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Management of Asthma at School: Treatment

 

Medications

Medications used for asthma at school will usually be inhaled either as a mist from a pressurized aerosol inhaler (puffer) or as a powder from one of several devices. Sometimes tablets, oral liquid medicines, or inhalation of a mist from a nebulizer may be used. Medication needs and forms may vary throughout the year.

Self-management of asthma should be encouraged, especially for older students who will normally retain their own medications at school. Parents must be aware of the importance of the student always having medication available at school, even if the asthma appears to be mild at home. Younger students will need some assistance with medications, including reminding them of the times for regular use. Students may need help to overcome embarrassment about taking medications at school.

Relievers

bronchodilator drugs which relax the muscle in the bronchial wall and often give prompt relief from chest discomfort. These are effective for treating an attack of asthma, as they are fast acting.

salbutamol / Ventolin®

Ventodisk®

ipratropium bromide / Atrovent®

fenoterol hydrobromide / Berotec 100µg®

orciprenaline / Alupent®

procaterol / ProAir®

terbutaline sulfate / Bricanyl®

They are not taken regularly, but are used only when an attack occurs. They are sometimes also taken before exercise to prevent exercise induced asthma.

Parents should be notified of any change in frequency of use.

Preventers

these medicines prevent asthma and treat the inflammation in the airways, the major underlying cause of asthma. These inhalers are used regularly (e.g. twice or four times daily) whether or not the students has current symptoms of asthma. The two types of drugs in this group are:

Non-Steroid

cromoglycate / Intal®

nedocromil / Tilade®

ketotifen fumarate / Zaditen®

Corticosteroids

beclomethasone / Beclovent®

Beclodisk®

Becloforte®

Vanceril®

budesonide / Pulmicort®

flunisolide / Bronalide®

triamcinolone / Azmacort®

Omission of these drugs may not have an immediate adverse effect but if they are often forgotten the asthma may become increasingly severe as control is lost.

Treatment of Exercise Induced Asthma

Exercise induced asthma can often be prevented or at least markedly reduced, by the inhalation of either a bronchodilator or cromoglycate. To be effective in prevention, the inhaler must be used before exercise begins (see manufacturers’s or physician recommendation, about 10-30 minutes beforehand).

If exercise induced asthma occurs, then the treatment for this is a bronchodilator (reliever) inhaler, as well as stopping the activity until full recovery. The cromoglycate inhalers do not work after asthma has begun. Corticosteroids do not have any immediate effect on exercise induced asthma, but when used long term to control asthma, will also reduce exercise induced asthma.

Management of Asthma at School: Treatment

Proper Use of Inhalers

Inhaled medication is very effective in both preventing and treating asthma, provided the inhaler is used correctly and as prescribed.

Many students now use dry powder inhalers which are breath-activated and are easier to use than pressurized aerosols. Examples of dry powder systems include turbuhalers, diskhalers (for which the powder is in “blisters” in a foil disk), and the rotahalers and spinhalers (for which the powder is in a capsule). Each dry powder system has clear instructions provided with the device on loading and use.

The most commonly used device is the metered dose inhaler or pressurized aerosol commonly referred to as a puffer. To be effective the correct technique must be used. All teachers should know the correct technique for the use of an aerosol inhaler, both for checking use by students, and in case treatment is ever needed for severe asthma at school.

The steps for proper use of a pressurized aerosol inhaler are:

1. Remove the cap and shake the inhaler well.

2. Breathe out with a sigh.

3. Tilt the head back and close mouth around the inhaler mouthpiece or hold the inhaler 1-2 inches in front of open mouth (for most drugs either way is acceptable).

4. Breathe in slowly and deeply through the mouth and press the canister down once as soon as you begin to breathe in. Breathe in over 3-4 seconds.

5. Hold the deep breath for 10 seconds if possible.

6. Breathe out gently through the nose.

Inhaler with a spacer device

Students may use a spacer device or holding chamber (AeroChamber) with their puffers, as more medication gets into the lungs than with the puffer alone.

1. Remove caps from puffer and spacer device.

2. Shake puffer well.

3. Place puffer into back of spacer device and hold upright as shown.

4. Breathe out and place spacer mouthpiece into mouth, or place spacer mask over

mouth and nose.

5. Push down on the canister (puffer) once.

6. Breathe in slowly and deeply over 3-5 seconds, then hold breath for 10 seconds.

In both methods, if a second puff is to be taken, wait I minute, then repeat steps 2-6.

What to do if an Asthma Attack Occurs at School

Be prepared

Always have the student’s information sheet readily available. Discuss management in advance with the student, the parents and the school nurse, and know the name and telephone number of the student’s doctor.

Every school should have a bronchodilator (reliever) inhaler in their first aid kit. All teachers should know how they are used. It is a good idea for each student with asthma to supply an extra inhaler, in a named envelope, to the principal or teacher, and for these to be kept together, in a safe but accessible place at school.

Severe Attacks

The attack is severe if:

1. the bronchodilator does not help after two treatments,

2. the student has difficulty in:

speaking or

moving or

is blue, pale or sweating, or

is struggling for breath, or

requests a doctor, or ambulance, or to go to hospital.

At this stage, the student may NOT be wheezing as there is not enough air moving in the lungs to generate a wheeze. Under these circumstances MEDICAL HELP IS URGENT. Delays can result in fatality.

Call the most appropriate emergency medical service in your area e.g. ambulance, doctor etc. If the ambulance or doctor is not available, get the student to the nearest hospital. Get someone else to telephone ahead to alert the service. Notify the parent.

Mild Attacks

If the attack settles quickly with rest and treatment, further medical action is probably not required. However, it would be inadvisable for the student to undertake further vigorous exercise that day. The student’s own judgement on exercise capacity should be considered. Some students, however, will overestimate their capacity for continued exercise, and do not like to be seen to be different, when attempting to keep up with their peers. Use caution.

When an attack occurs

1. Remove the student from any obvious trigger factor e.g. stop exercise, or come in from the cold.
2. Do not leave the student alone. Stay calm. Reassure quietly.
3. Sit the student comfortably leaning forward, supporting arms on a table or something of suitable height. Do not insist that the student lie down.
4. Give available bronchodilator medication. The usual dose is two puffs one to two minutes apart for a pressurized inhaler or one or two capsules or diskhaler blisters. This can be repeated after 10 minutes if symptoms persist. If the attack is not relieved after two treatments, seek medical attention immediately.
5. If the student is unable to use an inhaler effectively, and there is no AeroChamber available, use a large paper or plastic cup, held over the mouth with the inhaler inserted through a hole punched into the bottom, and fire four-six puffs into the cup. While the student breathes several times as deeply as possible. (It is a good idea to keep some cups on hand, readily available.)

 

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