This webinar was recorded on August 23, 2023

Asthma attacks can (and do) happen at school. Are you prepared to help? This webinar will teach you what to do.


Dave Stukus, MD, FACAAI
Professor of Clinical Pediatrics in the Division of Allergy and Immunology.
Associate Program Director, Pediatric Allergy/Immunology Fellowship Training Program Director, Food Allergy Treatment Center
Nationwide Children’s Hospital
Columbus, OH

CE is not available for this webinar.

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

>> Hi, everybody. I’m going to start in just a minute. There’s folks filling in the room right now. And once we get maybe another few seconds, we’ll go ahead and get started. Thank you for joining us today. OK, I’ll go ahead and get started. Hello, everyone. Thank you for joining us here today. I’m Lynda Mitchell, C.E.O. for allergy and asthma network. Welcome to this afternoon’s webinar. We’re in for a real treat today with Dr. Dave Stukus as the presenter. We have a few housekeeping items before we get started on today’s program. First, all participants will be on mute today for the webinar. We will be and are recording the webinar right now. And so we will post the link to the recording on our website. You can find all of our webinars on our website at, scroll to the bottom of our home page and you’ll find all of our webinars and the recordings along with any upcoming webinars. This webinar will be one hour in length and that includes times for Q&A. We will take those questions at the end and hope to get to all of them. Any time in today’s session you can enter the questions in the question box and we’ll monitor them and save them for the Q&A session at the end. We do not offer continuing education credits for today’s webinar. We do offer a certificate of attendance. And so you can ask for one of those for your records. A few days after the webinar, you’ll receive an email with a list of supplemental materials and a link to the download with the certificate of attendance. You will also try — you can also try to — we’ll also try to enter the link to the certificate in the chat box, but sometimes it works and sometimes it doesn’t. So, let’s get started. What can we do if a student as an asthma attack? That’s what we’ll talk about today. First starting with asthma basics. Today it’s my real pleasure to introduce our speaker, Dr. Dave Stukus. Dr. Dave is a professor of clinical pediatrics in the division of allergy and immunology at nationwide children’s hospital in Columbus, Ohio. He’s also the associate program director of the pediatric allergy and immunology fellowship training program at nationwide and he’s the director of the food allergy treatment center at nationwide. I have to tell you, before taking over as director of the food allergy treatment certainty, Dr. Dave was a director or co-director, I can’t remember quite which, of the severe asthma clinic at nationwide. He can clarify that for you when he gets started. Dr. Dave is also the social media editor for the American academy of allergy, asthma and immunology and is the podcast moderator. He may — you may be familiar with Dr. Dave from twitter and instagram as allergy kid stock where he’s active in his personal mission to address misinformation with evidence-based information and with a dose of humor too. So, Dr. Dave, you and I haven’t done a webinar in a long time, but I really am excited for you to be here today and thank you for joining us today.

Dr. Dave: Thank you very much, Lynda. And thank you all for joining today on this afternoon. Lynda and I have known each other for 15 years, but it has been a while since we’ve had the chance to work together. So thanks for the kind invitation. Do you want to go anything with the mission of the asthma and allergy network before I get going?

Lynda: sure. The mission is to end the needless death and suffering due to allergy, asthma and other related conditions through outreach, education, advocacy and research. We advance our mission through the lens of health equity and our key health ex which the program is our trusted program where we do outreach events into local Communities and then we invite people to enroll in our free virtual asthma coaching program. I thought i’d mention that since this is about asthma mod.

Dr. Dave: Excellent, all right. Well, here are my goals for today. I really want to help demystify asthma. Especially in the school setting. There’s a lot of sort of outdated thoughts in regards to asthma, lots of misconceptions that we’ll address. And my goal really is to make this more comfortable for all of you in recognizing and treating asthma. Ultimately that improves the lives of students and children and helps their families and basically makes your life less stressle. So I’ll go — stressful. So I’m going to do my best to make this as easy as possible because it is relatively straightforward when you look at it. But there’s a lot of nuance as well. Why are we here? Why are we talking about asthma? Well, we know that it is pretty much the most common chronic health condition affecting children of all ages across the world. In certain segments, 10 to 15% of children have asthma. So in the average classroom, you’re going to have a student at least, one to three students with asthma, if not more, depending upon where you’re located and where you live. And it’s not just that they have this common chronic health condition, but it is a leading cause of emergency department visits, hospitalizations, missed school days for adults, missed work days. Whether people don’t have well controlled asthma, they don’t feel well, they don’t participate in activities and it can impact so many factors of their health. So it’s a really big deal. And unfortunately it impacts millions and millions of people. We always have to talk about disparities and with asthma, they’re huge. We know that it can affect every race and every age, but it is much more common and not only more common, it’s more severe, there’s probably a different type of factors that influence the severity of asthma in certain minority populations, those who come from lower socioeconomic status backgrounds, and those who live in urban environments as well. So if you have students that come prosecute those backgrounds, we want to pay particular attention to them. Then again, we have to go back and say it impacts everybody. It’s important to recognize that. What is asthma? Let’s go back to the basics. There’s a couple key words. Asthma is chronic. It’s not that really bad cough or pneumonia you had that one time. These are symptoms that come back over and over and over again. At the root of asthma it’s down inside the lower airways, there’s inflammation. So it’s kind of like a sun burn on the inside of the airways. For some people they have significant inflammation which impacts their asthma to a higher degree. For other people, their inflammation isn’t that large but there is some degree of inflammation going on in anybody who has asthma. A big factor are these hyperresponsive or twitchy airways. So when they’re exposed to certain triggers which we’ll talk a lot, the airways will squeeze and tighten very rapidly which is what produces a lot of the symptoms that go along with asthma. That twitchiness is reversible. So we know that when we give people medications that help dilate, those airways can open up again. It’s not necessarily static and that they stay like that, although if we don’t adequately treat asthma and it lasts throughout life, it can lead to longstanding chronic changes and stiffened airways. In regard totz airflow limitation, I love this picture because it’s not just the squeezing of the muscles, so if you look at the lower broncioles or airways, the branches get smaller and smaller inside our lungs. The middle part here is where air is supposed to flow, both in and out. With asthma, you have constriction of those muscles so it can make it smaller and you also get swelling inside as well. Depicted on the right, on your picture there. And then lastly, individuals with asthma tend to have more mucus and it’s a different type of mucus. It’s more of a sticky tar-like substance. So if you imagine somebody with a narrowed airway because of squeezing of the muscles, with swelling on the inside, so you get squeezing on the outside, swelling on the inside, then you fill that with mucus, it’s going to make it really hard to breathe. Asthma is diagnosed clinically.

