National Asthma Education and Prevention Program

Managing Asthma
A Guide for Schools

U.S. Department of Health and Human Services

National Institutes of Health U.S. Department of Education
National Heart, Lung, and Blood Institute Office of Safe and Drug-Free Schools
Contents

Overview 1

What Is Asthma? 3

Develop an Asthma Management 5

Program in Your School

Actions for School Staff 9

Connecting With the Community 23

Asthma Education Materials 27

Resources 35


 Foreword

This guide was developed as a collaborative project between the National Asthma
Education and Prevention Program (NAEPP) (coordinated by the National Heart,
Lung, and Blood Institute [NHLBI]), U.S. Department of Health and Human Services
and the Office of Safe and Drug-Free Schools, U.S. Department of Education. These
agencies are working together because of the serious health and educational threats
that asthma poses to our Nation’s children. In the United States, approximately 2 in
15 children have been diagnosed with asthma before they reach 18 years of age. But,
with proper treatment, asthma can be controlled. This booklet is intended to provide
school personnel with practical ways to help students with asthma come to school
each day healthy and ready to learn.
Asthma is a leading cause of school absenteeism. According to parent reports, students
miss 14 million days of school each year due to asthma. By encouraging school
personnel to recognize asthma as a chronic disease requiring ongoing care, we hope
to improve school attendance and keep students in classrooms, where they can learn,
instead of in the health rooms of their schools. Although asthma cannot be cured,
it can be controlled. Schools can help by being supportive of students and staff with
asthma; adopting asthma-friendly policies and procedures; coordinating services with
physicians, school personnel, patients, and families to serve students with asthma;
and providing asthma education for students and staff.
This guide is intended to assist schools that are planning or maintaining an asthma
management program for their students with asthma. For further information, please
contact the NAEPP through the NHLBI Health Information Center at (301) 592-8573
or on the Web at http://www.nhlbi.nih.gov. By making our schools more
“asthma-friendly,” we can ensure that no child is left behind.

Claude Lenfant, M.D. Eric Andell, J.D.

Director Deputy Under Secretary
National Heart, Lung, and Blood Institute Office of Safe and Drug-Free Schools
U.S. Department of Health and Human Services U.S. Department of Education

ii MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 National Asthma Education
and Prevention Program

School Guide Working Group Katherine Pruitt

Lani S. Wheeler, M.D., F.A.A.P., F.A.S.H.A. (Chair) Director, Best Practices
Medical Officer, Division of Adolescent and School Health American Lung Association
Centers for Disease Control and Prevention Washington, DC
Annapolis, MD
Gary S. Rachelefsky, M.D., F.A.A.P., F.A.A.A.A.I
L. Kay Bartholomew, Ed.D., M.P.H. Director, Allergy Research Foundation
Associate Professor of Behavioral Sciences UCLA School of Medicine
University of Texas Health Science Center Los Angeles, CA
at Houston
Houston, TX Martha Ryder
Allergy and Asthma Network/Mothers of Asthmatics, Inc.
Rose Boehm, R.R.T., R.C.M. Fairfax, VA
Baylor Asthma and Pulmonary Rehabilitation Center
Dallas, TX Diana Schmidt, M.P.H.
Coordinator
Mary Brasler, Ed.D., R.N. National Asthma Education and Prevention Program
Director of Programs
Asthma and Allergy Foundation of America Kim Smith, M.S.W.
Washington, DC Public Affairs Specialist
U.S. Environmental Protection Agency
Carol Constante, R.N., M.A., C.S.N., F.N.A.S.N. Washington, DC
Past President
National Association of School Nurses Virginia Taggart, M.P.H.
Towson, MD Health Scientist Administrator
Division of Lung Diseases
Ellie Goldberg, M.Ed.
Education Rights Specialist Jennie Young
Healthy Kids: The Key to Basics Project Coordinator
Newton, MA National Education Association Health Information Network
Washington, DC
Brenda Greene
Director of School Health Programs Paul Williams, M.D.
National School Boards Association Clinical Professor of Pediatrics and Environmental Health
Alexandria, VA University of Washington School of Medicine
Seattle, WA
Pamela Luna, M.S.T., Dr.P.H.
Health and Education Consultant Linda Wolfe, R.N., M.Ed.
Riverside, CA President
National Association of School Nurses
Shirley McCoy Georgetown, DE
Principal
Shrevewood Elementary School Prospect Associates, Ltd.
Falls Church, VA Zoe Santiago-Font
Associate Partnership Leader
Jennifer Medearis
Safe and Drug-Free Schools Program Teresa Wilson, M.P.H., R.N.
U.S. Department of Education Senior Partnership Leader
Washington, DC

iii
 School Education Subcommittee Jennie Young
Lani S. Wheeler, M.D., F.A.A.P., F.A.S.H.A. (Chair) National Education Association Health Information
American School Health Association Network

Martha Ryder Diana K. Schmidt, M.P.H.

Allergy and Asthma Network/Mothers of National Heart, Lung, and Blood Institute, NIH
Asthmatics, Inc. J. Patrick Mastin
Gary S. Rachelefsky, M.D., F.A.A.P., F.A.A.A.A.I National Institute of Environmental Health Sciences, NIH
American Academy of Pediatrics Brenda Greene
Chris Brophy National School Boards Association
American Alliance for Health, Physical Estelle Bogdonoff, M.P.H., C.H.E.S.
Education, Recreation, and Dance Society for Public Health Education
Rose Boehm, R.R.T., R.C.M. Jennifer Medearis
American Association for Respiratory Care U.S. Department of Education
Tennille G. Brown Kim Smith, M.S.W.
American Association of School Administrators U.S. Environmental Protection Agency
Katherine Pruitt
American Lung Association

Paul V. Williams, M.D.

American Medical Association

Karen Huss, R.N., D.N.Sc.

American Nurses Association

Pamela J. Luna, M.S.T., Dr. P.H.

American Public Health Association

Mary Brasler, Ed.D., R.N.

Asthma and Allergy Foundation of America

Robin Brocato
Head Start Bureau

Shirley McCoy
National Association of Elementary School Principals

Linda Wolfe, R.N., M.Ed.

National Association of School Nurses

Mary Vernon-Smiley, M.D., M.P.H.

