoring to Health Office staff regarding asthma care. Train Health Office staff on all delegated tasks and supervise performance. Care Coordination (HSA) Care Coordination (LSN) Request AAP on students per LSN delegation. 1. Request AAP on students: whose asthma is out of control, with persistent mild, moderate or severe asthma. seen daily for administration of asthma medications. Document request in narrative notes of Pupil Health Record. Review IHP and AAP Develop or modify plan for case coordination as needed. end of the year or on withdrawal. goals in the IHP and on narrative notes of Pupil Health Record at the Request AAP on students per LSN delegation. Care Coordination (LPN) Refer students who have no insurance to the New Family Center using the Health Insurance Information Questionnaire. 1. Arrange transportation per LSN request. 2. Arrange interpreters for parents or students as needed. Communicate with parent/guardian regarding asthma care, asthma episodes, Release of Information Consents and need for medication or supplies. Refer students who have no insurance to the New Family Center using the Health Insurance Information Questionnaire 1. Arrange transportation per LSN request. 2. Arrange interpreters for parents or students as needed. Communicate with parent/guardian regarding asthma care, asthma episodes, Release of Information Consents and need for medication or supplies. 1. Determine if students have insurance. 2. Assess family s understanding of health care system and ability to access preventive and emergency care. 3. For students who have no insurance, refer to the New Family Center using the Health Insurance Information Questionnaire and Resource Directory. Arrange transportation and interpreters for students as needed. 1. Consistent communication with parents/guardians and providers regarding asthma care, need for medication, supplies, Release of Information Consents, asthma episodes. 2. Refer students to Health Care Provider to ensure consistent asthma care and follow-up according to NIH guidelines. Initiate referrals to: community based asthma programs, asthma case management health plan, hospital or clinic, home visiting services for f/u coordination, education or home environment assessment. other services as needed. 5

7 Components of Asthma Management in the Health Office Emergency Care Emergency Care Emergency Care 1. Provide first aid in accordance with Emergency Medical Care Flipchart or individualized Emergency Care Plan. 2. Notify LSN, parent/guardian and HCP of emergency care as needed. 3. Ensure Emergency Medical Care Flip Chart available in all classrooms (See policy and procedure manual). 1. Provide first aid in accordance with Emergency Medical Care Flipchart or individualized Emergency Care Plan. 2. Notify LSN. 3. Ensure Emergency Medical Care Flip Chart available in all classrooms (See policy and procedure manual). 1. At the beginning of the year. LSN reviews first aid for asthma on emergency flip chart with school staff including Health Office back-up staff. 2. Ensure Emergency Medical Care Flip Chart available in all classrooms (See policy and procedure manual). 3. Provide first aid in accordance with MPS Pathway For Acute School Asthma Care, Emergency Medical Care Flipchart or individualized Emergency Care Plan. 4. Complete Emergency Care Plan (ECP) on student if the following conditions apply: previous ICU admission or intubation for asthma extreme labile asthma (asthma symptoms that come on suddenly and rapidly worsen). poorly controlled severe persistent asthma. 5. File ECP in student record 6. Document development of ECP in health record narrative notes. When possible, include the parent and the Health Care Provider in developing the ECP. 7. Provide copies of ECP to Health Office Staff, PE teachers, coaches, classroom teachers and other personnel working with student. Student Counseling/Education Student Counseling/Education Student Counseling/Education 1. Review correct inhaler and peak flow meter techniques with students who come into the HO; 2. Educate students and families with asthma on key components of asthma self-management as delegated by the LSN. 3. Document on SHOAR or Daily Log. 4. Send Asthma Education material home to families of students as indicated by LSN. 1. Review correct inhaler and peak flow meter techniques with students who come into the HO; 2. Educate students and families with asthma on key components of asthma self-management as delegated by the LSN. 3. Document on SHOAR or Daily Log. 4. Send Asthma Education material home to families of students as indicated by LSN. 1. Review correct inhaler and peak flow meter techniques with students who come into the Health Office; 2. Provide counseling and educate students, families and school staff on key components of asthma self management. 3. Document education on SHOAR or Daily Log. 4. Determine need for Asthma Education materials including interactive computer games. Based on the: NASN Standards of Practice MPS Policy and Procedures NIH Guidelines for the Diagnosis and Management of Asthma MPS Asthma Manual 1 (HSA, LPN role) When a parent/guardian writes back indicating that their child has asthma symptoms but no asthma diagnosis: have student complete SBQ or call parent/guardian and administer PQ. Teach the student how to check a Peak Flow; check the student s height; check predicted Peak Flow value for height; if student s PF is not in the green zone (based on height), or has positive answers on SBQ or PQ, notify the LSN of those students. (LSN role) Call parent/guardian of students with positive finding from SBQ or PQ, and/or PF screening, and discuss evaluation by primary provider or asthma specialist. 2 Use the MPS Pathway for Acute Asthma Care in making decisions regarding the provision of acute asthma care in the school setting. 3 If you make a phone call in lieu of sending the AVN, complete the form anyway and give to the LSN. The call is documented on the daily log or on the AVN form. 4 If you make a phone call in lieu of sending the AVN, complete the form anyway and give to the LSN. The call is documented on the daily log or on the AVN form. 5 DEFINITION OF GOOD CONTROL: 1. No coughing 2. No shortness of breath, rapid breathing, wheezing or chest tightness 3. No waking up at night because of asthma symptom 4. Normal activities including play, sports and exercise 5. No episodes of asthma that require a doctor or NP visit, ED visit or urgent care visit 6. No absences from school or activities 7. No missed times from work for the parent or caregiver 8. Normal (or near normal) lung function (Excerpted from: Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children: American Academy of Allergy, Asthma and Immunology, NIH, AAAAI, 1999) 6 Peak Flow readings may be recorded on the Daily Log or the narrative notes of the Pupil Health Record if student is not checking peak flows on an ongoing basis. 7 Peak Flow readings may be recorded on the Daily Log or the narrative notes of the Pupil Health Record if student is not checking peak flows on an ongoing basis. 8 Do not document students coming in for routine pre-exercise asthma medications on the Daily Log. Students coming for PRN medications because of symptoms should be documented on the Daily Log. Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services or

