Managing Asthma in Our Schools
23
August

By Adem Lewis / in , , /


During the school year, students spend
most of their wakeful hours at school. For many students with chronic health
conditions, including asthma, schools play an important role in the overall
management of their condition. In recognition of the important role
schools play in managing asthma, Ryan’s Law came into
legislation in May 2015. Ryan’s Law requires all Ontario school
boards to have in place policies and procedures to help support and
protect students with asthma. Specifically, Ryan’s Law
requires schools to: Annually identify which students in
their schools have asthma, preferably every year during school registration; Communicate to school employees and
others in regular contact with the student that the student has asthma
and what the recommendations are for supporting the student, which are
detailed in the student’s individual plan; Allow students to carry asthma
reliever inhalers. For students under 16 years of age,
parental/guardian permission is necessary. Reduce and/or manage student
exposure to asthma triggers; Work with parents to understand needs
of students with asthma; Develop an individual plan for every
student with asthma that includes emergency contacts and management
steps necessary to support the student with asthma at school as recommended
by their health care provider. Maintain a file with up to date
information for each student with asthma that contains the individual
plan and other notes from health care providers; Provide regular training to school
staff/personnel and those in close contact with students with asthma
about asthma, how to identify worsening asthma and how to respond to
worsening asthma attacks. The supportive role required by Ryan’s
Law is two fold; the first is to support students in managing their
asthma and the second is ensuring that school personnel have the knowledge
and confidence to support students with asthma, including how to
recognize and respond to worsening asthma or asthma attacks. An important element of Ryan’s Law
that you should know is that in the case of an emergency or a school
employee suspects that the student is having an asthma flare-up or attack,
the school employee is permitted to administer or supervise the student
using the asthma reliever inhaler, even if there is no pre-authorization
from a parent and that the employee is released for damages. At school, students learn lifelong
skills and it is where students with asthma, in particular, start to take
responsibility for the management of their condition. The legislation permits each student
to carry his/her asthma reliever inhaler with
parent/guardian permission. For students 16 years of age and
older, parent/guardian permission is not required. Students with asthma, regardless of
age, require the support of principals, teachers, support staff
and volunteers in order to assume increasing responsibility for
managing their asthma. Creating an asthma friendly school
with supportive, knowledgeable staff is vital in allowing students to feel
confident to take control of their asthma. This video will give you the
information you need for this supportive role by: Providing you with a basic
understanding of asthma. Alerting you to the symptoms of
worsening asthma or an asthma episode. Preparing you to help students
manage worsening asthma. And providing you with asthma
resources that will help support your role. Although this video was created to
respond to the needs identified in elementary schools and the scenarios
reflect this, the content is generic and can be applied to a
secondary school setting. Asthma is a chronic condition that affects
the airways, the breathing tubes of the lungs. As many as 1 in 5 Ontario students are
affected by asthma making it the most chronic common
disease in children. Because asthma symptoms come and go,
it is often dismissed as not very serious by students with asthma, their parents
or guardians or school staff. In fact, asthma is the leading cause of
school absenteeism and emergency department visits Although rare, asthma can be
life threatening. Every year, over 200 people in
Canada die from their asthma. Students who have both asthma and
anaphylaxis are at much greater risk of dying from their conditions. Asthma and anaphylaxis episodes can be
preventable with proper management, a good asthma action plan
and education. As a principal at the school, I support my
students with asthma by doing a few things. As per Ryan’s Law, we have a process in
place to identify students with asthma. During registration, parents, guardians and
students are asked to provide information about their health and specifically
about asthma. Additionally, by law I am required to develop an
individual plan for each student with asthma that outlines recommendations for managing asthma
at school including whether or not the student may self carry their asthma inhaler. These management recommendations are
made by their healthcare provider. We have a process in place for sharing the
individual student asthma management plan so they are aware of the steps necessary for
supporting the student. We also provide regular training to all school
staff about asthma to support students with asthma and how to recognize and respond to
an asthma emergency. Signs and Symptoms
Students with asthma have sensitive airways in their lungs. When they are exposed to certain
triggers, such as colds or flu viruses, physical activity, allergens
or irritants, the airways can narrow making it hard to breathe. Three main changes cause the
airways to narrow: Inside the airway, the lining
becomes red and swollen; extra mucus production causes the
blockage of the airways; and Outside the airways, the muscles
tighten around and squeeze the airways. There are 4 common
