Management of Asthma Exacerbations: School Treatment

Suggested Emergency Nursing Protocol for Students with Asthma Who Don't Have a Personal Asthma Action Plan

A student with asthma symptoms should be placed in an area where he/she can be closely observed. Never send a student to the health room alone or leave a student alone. Limit moving a student who is in severe distress. Go to the student instead.

See list of Possible Observations/Symptoms at bottom of the page.

Acronyms Used in the Text

ED:  emergency department
ICU:  intensive care unit
MDI:  metered-dose inhaler
PEF:  peak expiratory flow
SABA:  short-acting beta2-agonist (quick-relief inhaler)

Immediate Assessment:

• Is the exacerbation severe? — Marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness OR
• Is the student at High Risk of a fatal attack? — Risk factors for a fatal attack (see bottom of the page)*.

If YES (exacerbation severe or student at High Risk):

• Take Immediate Actions
  • Treat with inhaled SABA.
  • Call 911 (student to ED)
  • Contact parent/guardian.
• IF NO RESPONSE
  • Consider epinephrine for life-threatening attack only.** (see bottom of the page).

If NO (exacerbation not severe and student not at High Risk):  Continue

If available, measure PEF:  Is PEF <50% of predicted or personal best?

If YES (PEF <50% of predicted or personal best):

• Take Immediate Actions
  • Treat with inhaled SABA.
  • Call 911 (student to ED)
  • Contact parent/guardian.
• IF NO RESPONSE
  • Consider epinephrine for life-threatening attack only.** (see bottom of the page).

If NO (PEF not <50% of predicted or personal best):  Continue

Check and record respirations, pulse, and PEF rate.

Initial Treatment

• Inhaled SABA: Up to two treatments 20 minutes apart of 2-6 puffs by MDI or nebulizer treatments (Note: medication must be authorized by a personal physician order or standing protocol signed by the school physician or public health physician).
• Restrict physical activity. Allow student to rest.
• Administer oxygen (if appropriate and available).
• Contact parent/guardian.
• Assess response after 10 minutes.

Response

• Good Response: (PEF ≥80% and no wheezing or dyspnea.)

  • Reassess after 3-4 hours.
  • Follow school protocol for returning to class.

• Incomplete Response: (PEF 50-79% or persistent wheezing or dyspnea.)

  • Repeat inhaled SABA.
  • Reassess after about 10 minutes.
  • Call parent immediately if response remains incomplete.

• Poor Response>: (PEF <50% or marked wheezing and dyspnea.)

  • Repeat inhaled SABA.
  • Call 911 (Student to ED)
  • Contact parent/guardian.
  • Consider epinephrine for life-threatening attack only.** (see bottom of page)

With parental permission, send a copy of the health room encounter report to the student's physician. Obtain a personal asthma action plan.

Updated August 2011

Reprinted from the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007

Possible Observations/Symptoms (May include one or more of the following):

• Coughing, wheezing, noisy breathing, whistling in the chest.
• Difficulty or discomfort when breathing, tightness in chest, shortness of breath, chest pain, breathing hard and/or fast.
• Nasal flaring (nostril opens wide to get in more air).
• Can only speak in short phrases or not able to speak.
• Blueness around the lips or fingernails.

Risk Factors for Death from Asthma

Asthma history

• Previous severe exacerbation (e.g., intubation or ICU admission for asthma).
• Two or more hospitalizations for asthma in the past year.
• Three or more ED visits for asthma in the past year.
• Hospitalization or ED visit for asthma in the past month.
• Using >2 canisters of SABA per month.
• Difficulty perceiving asthma symptoms or severity of exacerbations.
• Other risk factors:  lack of a written asthma action plan, sensitivity to Alternaria.

Social history

• Low socioeconomic status or inner-city residence.
• Illicit drug use.
• Major psychosocial problems.

Comorbidities

• Cardiovascular disease.
• Other chronic lung disease.
• Chronic psychiatric disease.

ED: emergency department
ICU: intensive care unit
SABA: short-acting beta2-agonist

Updated August 2011