8 Components of Asthma Management in the School (St. Paul Public Schools version) E3 School Staff Designee / Secretary Case Finding 1. Notify LSN of students with asthma or symptoms of asthma following established communication procedure. Delegated Nursing Care/Procedures 2. Collect asthma questionnaire, medication authorization, Asthma Action Plans or other communications from parent/guardian and/or health care provider. Provide episodic care to students with symptoms of asthma. Assessment Licensed School Nurse (LSN) Case Finding 1. Conduct case finding for asthma by reviewing data from a variety of sources including the student/ family, school staff, health/medical records, health history form, emergency cards, field trip permission forms. 2. Record health data in the Pupil Health Record and on Campus Health Condition List as indicated. 3. Obtain additional history as needed. Delegated Nursing Care/Procedures 1. The LSN uses the Asthma Questionnaire(AQ) as a tool to: a. determine if the student s asthma is under control b. help determine severity level c. develop an appropriate plan of care (IHP or ECP) 2. The AQ is given to: Annually to students who have asthma newly identified or newly discovered students with asthma students with asthma where more information is needed students whose asthma is out of control 3. Information from the AQ is summarized in the narrative notes of the pupil health record. 4. The AQ may be sent home with the student, mailed or given to the parent/guardian. 5. Document that the AQ was given or sent to parent/guardian on the asthma tracking sheet and/or SHOAR. 1. The LSN uses the Student Breathing Questionnaire (SBQ) for students in grades 6 12 in conjunction or in lieu of Asthma Questionnaire to: a. help determine if student s asthma is under control b. determine the student s severity level c. develop a plan of care (IHP or ECP) 2. Administer SBQ to any student in Grades 6 12 with asthma: on initial visit with asthma symptoms to the Health Office during the school year who takes medications on a routine basis who is reported as absent due to asthma or suspicious of asthma 1-day who frequently presents with asthma symptoms 3. If the student s asthma status appears to be changing, the LSN can repeat the SBQ if indicated. 4. Assist student with SBQ if student cannot read at 3 rd grade level or needs interpreter services. 5. Summarize findings in narrative notes of the Pupil Health Record. 6. Document that the SBQ was given to the student on the asthma tracking sheet and/or SHOAR. 1. Provide ongoing support and monitoring to school staff and designee regarding asthma care. 2. Train Designee/s on all delegated tasks and supervise performance. 1. Perform assessments 1 on students with symptoms of asthma, which nclude: Physical Assessment: visual inspection, auscultation of breath sounds (anterior/posterior, skin to skin), respiratory rate, peak flow. School: learner performance, ability to function in physical education /sports/ socially/ and attendance patterns. Resources: insurance status, transportation, finances, access to Health Care Provider (HCP). 2. Assessment can also include the following areas: Emotional/social status: student s reaction to illness, abuse, neglect. Environmental: home and school environment Family support Asthma Visit Notification (AVN) 1. Document asthma visit on Daily Log and/or Pupil Health Record. 2. Complete Asthma Visit Notification form (AVN) 2 when student is seen in the Health Office with asthma symptoms and/or distress and send home with student. 3. Using the MPS Pathway For School Asthma Care, provide appropriate level of intervention for students with exacerbation of asthma. 4. Phone parent/guardian if student is seen in the Health Office 2 times a week with asthma symptoms. 5. Document that AVN Form was sent to parent/guardian on the SHOAR. 6. File AVNs with the SHOAR, destroy AVN s at the end of the year or upon student withdrawal. 7. Determine if additional medical information is needed. Parental authorization can be used from the medication authorization form, Asthma Questionnaire (AQ) or Release of Information form. 1 Use the MPS Pathway for Acute Asthma Care in making decisions regarding the provision of acute asthma care in the school setting. 2 If you make a phone call in lieu of sending the AVN, complete the form anyway. The call is documented on the daily log or on the AVN form.

