Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2026 Feb 18.
Published in final edited form as: Pediatrics. 2025 Nov 1;156(5):e2025071143. doi: 10.1542/peds.2025-071143

Stock Inhalers in Chicago Public Schools: Using the RE-AIM Framework to Assess Impact

Andrea A Pappalardo 1,2, Caroline Youssef 1, Paige Hardy 1,2, Danita Hingston 3, TaShunda Green 4, Jeannette White 4, Alyse Lodise 4, Jasmine Fowler 4, Nicole Wilson 4, Lynn B Gerald 5, Molly A Martin 2
PMCID: PMC12911513  NIHMSID: NIHMS2139193  PMID: 41115680

Abstract

BACKGROUND AND OBJECTIVES:

Chicago children experience disproportionately higher asthma prevalence and worse health outcomes. Stock inhalers can be used to treat asthma exacerbations at school when a personal inhaler is not available. The purpose of this study was to evaluate the guided implementation of a stock inhaler program in Chicago Public Schools.

METHODS:

This mixed-methods pilot study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework for evaluation. Four pilot schools were selected based on high asthma prevalence and full-time nurse coverage. Data collection included demographics, pre-/postimplementation semistructured interviews, surveys, and stock inhalerutilization record review. Pilot activities ran from September 2023 through June 2024.

RESULTS:

Reach: The program initially reached a student population of 6023 students from 4 schools. Effectiveness: There were 124 total stock inhaler events over the 2023–2024 school year, where 67.5% of students returned to class, 25.0% left school, and 7.5% required emergency services. Nurses believed that stock inhalers improved the student’s outcome in 77.4% of incidents with available data. Adoption: All pilot schools used the stock inhaler. Implementation: Protocol fidelity analysis demonstrated that 60.2% of nurses gave the appropriate number of puffs for the incident severity documented. Maintenance: Because of early pilot success and presence of statewide funding, the intervention was upscaled to include 160 181 students from 306 schools by June 2024.

CONCLUSIONS:

Stock inhaler programming was feasible and beneficial to Chicago Public Schools, improving student outcomes. Guided implementation of scalable school health interventions is essential for future school-based asthma management.

BACKGROUND

Approximately 4.6 million US children have asthma.1 In Chicago, non-Hispanic Black school-aged children are 4.3 times more likely to visit the emergency department (ED) for asthma than white school-aged children.2 Asthma contributes to more than 13.8 million missed school days annually, disrupting educational achievement.3 Chicago Public Schools, the fourth-largest US school district, serves a predominantly non-Hispanic Black and Hispanic/Latinx student population.4 Approximately 5% of students have documented asthma, lower than the overall Chicago prevalence.5,6 Socioeconomic disparities exacerbate asthma’s impact on children from historically marginalized communities by creating barriers to consistent and effective care, documentation, and medication access.7

Sustainable multilevel interventions, such as stock inhaler programming, can improve school-based asthma management.8 Stock inhalers are school-supplied rescue inhalers available for anyone experiencing asthma symptoms without access to their own inhaler. The goal is to encourage families to obtain a personal inhaler and asthma management strategy.9 Illinois passed legislation in 2018 allowing stock inhalers in schools.10 Because implementation had been slow, additional efforts to facilitate adoption were necessary.11–13

The primary aim of this study was to implement, evaluate, and maintain a stock inhaler program in 4 Chicago Public Schools using implementation science (IS) methodologies. IS is the systematic study of methods to promote the adoption and integration of evidence-based practices into routine settings.14–16 To adequately understand the district context, we used the Exploration, Preparation, Implementation, and Sustainment framework to examine contextual factors and tailor interventions appropriately.17,18 We then evaluated the program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to prepare for implementing the stock inhaler program district-wide, with assistance from the statewide stock inhaler program Resources for Every School for Combating Unexpected Emergencies-IL (RESCUE-IL).11,19

METHODS

Study Design and Ethics

This stock inhaler programming pilot was part of a larger, multicounty pilot study but is presented here on its own due to differences in implementation approaches, data granularity, and setting. The research was approved by both University of Illinois Chicago and Chicago Public School institutional review boards. Data privacy and confidentiality were rigorously maintained, with informed consent obtained at the school level and from staff participants. Caregivers were informed about stock inhaler availability at their child’s school and allowed to opt out. Individual parental consent was not required prior to administration, although it was almost always obtained. Nurses were instructed to administer the stock inhaler if the child was in respiratory distress, caregivers were unavailable, and they had not previously opted out. Postincident notification was mandatory.

