Inhalers

[heavenwith7]

How do you triage your asthmatics/sudo-asthmatics? I'm elementary & have some students that routinely receive prn MDIs before PE/recess per mom. Others are just prn. If a student presents with complaints of dyspnea, I assess their lung sounds. If clear, sometimes I just offer sips of warm water to "cool down", sometimes I just send them back (usually my everyday right after recess kids). Of course I get questioned by the classroom teachers:banghead:

I have the avoiders that just want to come for their inhaler to get out of class. Often they come in directly from recess, where they've been running like crazy with no problem, are winded & think they need it, or because they can't transition from lunch/recess back to class, and the Health Office is the "escape hatch". I know them pretty well by now.

I am also an ER nurse per diem, so I feel that I maybe too cynical at times. Just wondering how some of you handle this "Epidemic" of prescribed inhalers.

[Flare, ASN, BSN]

If the student is a known asthmatic and is coming from time to time for their inhaler, I'll usually just give it after a quick listen. Lungs that sound crummy are a no brainer. If it's more the student telling me they feel like they are tightening, i'll usually allow it too. I can't tell how they are feeling simply by listening and pulse ox. But - if they begin to come habitually or i really feel like it's not necessary to give it, i'll go with the water, rest, observe route.

[Jedrnurse, BSN, RN]

I get "healthy" baseline peak flows as well, and compare that with current numbers, along with breath sounds, O2sat and subjective complaints. If their SOB resolves with just a quick break and a glass of water, chances are it's SOB from exertion, not asthma.

[NurseBeans, BSN, RN, EMT-B]

I just allow inhaler use for the most part, but when I notice it's daily or almost daily and never see/hear wheezing/coughing/trouble of any kind then I start assessing and saying no. And I try to keep parents updated on usage.

Does anyone else ask for an asthma action plan when given an inhaler for in-school use? When I look at them they usually say rescue inhaler use should be no more than 1-2 times per week, or some sort of limit. If it becomes more than what that action plan says I start telling the student they need to see their doctor because their asthma is not in control. And I call home. That's usually enough to slow the visits down.

[KKEGS, MSN, RN]

I struggle with this myself because I have asthma. I tend to let the kids use their inhalers whenever they ask for them. If they are requesting it more often than is usual for them or asking to use it sooner than the 4 hour limit I will call a parent to discuss it.

[KKEGS, MSN, RN]

I struggle with this myself because I have asthma. I tend to let the kids use their inhalers whenever they ask for them. If they are requesting it more often than is usual for them or asking to use it sooner than the 4 hour limit I will call a parent to discuss it.

[MrNurse(x2), ADN]

My "asthmatic" last year was an overweight, deconditioned 8th grader whose GF was an MD. She complained that she couldn't do PE because she was "wheezing" and needed to be excused. Our administrators didn't back down so GF had to save face and ordered a MDI pre/ post PE. Didn't help at all as I observed her for 10 minutes post PE, mainly to confirm my thoughts. The MDIs I have now are responsible and rarely used. I may have had 3 uses all year.

[WineRN]

Does anyone else ask for an asthma action plan when given an inhaler for in-school use? When I look at them they usually say rescue inhaler use should be no more than 1-2 times per week, or some sort of limit. If it becomes more than what that action plan says I start telling the student they need to see their doctor because their asthma is not in control. And I call home. That's usually enough to slow the visits down.

We require action plans with the doctor's orders...but NONE of mine have a 1-2 times per week limit.

I only have one who tries to abuse the system and claim she is wheezing to get out of strings class. The rest only come when they need it.

[RT->CRNA]

As a RT still working in pediatrics, (And an ICU RN) I always caution relying on breath sounds. Peak Flows are the way to go. Look for retractions, nasal flaring, duskiness, diminished bases. If they give you an upper airway wheeze, have them close their mouth and breath through their nose.

Something to consider. A unit dose of albuterol is 2.5mg (Neb). 2 puffs of Proventil/albuterol/pro-air/ventolin/max-air/whatever brand is 90mcg per puff. While allowance of lower dosing is rationalized by the smaller droplet size facilitating more medication making it to the lungs, recent trends are showing that doctors are increasing the dosage. It used to be that everyone and their mother was put on 2 puffs q4-6 hrs PRN. Now, you NEED to use a spacer (I can't source it this minute, but I remember seeing that the amount of medication lost sans spacer is ~80%), and doctors are ordering 4-8 puffs. I remember our clinical pharmacist stating that 8 puffs is roughly equivalent to a UD of nebulized albuterol.

That being said, we can tell when they are faking it. I'd call home every day though.

[Keepstanding, ASN, RN]

Whenever a student ask's for their inhaler, I always assess them first. If they are wheezing, short of breath and coughing, I will have them use their inhaler. Rest, drink cool water and observe them. If a student says they need their inhaler, but without any signs of an asthma episode, I ALWAYS let them use their inhaler. I preface them getting it by saying "your lungs are clear and I notice that you are not having any other symptoms of asthma, but because you asked for it, I will allow it. Then I document just that. Why do you give it just because they ask for it you say ?? Because that will be the student who will go home to their parents and say....." Mommy, I needed my inhaler today and the nurse wouldn't let me use it" !! Trust me, I have been burned too many times ! If you see that this is happening frequently, then I believe a call to the parent or doctor is in order. Just my 2 cents

[SassyTachyRN]

As a RT still working in pediatrics, (And an ICU RN) I always caution relying on breath sounds. Peak Flows are the way to go. Look for retractions, nasal flaring, duskiness, diminished bases. If they give you an upper airway wheeze, have them close their mouth and breath through their nose.

Something to consider. A unit dose of albuterol is 2.5mg (Neb). 2 puffs of Proventil/albuterol/pro-air/ventolin/max-air/whatever brand is 90mcg per puff. While allowance of lower dosing is rationalized by the smaller droplet size facilitating more medication making it to the lungs, recent trends are showing that doctors are increasing the dosage. It used to be that everyone and their mother was put on 2 puffs q4-6 hrs PRN. Now, you NEED to use a spacer (I can't source it this minute, but I remember seeing that the amount of medication lost sans spacer is ~80%), and doctors are ordering 4-8 puffs. I remember our clinical pharmacist stating that 8 puffs is roughly equivalent to a UD of nebulized albuterol.

That being said, we can tell when they are faking it. I'd call home every day though.

Good info. I have a student this year who has ordered 4 puffs prior to gym/recess. I have approx. 60 inhalers for 560 kids. Out of all those, I have maybe 3 spacers. One of those I bought myself for a 1st grade student who just wasn't understanding how to use an inhaler and I could see the albuterol escaping from the top. I wonder why more prescribers don't write for spacers when they write for inhalers...

[AdobeRN]

Good info. I have a student this year who has ordered 4 puffs prior to gym/recess. I have approx. 60 inhalers for 560 kids. Out of all those, I have maybe 3 spacers. One of those I bought myself for a 1st grade student who just wasn't understanding how to use an inhaler and I could see the albuterol escaping from the top. I wonder why more prescribers don't write for spacers when they write for inhalers...

I have found that parents do not want to pay the extra money for the spacers - majority of time insurance does not cover them and they run about $25 thru the pharmacies.

Do you have a Children's hospital near you? Children's Health here in the Dallas area started a "Asthma Spacer Bag Initiative" program. They provided us with spacers (as many as we thought we would need) & parent education materials to hand out. All I have to do is fax/email a monthly form to them telling them how many I gave out.

In the past if I had extra budget money at the end of the year I always purchased 3-5 spacers to have on hand to give out if needed.