National Center for Chronic Disease Prevention, CDC

Leslie P. Boss, Ph.D., M.P.H.

National Center for Environmental Health, CDC

iv MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 Overview

This guide is intended to assist schools that are Why Be Concerned About Asthma
planning and/or maintaining an asthma management
program. This guide provides followup steps for
at School?
schools that currently identify students with asthma As the figure shows, about 3 students in a class-
through health forms or emergency cards or plan to room of 30 currently have asthma. Uncontrolled
do so. It is designed to offer practical information asthma can result in reduced performance for
to school staff members of every position. the child with asthma and disruptions for the
entire classroom.
Asthma is a leading cause of Students with asthma can function to their maximum
school absenteeism. potential if their needs are met. The benefits to
Asthma is one of the leading causes of school students include better attendance; improved
absence due to illness. Approximately 9.2 million alertness and physical stamina; fewer symptoms;
children younger than 18 years of age have been and fewer restrictions on participation in physical
diagnosed with asthma in their lifetime; 3.2 million activities and special events, such as field trips,
or approximately 6 percent of children ages 5 to 17 and fewer medical emergencies. Schools and their
had an asthma episode (attack) in the preceding staff can work together with parents or guardians,
year (2001 NHIS data).* School staff members students, and health care providers to minimize
can play an important role in helping students risk and to provide a healthy and safe educational
with asthma manage their disease at school. environment for students with asthma. Good health
and safety are prerequisites to academic achievement.

Diagnosed with asthma in their lifetime.

* National Health Interview Survey, National Center for Health Statistics, National Center for Disease Control and Prevention, 2001.


 What to expect from effective Information you need to plan and
asthma management in school maintain an asthma management
settings program
Effective asthma management can lead to the Responding to the needs of students with asthma
following positive results: in the school setting requires a comprehensive,
• A supportive learning environment for coordinated, and systematic approach. This guide
students with asthma. will help by providing you with the following
information:
• Reduced absences—students have fewer
episodes and symptoms are treated earlier. • Background information on asthma, including
a brief definition of asthma and a list of common
• Reduced disruption in the classroom— “triggers” or stimuli that cause asthma episodes.
students have fewer symptoms when they
adhere to their asthma action plan • A description of ways to effectively manage
(See page 5). asthma in schools.

• Appropriate emergency care—school staff • Strategies for developing an asthma manage-

members know how to respond to emergecies. ment program for schools.

• Full student participation in physical activities— • Tips for developing strong partnerships between
physical education (PE) instructors and coaches school staff, families, and physicians.
know how to prevent exercise induced asthma. • A checklist of basic elements for a compre-
hensive school asthma management program.
• Action sheets for specific school staff, listing
ways each person can reinforce implementation
of an asthma management program.
• Sample outreach letters to families and physicians.
• Asthma resources, including a student asthma
action plan, and other educational materials.
• A resource directory of organizations to contact
for assistance.

 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 What Is Asthma?

Asthma is a chronic lung disease that affects the Common Asthma Triggers
airways. Children with asthma have airways that
are inflamed. Inflamed airways are very sensitive, Although triggers that cause an asthma episode vary
so they tend to react strongly to things called among individuals, there are several common triggers.
“triggers.” Triggers are either allergy-causing • Allergens such as pollen, animal dander, dust
substances, such as dust mites, mold, and pollen; mites, cockroaches, and molds
or irritants, such as cigarette smoke and fumes • Irritants such as cold air, perfume, pesticides,
from paint and cleaning fluid. When the airways strong odors, weather changes, cigarette
react to a trigger, they become narrower due to smoke, and chalk dust
swelling and squeezing of the airways by the
small muscles around them. This results in less • Respiratory infections such as a cold or the flu
air getting through to the lungs and less air getting • Physical exercise, especially in cold weather
out. Symptoms of asthma include acute episodes of:
• Coughing Effective Management Can
• Wheezing (a whistling or squeaky sound Control Asthma
during breathing) Asthma can be controlled with proper medical
• Chest tightness diagnosis and management. It cannot be cured.
• Shortness of breath With appropriate asthma care, students with
Symptoms can vary in severity; they can be mild asthma should have minimal or no asthma
or moderate and affect activity levels, or they can symptoms. When their asthma is managed
be severe and life threatening. effectively, they can safely participate in all
school activities. New treatment approaches
Asthma triggers and symptoms vary from one
emphasize preventing episodes by using
person to another. Some children have asthma
medication appropriately and by protecting
symptoms only occasionally, while others have
the airways from exposure to the triggers
symptoms almost all the time. With proper control
that cause inflammation.
of asthma, children should have minimal or no
asthma symptoms.


 In the past, asthma care focused on treating acute
episodes. We now know that asthma episodes
should be prevented to reduce long-term lung
damage. Effective management of asthma enables
students with asthma to maintain a normal activity
level, prevents symptoms of acute episodes, and
minimizes the amount of medications and medication
side effects.

Managing asthma relies on:

• Taking medication exactly as prescribed.
A person with asthma may need two types
of medications. One type is used to relax
the airways and is taken as needed when
symptoms occur. The other is used daily
to decrease the inflammation in the airways
and prevent episodes from occurring.
• Monitoring students with asthma. A peak
flow meter, which helps to keep track of
how well air is moving through the lungs,
is helpful for some patients with asthma.
When the airways become narrow from
inflammation, the peak flow measurement
will be lower.
• Recognizing the early warning signs of asthma.
These signs may include coughing, shortness
of breath, and increased breathing rate.
• Avoiding or controlling triggers.
• Intervening with proper therapy when early
signs are recognized.
• Forming a partnership among the student, parent(s)
or guardian(s), the physician, and school staff.
The school team plays an important role in helping
students manage their asthma by providing
support for development and implementation
of an asthma management program.

 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 Develop an Asthma Management
Program in Your School

Developing an asthma management program This action plan should be developed by a licensed
shows that your school is responsive to the needs health care provider or physician, signed by a parent
of students with asthma. By developing procedures and the physician, kept on file at school, and renewed
and guidelines, the asthma management program every year. Because every student’s asthma is
ensures that staff knows how to help students with different, the action plan must be specific to each
asthma. A management program should contain: student’s needs. The asthma action plans included
in this guide serve as examples that may be adapted
• A confidential list of students who have asthma. to fit the needs of your school in gathering and
• School policies and procedures for administering sharing asthma management information among
medications, including protocols for emergency school staff, parents or guardians and physicians.
response to a severe asthma episode.
• Specific actions for staff members to perform
in the asthma management program.
• A written action plan for every student
with asthma.
• Education for staff and students about asthma.