9 Delegated Nursing Care/Procedures (continued) 1. Complete the School Health Office Asthma Record (SHOAR) on all students with asthma medication or asthma symptoms. 2. The SHOAR is used to: Record asthma medication Document asthma symptoms Delegated Nursing Care/Procedures (continued) School Health Office Asthma Record (SHOAR) 1. Complete or initiate the School Health Office Asthma Record (SHOAR) on all students with asthma medication and/or students who need documentation of Peak Flow or Education. (See instructions under peak flow and SHOAR instructions). 1. The SHOAR is a asthma management tool used to: Document asthma medication administration Record peak flow readings Document asthma symptoms Document student education Document nursing interventions Document student outcomes Asthma Medical Request (AMR) 1. The Asthma Medical Request form (AMR) is used for communication between the Health Care Provider (HCP) and the LSN. 2. Complete the AMR or contact the HCP when there are asthma control or management concerns. Attach SHOAR as appropriate. 3. The AMR should be sent to the HCP only after parent/guardian consent is obtained, except in the event of an emergency. 4. When a student is transported by ambulance to the Emergency Dept. (ED), the AMR form should be sent along with the student. Fax copy to HCP (if known). 5. When a student needs immediate care (based on the MPS Pathway for AcuteAsthma Care) and he/she is going to their primary clinic or urgent care, the LSN should call the HCP to inform them of the referral. The AMR should be sent with the student and faxed to the HCP. 6. For situations not requiring immediate attention, the LSN should fax the AMR to the clinic without calling the clinic. The LSN should call the parent/guardian or send the AVN form home informing parent/guardian of AMR faxed to clinic. 7. The LSN will send the AMR when: Student is seen in the Health Office 2 or more times a week with asthma symptoms. Medication/peak flow meter/spacer are needed at school. There are other questions about medications. Student experiences an acute asthma episode requiring immediate care. Student has missed 5 or more days of school due to asthma within the current school year. 8. Document on the SHOAR and/or the narrative notes of Pupil Health Record that the AMR was sent to the clinic or HCP. File original/copy with the SHOAR. Individual Health Plan (IHP) 1. Develop Individual Health Plan (IHP) for students with moderate to severe asthma who require nursing care (see IHP instructions). 2. Review and modify IHP as needed. 3. Summarize progress towards goals / education on IHP form annually or upon student s withdrawal from school. Asthma Action Plan (AAP) 1. Send request for AAP on students: whose asthma is out of control with mild, moderate and severe persistent asthma who take asthma medications at school on a daily basis who have had ED or hospital visits within the last year 2. Review new AAPs on a weekly basis. 3. Place AAPs in with SHOAR form. Enter AAP treatment code (329) under appropriate health condition code in Campus. Campus 1. Review/add appropriate health condition code in campus. 2. Review AQ, SBQ, AVN Form, and AAP to determine student s current level of control 3 and asthma severity level and enter in Campus. 3. Enter AAP treatment code (329) under appropriate health condition code in Campus. 3 DEFINITION OF GOOD CONTROL: 1. No coughing 2. No shortness of breath, rapid breathing, wheezing or chest tightness 3. No waking up at night because of asthma symptom 4. Normal activities including play, sports and exercise 5. No episodes of asthma that require a doctor or NP visit, ED visit or urgent care visit 6. No absences from school or activities 7. No missed times from work for the parent or caregiver 8. Normal (or near normal) lung function (Excerpted from: Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children: American Academy of Allergy, Asthma and Immunology, NIH, AAAAI, 1999)

10 Components of Asthma Management in the School (St. Paul Public Schools version) E3 Delegated Nursing Care/Procedures (continued) 1. Administer medications per LSN delegation and /or Health Care Provider (HCP) order. Care Coordination 1. Communicate regularly with LSN regarding concerns and care of students with asthma. Delegated Nursing Care/Procedures (continued) Peak Flow Meter Check peak flow on students: with persistent asthma with asthma symptoms to determine if medication is needed per AAP. Periodic evaluation for students receiving pre-exercise meds. Document peak flow readings, signs, symptoms and medications given on SHOAR form 4 : a = peak flow reading before medication, p = peak flow after prn medication. Record actual PF number above a or p on graph section of SHOAR. If student returns with symptoms a second time on that same date and requires repeat peak flow monitoring, the following adjacent vertical column is used to document the peak flow (If AAP is not available, calculate student s predicted peak flow using the table: Average Peak Flow Rate For Healthy Children. Medication Assess, monitor, and/or administer medications. Document medication in the same vertical column, that peak flow is recorded on the SHOAR form, in the first available box corresponding to the medication given. 5 If student returns with symptoms a second time on that same date and receives PRN medication and/or requires peak flow monitoring, the following adjacent vertical column is used to document the peak flow and medication given (use one line only for PRN medication). Use one line for each medication unless a medication is routinely given twice during the each school day. In this case, use a separate line for each administration time. Pupil Health Record 1. Document all 911 calls on the pupil health record. 2. Document all medication orders on the pupil health record when med is received. 3. Document other pertinent information in narrative notes per LSN judgement. 4. At end of year or upon student withdrawal, file SHOAR, AMR, AQ, SBQ, IHP/ECP, AAP, and medication authorization in the pupil health record. Care Coordination (LSN) 1. Request AAP on students: whose asthma is out of control with mild, moderate and severe persistent asthma who take asthma medications at school on a daily basis who have had ED or hospital visits within the last year 2. Document request sent in narrative notes of Pupil Health Record or on SHOAR. 1. Review IHP and AAP 2. Develop or modify plan for care coordination as needed. 1. Determine if students have insurance. 2. Assess family s understanding of health care system and ability to access preventive and emergency care. 3. For students who have no insurance, refer to Community Resources. 1. Assist with transportation and interpreters for students as appropriate. 1. Consistent communication with parents/guardians and providers regarding asthma care, need for medication, supplies, Release of Information Consents, asthma episodes. 2. Refer students to Health Care Provider to ensure consistent asthma care and follow-up according to NHLBI/NAEPP guidelines. Initiate referrals to: community based asthma programs, asthma case management health plan, hospital or clinic, home visiting services for f/u coordination, education or home environment assessment other services as needed i.e. asthma camp 4 Peak Flow readings may be recorded on the Daily Log or the narrative notes of the Pupil Health Record if student is not checking peak flows on an ongoing basis. 5 Do not document students coming in for routine pre-exercise asthma medications on the Daily Log. Students coming for PRN medications because of symptoms should be documented on the Daily Log.