There is no special test that diagnoses asthma. We have tests that show us what lung fuption looks like but we have to put that in the context of the clinical history. When we diagnose asthma it’s based upon what symptoms are occurring. So you have to have symptoms in order to diagnose asthma. It’s often underdiagnosed or people use terms like reactive airway disease or they call them these other things but we have to call it what it is so we can properly manage it. It is going to change over time. This is something I counsel families all the time on. Your asthma is going to be different in the autumn and winter, as we’ll talk about, and it often gets better as people get older so our management should change all the time as well. We have so many different treatment options available and we’ll talk about some of those because your students may have different types of inhales that are you’re not used to seeing or different — inhalers that you’re not used to seeing. This is very individualized when it comes to asthma. It is not one size fits all. There are many types of asthma. So you can have intermittent asthma, meaning you have symptoms infrequently. Or you can have chronic asthma, when you have more frequent symptoms, more severe symptoms that impact you on a more regular basis. There’s different degrees of severity. You could have mild, severe, moderate asthma. This is based upon frequency of symptoms, level of therapy that’s required to get things under control, as well as lung function testing. And symptoms can be highly variable. So it’s important to kind of keep in mind that every student’s different and then each student can also change over time. So whatever that student — however you treated them last year, they may have a completely different treatment plan this year in regards to their asthma. That may change throughout the school year as well. And it can develop at any age. We often see it in toddlers who go on to develop more persistent asthma it but it can present later in childhood or adulthood for first time as well. I get asked a lot about what causes x, y and z, and just like most health conditions, there is no single cause. It’s the same with asthma. There are multiple factors that contribute to which individual develops asthma, including risk factors. We know there’s a strong genetic predisposition. So when you have parents with a history of asthma or other electric conditions, it’s more likely that their children are going to develop asthma. Obesity increases risk for developing asthma as well. Exposure to the environment. So early life exposures especially, viral infections, exposure to small particulates and pollution. We know people who live within three or four football fields of a major highway have increased risk of experiencing wheezing and asthma over time. So just exposure to that pollution on a regular basis can influence the development of asthma. Same with those who have allergies, exposure to passive tobacco smoke. There’s lots of work looking at the microbiome. We know infants treated with frequent courses of antibiotics are more likely to develop asthma, not that antibiotics cause asthma. We don’t know what’s going on there. But these are associations that have been identified. Then there’s different types of immune cells involved in that inflammation THAT I mentioned before. For some people these are called — thinking through the immuning to and pathology can help me find the best treatment fit for that individual. All right. So symptoms are really important to recognize the. Cough. Cough is the most frequent symptom associated with asthma. Especially at night, particularly if it wakes children from sleep. So I always ask those questions. If they’re sleeping through the night and not waking due to cough, that’s a relatively good sign that their asthma is under good control. But it certainly can impact them ducker the day as well — impact them during the day as well. If you’re coughing so hard that you throw up, including just mucus, that’s a pretty good sign that that’s asthma. So that’s severe bronci, ole constriction going on.

You can’t always hear wheezing, especially if you’re not listening with a stethoscope so I don’t counsel families to wait for the wheezing. You can have very severe asthma and not hear a wheez. It’s usually coming from the nose and upper airway, but it can be present as well. People often say they are out of breath or short of breath or they feel like somebody’s squeezing their chest. I feel like a fish out of water, I’m breathing through a straw, that sort of thing. This can lead to increased respiratory distress and if you have a student who is really struggling to breathe and you see them sucking into the point where the muscles above their stern umor in their ribs are really retracting very hard, that’s a late sign that their asthma is very severe and they need to be treated immediately. And when we’re trying to figure out if somebody has asthma or somebody with asthma, if their symptoms are due to asthma, I ask a simple question. Use your albuterol, does that make you feel better? One of the more common ones we see in older children, adolescents, is voCal cord dysfunction. This can be very similar to asthma, often occurs in the same individual with asthma, and it’s very acute. They say, I feel like I’m dying. And this occurs very suddenly and the voCal cords when they’re supposed to open when you inhale, they actually squeeze and tighten, you feel like you’re dying. That may cause audible wheezing you can hear. We need to tease some of these things out. You’re never going to fail, if you think it’s asthma symptoms, use albuterol and see if it makes them feel better. You’re going to be so sick of me saying this but I think it’s important to really understand all of your students with asthma and children, they’re all different. They’re all different in regards to the severity, the frequency of symptoms, the response to therapy, the triggers that are occurring, it’s going to change throughout the year and I want you to get comfortable with really having that fluid approach to management and changing things that may be more intense in the fall and winter as opposed to in the spring or summer. When it comes to asthma management, it really depends on how severe their asthma is or how chronic their asthma is. So we have intermittent asthma that I mentioned before. When somebody has infrequent symptoms, we really focus just on recognizing those symptoms when they occur, trying to avoid those triggers and using as-needed therapy. Whereas if somebody has persistent symptoms, they often would benefit from having daily scheduled medications to treat the inflammation inside the lungs. The most common are inhaled steroids. We want to address their conditions. If they have environmental allergies and they have all this is not running do — snot running down their throat because of nasal con veston, we want — congestion, we want to address that. If you have asthma and you go home, and inside your home you’re exposed to multiple chronic triggers such as pollution, pet dander, tobacco smoke, whatever it may be, we need to reduce that exposure to those triggers otherwise we may never be able to get your asthma under control, despite our best efforts and use of high potency medications. But that’s not all. We want to make sure that anybody with asthma, especially parents of children and then children as they get older, we need to educate them and to help understand, here’s what’s going on, here’s why these medications are important, really focus on self-management skills. I see them in the office, when I was running our complex asthma clinic, I would say the most severe asthmatics every two months. I’m seeing them six times a year for 30 minutes at a time but the rest of the time they have to be out in the world recognizing and living with their asthma. It’s up to me to help them develop those skills so they can self-manage their own disease. Because they’re the ones who have to live with it and know how to treat it when they’re at home or school or wherever they are. We want to make sure they have proper teaching in regards to proper inhaler technique and using spacers and it’s not just there.