Student Asthma Action Plan

Schools should request that parents or guardians
send a written student asthma action plan to school.
This action plan should include daily management
guidelines and emergency steps in case of an
asthma episode. The plan should describe the
student’s medical information and specific steps
for responding to worsening asthma symptoms.
The asthma action plan should contain:
• A list of medications the student receives,
noting which ones need to be taken during
school hours. Also, medications needed during
school activities “off-site” and “off-hours”
should be noted and available.
• A specific plan of action for school staff in case
of an acute episode that includes guidance for
monitoring peak flow.
• Identified triggers that can make asthma worse.
• Emergency procedures and phone numbers.


 Partnerships for an
Asthma-Friendly School

A strong family-physician-school partnership

is essential for students with asthma. A strong
partnership improves attendance and positive
educational outcomes for students with asthma.
School policies supportive of partnerships contain
the following:
• Outreach to families to encourage participation
in managing students’ asthma at school.
• Professional development for teachers and
staff to enhance their effectiveness in asthma
management and their skills in communicating
with families.
• Good communication among physicians,
school staff, and families, such as an ongoing
exchange of information, agreement on goals
and strategies, and a sharing of responsibilities.
• Opportunities for families to share in decision-
making regarding school policies and procedures
affecting their children.
• Linkages with special service agencies and
community groups to address family and
community issues when appropriate.

 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 How Comprehensive Is Your School
Asthma Management Program?

From the list below, check off those basic elements that make up the school
asthma management program that you already have in place at your school.
 Indentified staff person(s) to coordinate the program
 A confidential list of students who have asthma
 School policies and procedures for administering medications, including
protocols for emergency response to a severe asthma episode
 Specific actions for staff members to perform in the asthma
management program
 Education for staff and students about asthma
 A written action plan on file for every student with asthma, including:
• A list of medications to be taken
• Steps for school staff to take in case of an asthma episode
• Identified triggers that can make asthma worse
• Emergency procedures and phone numbers
 A strong family-physician-school partnership

If there are gaps in the basic elements included in your current school asthma
management program, or if you are looking for resources to enhance your
current efforts, the following sections of this guide provide reference materials
intended for use by school staff members in their asthma management efforts.
• Actions for School Staff, p. 9
• Connecting With the Community, p. 23
• Asthma Education Materials, p. 27
• Resources, p. 35


Managing Asthma
A c t i o n s for S c h o o l S ta f f

• Principal or School Administrator

• School Nurse
• Health Assistants, Health Aides, or Other Health Service
Providers in the School
• Classroom Teacher
• Physical Education Instructor and Coach
• Guidance Counselor, Social Worker, and Psychologist
• Facilities and Maintenance Staff

Note:
Although all action steps outlined in the following section for various school staff members can
contribute to the goal of improved asthma management at school, some actions may have greater
impact than others. Therefore, an effort is made to list the actions for each staff member in order
of relative priority. Ultimately, however, each school must decide which steps are most practical
to implement and best meet the school’s own needs and circumstances. Every small step can
make a difference.
Apparent overlap of some action steps across different staff positions serves as a means of
reinforcing each other’s efforts and makes the point that the implementation of a coordinated
asthma management program requires a cohesive team approach where each staff member
shares in the overall responsibility. Ideally, a qualified school nurse should be part of the
team which supervises or provides nursing care to a student in the school setting.
9
 Actions for the Principal
or School Administrator

Help Children With Asthma and Teach Staff, Students, and Families
Their Families Manage Asthma About Asthma
• Involve your staff in developing a school • Make sure that staff members understand the
asthma management program. An effective school’s responsibilities under the Individuals
program requires a cooperative effort that With Disabilities Education Act (IDEA), Section
involves students, parents or guardians, teachers, 504 of the Rehabilitation Act of 1973, Title II
school staff, and physicians. Many members of the Americans With Disabilities Act (ADA),
of the school staff can play a role in maintaining and, where applicable, Title III of the ADA,
your school’s asthma management program, which applies to nonreligious private schools.
however, the principal or school nurse are the In addition, staff should be familiar with any
most instrumental in initiating and implementing applicable State and local legal requirements.
the program.
• Provide in-service programs for staff members
• Work with school nurses, other medical about managing asthma and allergies. You may
professionals, and parents or guardians to get assistance from your school nurse, your
develop a policy that ensures that medication local pediatrician or specialist, or a local
administration is safe, reliable, and effective hospital or medical society. Other sources
and, to the extent possible, allows students to of information are the Allergy and Asthma
self-administer medication. Consult State Network/Mothers of Asthmatics (AAN/MA),
regulations and nursing practice acts to the American Lung Association (ALA), and
ensure appropriate professional standards the Asthma and Allergy Foundation of
for student care. America (AAFA).

• Designate one person on the school staff, • Develop and present an information program
preferably the school nurse, to be responsible for all students to make them aware of the
for maintaining students’ asthma action plans symptoms of asthma. Involve the public health
and for educating appropriate staff members, nurse and/or school nurse.
including teachers, about each student’s
individual asthma action plan. Have a backup • Support and encourage communication with
plan for emergencies in case the designee is parents or guardians and health care providers
not immediately available. to improve school health services.

• Provide health alerts and institute appropriate • Arrange for the development of an asthma
guidance for outside play designed to protect resource file for parents or guardians, students,
students from extreme temperatures, high and school personnel.
pollen counts, and air pollutants that may
affect asthma.

10 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

Keep the Environment Clear of
Asthma-Provoking Substances
• Work with maintenance staff and environmental
health specialists to set and monitor standards
for school maintenance, humidity, ventilation
and indoor air quality, mold, and dust control.
Design and schedule building repairs,
renovations, or cleaning to avoid exposing
students and staff to fumes, dust, and other
irritants. When possible, try to schedule painting
and major repairs during long vacations or the
summer months.

• Enforce smoking bans on school property.