11 Emergency Care 1 Provide first aid in accordance with First Aid for Asthma and Breathing Trouble or Emergency Medical Care Flipchart found in Student Wellness Site Plan or individualized student Emergency Care Plan. 1. Notify LSN, parent/guardian and HCP of emergency care as needed. Student Education/Counseling Asthma Education Program Emergency Care 1. At the beginning of the year. LSN reviews First Aid for Asthma and Breathing Trouble and Emergency Care Flip Chart with school staff and delegated designees. 2. Ensure Building Site Plan is completed and includes First Aid for Asthma and Breathing Trouble Emergency Medical Care Flip Chart. 3. Provide first aid in accordance with MPS Pathway for Acute School Asthma Care, First Aid for Asthma and Breathing Trouble, Emergency Medical Care Flipchart or individualized student Emergency Care Plan. 4. Complete Emergency Care Plan (ECP) on student if the following conditions apply: previous ICU admission or intubation for asthma extreme labile asthma (asthma symptoms that come on suddenly and rapidly worsen). Poorly controlled moderate or severe persistent asthma. 5. File ECP with SHOAR, sub folder, and site plan. 6. Document development of ECP on SHOAR narrative notes. When possible, include the parent and the Health Care Provider in developing the ECP. 7. Provide copies of ECP to Office Staff, PE teachers, coaches, classroom teachers and other personnel working with student per LSN judgment. Student Education/Counseling 1. Review correct inhaler and peak flow meter techniques with students who come into the Health Office; do pre/post test of technique. 2. Provide counseling and educate students, families and school staff on key components of asthma self management. 3. Document education on SHOAR or IHP. 4. Determine need for Asthma Education materials. Asthma Education Program This is a series of 6 class sessions, 30 minutes long using a curriculum developed by SPPS Student Wellness. The objectives / student performance standards are: The student produces evidence that demonstrates understanding of asthma and the respiratory system triggers of asthma attacks, the importance of peak flow meters, their own individual asthma action plan and the role of medications. The student uses technology and tools to gather data and extend the senses by demonstrating competence with his/her inhaler and spacer and peak flow meter The student shows or explains something clearly enough for someone else to be able to do it. The LSN or in conjunction with a PNP or asthma resource nurse: 1. Identifies students who would benefit from attending class: Those with medications in school Those with frequent exacerbation of asthma symptoms Those whose asthma is out of control Those who had emergencies (911) during school due to asthma. 2. Coordinates with school staff time, place and dates for classes. 3. Coordinates with school staff time, place and date for parent meeting. 4. Attend and help facilitate each class and parent meeting. Adapted from: Minneapolis Healthy Learners Board Asthma Initiative

12 Asthma and Breathing Trouble E4 Symptoms of breathing trouble: Unusually slow or fast breathing Breathes unusually deep or shallow Gasping for breath Wheezing, gurgling, or making high-pitched noises Skin unusually moist Skin flushed, pale, ashen or bluish looking Person feels short of breath Person feels dizzy or light-headed Person feels pain in chest or tingling in hands or feet Person feels apprehensive or fearful Symptoms of asthma attack can also include: Coughing, wheezing, restlessness, or upset stomach Care of asthma and breathing trouble 1. Remain calm and reassure person. 2. Have person sit up and breathe evenly, breathing in through nose, and breathing out with pursed lips. 3. If asthma episode is suspected, give glass of room temperature water to sip. 4. Elevate arms to shoulder level and provide support for the arms (desk or back of chair). 5. Notify your site's health office to: 1) Give medication if ordered and available (Some students carry their asthma inhaler with them); 2) Contact parent/guardian. Reasons to call 911: Child is not breathing Blue lip area or blue nail beds Difficulty talking, walking or drinking "Quick relief" reliever medication (inhaled bronchodilator) is ineffective, unavailable, or used too recently to repeat Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) Nasal flaring when inhaling Obvious distress Altered level of consciousness/confusion Rapidly deteriorating condition