symptoms for asthma: Coughing; chest tightness; difficulty breathing; and wheezing, which is a whistling
sound inside the chest. Students with asthma may experience
one or more of these symptoms. Coughing may be the first symptom
recognized in schools because it can be very disruptive to a class. A common response to coughing is to
send the student for a drink of water. This is not helpful in relieving the
symptoms, and may in fact delay the student from getting their
reliever inhaler. Using their reliever inhaler is the
fastest and most effective step in relieving asthma symptoms. When I have trouble breathing, I tell my teacher,
take my inhaler and I feel better. I know when my asthma is getting worse
because I start to cough and I have trouble breathing. It feels like someone’s sitting
on my chest. It feels like someone’s choking me
and I can’t breathe. Asthma Triggers
Students with asthma have airways that are more sensitive to things in the
environment that typically don’t cause problems for students without asthma. These are called “triggers” because
they trigger asthma symptoms by narrowing the airway. Every student’s asthma is different. Not all students will have the same
triggers, nor will they react to every trigger discussed in this video. Triggers can also change over time
for the individual. The most common asthma triggers are
colds or viruses, physical activity and cold air. We will talk more about physical
activity as a trigger later in the video. Most triggers can be divided into 2
groups: allergens and irritants. Allergens trigger the immune system
and cause inflammation and airway narrowing. Allergic triggers are things like tree
and grass pollen, animal dander, dust mites, house dust, mould,
and some foods. Irritants are things like smoke, cold
air, strong smells and air pollution. Some triggers are more commonly found
in and around schools. These include marker and crayon
scents, scents, smells and fragrances, musty and dusty gym mats, carpets and
drapes, or exhaust fumes from idling cars and school buses. Triggers are unique to every student. Helping students to avoid or limit
exposure to their triggers is one way to prevent asthma symptoms
from developing. As a classroom teacher, it’s really important to
be aware of the triggers in the environment that affect our students with asthma. Wherever possible we should try to eliminate those
triggers and if that’s not possible, we try to remove our students from the areas where those
greatest triggers are most evident. Sometimes, simply going outside for recess can be
a problem for our students with asthma. Things in the environment such as poor air
quality, high levels of pollen and the cold air can affect our students. It’s really important that these students know
where their inhalers are and they have access to them at all times. It’s also very important for our support staff and
those on duty to be aware of the students who have asthma, so they can be readily available
to support them if needed. Asthma Medications There are 2 main types of asthma
medications: controllers and relievers. Controller medications work slowly and
can take days to several weeks to work and thus are not used to provide
quick relief from symptoms. Controllers are typically used at home
on a daily basis, often in the morning and evening. Controller medications rarely need
to be kept at school. Reliever inhaler medications, which
are usually blue in colour provide quick relief of asthma symptoms by
opening up the airways. Relievers work within 5-10 minutes to
make breathing easier. It is very important for students to
have easy access to their reliever inhaler throughout the school day,
including when off-site on school outings. You play a critical role in supporting
students to access their asthma medication. Most students 7 years of age and older
are capable of learning how and when to use their reliever medication. It is very important that school staff
support students in getting and using their reliever medication when needed. It takes only minutes for the airways
to narrow enough to cause severe breathing difficulties. Some students may be unable to use
their reliever inhaler on their own and may require assistance from you. Demonstration and usage Reliever inhalers come in two
different types of inhalation devices: metered dose inhalers (MDI)
and dry powder inhalers (DPI). MDIs, also referred to as puffers,
deliver the medication in the form of an aerosol spray. It sprays a cloud of medication when
pressed, which is subsequently inhaled. Students using an MDI should also use
a spacer with it, which is a holding chamber that makes the MDI easier to
use and increases the amount of medicine reaching the lungs. MDIs are the most common
inhaler seen in schools. The steps involved when using an MDI
with a spacer include: Remove the covers of the
inhaler and the spacer; Shake the inhaler well; Insert the inhaler mouthpiece into
the back of the spacer; Breathe out through the mouth
to empty the lungs; Place the mouthpiece of the
spacer in the mouth; Press down on the inhaler to release
a dose of medication; Breathe in slowly and
deeply a full breath; Hold breath for a count of
10 if possible; Breathe out normally. Dry powder inhalers are different from
MDIs in that they do not deliver the medication through an aerosol spray
but rather from a powder that must be forcefully inhaled. They are easier to use and cannot be
used with a spacer. The most common DPIs seen at school
are Turbuhalers and Diskus. The main differences in technique
between the two types of devices are 1) MDIs must be shaken to mix the
medication with the aerosol propellant. DPIs are not to be shaken. 2) MDIs are to be used with a spacer
or holding chamber. DPIs are not to be used with a spacer. 3) MDIs require a slow inspiration.