11
 Actions for the School Nurse

Help Children With Asthma and Look for Children With

Their Families Manage Asthma Uncontrolled Asthma
• Communicate with parents or guardians
• Identify students with asthma by:
and health care providers (with parental
– Reviewing medical records and emergency
permission) about acute episodes, if any,
information.
and about changes in students’ health status,
– Including questions related to asthma in
and to track asthma control.
the health history.
• Discuss situations of suspected undiagnosed
• Talk with teachers to help them become or poorly controlled asthma with the students,
familiar with the needs of students who parents, or guardians and suggest referral
have asthma. to their physician for a proper diagnosis
or a treatment update.
• Maintain an asthma action plan for every
student with asthma. Include information on Teach Staff, Students, and Families
administering medications, monitoring peak
flow, reducing triggers, and responding to an About Asthma
asthma attack. • Educate all staff members about asthma and
its potential impact on students’ health, safety,
• Have an emergency backup plan for times and school performance. Within confidentiality
you are not immediately available. File student guidelines, talk to school staff about students
asthma action plans in a location that ensures with asthma and their unique needs.
easy access in an emergency. – Teach staff to refer students to you when
symptoms or side effects are interfering
• Arrange for administration of medication
with breathing or school activities.
in accordance with school policy and State
– Provide this information to parents or
mandates. Provide easy access to emergency
guardians and encourage them to take
medications. Support self-administration
the student to see a physician.
when appropriate. Consult medical and State
Nurse Practice Acts to determine the legal • Conduct in-service courses on asthma, and
scope of practice for those providing nursing consult with staff to guide decisions about both
interventions and management. appropriate school activities for students with
asthma and the importance of full participation.
• Use a peak flow meter to monitor daily
management of asthma among students with • Provide asthma education for students
more severe or difficult-to-manage asthma. with asthma to help them improve their
In addition, a peak flow meter should be used self-management skills.
during acute episodes of asthma—both to
assess severity of an episode to determine • Collaborate with parent teacher
action needed, and to assess response to organizations to offer a family asthma
medication during an asthma episode. education program in school.

• Provide asthma education for the general

student body to encourage students to be
supportive of classmates who have asthma.

12 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

• Train health aides or school assistants, if Keep the Environment Clear of
appropriate, in proper Metered Dose Inhaler
(MDI), Dry Powder Inhaler (DPI), and peak
Asthma-Provoking Substances
flow techniques; use of a nebulizer; and • Help provide a safe and healthy school
recognition of the signs and symptoms environment for students with asthma,
of acute asthma. including off-hours and off-site school
programming.

Note:
School health services managed by licensed school nurses are the most effective way schools can meet the
needs of students with asthma for safe, continuous, and coordinated care in a safe environment. The school
nurse’s care plan, the Individualized Health Plan (IHP), or an asthma action plan document a student’s
health management needs and direct how those needs will be met at school. Check with your State Nurse
Practice Act for guidelines on delegation of health care tasks.
School health services are a related service under the Individuals With Disabilities Education Act (IDEA),
Section 504 of the Rehabilitation Act of 1973 (Section 504), and Title II of the Americans With Disabilities
Act (ADA). School health services must be provided to individual students if indicated on the student’s
Individualized Education Program (IEP) under the IDEA, or if deemed necessary in providing a free,
appropriate public education to students who are covered by Section 504 and Title II of the ADA. Not
all students with asthma are covered by the IDEA. Students who experience difficulty breathing at school
because of asthma may have a disability under Section 504 and Title II, which may qualify them to receive
services under these laws. With respect to students who are covered under one or more of these laws, the
individual situation of any particular student with asthma will affect what services are legally required for
that particular student. For more information about these laws, please contact the Office for Civil Rights
at the U.S. Department of Education.

13
 Actions for Health Assistants, Health Aides,
or Other Health Providers in the School

Help Children With Asthma and Teach Staff, Students, and Families
Their Families Manage Asthma About Asthma
• Identify students with asthma by: • Collaborate with parent-teacher
– Reviewing the medical records and organizations to offer a family asthma
emergency information of all students education program in school.
– Asking questions related to asthma on
the school’s health history forms • Help to provide asthma education for all
students and encourage them to be supportive
• Maintain (in coordination with the school of classmates who have asthma.
nurse) an asthma action plan for every
student with asthma. Include information on Keep the Environment Clear of
administering medications, monitoring peak
flow, reducing triggers, and responding to an Asthma-Provoking Substances
asthma attack. File action plans in a location • Help provide a safe and healthy school
that ensures easy access in an emergency. environment for students with asthma,
including off-hours and off-site school
Look for Children With programming.
Uncontrolled Asthma
• Communicate (in coordination with the school
nurse) with the parent(s) or guardian(s)
and health care provider(s) (with parental
permission) about acute episodes, if any, and
about changes in a student’s health status, and
to track asthma control.

• Talk with teachers to help them become familiar

with the needs of students with asthma. Encourage
them to refer students with poorly controlled
asthma to you. Use the warning signs presented
in this publication. (See page 28.) When you
suspect a student has poorly controlled asthma,
notify the school nurse who will discuss this
with the parents or guardians and encourage
them to take the student to see a physician.

14 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

Note:
School health services managed by licensed school nurses are the most effective way schools can meet the
needs of students with asthma for safe, continuous, and coordinated care in a safe environment. The school
nurse’s care plan, the Individualized Health Plan (IHP), or an asthma action plan document a student’s
health management needs and direct how those needs will be met at school. Check with your State Nurse
Practice Act for guidelines on delegation of health care tasks.
School health services are a related service under the Individuals With Disabilities Education Act (IDEA),
Section 504 of the Rehabilitation Act of 1973 (Section 504) and Title II of the Americans With Disabilities
Act (ADA). School health services must be provided to individual students if indicated on the student’s
Individualized Education Program (IEP) under the IDEA, or if deemed necessary in providing a free,
appropriate, public education to students who are covered by Section 504 and Title II of the ADA. Not
all students with asthma are covered by the IDEA. Students who experience difficulty breathing at school
because of asthma may have a disability under Section 504 and Title II, which may qualify them to receive
services under these laws. With respect to students who are covered under one or more of these laws, the
individual situation of any particular student with asthma will affect what services are legally required for
that particular student. For more information about these laws, please contact the Office for Civil Rights
at the U.S. Department of Education.