It’s not, OK, you have bad asthma, have a nice life. It’s, I want to come back and see you, long-term follow-up at every visit, we’re going to provide anticipateory guidance about the upcoming seasons that are going on, review your controller to this point and really provide written treatment plans that they can share with all of you at school and talk about dynamic treatment options. So it really is a very comprehensive approach to helping people manage and understand their asthma. It’s much more involved than giving them an inhaler and saying, use this whenever you get short of breath. This is a great graphic from the guidelines. There’s the global asthma initiative guidelines, then we have our U.S. guidelines. I’ll show you a screen shot of both of them toward the end here. I like this little circle because it sets the stage for, OK, let’s assess your asthma. How are we doing? Are your symptoms under control? Are we addressing your combover conditions? What’s your adherence like with your medications? Let’s adjust therapy. Are you doing great? We can step things down. Are you not doing so well? We need to step things up and we need to add things or we need to address the environment, things like that. Then we need to review things at every visit. This really is the cycle that never ends in regards to asthma management. And I hope that we get to a good place where most folks get used to this and it’s more tune-ups along the way. Sometimes it’s major adjustments at the beginning of initial diagnosis or after a hospitalization, but whenever I see folks in follow-up, it’s usually more minor tweaks over time. So what are our goals of therapy? We want to make people feel better. We’re never going to be able to completely eliminate symptoms because if that’s the case, then you don’t have asthma. Although I will state that there is a recent working group report that’s going to come out talking about remission of asthma. Because there are some people that just — their asthma gets better as they get older. That’s going to be a little bit controversial but for most people, if you have asthma, you’re going to have symptoms at some point. But our goal is to reduce the frequency and reduce the severity of those symptoms. Well-controlled asthma means using albutero willing two — albuterol two times a week or less. We want to properly manage it and keep people out of the emergency room and from needing oral steroids. We want people to run around and be active and play sports. Please don’t tell any child with asthma that they can’t play sports or be active because of their asthma. Exercise with one of the best things they can do for their lungs. If they can’t exercise because of their asthma, we need to find a way that they can do that. That’s our goal. I think there’s 30% of Olympians have asthma or something like that. That’s what we should be striving for. Then we really want to also minimize any side effects of treatment as well. So we need to monitor that long-term. All right. When we talk about sending students or children with asthma to school, I like to think about the different roles and responsibilities. And there’s different categories. So what are the responsibilities of the family? They really need to inform the school that their child has asthma. You need to be aware of which students have asthma. So that’s up to them to make sure that they inform you. They need to make sure they send all of their medications at the start of the school year with up to date prescriptions. August is my busiest month of the year because of all the school forms and treatment plans and refills. I love it. It gets to be a bit. But we have processes in place to help all of our families make sure they get what they need. The written treatment plan really should be updated every year because asthma can change. And then if your child or if that student isn’t feeling well, the school should be informed. So if they’re starting to use their it albuterol more, if they’re fighting a cold, but they’re well enough to go to school, please let the school nurse know or their teacher know, OK, we have everything under control. They may need to use their albuterol during the day or you may request they use it during the day on a scheduled basis to help maintain — let them stay in school. What are the responsibilities of the school? You need to be able to listen to that family. Obviously. And acknowledge that — which students have asthma. How you keep track of that is up to you. Monitor students for increased symptoms. Treat them when they need to be treated in the school setting. And then if they’re not doing well in school, please let the family know and say, you know, so and so was complaining of chest tightness today or they were coughing. We gave them albuterol so they can continue their treatment at home. We know that when we rely on our children to communicate with us about how their school day went, they’re not always very forthcoming with that sort of information. And really what’s the responsibility of the student? It depends on the age but they need to let somebody know, let an adult know if you’re not feeling well because we can do something about it. So let’s talk about triggers for a moment. Triggers can occur both on a chronic basis or acute basis and you can have a child with asthma who is either well controlled or not well controlled and they’re exposed to one of these triggers and it can increase their symptoms by increasing the brong yol symptoms. The school set something loaded with potential triggers. He not every child with asthma has the exact same triggers and it’s not a blanket approach of if you have asthma, all of these are going to be trigger symptoms so we need to figure out who has what triggers. Exercise is not a trigger for everybody with asthma but those that do have that, we want to know that and come up with a plan to help them use their albuterol 15 minutes prior to gym or recess or any planned physical activity. Viral infections are a common trigger. They get sick with a cold and within 24 to 48 hours, they develop a more severe, persistent cough and/or wheez and symptoms progress from there. Whether can be a trigger. Here in the midwest, it’s going to be 97 degrees tomorrow. So heat and humidity can be a major trigger. As can extreme cold and the reason why cold air is a trigger is because cold air lacks humidity and it’s very dry. And that can cause irritation and bronchial spasms. I’m sure you’ve been exposed to extremes of cold and it can burn when you try to breathe. For people with asthma, that can trigger their symptoms. But changes in weather can do it as well. Cold fronts moving through or thunderstorms, or severe weather, that can be a trigger for asthma. We all have to be aware now of air quality, especially with the Canadian wildfires and other wildfires, depending on where you live. That introduces small particulates into the air. Ozone action days occur on very hot, humid days with very little wind. That can be a trigger for asthma as well. And then for those who also have allergies, they can exposed to cockroaches inside the school or mouse infestations. Other students who have pets, especially cats and dogs, the dander from their pets, they carry on their clothes to the school, and if you’re sitting next to somebody who has a cat or dog, that dander can actually trigger asthma symptoms.