13 Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. E5 -OVER - -OVER - Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. -OVER - Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. -OVER - Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. -OVER - Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. -OVER Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. -OVER - Asthma and Breathing Trouble Symptoms of breathing trouble: -Unusually slow or fast breathing -Breathes unusually deep or shallow -Gasping for breath -Wheezing, gurgling, high-pitched noises -Skin unusually moist -Skin flushed, pale, ashen/ bluish looking -Person feels short of breath -Person feels dizzy or light-headed -Chest pain or tingling in hands or feet -Person feels apprehensive or fearful -Coughing -Possibly restlessness or upset stomach Care of asthma and breathing trouble -Remain calm and reassure person. -Have person sit up and breathe evenly, breathing in through nose, breathing out with pursed lips. -OVER -

14 Document courtesy of: Healthy Learners Asthma Initiative, Minneapolis Public Schools, Health Related Services Phone# or website: Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition Care of asthma & breathing trouble -If asthma episode is suspected, give glass of room temperature water to sip. -Elevate arms to shoulder level and provide support for the arms (desk or back of chair). -Notify your site's health office to: -Give medication if ordered and available (some students carry their asthma inhaler with them) -Contact parent/guardian. Reasons to call 911: -If not breathing -Blue lip area or blue nailbeds -Difficulty talking, walking or drinking -"Quick relief" reliever medication (inhaled bronchodilator such as albuterol) is ineffective, unavailable, or used too recently to repeat -Neck, throat, or chest retractions (Sucking in of the skin between ribs or at base of the neck) -Nasal flaring when inhaling -Obvious distress -Altered level of consciousness/confusion -Rapidly deteriorating condition

15 Pathway for School Asthma Care (Acute) for LSNs/PHNs/RNs E6 Assess severity of symptoms (Sx): Look for rapid respiratory rate, complaints of chest tightness, coughing, wheezing, anxious look, stooped posture, sweating, shortness of breath (SOB), inability to speak a full sentence without SOB, inability to walk well, increasing lethargy, cyanosis, rapid heart rate. Physical assessment should include RR and effort, capillary refill, breath sounds / air exchange, presence of retractions or nasal flaring, pulse rate and/or heart rate, and level of consciousness. MILD Symptoms MODERATE Symptoms SEVERE Symptoms Symptoms may include: Cough with exercise only Cough with laughing only Night time cough only Minimal or no wheezing No apparent symptoms Conduct physical assessment, if time allows Put child in comfortable position (usually upright) Reassure child Child may sip water slowly Try deep breathing or relaxation exercises prn Observe child Review Asthma Action Plan (AAP), School Health Office Asthma Record (SHOAR), and/or Emergency Care Plan, if exists Symptoms may include: Persistent coughing Chest tightness Rapid breathing ( > normal rate for age) Breathing out may take longer than breathing in Noticeable wheezing (most likely,/ not always) Trouble sleeping at night due to Sx Conduct physical assessment Put child in comfortable position (usually upright) Reassure child Child may sip water slowly Try deep breathing or relaxation exercises prn Observe child continuously Symptoms may include: Wheezing when breathing in as well as breathing out, or no wheezing due to poor aeration Sucking in of the skin below the ribcage, between the ribs, and/or at the base of the neck (retractions) Anxiety Very rapid breathing Lips and nail beds may have a grayish or bluish color * Trouble talking or walking * If you are worried about how to get through the next 20 minutes * Gasping for air Rapidly deteriorating Sx * Medicine not helping Confusion * * denotes more serious Sx call 911 immediately, then call parent/guardian CALL 911 Conduct physical assessment Assess Sx and check Peak Flow (PF) reading (always assess effort and technique) Give medication according to AAP or SHOAR If quick relief meds not at school, call parent/guardian to bring meds and administer prn PF and Symptoms improved in minutes No Instruct back-up person to call parent/guardian, cover HO / treat other students who may come in, and to arrange for staff to meet and direct EMS provider. Review/follow Asthma Action Plan (AAP), SHOAR, and/or Emergency Care Plan. Give a quick-relief med ASAP, if available at school. Yes If in Green Zone and Sx improved, return to class If in Yellow Zone and Sx NOT improved, call parent to notify may send back to class with instructions to return to HO in 4 hours, or send home/ to clinic (depending on symptoms and parental preference/comfort level) Place in comfortable upright position Provide reassurance Sip water slowly if able Try deep pursed lip breathing and/or relaxation exercises prn if able If in Yellow Zone and Sx improved, return to class, with instructions to return to H.O. if symptomatic in 4 hours for re-check If Sx improved, but still in Red zone, call parent / guardian to pick up and follow AAP and/or bring into clinic. If in Red zone, and Sx NOT improved, but child without severe symptoms, call parent/ guardian to pick up and bring into clinic or Urgent Care ASAP. If parent / guardian not reached, keep trying to reach them. Monitor student continuously in H.O. / continue to reassess student and give Tx per AAP and SHOAR If symptoms worsen to severe level follow the severe pathway above and call 911 immediately Continuously monitor and/or treat student until EMS provider arrives and document Prepare for transfer to hospital Provide EMS provider with: student s current physical symptoms, VS, health history, interventions at school including medications (AMR either give to EMS, or fax), a copy of Emergency Card Post-emergency actions: Review emergency situation with appropriate school staff, parent/guardian, and/or HCP. Determine if additional action/interventions at school are indicated (e.g. AAP, meds, team effectiveness). Document asthma episode in Pupil Health Record and complete Accident/incident student report. Notify Nursing Service Manager of 911 call. Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services or