15
 Actions for the Classroom Teacher

Help Children With Asthma and stamina or tolerance for exercise, especially
if the student is recovering from illness.
Their Families Manage Asthma Changes in weather conditions (hot, cold,
• Consult with your school nurse or principal breezy) and poor air quality (smoke, smog,
for updated policy and procedures for managing pollen) often can aggravate asthma.
students with chronic health conditions, such
as asthma, including managing medication and • Plan field trips and other activities in a way
responding to emergencies, such as an asthma that ensures students with asthma can fully
episode (attack). participate.

• Know your role. Know how to easily access a Look for Children With
student’s asthma action plan or have a copy of it Uncontrolled Asthma
in the classroom, maintained in a confidential
• Be alert for signs of uncontrolled asthma.
manner. Review it with the student and his or
– Lingering cough after a cold
her parent(s) or guardian(s) to determine if
– Persistent cough during the day
any classroom modifications are necessary and
– Coughing during the night or early in
how to otherwise work toward the goal of the
the morning
student’s full participation in class activities.
– Coughing, wheezing, chest tightness, or
Ask the student to tell you when he/she is
shortness of breath after vigorous physical
experiencing any difficulty in breathing,
activity or activity in cold or windy weather
and know what steps to take in case of an
– Low level of stamina during physical
asthma episode. Don’t delay getting medical
activity or reluctance to participate
help for a student with severe or persistent
– Coughing, wheezing, chest tightness, or
breathing difficulty.
shortness of breath even though the child
• Develop a clear procedure with the student is taking medicine for asthma
and his or her parent(s) or guardian(s) for – Increased use of asthma medicine to
handling schoolwork missed if the student relieve coughing, wheezing, chest
has episodes of illness or misses school. tightness, or shortness of breath

• Report if a student’s symptoms are • Advise the school nurse when you suspect
interfering with learning or activities with poorly controlled asthma in a student, so
peers. Possible side effects of medicine that that the school nurse can discuss the situation
warrant referral are nervousness, nausea, with his or her parent(s) or guardian(s) and
jitteriness, hyperactivity, and drowsiness. suggest referral to their physician for a proper
diagnosis or a treatment update.
• Alert school administrators, school nurses,
and parent(s) or guardian(s) of changes in a • Be aware of students with asthma in your
student’s performance or behavior that might class or classes. Understand their triggers and
reflect trouble with asthma. The vast majority symptoms. Observe what seems to make them
of students with asthma are able to participate better or worse, and share your observations
fully in the school program when their asthma with the school nurse, who in turn may discuss
is well managed. the situation with parents or guardians as
appropriate.
• Encourage the student with asthma to
participate fully in physical activities.
Plan activities to allow for variations in

16 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

• Know the signs and symptoms of asthma Teach Staff, Students, and Their
and the early warning signs of an asthma
episode. (See page 28.) If you have concerns
Families About Asthma
about a student’s health, communicate them • Educate all students about lung health and
to the principal and to the parent or guardian asthma so they will be more understanding
in coordination with the school nurse. and accepting of students with asthma. Involve
students with asthma in the manner and to the
extent they prefer. Some will request complete
Keep the Environment Clear of confidentiality; others may want to talk about
Asthma-Provoking Substances their symptoms or management.
• Reduce allergens and irritants in the
• Use the resources found in this document,
classroom to help students who have allergies.
including the Asthma Action Plan and the
Common allergens and irritants that can make
checklist, How Asthma-Friendly Is Your School?
asthma worse in classrooms include chalk dust,
animals, dust, and strong odors (colognes
or perfumes, paints, pesticides, cleaners
or deodorizers, and markers).

17
 Actions for the Physical Education
Instructor and Coach

Help Children With Asthma and • Maximize participation and minimize the risks
by establishing good communication among
Their Families Manage Asthma parents or guardians, students, health care
• Follow the student’s asthma action plan; if providers, and school staff. Learn about the
indicated, follow premedication procedures student’s asthma triggers and medication plan.
before the student exercises. Know how to easily
access the action plan. Consult with the school • Encourage exercise and participation in
nurse for clarification. sports for students with asthma. When asthma
is under good control, most students with
• Be sure that the student’s medications are asthma are able to play most sports. A number
available for exercise activities that take place of Olympic medalists have asthma.
away from school or after regular school
hours. This preventive medicine enables most • Encourage students with asthma to participate
students with exercise-induced asthma to actively in sports, but also recognize and respect
participate in any sport they choose. their limits. Plan to adjust the type, pace, or
intensity of activities during extreme weather,
• Warm-up and cool-down activities the pollen season, poor air quality, or when a
appropriate for any exercise will also help the student has allergy symptoms or a peak flow
student with asthma. number lower than usual. Permit less strenuous
activities if a recent illness precludes full
• Keep students’ quick relief medications participation.
readily available. Even with precautions,
breathing problems may occur. Learn the
signs of severe distress and allergic reactions.
Have an emergency plan. Don’t delay getting
medical help for a student with severe or
persistent breathing difficulty.

18 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

Look for Children With
Uncontrolled Asthma
• When you suspect poorly controlled asthma
in a student, notify the school nurse who,
in turn, can discuss the situation with the
student’s parent(s) or guardian(s) and suggest
referral to their physician for a proper diagnosis
or a treatment update. Signs of poorly controlled
asthma include: coughing, wheezing, chest
tightness, or shortness of breath. Exercise is
a common trigger for children with asthma.

19
 Actions for the Guidance Counselor,
Social Worker, and Psychologist

Help Children With Asthma and Look for Children With

Their Families Manage Asthma Uncontrolled Asthma
• Help make sure that students with asthma are • Advise parents and guardians on behavioral
treated the same as students without asthma, strategies that improve adherence to treatment
except to address asthma needs. for students with poorly controlled asthma.
Encourage families with life stressors to seek
• Promote and encourage independence case management services from their health
and self-care consistent with the student’s care providers.
knowledge, skills, and behaviors.