DPIs require a forceful inhalation. It is important to have written
instructions from the parent or guardian regarding what medications
are needed and when at school. This information is part of each
student’s individual asthma plan in addition to identifying triggers
and emergency contact. It is the obligation of the
parent/guardian and the student to ensure the information is up to date. Asthma relievers are life saving
medications, similar to the epinephrine autoinjector for anaphylaxis, and should therefore be treated similarly. Ideally, students with asthma should
carry their medication with them for easiest access. Every principal must permit a student
to carry his/her asthma medication with parent/guardian permission, if
under 16 years of age. If a student is 16 years of age or
older, he/she is not required to have parent/guardian permission to
self-carry their reliever inhaler. School staff play an important role in
helping students with asthma manage their condition at school. Schools are critical partners in
implementing Ryan’s Law and successfully managing asthma. You are often the first person to
notice an increase in asthma symptoms indicating a loss of asthma control. Additionally, you are often the first
to respond when breathing difficulties occur. If properly managed at home and fully
supported at school, asthma should not interfere with a student’s attendance,
performance or participation in school activities. Exercise-Induced Asthma Regular physical activity is an
important part of a healthy life. It is important for all students to
participate in physical activity—even those with asthma. When asthma is well-managed, it should
not limit a student’s ability to participate in physical activity. Proper asthma control can be achieved. Physical activity at school may
include Daily Physical Activity (DPA), phys-ed class, recess, intramurals or
interschool athletics. When preparing my students for gym classes or a DPA
activity, I make sure these students have their inhalers with them and if needed
they take it beforehand. It’s also important to provide a proper warm-up
before we start any physical activity. Sometimes it’s key that you know what you’re
looking for during a worsening asthma attack. That could be anything from wheezing, shortness of
breath or continuous coughing. And it’s important to recognize asthma and know
the procedures that you have to initiate if an asthma attack should occur while your
students are with you. It’s also really, really important that you
develop a relationship with your students at the beginning of the year, so they can feel
comfortable coming to you and discussing their needs with you or for you to recognize their needs
if they have to sit out during a strenuous physical activity. Exercise-induced asthma may occur
during physical activity or following cessation of physical activity. It is more common when activities are
performed in cold, or hot or humid weather, when air quality is poor, or
when the student has a cold or flu. A student should not be discouraged
from participating in an activity if their asthma is under control. Steps can be taken to
enable participation. All students need to be physically
active, including those with asthma. However, physical activity should not
be forced if the student knows that some distress is likely to occur or
the student is already experiencing symptoms. There are several strategies you can
use so that most students with exercise-induced asthma are able to
participate in physical activity to the best of their abilities. These include: Providing a gradual warm
up and cool down; Ensuring easy access to their reliever
medication throughout the activity; Some students may need to use their
asthma reliever inhaler 10-15 minutes prior to physical activity. Use of the reliever inhaler can
prevent the onset of symptoms such as coughing, wheezing, chest tightness
and difficulty breathing. A student who is currently
experiencing asthma symptoms should not begin the physical activity. The student should take their reliever
inhaler, and then sit and rest until breathing returns to
normal and is easy. If symptoms develop during physical
activity, the student should: Stop the activity; Take the reliever inhaler; and
Sit and rest. Symptoms should improve within 5-10
minutes of taking their reliever inhaler. Well, I ususally tell my teacher, take my inhaler
and rest a little while and see what happens. Once symptoms have resolved, the
student can then resume the activity. If you have concerns about a student
with asthma who is continuing to have difficulties participating in physical
activity, it is important to communicate this occurrence with the
parent or guardian of the student and to the student, if age appropriate. This is often a sign that asthma is
not properly controlled and medical follow up is needed for changes to
management strategies. Signs of Worsening Asthma There are certain indications that a
student is experiencing worsening asthma symptoms that may progress
to an asthma attack. They may experience one or more of
these symptoms and signs: Continual coughing; Chest tightness; Fast, shallow breathing; Wheezing; and
Increased reliever medication use. Any of these symptoms may be
accompanied by restlessness, irritability and fatigue. When symptoms occur, students should
be encouraged to use their reliever inhaler and take slow, deep breaths. Usually symptoms will disappear within
5-10 minutes of using their reliever inhaler and the student can return
to regular activities. It is important to notify the parent
or guardian that an episode occurred so they can monitor the asthma at home
and follow up with a health care provider if necessary. Some asthma episodes are more
severe than others. A student is having a severe asthma
episode if there is incomplete relief or no improvement in a student’s
breathing within 5-10 minutes of taking their reliever inhaler. Physiological signs of a severe
episode you can observe include: Lips or nailbeds become blue or grey; Breathing is very difficult and fast; The student can only say 3-5
words between breaths; When breathing in the skin between the
ribs is pulled in and neck muscles tighten/bulge with each breath; and The student appears very
anxious or agitated. These signs indicate that this is an
emergency and that you should: Give the reliever inhaler Call 911. Inform the attendant that
the call is for asthma and that an inhaler has been given but is
not providing relief. Do not make the student lie down.
Rather, have the student sit up with their arms resting on a table
or on their legs. Have someone remain with the
student at all times. Encourage the student to slow down
their breathing by taking slower and deeper breaths. Notify the parent/guardian or
emergency contact If the student continues to experience
trouble breathing, continue to give their reliever inhaler every few
minutes until help arrives. It is important to wait for Emergency
Medical personnel – do not drive to the hospital. Remain calm and stay with the student. For more information on the wide
variety of support materials available to educators regarding asthma
management and prevention in schools visit: www.ophea.net and asthmafriendly.ca Additional web-based and print
resources to support the management of asthma are available from: The Ontario Lung Association and The Asthma Society of Canada www.asthma.ca To speak to a Certified Respiratory
Educator, please contact The Lung Association’s Lung Health Information
Line at 1-888-344-LUNG.


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