16 Pathway for Acute School Asthma Care For LSN/PHN/RNs Instructions E7 Purpose: This asthma pathway or algorithm was designed to assist LSN/PHN/RNs in making decisions regarding the provision of acute asthma care in the school health office or other school setting. It is designed to be useful for students experiencing mild, moderate or severe asthma symptoms. Instructions: Post the asthma pathway in an accessible place in the school health office. This pathway may be used as a guide to help educate Health Assistants or Licensed Practical Nurses re: providing asthma care to students. If using this pathway in such a way, omit any nursing activities such as assessment or documentation. Use normal respiratory rates (below) to determine whether a student is tachypnic. Normal Respiratory Rates for Children (breaths/minute) (Whaley & Wong, 1991) Age Rate Age Rate Newborn years mo years 19 2 years years 19 4 years years 17 6 years years years 20 Documentation: This pathway is a reference, and no documentation is necessary when using this asthma pathway. Document student's symptoms, medication given, and emergency care provided according to school policy/guidelines. Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services or

17 Asthma Medications E8 Quick Acting Bronchodilators (Relievers) Brand Name AccuNeb TM inhalation solution Albuterol inhalation aerosol (generic) Albuterol sulfate inhalation solution (generic) Generic Name Alupent Metaproterenol sulfate Atrovent Ipatropium bromide Combivent Albuterol sulfate and ipatroprium bromide DuoNeb Inhalation Solution Delivery System Dosages Available / Frequency Albuterol sulfate Nebulizer 1.25 mg and 0.63 mg in 3 ml unit-dose vials / 3-4 times per day Albuterol dose inhaler 90 mcg per inhalation / 3-4 times per day Albuterol sulfate Nebulizer 0.083% in 3 ml unit-dose vials / 3-4 times per day Albuterol sulfate and ipatroprium bromide dose inhaler nebulizer dose inhaler 65 mcg per inhalation / 3-4 times per day 0.4% or 0.6% in 2.5 ml unitdose vials / 3-4 times per day 5.0% solution in 10 or 30 ml multi-dose bottle / 3-4 times per day 18 mcg per inhalation / 4 or more times per day Nebulizer 0.02% in 2.5 ml unit-dose vials / 3-4 times per day dose inhaler 103 mcg alberterol sulfate and 18 mcg ipatropium bromide per inhalation / 4 times per day Nebulizer 300 mcg Albuterol sulfate and 50 mcg ipratroprium bromide in 3 ml unit-dose vials / 4 times per day Things to Know Side Effects Opens airways by relaxing the muscles around the airways. Should be used first if other inhalers are taken at the same time. Wait 1 to 3 minutes between puffs to let first puff begin working. These medicines start working in about 5 minutes and last 4 to 6 hours. Shaky hands, hyper feeling, fast heartbeat, headache. Side effects usually only last a short time. They can go away after using the medicine regularly. Call health care provider if the side effects persist or do not stop. Minnesota Department of Health February

18 Asthma Medications Ipatroprium bromide inhalation solution (generic) Ipatroprium bromide acetate Pirbuterol Maxair dose inhaler Maxair Autohaler Metaproteronol sulfate inhalation solution (generic) Proventil Inhalation Aerosol Metaproteronol sulfate Nebulizer 0.02% solution in 2.5 ml unitdose vials / 3-4 times per day Breathactuated metered dose inhaler Albuterol, USP dose inhaler Proventil -HFA Albuterol sulfate, USP Proventil Inhalation Solution Ventolin Inhalation Aerosol Ventolin Nebules Ventolin HFA inhalation aerosol Xopenex Inhalation Solution Albuterol sulfate, USP 200 mcg per inhalation / 3-4 times per day Nebulizer 0.4% and 0.6% solutions in 2.5 ml unit-dose vials / 3-4 times per day dose inhaler Albuterol dose inhaler 90 mcg per inhalation / 3-4 times per day 108 mcg per inhalation / 3-4 times per day Nebulizer 0.083% solution in 3 ml unitdose bottle or 0.5% solution in 20 ml multi-dose bottle / 3-4 times per day 90 mcg per inhalation / 3-4 times per day Albuterol Nebulizer 0.083% in 2.5 ml unit-dose nebules / 3-4 times per day Albuterol sulfate dose inhaler 108 mcg per inhalation / 3-4 times per day Levalbuterol HCI Nebulizer 0.63 mg or 1.25 mg in 3 ml unit-dose vials / 3 times per day Minnesota Department of Health February