They found pet dander in movie theaters, on public transportation, on the international space station, despite not having animals there. So it is everywhere in our environment. Food allergies can provoke asthma symptoms, for those who have asthma, but typically those are going to be more things like hivings and swelling and vomiting. Despite your best intentions to keep everything clean, the cleaning supplies themselves may actually trigger asthma symptoms. So any aerosol that has a scent to it, even if it’s a cleaning product, that can get inside the small airways and trigger bronchial spasms. If you can smell these smells from the detergents or cleaning products that you’re using, that can be a trigger and we may want to protect that student with asthma from going into that area until the smell is gone. Same thing if you’re fumigating. Want to make sure you let everybody aware. Then emotions can trigger asthma as well. I have many patients that tell me if they get tickle order laugh too hard, that triggers them to cough and struggle to breathe. Or if they get very upset in a negative way. I have a plea for all of you. You ready? Here’s my plea. Please, essential oils, they are not only not essential, but essential oils can absolutely be a trigger for people with asthma and allergies. Any scented product, whether it’s all natural or it smells good to people, if you get it in the air, it can be really irritating for those with sensitive noses or lungs. I’ve met a lot of families over the years and talked to teachers where they’re using essential oil diffusers in the classroom for good purposes, they have good intentions of trying to provide relaxation to students and make things much more calm, but that can be a trigger for those with asthma. So please keep that in mind if you’re using those in the classroom setting. All right. What about after school? If they’re going to athletic events, or practice for sports, it goes back to exercise, if they’re waiting for thes but stop or they’re going to be — the bus stop or they’re going to be outside and there’s an exchange of weather, and we need to be aware of the outdoor allergens. There’s a consistent pattern, it’s going to change based upon when it starts and how long it lasts by where you live but typically trees will pollinate in the spring, grasses and weeds in the summer, right now is ragweed season, it’s typically mid August until the first frost of the year, then we see mold supports outdoors during — supports outdoors during — spores outdoors during wet weather. So as you see, I spent a few minutes here talking about all of the multiple different triggers and they can vary based upon students and they can impact a lot of students that have asthma for various reasons. We have to talk about the autumn asthma speak. Every single year — spike. Every single year in mid to late September, approximately 22 days after the start of the school year, this has been documented on multiple continents, we see a spike in asthma exacerbations and there’s a combination of factors. 22 days happens to be a pretty good ink baition period for respiratory viruses. After three weeks, that’s when the first respiratory virus begins to circulate through everybody. This is also a time when many locations experience weather changes or, streams of weather and those who have pollen allergies to ragweed or mold allergies, that Spikes in the autumn as well. September, October is always a big spike in asthma exacerbations and it’s important to be aware of that, it’s important that you know which students have asthma and if they’re starting to increase symptoms, pay close attention to them, especially during this time of year. We see a similar spike in the string spring as well acialtion froms remain pri — as well, also from respiratory devices and weather. Medications and treatment. We have two basic types of medications for asthma. Most of these are going to be given through an inhaler. Why? Because we want the medicine to go to the lungs and act right where the symptoms are occurring. There’s relievers. They work very fast, they treat the symptoms and people should always have them available or have access to them. Then we have controllers.

So controllers are more for those with more persistent asthma, more severe asthma. We want to get these on a more scheduled basis. That’s going to address the inflammation inside the lungs. They don’t provide immediate relief. But that’s changed. So now we have smart therapy which I’m going to talk about, there are two specific types of controllers that can be used on-demand, that can also dilate while they treat the inflammation. You’re going to see more and more students that have this as part of their treatment plan and it’s important to be aware of this and increase your comfort with it. Inhalers vary. I love this. This is from the allergy and asthma network. Threa different types of inhalers. We have a medicine that’s a liquid, you express it by pumps, it turns into a mist. You breathe it into the lungs. We have dry powder inhalers where the medicine sits as a powder and you have to activate it by clicking it or something like that and then you have to breathe it in and hold it in your lungs to make sure it settles there. There are breath actuated inhalers where you put it in your mouth and it does nothing until you breathe in really fast. All of these deliver medications very differently. All of these require very different technique. So if you’re not familiar with the technique of an inhaler that your student gives to you, there’s great resources on the allergy and asthma network website or you can ask that student or ask that student’s parents to really walk you through it, to make sure you know how to use it. And these are changing all the time. So when somebody has acute asthma symptoms, what do we want to do? We want to open up the airways. A major part of those acute symptoms is constriction of the airways and we can do that through four different approaches. The most common one that you’re familiar with is a short acting bronchodilator. Albuterol hits receptors inside the lungs that are causing restriction and helps them relax. You see this effect within minutes, generally within 15 minutes. But the effect wears off after three to four hours. So they need to be repeated that. Doesn’t treat the inflammation, though. We want to open them up, the most common form, albuterol. Now we have long actinger bronchodilators. They work very quickly, similar to albuterol, but they last for 12 hours. They can be used acutely. If somebody’s having asthma symptoms. Or they may be also prescribed as a controller therapy. There are medications that work on other receptors called cholinergics receptors. You may have some students that respond better to a member nebulizer. So there’s lots of different receptors inside the lower respiratory tract. You may see variations ever these medications in some of krur students. Like I said at the onset of this webinar, things are changing. Our understanding of asthma continues to grow. Year by year. Treatment options continue to evolve. We need to sort of move part of some outdated thoughts in regards to asthma and stay up to date with current evidence-based practices. OK. I always like to talk about albuterol because there’s a lot of misconceptions surrounding this. Please don’t refer to albuterol as an emergency inhaler. It is a reliever. If you have asthma, you will have symptoms. If you have symptoms, you will need to bronchodilate. You’ll need albuterol. If we edkate parents that this is an — if we educate parents that this is an emergency inhaler, it sends a negative message. One, I should only use this in in the case of an emergency. The sooner you treat, the better is works. The other message it sends is, if I use my albuterol, I have to go to the emergency room. We don’t want to do that. We want self-management skills, we want people to understand, this is your reliever, you’re going to need to use this, I want you to feel free to use this, it’s going make you feel better. If you find that you’re using this on a regular basis, or more frequently, please talk to your doctor because we can adjust your therapy and hopefully reduce that use. So hopefully that will resonate with you. But it is not an emergency inhaler, it is a normal standard expected part of asthma management. So when should we give albuterol? It’s really easy. If you have a student with asthma and they report an increase in storages treat them with albuterol — in symptom, treat them with albuterol. You don’t need to have a peak flow monitor, you don’t need to have a pulse ox reading, you don’t need to have wheezing. If they’re telling you they’re having chest tightness or coughing, give them albuterol. It’s a safe medication to use. You’re not going to hurt them if you give it when it’s not necessary. We’ll talk about that in second. Some of your students may have peak flow monitors, that’s nice, but that’s very effort-dependent so I don’t really care what the number says, if you tell me you don’t feel well, I’m treating you. Same thing with a pulse reading.