• Help the student resolve any issues related Teach Staff, Students, and Families
to school policies or practices and to his or About Asthma
her asthma management.
Help school personnel understand that asthma is
• Recognize that learning to cope with asthma, an inflammation in the airways, not an emotional or
as with any chronic illness, can be stressful. psychological disease. It is not “all in the student’s
Teachers may notice low self-esteem, withdrawal head.” Physical responses to strong emotions, such
from activities, or difficulty making up schoolwork. as laughing or crying, can trigger an acute episode,
Counseling may help identify unnecessary because rapid breathing mechanically irritates and
stressors and help the student handle problems constricts the inflamed airways. However, these
more effectively. emotions do not “cause” asthma.

20 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 Actions for Facilities and
Maintenance Staff

Keep the Environment Clear of Teach Staff, Students, and Families

Asthma-Provoking Substances About Asthma
• Develop an Indoor Air Quality (IAQ) • Provide information to school staff, parents
Management Plan to identify, solve, and or guardians, and students about air quality
prevent IAQ problems, such as mold growth, problems, and involve them in plans to reduce
improperly maintained ventilation systems, asthma triggers (such as mold and secondhand
and chemical pollutants from science and art smoke) and allergens (such as cockroaches,
classes. If allergens from classroom animals dust mites, and classroom animals) if they
and cockroaches or other pests are known are known to cause problems for students
to cause problems for students with asthma, with asthma.
include allergen control in your IAQ plan.
• Obtain a copy of the U.S. Environmental
• Inspect the building regularly for signs of Protection Agency’s (EPA) Indoor Air Quality
mold, moisture, leaks, or spills. Tools for Schools Action Kit to help staff identify
and learn ways to reduce or eliminate
• Establish and follow a regular cleaning pollutant sources in the school environment
and maintenance schedule to help minimize that may bring about asthma attacks. Other
allergen and irritant levels in your school. relevant EPA publications include:
– Pest Control in the School Environment:
• Enforce smoking bans on school property.
Adopting Integrated Pest Management
• Schedule extensive building repairs, pesticide – Mold Remediation in Schools and
applications, renovations, or cleaning when Commercial Buildings
the building is unoccupied to avoid exposing
students to fumes, dust, and other irritants.

21
Managing Asthma
C o n n e c t i n g W i t h the Co m m u n i t y

• Sample Letter to Parents or Guardians

• Sample Letters to Physicians

Note:
The sample letters on the following pages can
be sent as is or modified to meet the particulars
of your school. The purpose of the letters is to
outline steps parents or guardians and physicians
can take to partner with the school in facilitating
good asthma management.
23
 Letter to Parents or Guardians
(SCHOOL DISTRICT LETTERHEAD TO GO HERE)

Dear __________________:

The school team at _______________________________ school is looking forward to an excellent year for
your child, ______________________.

Our School Asthma Management Program will provide the following health services:
• Access to the school nurse
• Help for students with asthma in following their asthma action plans
• Asthma education for all students in grade(s) ______
• Asthma in-service training for all school staff
• Indoor Air Quality (IAQ) Tools for Schools to promote a healthy environment

In order to provide the best possible school asthma management for your child, we request your assistance
with the following:
Please
• Obtain an asthma action plan (a statement of your child’s treatment goals, medication and peak flow
plan, and environmental risk reduction measures) from your physician. Please be sure guidelines are
included for managing symptoms during special school or off-site events (recess, gym, outdoor play,
field trips, parties, art class, etc.). You may use the attached form.
• Meet with the school nurse—before school entry and as needed—to explain your child’s condition,
medication, devices, and environmental triggers.
• Submit the attached Medication Administration form for any medication that is administered
in school. Please provide pharmacy-labeled medications, personally bring them to school, and
keep them refilled as needed.
• Meet with teachers to setup expectations for maintaining communication and continuity
during absences.
• Prepare your child. Discuss and rehearse the medication plan; discuss how to handle symptoms,
triggers, food restrictions, and school policies.
• Keep the school staff up to date on any changes in your child’s asthma action plan.
• Keep your physician up to date on school services and supports for helping your child manage
his or her asthma.

Thank you for working with us to assist your child.

Sincerely,

Principal (signature) School Nurse (signature)

 Letter (Sample 1) to Physicians
(SCHOOL DISTRICT LETTERHEAD TO GO HERE)

Dear __________________:

The school team at _____________________________ school is looking forward to an excellent year for your
patient, ______________________.

Our School Asthma Management Program will provide the following health services:
• Access to the school nurse
• Help for students with asthma in following their asthma action plans
• Asthma education for all students in grade(s) ______
• Asthma in-service training for all school staff
• Indoor Air Quality (IAQ) Tools for Schools to promote a healthy environment

In order to provide the best possible school asthma management for your patient, we request your assistance
with the following:
• Complete the attached asthma action plan or provide comparable information on another form and
return to us at school.
• Complete the attached medication administration form for any medications that may need to
be administered in school and return it to us at school. (Students may self-carry and administer
their quick relief medications if you and the parents or guardians indicate approval on the form).
• Inform us of additional patient needs.
• Assist us in supporting family priorities. Connect parents or guardians with each other, support
groups, and resources such as the Allergy and Asthma Network/Mothers of Asthmatics (AAN/MA),
the American Lung Association (ALA), and the Asthma and Allergy Foundation of America (AAFA).

Let us know if you need information on educational rights and responsibilities (Individuals with Disabilities
Education Act [IDEA] and Section 504 of the Rehabilitation Act of 1973) for your patients.

We look forward to working with you. Thank you for your help.

Sincerely,

Principal (signature) School Nurse (signature)

 Letter (Sample 2) to Physicians
(SCHOOL DISTRICT LETTERHEAD TO GO HERE)
Date ___________
Dear ______________________: [name of provider]

Asthma may be affecting your patient’s school performance.

We are writing about your patient, _______________________________ Date of Birth __________.

The following information is being provided for your information and records.
 Missed _________ days in ___________ period of time, possibly due to asthma.
 Is not complying with asthma medication at school or the treatment plan you have provided.
 Is not participating in physical education because of symptoms related to asthma.
 Visits school health office frequently because of symptoms related to asthma.
 Has required emergency management of asthma (e.g.: 911, ER referral).
 Our observations would suggest that this student’s asthma severity may be as follows
(observations are circled on chart below).

