ASTHMA MANAGEMENT AND NEW JERSEY SCHOOL POLICY
Marilyn Kent, MSN, RN
New Jersey State Department of Education

(click here for Dr. Torre's replies)

1. Please explain the funding for school nebulizers both public and non public.

The department of education will reimburse any public or non public school for the cost of nebulizers. The forms have been developed and mailed to school districts on December 3, 2001. Final date for reimbursement is March 15, 2002.

2. When will the regulations for nebulizer use in schools be forthcoming to Boards of Education?

It has been sent out. Chapter 61 or statute NJSA18A:40-12.8 addresses use of nebulizers in schools.

3. If nebulizers are required in schools, how and when will monies be available for this purchase?

(See answer 1- Final date for reimbursement is March 15, 2002).

4. We are aware of the need for the use of compressor/nebulizer in the nurse’s office. Why isn’t the use of the peak flow meter also considered a necessary tool in working with asthmatic children?

It is considered a necessary tool if the “medical home” of the student writes an order for it.

5. When is it indicated for use of nebulizer in school? Should this be considered as part of the whole plan or is this reserved for emergency situations only and if a child requires use of a nebulizer does this indicate lack of control and need for medical evaluation?

The “medical home” will write an order as to what medication should be administered via nebulizer and when the nebulizer is viewed as an emergency treatment in the school setting.

6. Utilizing the Asthma Self Medication law- It was previously stated that a child from 3-5 years of age if properly taught could use an inhaler. Later in the conference it was said that all elementary school children should be supervised by a nurse. If the nurse is not immediately on the premises and the asthma self-administration form is appropriately completed, is there an age concern?

Age and maturity of the student must always be considered. This is the beauty of an Asthma Action Plan and the resulting IHP- all are individual.

7. You state the child may carry the inhaler and use it when he/she wants. What about the child who misuses the inhaler? How do the nurses provide the supervision of younger students?

Any misuse leads to – “use only under the nurses direct supervision” the law states that. The young child needs Doctor’s, parents and nurses’ permission to use. If any party has a legitimate concern, then it must be addressed and written into IHP – which can be changed, amended or modified as behavior warrants.

8. What recourse do you have if MD feels Asthma Action Plan is not necessary for school?

If there is an asthma episode, you need to call 911 because you have no written orders. Alert parents of this scenario, and let them handle it with the “medical home”.

9. Who is responsible for those in after school care in your district if they have an inhaler for use as necessary?

An individual health care plan must be written on each child with asthma detailing the use of inhalers in after school care- if it is a school sponsored activity. Only nurse, physician or parent can administer medication.

10. Can a school develop their own Action Plan?

The Asthma Action Plan developed by the Pediatric Asthma Coalition of New Jersey and the New Jersey Department of Education is the only “approved” plan for use in the State of New Jersey for children with asthma.

11. Need to tell Doctor who orders inhalers to order spacers. Approximately 50 with inhalers and no spacers in nurse’s office. How do we reach them besides calling each one? Please help!!

Schools need to have direction from the “medical home” before they can treat a child with asthma. The physician is the only one to make a decision on treatment.

12. Can we receive colored Asthma Action Plan sheets from one of these agencies listed?

Currently you may download the Asthma Action Plan on the PACNJ website- www.pacnj.org. After April 1, 2002 or when funding is approved, colored copies can be ordered by school nurses through PACNJ for free, with the agreement that school nurses will maintain a tally of the number of children with asthma in their school with Asthma Action Plans.

13. Where can we receive spacers for children whose families cannot afford them?

Check with drug companies to see if they will donate.

14. Will each child supply their own tubing for the nebulizer and will there be a standardized protocol for sanitization?

Each district must write their own policies regarding who will supply tubing. Every child must have their own tubing, regardless of who pays for it.

15. Any suggestions re:

a. Students whose parents lack dollars to fill/renew prescriptions for school: (pharmaceutical company, etc.)

Parents are always responsible, schools can never provide medication.

b. For Doctor’s that ignore a school nurse’s request for an Asthma Action Plan:

If the child’s “medical home” ignores requests, the school nurse should send a letter to parents stating, “911 will be called if child exhibits asthma symptoms”.

c. Dollars available for school nebulizer:

Schools will be reimbursed by Department of Education for the cost of one nebulizer per school. Reimbursement ends March 15, 2002.

Any further questions can be sent to Marilyn Kent at marilyn.kent@doe.state.nj.us
or call 609-292-5935.

STEPWISE APPROACH TO ASTHMA MANAGEMENT
Arthur Torre, MD
Pediatric Allergist UMDNJ-New Jersey Medical School

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1. What do you recommend for asthmatic children who use the ER as their primary care for treatment of their asthma and the inconsistencies of treatment depending on the particular physician on duty in the ER?

They need to find a primary care doctor that is knowledgeable in asthma and/or an asthma specialist. No one should be using the emergency room as a primary care doctor.

2. How do we treat adequately those students with profound disability, since peak flows etc. are not possible?

Use symptoms: both severity and frequency, as outlined in the work sheet.

3. I’ve noticed that physicians are including more detailed orders when an Asthma Action Plan is asked to be submitted to the school nurse than when he/she just writes an initial order for prescriptions in school. What do you attribute these detailed instructions to? Ethical practice on part of the physicians; presentation by the parents for Asthma Care Plan to be completed; connection to the school nurse as first responder in an asthma episode or “other”?

Physicians are often hard pressed for time and trying to comply with the NHLBI guidelines is frequently considered time consuming. Sometimes a little push from the school nurse to fill out an asthma action plan may be just what’s needed.

4. Please address appropriate referrals to Pulmonologist VS. Allergist for children/teens/adults. This is a very frequent question. How does treatment differ?

The basic treatment should be the same, as per NHLBI guidelines. Allergists treat asthma in addition to hay fever, eczema, hives, food allergy and immune disorders. Pulmonologists treat lung disorders including asthma as well as COPD, emphysema, chronic bronchitis and cystic fibrosis. So depending on the presence or absence of other symptoms or related illnesses one may choose one specialist over another.

5. Systemic Corticosteriods: Up to how many before need to be concerned?

Up to four times a year may be considered relatively safe.

6. What if using nebulizer machine nightly 2-4 ampules? Alternatives?

MDI’s with spacer or dry powdered inhalers. To make nebulizer treatment faster consider using a Pari LC + nebulizer.

7. How many times use peak flow for evaluation?

Three times, then take the best of the three results.

8. What are Leukotriene Modifiers etc. mode of action?

Leukotriene Modifiers work on one specific asthma mediator which causes both bronchospasm inflammations.

9. No children in schools have peak flows, how do we get this out to Pediatric Doctor?

Just ask. Perhaps discuss this personally with the physician.

10. I also work at a summer camp. Some campers’ asthma are triggered by allergens in the cabin or the camp itself. Should an antihistamine i.e. Claritin, be started or just use the inhaler?

Antihistamines may be helpful if the asthma is triggered by allergies. But the use of inhaled steroids should be sufficient for most patients if used on a regular basis.

11. Is the dose in the Albuteral used in the nebulizer the same equivalence as one or two puffs of a metered dose inhaler?

No. 180 micrograms are in two puffs of the meter dose inhaler, where as 2.5 milligrams are typically used in a nebulizer.

12. Are children more prone to develop asthma if they have atopic dermatitis?

Yes.

13. Could long-acting (Serevent) be used in mild persistent asthma?

If the patient is not controlled on inhaled steroids alone, a long-acting bronchodilator would be appropriate.