We’re not going to see a drop in the pulse reading until it’s too late, until asthma has progressed to the point where it’s actually restricting the airflow and causing more systemic issues. So we don’t need to wait for these things. So how many puffs of albuterol? I put this up here. Look, these are guidelines, the top one, from the United States, from 16 years ago. And then these were updated in the international guidelines. It’s very safe to give. We want to bronchodilate. Four to 10 puffs every 20 minutes for an hour. How many of you gasped when I said that? Why, because it’s very safe. If they’re not breathing well, we want to improve airflow. It’s very safe to do this. This is guideline-based management. All of our patients are advised, at least four to six puffs. Every three to four hours. And we give them that Leeway to really bronchodilate. If they think they’re managing their asthma OK but they wake up in the morning and they’re coughing more than usual, go ahead and use more puffs. Use it 20 minutes later. Let’s see how you feel. It’s very safe to approach it that way. What about inhalers versus nebulizers? There are studies looking at this. Over 2,000 children and adults in over 40 clinical trials having mild or moderate, using the inhaler with proper technique is equivalent to delivering the medication through a nebulizer and you get more side effects with the nebulizer. Here’s the difference. You often need to give at least four puffs through the meter dose inhaler to be equivalent to one dose of the nebulizer. I know everybody’s going to say, the nebulizer seems to work better. Well, yes, it does, but if you try the other approach, it’s faster, it has less side effects and it’s going to actually be equivalent if not better. A lot of the times nebulizers are used incorrectly and you’re just spreading medicine into the environment and not actually into the lungs. Other times, especially for younger children, if they have a lot of nasal congestion, sometimes the humid air can help break that up. We want to empower people. I’ve had families tell me they had to leave a soccer game because they had to drive home to give their child the nebulizer treatment. No, have the inhaler, have the spacer and use it when you need it. Speaking of spacers. So every meter dose inhaler, not dry powder inhaler, a meter dose inhaler, this is liquid inside there, when you compress it, it turns it into a mist but it takes about four inches for that mist to turn into a fine enough particle so you can breathe it into lungs. So what happens is if you just put that meter dose inhaler in your mouth, you can have the best coordinated technique in the world. It’s just not enough space. Most of the medicine stays as a liquid and it sits on the tongue and gets swallowed and it goes to the stomach, not the lungs. There’s great studies where they put radio labels on this and you see where the medicine goes. So a spacer attachment, there’s all kinds of different ones you can use, just adds that distance to allow the medicine to turn into a mist, then you can take a slow, deep inhalation. It’s already a mist by the time it hits your lip, goes inside the lungs where it needs to go and it’s much more more effective — it’s much more effective that way. It doesn’t matter your age or technique. The best argument I’ve ever thought of in regards to why we need to use a spacer, there’s a condition causes inflammation in the esolve Gus. You take an asthma inhaler and you have them do that without a spacer. Why? Because they’re going to swallow it and it’s going to treat the esophagus. If that’s not the best argument, I don’t know what is. Albuterol is very safe.

There are so many misconceptions about it could be dangerous. There are common side effects. So it also hits receptors in the nervous system and in the heart which can increase the heart rate slightly. Not to a dangerous degree. And it can cause some jitteriness. So people can feel the side effects and some are more sensitive than others but it doesn’t change the blood pressure or things like that that’s going to be worrisome. AAll of the series as verse effects are — series adverse effects, we don’t want to withhold treatment of albuterol due to unnecessary concerns about side effects that aren’t really going to occur. Why do we want to Rita? Because you’re going to — retreat? — why do we want to treat? It’s going to make them feel better. It can be more dose affect. So I showed you the recommendations from the world guidelines about how many puffs to give, please consider this and don’t withhold giving albuterol because you think it’s going to cause major side effects. Some of the things I’ve heard over the years about what people have been told in school to treat their acute asthma, take a drink of water. That’s not going to make you feel better. Going outside. Well, that actually might make you feel worse, depending upon what’s going on with the weather or your pollen allergies. Just one puff of albuterol, that’s not going to do anything. If you’re going to do it, give at least two, don’t hesitate to give up to four to sifntle yes, I know you may be stuck based upon what the written treatment plan states or what’s prescribed but that’s why aim also working with Pediatricians and other asthma specialists to help get them to write down the right thing so you can give it in a school setting. Lying down, that’s not going to make you feel better or foe cushioning on your breathing — focussen your breathing. I’ve had people had essential oils rubbed on their skin, that’s a terrible idea. Other people have said, what about having them drink coffee or get caffeine? Yeah, caffeine is a brong delighter. Do you — brong delighter — brong delighter — bronchodilator. The amount of caffeine you’d need to drink to improve asthma symptoms, it’s not worth it. It’s not an effective treatment for asthma. There’s also some evidence that shows that cannabis can actually serve as a bronchodilator but again, we don’t want to be using that, especially in the school setting. Smarter therapy. Single maintenance and reliever therapy. One inhaler, it’s your controller and your reliever, or it can just be your reliever. I’ve talked about this already but let’s get into the weeds a little bit. You can use this, you can increase the use when you’re sick. There’s two medications, we always try to refrain from brand names but I think it’s important you use these for this case because this is the only two you can use. Why are these the only two? Because the long acting albuterol they have is called formotero will there’s a couple of other — formoterol. It acts like albuterol. It works very, very quickly. But it lasts for up to 12 hours. That’s why these are the specific ones that we can use for this type of therapy. And these are now guideline-based. So for anybody who is interested, I encourage you, please go check out the global asthma guidelines. The last time the U.S. guidelines were updated was in 2020 so now it’s three years of having smart therapy being recommended and this is what it looks like. I’m not going to read the whole slide for you but there’s recommendations for younger children as well as older children. Both to use those combination inhalers either as a controller and then increase use when you start to have symptoms or just use it as your reliever. So there are some of your students that may not actually be sent to school with albuterol, they may be sent to school with others and that’s the reliever medication that you want to administer to them according to their treatment plan.

