Asthma affects 8.6% of children in the U.S. Children in high-burden areas, including inner-city and rural areas, are disproportionately affected due to barriers to care and environmental factors. Asthma exacerbations account for over 14 million missed school days per year, impacting school work and daily living. Healthcare expenses incurred by families can be staggering, and long-term effects are far-reaching, putting children's lives at risk.
Currently, all 50 states have laws permitting students to self-carry and self-administer asthma medication in schools. However, as few as 14% of children have access to a personal inhaler while at school. This could be due to various factors, including having undiagnosed asthma, having an asthma diagnosis but forgetting medication at home, or lack of cooperation from parents to allow children with asthma to self-carry medication. Thus, it is imperative for schools to stock and provide medication for any child experiencing respiratory distress.
Despite continued advocacy from national organizations such as the American Lung Association and the Asthma and Allergy Foundation of America, only 17 states have enacted laws or guidelines allowing schools to stock quick-relief medication. Furthermore, many school staff across the country are hesitant to administer medication to children. The issue falls into two primary buckets: (1) difficulty to understand the feasibility of establishing a school stock albuterol program and (2) lack of adequate training for school staff.
Feasibility of Stock Albuterol in Schools
Ensuring access to albuterol sulfate in schools is critical for managing emergencies and directly aligns with evidence-based asthma care. To dispel concerns regarding the feasibility of providing asthma medication in schools, we can look to states and schools with established programs and learn from their implementation strategies and their leaders.
Arizona is one of the first states to have successfully established a school stock albuterol program. In 2012, a pilot program was conducted in Pima County. Two years after implementation, the number of asthma-related 9-1-1 calls and EMS transports decreased by 20% and 40%, respectively. While not statistically significant, the study authors noted this was not unexpected, given the small sample size and rare event occurrence.
More recently, during the 2017-2018 school year, a county-wide stock inhaler program was launched in 229 schools across Pima County. There were 1,038 recorded cases where albuterol was administered. Of these cases, 84% resulted in the student returning to class instead of being sent home or transported to the emergency room via EMS. Both nurses and school staff reported being able to confidently manage respiratory conditions due to thorough training. As of 2023, the program has expanded to schools in eight additional counties.
Expanding Education and Training
Some licensed nurses and school staff remain hesitant to administer albuterol to students in respiratory distress with undiagnosed asthma. This, in part, stems from concerns among some staff regarding differentiating between asthma versus anaphylaxis, both of which can present with respiratory distress. While there are overlapping symptoms, anaphylaxis and asthma are separate conditions with clear distinctions, mandating different treatments.
A study from Kevin Murphy, MD, et al, discusses the implementation of a program in schools in Omaha, Nebraska, to distinguish between emergency responses for asthma and anaphylaxis. Specific emergency protocols were established, and school staff were trained and tested on steps for administering an EpiPen versus albuterol, depending on a student's symptoms.
Over a period of 5 years, 99 students were treated. Of these, five students (5%) were treated with epinephrine alone, and 89 students (90%) were treated with albuterol alone. The greater number of cases of suspected asthma attacks compared with suspected allergic reactions highlights the need for incorporating albuterol training into school health policies.
More recently, Maricopa county -- the largest county in Arizona -- implemented both stock albuterol and stock epinephrine programs in order to account for the separate treatment needs for asthma and anaphylaxis, respectively.
When considering state-specific legislation, it is important to advocate for unlicensed personnel such as school staff to be trained to administer stock albuterol inhalers. While school nurses play an instrumental role, some U.S. schools lack the funding to hire a licensed nurse full-time. Therefore, in the event that a school nurse is not available, having a trained, unlicensed staff member administer albuterol to a child with an asthma attack can be life-saving.
Albuterol has a broad therapeutic index and high safety profile. Consequently, complications are rare, and trained school staff should be able to confidently administer medication without fear of harming a child with a suspected, but unconfirmed, asthma diagnosis. States with stock albuterol statutes also protect trained individuals administering albuterol in good faith, in alignment with best practices for asthma management.
Future Directions
A significant barrier to implementing stock inhaler programs is sustainable funding. More advocacy nationally, statewide, and at the level of school boards is undoubtedly needed to push for financial support. In Illinois, statewide funding has been made available to implement pilot programs as a result of advocacy led by physicians, licensed school nurses, and the state's educational board. Additionally, a coalition of academic, state, and community-based programs in Arizona has come together to support albuterol implementation in schools. Establishing a robust committee with academic experts, health officials, and data infrastructure is key for progress, both in terms of program implementation and funding.
As more states take steps toward stock albuterol legislation, we must standardize protocols to ensure consistency with medication dosing. In addition, continuing education should be expanded to community paramedics and EMS teams, in order to facilitate quick communication during emergencies.
Children spend most of their time in school, and protecting the health of the child during the school day is of utmost importance. For children with diagnosed or suspected asthma, developing a comprehensive, school-based approach to albuterol access can save lives.
Pranati Movva is a medical student at Michigan State University College of Osteopathic Medicine.