19 Asthma Medications E8 Long-Acting Bronchodilators (Controllers) Brand Name Generic Name Proventil Repetab Volmax Foradil Aerolizer Serevent Inhalation Aerosol Albuterol sulfate Formoterol fumarate Salmeterol xinafoate Delivery System Oral (by mouth) Dry powder inhaler dose inhaler Serevent diskus Salmeterol Dry powder inhaler Dosages Available / Frequency 12 mcg per inhalation / 2 times per day 21 mcg per inhalation / 2 times per day 50 mcg per inhalation / 2 times per day Things to Know Side Effects Opens airways by relaxing muscles around the airways. Take about 12 hours apart. Do not take more than twice a day. Never use to relieve urgent symptoms. Same as quick acting bronchodilators Oral Bronchodilators (Controllers) Brand Name Generic Name Slo bid Theo-Dur Uniphyl Delivery System Dosages Available / Frequency Things to Know Side Effects Theophylline Opens airways by relaxed. Take at regular time(s) each day. Works in 4 to 6 hours. Lasts for 8 to 12 hours. around the airways keeping the muscles Nausea, vomiting, tremors, doses Call health care provider if side effects appear or if fever effects can occur with high behavior changes; side sleep problems, bedwetting, Minnesota Department of Health February

20 Asthma Medications Long Acting Inhaled Corticosteroids (Controllers) Brand Name Generic Name Aerobid Aerobid -M (menthol) Azmacort Inhalation Aerosol Beclovent Inhalation Aerosol Flovent Inhalation Aerosol Flovent Rotadisk Pulmicort Respules Pulmicort Turbuhaler QVAR Inhalation Aerosol Vanceril Inhalation Aerosol Delivery System Flunisolide dose inhaler Triamcinolone acetonide Beclomethasone dipropionate Fluticasone propionate Budesonide Beclomethasone dipropionate HFA Beclomethasone dipropionate dose inhaler with spacer dose inhaler dose inhaler Dry powder inhaler Dosages Available / Frequency 250 mcg per inhalation / 2 times per day 100 mcg per inhalation / 2-4 times per day 42 mcg per inhalation / 2-4 times per day 44 mcg, 100 mcg, or 220 mcg per inhalation / 2 times per day 50 mcg, 100 mcg, or 250 mcg per inhalation / 2 times per day Nebulizer 0.25 mg or 0.5 mg per 2 ml unit-dose ampule / 1-2 times per day Dry powder inhaler dose inhaler dose inhaler 200 mcg per inhalation / 2 times per day 40 mcg or 80 mcg per inhalation / 2 times per day 42 mcg per inhalation / 2-4 times per day Things to Know Side Effects Prevents swelling, inflammation, and mucus secretion inside the airways. Continue using this medicine every day to prevent episodes. Do not stop taking this medicine until health care provider tells you to stop. Voice hoarseness Possible thrush; rinse mouth and spit after each use to prevent it. Should be used with a spacer (except if using a dry powder inhaler) Minnesota Department of Health February

21 Asthma Medications E8 Inhaled Corticosteroids / Long-Term Bronchodilators (Combination, Controller) Brand Name Generic Name Adviar Diskus Fluticasone Propionate and salmeterol xinafoate Delivery System Dry powder inhaler Dosages Available / Frequency 100 mcg, 250 mcg, or 500 mcg fluticasone and 50 mcg salmeterol per inhalation / 2 times per day Things to Know Side Effects Prevents swelling, inflammation, and mucus secretion inside the airways. Opens airways by relaxing muscles around them. Take every day to prevent episodes. Do not stop taking this medicine until your health care provider tells you to stop. Never use to relieve urgent symptoms. Take doses about 12 hours apart. Do not take more than twice a day. Voice hoarseness Possible thrush; rinse mouth and spit after each use to prevent it. Inhaled Non-Steroidal Anti-Inflammatory Medicines (Controllers) Brand Name Generic Name Cromolyn sodium inhalation solution (generic) Intal Inhalation Aerosol Intal Inhalation Solution Tilade Inhalation Aerosol Cromolyn sodium Cromolyn sodium Nedocromil sodium Delivery System Dosages Available / Frequency Nebulizer 20 mg in 2 ml unit-dose vials / 4 times per day dose inhaler 800 mcg per inhalation / 4 times per day Nebulizer 20 mg in 2 ml unit-dose ampules / 4 times per day dose inhaler 175 mcg per inhalation / 4 times per day Things to Know Side Effects Prevents inflammation by stabilizing cells that line the airway; blocks the reaction to triggers. Take every day to prevent episodes. Do not take more than 4 times daily. Do not stop taking this medicine until your health care provider tells you to stop Side effects are rare Minnesota Department of Health February