So things are changing in a very good way and this works great. And you’re going to say, what about overuse? What happens is, if you have somebody with asthma, the typical story is, I feel fine most of the time, I’m exposed to my trigger four, five, six times throughout the year, if you start puffing away on one of these combination inhalers and you only use it for seven-days every other month, that’s great you’re reducing your overall use of medication throughout the year, you’re reducing the use of unnecessary medication and it’s going work really well to prevent exacerbation. So just want you to be aware of that. Some of your students are hopefully already on this type of therapy because it works really well. I’m sure you’re all familiar with asthma action plans. This is written communication from a family and the student’s doctor to you telling you this is what their asthma is like, their triggers, their severity. In the green zone, all systems go. This is what they do on regular basis regardless of how they feel. Probably won’t have to do anything inside the school setting. The red zone, they need to be treated immediately. At the onset of a severe exacerbation and you should be think being notifying the parents and calling E.M.S. The yellow zone is where we want to focus our effort and this is really individualized. So some people may be told to start their medication sooner, some people may be told to give six puffs of albuterol, some people may be told to use that smart therapy I just talked about but it’s important that every student has this action plan that’s up to date because that’s what you really go to when they present to you and they say, I’m having a hard time breathing today. So we really want to recognize when they’re losing control and do something about it as soon as possible. In the green zone, all systems clear. Red disowners too late, seek care — red zone, too late, seek care. It’s a fine balance at times and for some of your student, they’re going to require treatment more frequently than others. But it’s important to be aware of their management plan. What if I give albuterol and it’s not necessary? Well, a false start may actually lead to treatment when they don’t need it. But the risk of a late start means that their symptoms are going to progress and they may end up in the emergency room. It’s much better to be early. You’re not going to hurt them by giving albuterol if they don’t actually need it. You may actually contribute to their worsening asthma exacerbation if you don’t treat them when they actually needed it. So it’s much, much better to use it if you’re not sure, use it early rather than wait. A lot of schools are opting to use stock albuterol. This is legislation that was passed in 17 states and then there’s guidelines in two others. And what this allows for is this allows for schools to actually obtain a prescription or an order from any physician, to obtain inhalers for the school. You can put this in your school. This also involves training of school personnel, this also involves having sort of the documentation of when to treat and how to treat and things like that. And what the legislation allows for is you can treat any student in your school. When they have asthma or don’t have asthma, you’re not sure if they have asthma, with this medication that you’ve now procured. This is similar to the stock epinephrine which is in almost every state. This is great because albuterol is very safe. Albuterol, if you have a student that doesn’t have their own inhaler, I know you all have students in Your school that have asthma that don’t have their medication on site.

You can obtain it and treat them with this. And there’s a lot of nuance that goes into this. There’s a lot of great information on the allergy and asthma network, as well as other places but I encourage you, if you live in one of these states, look into this. Get albuterol. I’ll put a plug in, lynda mentioned I’m the host of a podcast of the American academy of allergy, asthma and immunology. We had two recent episodes just on stock epinephrine and stock albuterol this summer. You can search for it. We had two experts that really walked through what this entails. Lots of details there. I encourage you to look into this. What does this mean for families that live in these states? Don’t trust this, this is going to be — very inkeftent into — inconsistent into which states allow it and have it. We want to encourage families to send medication to school, but this is a wonderful backup plan. What about self-carry? As of almost 10 years, every state allows for students to self-carry their own inhalers. So by law they’re allowed to carry their own inhalers but it’s important for you to also know which of those students actually have their inhaler ON them and are allowed to treat themselves. There’s no easy answer for this. There’s no age cutoff. Sometimes there are 9-year-olds that are able to recognize their symptoms and use proper technique. I have many patients that are 16 and they’re unable to do this. There are a lot of adults unable to do this. There’s no magic age. For me, I talk to the families about this when they express interest. I need that child to really demonstrate, here’s when I would use my inhaler, here’s what my body feels like and they need to show me they have the right technique and they know what they’re doing. So the benefit would be immediate access. It’s really self-management to the nth degree and you can treat quickly. The cons are, they may use their inhaler and not let the school know or let their parents know. Obviously they can lose their inhaler and not have it when it’s necessary for treatment. Or they may be abusing it, inappropriate use. That’s usually not the case. But every state allows for self-carry and it’s up to you to work with families and figure out what works best for your school and your school building and school district. So as we wrap up here, we know that there are students in your school and in your classroom that have asthma. Symptoms are variable. They can occur suddenly or be chronic. Really communication, it’s all about communication and preparation. And I truly hope that I offered some new concepts and there’s a bit of a paradigm shift in some of this to increase your comfort level with some new approaches to asthma. And hopefully we can keep everybody safe this school year. And with that, I think we have time for questions. Is that correct?