Setting and Participants

Chicago Public Schools is the largest Illinois school district, serving more than 330 000 students across more than 600 schools. Students identify predominantly as Hispanic/Latinx (46%), Black (36%), and white (11%).4 All school nurses are required to be registered nurses. The Office of Student Health and Wellness ensured alignment with district priorities. The administrative core facilitated program approvals and logistics and ensured compliance.

Pilot and Ramp-up School Selection

The intervention occurred during the 2023–2024 school year. One elementary and 3 high schools were selected based on highest number of asthma-related 504 plans and full-time nurse presence. The program was expanded to 302 additional schools (chosen alphabetically) between February and June 2024. The district’s chief medical officer provided the standing order for pilot schools, with the study providing supplies and funding. Standing orders, stock albuterol inhalers, and spacers for ramp-up schools were provided by the RESCUE-IL program with funding from the Illinois Department of Human Services.

Program Initiation

School nurses district-wide received stock inhaler program online training in August 2023. All staff were trained by December 2024. Pilot schools received hands-on training by nursing leadership and the study team during supply delivery in the fall, which included inhaler-spacer technique. Each school received 2 stock albuterol metered-dose inhalers, 6 plastic spacers, and a box of 20 to 25 disposable spacers, with supplemental stock provided as needed. Bimonthly meetings with pilot nurses and/or district leadership allowed for incident debrief, protocol and procedural adaptations, and future programming discussions.

Protocol/Procedures

A stock inhaler protocol was cocreated with nursing leadership in accordance with asthma guidelines. Staff were instructed to follow a mild to moderate respiratory distress pathway prompting 4 puffs or a severe respiratory distress pathway prompting 8 puffs based on symptoms displayed (Figure 1). Preventive doses could be given by nurses only at their discretion. Spacers were required. Utilizations were documented through the Chicago Public Schools Stock Inhaler Assessment Tool (CPS-SIAT). Nursing leadership followed up with each school nurse within 48 to 72 hours after utilization to collect feedback on protocol, get updates on outcomes, fulfill replenishment requests, provide inhaler technique corrections, and gather clinician follow-up information. Mandatory Illinois State Board of Education (ISBE) and RESCUE-IL reporting forms were also completed on a weekly basis. In some instances, the PI assisted in connecting the student to care.

FIGURE 1.

FIGURE 1.

Open in a new tab

Chicago Public Schools stock inhaler protocol and action plan.

Data Collection

We evaluated the program using the RE-AIM framework.19

Reach

Publicly available demographic information, such as enrollment and racial and ethnic composition, was obtained from Chicago Public Schools and ISBE.4,20 Chicago Public Schools categorizes “Hispanic/Latinx” as a racial group and does not separately report ethnicity. Descriptive statistics (counts, percentages, mean, median, and IQR) were calculated.

Effectiveness

Stock inhaler utilization data documented student demographics, asthma history, symptoms, and outcomes after administration. Disposition was classified as returned to class, left with parent, and 911 called. Students with an expired asthma action plan or who self-reported an asthma diagnosis previously unknown to the school were considered to have an asthma diagnosis. Students who normally self-carried their personal inhalers were given a stock inhaler and included in the evaluation if their personal medication was expired or unavailable. Nurses were instructed to follow Chicago Public Schools’ protocol even when the student had an asthma action plan. Situations where a caregiver picked up a student early were categorized as left with parent, regardless of whether the parent took the child for additional care. Descriptive statistics were calculated.

Adoption

Lists of selected ramp-up schools and supply pickup were shared with the study team.

Implementation

Surveys of school nurses and administrators were conducted before and after the pilot. Surveys (ranging from 32 to 61 items for presurveys and 18 to 41 items for postsurveys) captured asthma management practices, stock inhaler awareness, implementation satisfaction, and school-level asthma prevalence data. Surveys included measures of acceptability (Acceptability of Implementation [AIM]) and feasibility (Feasibility of Implementation [FIM]).21 Averaged respondent scores for each measure closer to 5.0 indicated highest acceptability or feasibility. These scores are based on respondents’ agreement measured on a Likert scale with statements such as “stocking inhalers is easy,” with 4 statements in AIM and 4 in FIM. Fidelity to the protocol was calculated from the CPS-SIAT using reported symptoms, assigned severity, and number of actuations administered.

Maintenance

The fall scale-up results are based on conversations with nursing leadership about the future of stock inhalers in the district and qualitative interviews.