Days with Symptoms Nights with symptoms Peak Flow % Normal

Severe Persistent Continual Frequent < 60%
Moderate Persistent Daily > 4 per month 60% to 80%
Mild Persistent > 2 per week 3 to 4 per month > 80%
Mild Intermittent ≤ 2 per week ≤ 2 per month > 80%

The family was asked to schedule an appointment with you. Parents have provided permission for us to exchange the student’s
health information with you (attached or shown below). Please contact us if there are questions or concerns. Thank you!

If you feel it is appropriate, please help us with the following:

 Send an “Asthma Action Plan” (attached form), so we can assist with your management plan.
 Student has no Peak Flow Meter. Please prescribe one so that we may better assist with management.
 Please prescribe a “Spacer.” This student’s technique with an MDI was observed and is not adequate.
 An additional MDI _______________ (medication name) is needed at school for optimal availability/safety.
 Please reassess this child and his/her current medical regimen (see symptoms/severity above).
 Other_ ___________________________________________________________________

_______________________________________________________________________
Sincerely,

District Medical Consultant (Signature) School Nurse (Signature)

School: __________________________________ Phone: ( ____) _____________ Fax: ( ____) ______________
Best days/time to call: _______________________

I permit my child’s doctor (named above) to communicate with school staff regarding my child’s asthma.

Parent’s Signature _________________________________________ Date______________

Asthma Education Materials
• Early Signs of an Asthma Episode

• Sample Asthma Action Plans

• Use of a Metered Dose Inhaler

• Use of a Peak Flow Meter

• How Asthma-Friendly Is Your School? Checklist

27
 Early Signs of an Asthma Episode

In asthma education programs, students are taught to identify early warning signs—
the physical changes that occur in the early stage of airway obstruction. These early
warning signs usually happen before more serious symptoms occur. They alert
students that it is time to measure their peak flow and take medication according
to their action plan. Each student’s early warning signs should be documented in
the student’s asthma action plan available in the school health room or clinic. Teachers
should be aware of each student’s early signs and symptoms and enable students with
asthma to take the proper steps to prevent more serious asthma trouble.

Recognizing the early warning signs of an asthma episode can avoid a more serious
medical emergency. There should be no delay once a student has notified the
teacher of a possible problem.

A student may have one or more of these symptoms during the initial phase
of an asthma episode.

1. Changes in breathing
Early signs may include:
– Coughing
– Chest tightness
– Throat tightness
– Breathing through the mouth
Later signs may include:
– Wheezing
– Shortness of breath
– Rapid breathing
2. Verbal Complaints
Often a student who is familiar with asthma will know that an episode
is about to happen. The student might tell the teacher:
– “My chest is tight.”
– “My chest hurts.”
– “I cannot catch my breath.”
– “My mouth is dry.”
– “My neck feels funny.”
– “I don’t feel well” or “I feel tired.”
– “My chin (or neck) itches.”—the student may rub his or her chin
or neck in response to this feeling.
Students may also use “clipped” speech—very short, choppy sentences.

28 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

 Sample (1) Asthma Action Plan

STUDENT ASTHMA
ACTION CARD
Name: Grade: Age:
Homeroom Teacher: Room:
Parent/Guardian Name: Ph: (h): ID Photo
Address: Ph: (w):
Parent/Guardian Name: Ph: (h):
Address: Ph: (w):
Emergency Phone Contact #1
Name Relationship Phone
Emergency Phone Contact #2
Name Relationship Phone

Physician Treating Student for Asthma: Ph:

Other Physician: Ph:

EMERGENCY PLAN
Emergency action is necessary when the student has symptoms such as, _________________________ , ___________________,
_________________________ , _____________________or has a peak flow reading of ________________________.

• Steps to take during an asthma episode:

1. Check peak flow.
2. Give medications as listed below. Student should respond to treatment in 15-20 minutes.
3. Contact parent/guardian if

}
4. Re-check peak flow.
5. Seek emergency medical care if the student has any of the following:
� Coughs constantly
� No improvement 15-20 minutes after initial treatment
with medication and a relative cannot be reached.
� Peak flow of ______________________
� Hard time breathing with:
• Chest and neck pulled in with breathing
• Stooped body posture
• Struggling or gasping
� Trouble walking or talking
� Stops playing and canít start activity again
� Lips or fingernails are grey or blue

• Emergency Asthma Medications

Name Amount When to Use
1.

2.

3.
4.
See reverse for more instructions
 Sample (1) Asthma Action Plan (Continued)
DAILY ASTHMA MANAGEMENT PLAN
• Identify the things which start an asthma episode (Check each that applies to the student.)
 Exercise  Strong odors or fumes  Other
 Respiratory infections  Chalk dust / dust
 Change in temperature  Carpets in the room
 Animals  Pollens
 Food _______________________  Molds
Comments

• Control of School Environment

(List any environmental control measures, pre-medications, and/or dietary restrictions that the student needs to prevent an asthma
episode.)

• Peak Flow Monitoring

Personal Best Peak Flow number:
Monitoring Times:

• Daily Medication Plan

Name Amount When to Use
1.
2.
3.
4.

COMMENTS / SPECIAL INSTRUCTIONS

FOR INHALED MEDICATIONS

 I have instructed _______________________________________ in the proper way to use his/her medications. It is my
professional opinion that ________________________________ should be allowed to carry and use that medication by
him/herself.
 It is my professional opinion that _________________ should not carry his/her inhaled medication by him/herself.

Physician Signature Date

Parent/Guardian Signature Date

AAFA • 1233 20th Street, N.W., Suite 402 , Washington, DC 20036 • www.aafa.org • 1-800-7-ASTHMA
02/00
 Sample (2) Asthma Action Plan

National Asthma Education and Prevention Program; National Heart, Lung, and Blood Institute; NIH Publication No. 97-4053
 Use of a Metered Dose Inhaler

A metered dose inhaler (MDI) is a device used to deliver asthma

medication directly to the lungs. In order to ensure effective administration
of the medicine, the following steps should be performed:

1. Remove cap and hold inhaler upright.

2. Shake inhaler.

3. Tilt head back slightly and breathe out.

4. Position inhaler in one of the following ways:

A. Open mouth and hold inhaler 1–2 inches away.
B. Use spacer (recommended for children for any
inhaled asthma medication and for adults/children
using inhaled steroids).
C. Put inhaler in mouth.
(B is optimal, but C is acceptable if you have trouble
with either A or B.)