Lynda: We have about 15 minutes. Thanks for your presentation. Really appreciate it. A long time ago I was the mom with the kid with asthma and allergies so I relied on school nurses knowing how to manage that asthma and it was just so important. So really appreciate you coming here to share your information today. I want to just do some Q&A and then we’ll talk about the upcoming webinars that we’ll be having later in September. But first, I’m going to go through the questions that came in and I hope I can read them. Let’s see. Here’s an easy one for you. Can cannabis be an asthma trigger for children?

Dr. Dave: Oh, yes, thank you. Any form of smoke. So whether it’s from a pipe, from cannabis, marijuana, vaiping. So vaiping is not safe. Anything that releases aerosols into the air absolutely can be a trigger. Forgive me for not mentioning that specifically but thanks for asking.

Lynda: Yeah. And how — can anxiety be a trigger for asthma? It doesn’t cause inflammation, but can it be a triger?

Dr. Dave: Yes, it gets a little tricky. Absolutely as with other emotional stressors, that can be a trigger for asthma. But then this is on my end to try to separate out of, like, OK, what’s actually anxiety? Symptoms due to anxiety and not asthma? Because they can often feel similar and those are some of the most satisfying families that I help. Those are also some of the most challenging ones. So we have different techniques and ways to do that. Let me just say that there’s a reason why we have psychologists on our staff. They’re very helpful, especially when we get into this overlap.

Lynda: So from a school nurse perspective, when is it time to call 911 for a child with asthma or a child with rapid airway disease?

Dr. Dave: So it’s really easy. If you treat them according to their treatment plan and their symptoms do not improve. Because you’re kind of stuck, right? It’s not your job to be the Emergency room and manage their asthma. But I want you to hopefully allow a reasonable period of time for their symptoms to improve. I mentioned it can take 10 to 15 mintz to see some benefit. So if it’s more to mild to moderate symptoms and you give them albuterol and allow them to relax in the office and they start to slowly improve, that’s a great sign. If they come in we is veer symptoms — with severe symptoms, you’re going to begin treatment right away and inform 911.

Lynda: Thank you very much. I saw a couple questions come up about how to obtain that inhaler chart. That’s free on our website. Just go to our online store and you can just register or whatever it takes and you get a free digital download for that inhaler chart. And it’s going to be updated again in a couple of months because there’s another new inhaler coming on the market, a combination inhaler.

Dr. Dave: How many versions do you think we’ve seen since you started that? Maybe a dozen?

Lynda: It’s always hot off the press. That’s all I can tell you. We can’t keep up. Yeah. So you talked about diffusers for essential oils. What about those bottles of oil that have reeds in them? Is that also not recommended? Or how do you approach those two?

Dr. Dave: If you can smell it, it can be potentially a trigger. It’s really that scent. That tells you it’s been aerosolized. And those are all potential triggers. I’m not saying it’s going to trigger but those are some of the hidden ones. And people use them because they have good intent. They think they may be beneficial but I just want people to be aware, they may be harmful for that student with asthma.

Lynda: What to do while waiting for a parent to bring an inhaler to school when the child is symptomatic?

Dr. Dave: One, if you have stock albuterol, that’s ideal. If you don’t, you can always try to help them focus on slowing their breathing and just relaxing as much as they can. Otherwise your hands are kind of tied. But that’s also a learning opportunity. So if that ever occurs, I mean, not in the moment necessarily, but that child absolutely needs to have their own inhaler at school. So take advantage of that opportunity to say, listen, thank you for bringing it, we need to have this, talk to your doctor, we need to have your own inhaler here so we can treat them and not wait for you to come in.

Lynda: Another thing I just want to recommend or mention and we’ll include this in the follow-up email, is the American lung association just released a new course on stock albuterol implementation. Because a lot of difficulty in getting it actually implemented in school districts. So I want to share that. I got a notification about it today. Let’s see if I can find another question to ask you. CAN YOU describe or explain the difference between asthma and reactive airway disease?

Dr. Dave: Yes. Reactive airway disease is a mispronunciation of the word asthma. It’s a made-up term. To be totally honest with you. There’s great review articles on this and, yeah, but we don’t want to use that term because it’s confusing. And I know a lot of folks are afraid to use the big bad a word. But when you finally diagnose asthma, we can do something about it. When you’re having these symptoms, we can treat it. Whereas with reactive airway disease, a lot of times that send the message, they’re just reacting again and nothing I can do. No, that’s not it at all. So, yeah, believe me. I do a lot of education for the primary care Pediatricians as well. I make it a point to say that reactive airway disease is not an actual diagnosis.

Lynda: Thank you for that. Should a nurse give an inhaler based on symptoms alone like tightness in the chest or should the nurse assess the student first like listen to breath sounds and things like that?

Dr. Dave: I think it’s always important to listen for breath sounds but this can be variable and this can be very tricky. The absence of wheezing can sometimes be a really bad sign because the airflow is so obstructed that you’re not going to even hear that wheezing. So as I mentioned before, if somebody’s complaining of symptoms, treat them. You’re not going to hurt them. You don’t want to withhold treatment because of whatever reason. But, yeah, I think an assessment is an important part of that. In the two minutes it takes you to do a good lung examine, that’s fine as well. But that’s not going to change anything in my mind. Although I would say, it’s preimposed. Listening to the lungs before they get their albuterol or right afterwards and then waiting 15 minutes and listening again, if you hear a dramatic improvement, that’s a very good sign that the medication’s helping them.

Lynda: I know you mentioned this in your presentation but since we got a question I’ll ask it again. CAN YOU talk about the peak flow meter and how it’s gone out of favor now? And not used as much.

