Inhaler use prior to P.E.

I'd just like to start of by staying I am completely unfamiliar with the world of school nursing, however I have been a severe asthmatic/athlete my entire life. I'm not sure what age of school age child you a dealing with but I frequently ran into issues with my school nurse as well (starting in elementary) . Issues such as not being able to use my inhaler when I thought needed etc. If you're administering the prescribed dose I wouldn't be too anal about it. Just because you don't see any coughing or ascultate any wheezes doesn't necessarily mean they are asymptomatic and not feeling short of breath. Maybe get the order changed to "prn for sob/wheezing" to cover yourself.

Thank you for your advice. I didn't want to deny her to use of her inhaler prior to pe. My thought process in giving 2 puffs vs 4 was that when the student (around 8 or 9 y/o) initially presented she wasn't short of breath, wheezing, or coughing...I knew her asthma could potentially be exacerbated during pe so I opted for 2 puffs. Since the dosing was 2-4 every 4-6 hours prn coughing/wheezing I felt like giving her 4 puffs initially wouldn't allow me to give additional puffs should she return after pe requesting it. When I looked up Davis drug guide as well as the medication insert the recommended dosing was 2 puffs prior to exercise. I've learned with most medications not to start off with the max dose unless there is a clinical indication to do so. Paradoxical bronchospasm is noted as a potential adverse affect with the excessive use of inhalers. Am I completely off here? School nurses, do you typically give 4 puffs to students prior to exercise?

The order probably should be rewritten with an Action Plan. Many RTs, Asthma Educator RNs and Asthma educators will instruct patients to take their Albuterol or Levalbuterol inhalers 15 minutes prior to exercise. This is pretty standard per the EPR 3 Asthma guidelines and should be listed on an Asthma Action Plan. Actually, the Asthma Action Plan should accompany any script to be used as a guideline. This is extremely important. The plan should fit the child and the activity and not some tired old only q6 prn and only if wheezing order. This just limits the child and enforces poor coping/management techniques.

The number of puffs will be determined by the child's severity (see the EPR) and response from an Exercise Test which may have been done in a PFT Lab. Again the old 2 puff orders do not fit everyone. It is not uncommon for kids to be discharged on 4 puffs of albuterol and tapered as their maintenance medications are regulated. In the hospital, asthma protocols start at 8 puffs of albuterol q 2 hours.

Take an Asthma educator class. I think the AE-C should be required for all school nurses since asthma can kill and is so poorly understood by several health care professionals and EMS providers.

Occasionally I see a bona fide case of EIB on the elementary level but it is very occasional and usually manifests as a result of recess, where kids exert themselves many times greater than they do at PE. But what do you hear from the physicians...2 puffs prior to PE or "exercise?" Most of the orders to pre-treat for EIB on the elementary are unnecessary and have arisen from a single office visit to the pediatrician resulting in a great dis-service for the child and creating an unnecessary dependency on using the inhaler; and usually using it in a ridiculous manner, pumping the inhaler twice and a brief inhalation with no spacer and everything is good. I get the same thing where asthmatic kids have been brain washed into thinking if they run, they start to breathe heavily and thus they have to scream to the nurse office and use their inhaler - lungs clear, no wheezing, respiratory effort what you would expect for the level of activity in any kid, yadda, yadda, but they have been taught to be inhaler dependent. I understand asthma, EIB, EIA, etc. I did my time in a pediatric pulmonology clinic so don't start the dog piling, I appreciate the need for bronchodilators. Remember we're talking the elementary level.

So, Jen...don't worry about it. Just do what the MD paper says and move on.

Heinz...I hear ya. I respect and appreciate what your offering and agree with ya. Just keep in mind these little guys don't even know how to spell asthma, much less how to generate an accurate PFT effort.

I respectfully disagree with what you have stated.

Do you actually know how exercise testing is done? Do you know how extensive the education is for many of these kids? This is not the 1970s.

Have you looked at the statistics for asthma deaths of school age children? Yes, elementary school kids die also from asthma. Have you ever sat with the parents of a child on ventilator from an asthma event for which they will not recover? Don't preach this is made up bogus stuff. Maybe some doctors do over react but then maybe they don't. With the number of kids having asthma, it is difficult to reach everyone with the appropriate teaching especially if other providers would rather criticize than find an alternative solution.

IF you have seen kids doing poor technique, what have you done to correct it?

Did you know that not all asthmatics wheeze when they are short of breath?

Why do your kids still have to come off the athletic fields to "scream" to a nurse's office for their inhaler?

Your system seems very broken and probably doesn't benefit the kids.

I again with tell anyone working with pediatric asthma patients to take the Asthma course and learn the alternatives and latest guidelines rather than taking advice from an anonymous forum with a few very obviously burnt out nurses.

Nurse.jen- By all means protect the child and your license. Set the tone early in the year. Follow the order. Hope the parent can get the dr. to provide the order that meets the needs of the student while at school. If the parent can't do this. I always, always, always offer for the parent or other designated care giver to come and administer the the medication in question. Offering this option does not deny the student the medication. It just puts the ball in the parents court, while they help come up with a solution. Make sure to provide a schedule of the student's PE and recess schedule. Just a thought....but, are nurses in other practice settings considered "burnt out" because they request clarifications for orders?

Personally, I would FAX the Medication Order to the physician with a request to modify it to include pre exercise prevention, per parents request. This takes me just a few minutes. I might even place a phone call to alert the clinic nurse that I am sending the request - Use the "If you are a healthcare provider, please press 1" button. I get much better response doing this than having the parent call. and it sets up a good pattern of communication because they appreciate it.

In Oklahoma, state law is that kids can keep their inhaler with them and use when they would like as long as the parents (and the school) agree that the child is able to safely self-administer. The same law also covers Epi-pens

In Oklahoma, state law is that kids can keep their inhaler with them and use when they would like as long as the parents (and the school) agree that the child is able to safely self-administer. The same law also covers Epi-pens

It is the same in Missouri, but all the T's have to be crossed and the I's dotted on the paperwork.