5. Press down on inhaler to release medication as you start to

breathe in slowly.

6. Breathe in slowly (3–5 seconds).

7. Hold breath for 10 seconds to allow medicine to reach deeply
into the lungs.

8. Repeat puffs as directed. Waiting 1 minute between puffs

may permit the second puff to penetrate the lungs better.

32 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

Use of a Peak Flow Meter

A peak flow meter is a useful tool for objectively measuring the

severity of asthma. The number obtained is called a peak expiratory
flow rate (PEFR). The PEFR indicates the degree of obstruction or
narrowing of the airways. The PEFR is the amount of air that can
be forcefully exhaled. Each individual has a predicted rate based on
height and age. However, many physicians prefer to use the person’s
“personal best” value. This number represents the highest rate
obtained when a person is feeling well.

This procedure can help determine when medicine or a change in

treatment is necessary. In order to ensure accuracy of the results,
the test must be performed using the correct technique. The
following steps outline the procedure for this test.

1. Place indicator at the base of the numbered scale.

2. Stand up.

3. Take a deep breath.

4. Place the meter in the mouth and close lips around the
mouthpiece.

5. Blow out as hard and fast as possible.

6. Write down the achieved value.

7. Repeat the process two more times.

8. Record the highest of the three numbers achieved.

This procedure can help determine when medicine or a change in

treatment is necessary.

33
 National Heart, Lung, and Blood Institute
National Asthma Education and Prevention Program
School Asthma Education Subcommittee

How Asthma-Friendly Is Your School?

Children with asthma need proper support at school to keep their asthma under control and be fully active.
Use the questions below to find out how well your school assists children with asthma:
 Yes  No 1. Is your school free of tobacco smoke at all times, including during school-sponsored
events?
 Yes  No 2. Does the school maintain good indoor air quality? Does it reduce or eliminate
allergens and irritants that can make asthma worse? Check if any of the following
are present:
 Cockroaches
 Dust mites (commonly found in humid climates in pillows, carpets, upholstery,
and stuffed toys)
 Mold
 Pets with fur or feathers
 Strong odors or fumes from art and craft supplies, pesticides, paint, perfumes,
air fresheners, and cleaning chemicals
 Yes  No 3. Is there a school nurse in your school all day, every day? If not, is a nurse regularly
available to help the school write plans and give the school guidance on medicines,
physical education, and field trips for students with asthma?
 Yes  No 4. Can children take medicines at school as recommended by their doctor and parents?
May children carry their own asthma medicines?
 Yes  No 5. Does your school have a written, individualized emergency plan for each child in case
of a severe asthma episode (attack)? Does the plan make clear what action to take?
Whom to call? When to call?
 Yes  No 6. Does someone teach school staff about asthma, asthma management plans, and
asthma medicines? Does someone teach all students about asthma and how to help a
classmate who has it?
 Yes  No 7. Do students have good options for fully and safely participating in physical education
class and recess? (For example, do students have access to their medicine before
exercise? Can they choose modified or alternative activities when medically
necessary?)
If the answer to any question is “no,” students in your school may be facing obstacles to asthma control.
Uncontrolled asthma can hinder a student’s attendance, participation, and progress in school. School staff, health
professionals, and parents can work together to remove obstacles and promote students’ health and education.

Contact the organizations listed on the following pages for information about asthma and helpful ideas for
making school policies and practices more asthma-friendly. Federal and State laws are in place to help children
with asthma.

Asthma can be controlled; expect nothing less.

 Resources Available to Schools
To Help Manage Asthma

For more information contact:

The National Asthma Education

and Prevention Program
NHLBI Health Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
www.nhlbi.nih.gov
(301) 592-8573
TTY (240) 629-3255

The following organizations can provide additional

materials and additional information about asthma:

Allergy and Asthma Network/

Mothers of Asthmatics, Inc.
2751 Prosperity Avenue
Suite 150
Fairfax, VA 22031
www.aanma.org
(800) 878-4403

American Academy of Allergy,

Asthma, and Immunology (AAAAI)
Patient/Public Resource Center
611 East Wells Street
Milwaukee, WI 53202
www.aaaai.org
(800) 822-2762

American Academy of Pediatrics

141 Northwest Point Boulevard
Elk Grove, IL 60007
www.aap.org
(847) 434-4000

American College of Allergy, Asthma,

and Immunology
Resource Center
85 West Algonquin Road
Suite 550
Arlington Heights, IL 60005
allergy.mcg.edu
(800) 842-7777

35
 American Lung Association
National Office
1740 Broadway
New York, NY 10019
www.lungusa.org
(212) 315-8700
(or call your local Lung Association office)

Asthma and Allergy Foundation of America

National Headquarters
1233 20th Street, NW
Suite 402
Washington, DC 20036
www.aafa.org
(800) 727-8462

Centers for Disease Control and Prevention

4770 Buford Highway, NE MSK-12
Atlanta, GA 30341
www.cdc.gov/asthma
www.cdc.gov/HealthyYouth/asthma
(800) 311-3435

National Association of School Nurses

P.O. Box 1300
Scarborough, ME 04070-1300
www.nasn.org
(877) 627-6476
(877) NASN4SN

U.S. Environmental Protection Agency (EPA)

Information Clearinghouse
Headquarters
1200 Pennsylvania Avenue, NW
Washington, DC 20460
www.epa.gov
(800) 438-4318

36 MANAGING ASTHMA: A GUIDE FOR SCHOOLS

Discrimination Prohibited: Under provisions of applicable
public laws enacted by Congress since 1964, no person
in the United States shall, on the grounds of race, color,
national origin, handicap, or age, be excluded from
participation in, be denied the benefits of, or be subject
to discrimination under any program or activity (or, on
the basis of sex, with respect to any education program
or activity) receiving Federal financial assistance. In
addition, Executive Order 11141 prohibits discrimination
on the basis of age by contractors and subcontractors
in the performance of Federal contracts, and Executive
Order 11246 states that no federally funded contractor
may discriminate against any employee or applicant
for employment because of race, color, religion, sex, or
national origin. Therefore, the National Heart, Lung, and
Blood Institute must be operated in compliance with these
laws and Executive Orders.


U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Heart, Lung, and Blood Institute

NIH Publication No. 02-2650

Originally Printed 1991
Revised July 2003