Dr. Dave: Yeah. It’s very effort-dependent. So people can blow the number, whatever number they want to blow, and it can change over time and there’s a lot of technique involved with it. So it’s one piece of the puzzle. I certainly would not depend entirely on that. Either saying, oh, my gosh, your number is terrible. But they look completely fine to you. Or, you know, because sometimes you can manipulate that for certain reasons as well. For positive reinforcement, getting out of class. Or if the number looks good, but they’re complaining of symptoms, we wouldn’t want to withhold treatment. It’s certainly not the end all, be all. But at our institution, boy, we haven’t used them for over 10, 15 years.

Lynda: Wow. That’s incredible. OK. Thank you for that. So, does it matter if a little kid who might be out of shape is winded after exercise in terms of whether or not you give albuterol?

Dr. Dave: All right, so this is — I love that question. It’s tricky, right? So anybody, including the most conditioned folks in the world, are going to reach a point during physical exertion where they get breathless. That’s a normal part of exertion. Especially if somebody is deconditioned or if they have obesity and things like that. That’s different than asthma. That is sort of shortness of breath, you have to catch your breath. That should improve after a couple of minutes of rest. So that’s one clue. Asthma often will not occur immediately when you start to exercise. It can take a period of time before you’re exercising to trigger the bronchial constriction and that’s not going to get better with rest alone. That’s another indicator as well.

Lynda: A saw a question come in. CAN YOU talk a little bit about management of — [indiscernible] — asthma in school?

Dr. Dave: It’s really the same. It’s just their predominant symptom is cough. I would argue that that’s the prominent symptom more most children with asthma. It’s an interesting term. We know there’s all these different sort of subtypes of asthma based upon the immunology that’s going on inside the lungs or the symptoms that are there or even response to therapy. There’s a lot of folks that just — they don’t get better without albuterol so we have to treat them w. There’s no easy way to figure that out other than with trial and error. Coughing is a nuance of a different type of asthma.

Lynda: Great. I see a question coming in about smart therapy. We have a really good article on our website about smart therapy and the easiest way to find it, we can put it in the follow-up email, is just Google smart therapy asthma and we’re the first listing after the ads that come up and you can get to the article that way. So just wanted to tell you that. And then I’m going to read a little bit of a long thing about — when treating a student in the yellow zone and it says two puffs every four hours, if a student gets relief from those two puffs and comes later in the day, do you go ahead and treat or do you think they’re in the red zone and take other kind of action? That something you can answer easily?

Dr. Dave: I would say, definitely treat. I would not withhold treatment. There’s a certain level of common sense here and I know that there are restrictions based upon what’s prescribed and stuff like that. But we also want to help that student in front us and nothing bad’s going to happen by doing that. That’s also — that to me is an indication that they have an ineffective yellow zone treatment plan and as I mentioned, you know, four to six puffs may have prevented that, them coming back again. But that’s also what asthma does. The medication wears off after a couple of hours. So they’re going to need to be retreated again.

Lynda: OK. And then somebody else asked about asthma action plan. We have a whole page on our website about a whole bunch of different asthma action plans, including ones in multiple languages a and an action plan for smart therapy. We have that in the follow-up email you’ll get in a few days. So I wanted to let you know, just look for that email. So I don’t know if we have any other questions. Let me see here. A lot came in after you started answering them.

Dr. Dave: I hope everybody gets the sense, I really am thankful for being here and enjoy this. I love, love, love working with school personnel, school flurrieses. I learn so much from — nurses. I learn so much from all of you and I want to do everything I possibly can to make your lives easier as well. I’ve also learned that your hands are tied when it comes to a lot of this which is unfortunate. Anything we can do to support each other, that’s all we can do.

Lynda: Thank you. CAN YOU talk about the difference between albuterol and others? I know sometimes it’s prescribed and should there be stock for kids?

Dr. Dave: Xopenex is like the mirror image of it and it still works on receptors but it allegedly has less side effects, so less jitierness, but it has a significantly higher cost. From a stock standpoint, don’t waste your money. From a reality standpoint, boy, this was all the rage like 10 years ago. And then it just fell out of favor because it doesn’t really have that much of a difference in regards to reducing side effects. I suppose if you have somebody with a true cardiac be a normals and we definitely — be a normality and we definitely want to make sure there’s zero impact on that. As a general rule, it’s not worth the cost.

Lynda: Somebody asked is it necessary for a doctor to indicate that a child is allowed to self-carry their inhaleer? My guess is some of it might vary by state law. But if you have an answer to that.

Dr. Dave: We all have the forms and oh, boy, if any of you can create a universal medication administration form for schools across the United States, please do so. And implement that. Because they’re all different. So there is a provision, parents can check it off. Or physicians can check it off. But if it’s on that form, yeah, I guess you don’t know who checked it off.

Lynda: OK. So somebody said — do not have rescue medication — [indiscernible] — way to control breathing?

Dr. Dave: Yeah. The idea is just slow, deep inha lagses, — inhalations, ex hallucinatations to calm things down. If you have nothing else, do that, it’s just not going to be extremely effective, unfortunately.

Lynda: OK. It’s 4:58. I’ll see if I have one more quick question for you and then we’ll go. Somebody asked if this is recording. Yes, I heard it say the recording has started so we will have this recorded. It will be on our home page probably in a couple of days. And then we’ll send a link to you in the follow-up email as well. Let’s see. Is there a youngest age you can be diagnosed with asthma?

Dr. Dave: No. But you need to be old enough to exhibit a pattern of recurrentes respiratory symptoms. So it’s going to be at least 6 to 12 months before you’re going to have that time period to demonstrate that you have persistent cough or a wheeze when you get sick with colds and stuff like that. So it’s more of a time issue. But there’s no lower age limit.

Lynda: OK. I think that’s going to have to be where we cut off here. But Dr. Dave, I thank you so much. This has been fantastic. We should see all the comments in the chat. Some said, this is the best asthma webinar ever. So just super terrific. Thank you so much. And I look forward to working with you again. It’s been a lot of fun today. And I hope you have a great rest of the day.

Dr. Dave: Thank you very much and thank you all very much for taking time out of your lives to join us. I hope this was helpful.

Lynda: Thank you. Bye.

Dr. Dave: Bye.