22 Asthma Medications Leukotriene Modifiers (Controllers) Brand Name Generic Name Delivery System Dosages Available / Frequency Accolate Zafirlukast Tablets 10 or 20 mg tables / 2 times per day Singulair Montelukast sodium Tablets 4 or 5 mg chewable tablets; 10 mg coated tablets / 1 time per day Zyflo Filmtab Zileuton Tablets 600 mg tablets / 4 times per day Things to Know Side Effects Prevents swelling, inflammation, and mucus secretion. Take every day to prevent episodes. Never use to relieve urgent symptoms. Take Accolate on an empty stomach. Do not stop taking this medicine until your health care provider tells you to stop. Headache or stomachache Call the health care provider if flu-like symptoms occur. Oral Corticosteroids (Relievers) Brand Name Generic Name Delivery System Medrol Methylprednisolone Pediapred Prednisolone Prelone Prednisone Dosages Available / Frequency Things to Know Side Effects Decreases swelling, airways. Take exactly as prescribed by your health care provider. Starts to work in 6 to 12 hours. secretion inside the inflammation, and mucus Increased appetite, stomachache, mood changes, fluid retention, flushed face. Long-term use may cause other side effects; talk to your health care provider. Take with food or milk to avoid stomachache. Minnesota Department of Health February

23 E9 United States Environmental Protection Agency Indoor Environments Division (6609J) EPA-402-F , January 2004 When mold grows in school buildings and portable classrooms, some staff and students, particularly those with allergies or respiratory problems, may report adverse health effects. Mold requires oxygen, water, and a source of food to grow. There are molds that can grow on almost anything including: wood, paper, carpet, foods, and insulation. Controlling moisture is the key to managing mold in schools. Why is Mold Growing in Your School? Mold grows in schools when airborne mold spores land on a damp food source and begin digesting it in order to survive. The water required for mold growth can enter school buildings and portable classrooms through leaky roofs, pipes, windows, foundations, and other structural openings. Water may also enter schools due to floods, poor drainage, or mis-directed sprinklers. Moisture problems in schools can result from scheduled maintenance activities or conditions during school breaks such as: Increased moisture due to painting or carpet cleaning; High humidity during the summer; and No air conditioning or heating system operation (or reduced use) when school is not in session. When moisture enters the building and its interior structure, it can condense as it comes into contact with cooler indoor surfaces, such as windows, walls, and water pipes. Where Does Mold Grow in Schools? Mold growth often results from excess moisture or water build-up in the following areas: On roof materials above ceilings; Around windows; Near water fountains; On walls, ceiling tiles, and other visible surfaces; On hidden surfaces, such as the back side of dry wall or wall coverings; Around bathroom tiles; In cooling coil drip pans and inside ductwork; and In books and carpet. Photos above: mold growing on the surface of a unit ventilator and a ceiling tile.

24 What Health Effects are Associated with Mold? Potential health effects associated with mold exposure may include irritation of the eyes, skin, nose, throat, and lungs of both mold allergic and non-allergic people. In sensitive individuals allergic reactions can be caused by breathing in or touching mold. Dead mold may still cause allergic reactions in some people, so it is not enough to simply kill the mold and leave it there, the mold must be removed. How Can You Manage Mold in Schools? The key to controlling indoor mold growth in schools is to control moisture. Conduct maintenance as scheduled and perform Photo above: mold growing on backside of wallboard. regular school building inspections for signs of mold, photo by Daniel Friedman moisture, and leaks. Report all water leaks and moisture problems immediately to your maintenance staff. Clean and dry damp or wet building materials and furnishings within hours after a leak or spill to prevent mold growth. Keep indoor relative humidity between 30% and 50%: Ventilate bathrooms, locker rooms, and other moisture-generating sources to the outside. Use air conditioners and dehumidifiers. Scrub mold off hard surfaces with water and detergent, and dry completely. Remove and replace porous materials, such as ceiling tiles or carpet, that become moldy. Avoid installing carpet in areas with perpetual moisture problems: Near drinking fountains and classroom sinks. On concrete floors in contact with the ground and subject to frequent condensation. Cover cold surfaces, such as cold water pipes, with insulation. Ensure that the school operates exhaust systems, such as bathroom fans, together with air conditioning or heating systems. Establish policies that restrict moisture generating activities, such as carpet cleaning, during vacation unless moisture removing equipment is operating. Consider cycling the air conditioning system several hours every day or running portable dehumidifiers. Participate in U.S. EPA s IAQ Tools for Schools Program. This program provides guidance on good maintenance practices that help prevent mold growth and other IAQ problems. Additional Resources You can find more information on mold-related issues and moisture prevention in the following EPA documents: Mold Remediation in Schools and Commercial Buildings A Brief Guide to Mold, Moisture, and Your Home IAQ Tools for Schools Kit Managing Asthma in the School Environment For free copies, call the EPA Indoor Air Quality Information Clearinghouse at (800) or (703) , fax (703) , iaqinfo@aol.com, or visit EPA s Web site at