Qualitative Data

Key informant interviews with pilot school nurses, administrators, and teachers were conducted before and after the pilot to understand implementation, challenges, and perceived outcomes. Two interviewers, both with MPH degrees, conducted online or in-person semistructured interviews; one interviewer was also a resident physician. Interview guides developed a priori covered the participant’s role, the school environment, school-based asthma management, and stock inhaler opinions. We recorded interviews electronically through Zoom or a digital recorder and then transcribed, deidentified, and uploaded them to Dedoose for analysis.

A preliminary codebook was created before interviews began and was subsequently modified as coding progressed, resulting in a hybrid qualitative approach.22,23 Two transcripts were coded by 8 coders and discussed as a group to reach concordance. Ten additional transcripts were coded in pairs, mutually agreeing on code applications after blind coding. All remaining transcripts were coded by 1 coder with the assistance of weekly group meetings. Thematic analysis was performed through 3 sessions to identify overarching themes and subthemes.24 For the postimplementation analysis, a similar process was followed by all 4 coders.

RESULTS

Reach (Table 1)

TABLE 1.

REACH: Student Demographics of Pilot, Ramp-Up, and All Chicago Public Schools

Characteristics Pilot Ramp-Up Schools Chicago Public Schools Total
Race and ethnicity, n (%)a
 Asian 82 (1.4) 7430 (4.8) 14 703 (4.5)
 Black/African American 2917 (48.4) 49 732 (32.3) 113 197 (35.0)
 Hawaiian/Pacific Islander >10 189 (0.1) 407 (0.1)
 Hispanic/Latinx 2396 (39.7) 73 397 (47.6) 151 604 (46.9)
 Multiracial 127 (2.1) 2780 (1.8) 5241 (1.6)
 Native American/ Alaskan Native 17 (0.3) 398 (0.0) 827 (0.3)
 White 481 (8.0) 19 581 (12.7) 35 853 (11.1)
 Unknown/missing >10 (0.1) 641 (0.4) 1422 (0.4)
English learners, n (%)b
 Yes 815 (13.5) 39 498 (25.6) 79 833 (24.7)
 No 5217 (86.5) 114 651 (74.4) 243 418 (75.3)
Diverse learners, n (%)c
 Yes 536 (8.9) 25 164 (16.3) 51 910 (16.1)
 No 5496 (91.1) 128 985 (83.7) 271 341 (83.9)
Economically disadvantaged, n (%)d
 Yes 3969 (65.8) 104 809 (68.0) 228 466 (70.7)
 No 2063 (34.2) 49 340 (32.0) 94 785 (29.3)
Open in a new tab
a

Although we recognize according to the AMA Health Equity guide that identifying and reporting race and ethnicity should be separate, Chicago Public Schools collect these data in aggregate; therefore, this is how it was reported.

b

Chicago Public Schools define “English learners” as students whose primary language is not English and who require specialized instruction in English to develop proficiency.

c

Chicago Public Schools define “diverse learners” as students who qualify for special education services due to disabilities and have an Individualized Education Program or 504 Plan.

d

Chicago Public Schools define “economically disadvantaged” as students who qualify for free or reduced-price lunch under the National School Lunch Program or meet other criteria for low-income status, including eligibility for other federal or state assistance programs.

There were 6023 children initially enrolled in the stock inhaler program through 4 pilot schools. Of these, 2917 identified as Black (48.4%), 2396 identified as Hispanic/Latinx (39.8%), 481 identified as white (8.0%), and 229 as a different race or ethnicity (3.8%). There were 3969 children from families who were considered low-income (65.9%) and 813 (13.5%) considered English learners.4

Effectiveness

Demographics

We documented 15 stock inhaler events from pilot schools and 109 from ramp-up schools during the 2023–2024 school year for a total of 124 events (Figure 2). Out of 108 unique stock inhaler recipients, the majority identified as male (53.7%), Black (56.5%), and non-Hispanic (53.7%). The average age of recipients was 10.6 years (SD = 3.2 years). The majority had a known or self-reported asthma diagnosis (71.3%); however, only 33.8% had an asthma action plan. Only 16 (13.3%) of incidents involved students who had previously used the stock inhaler. Elementary schools reported most stock inhaler uses (85.5%).

FIGURE 2.

FIGURE 2.

Open in a new tab

Chicago Public Schools stock inhaler incident characteristics.

Triggers

Physical activity was the most common trigger (43.5%). Unknown exposures (29.8%), pollen (5.6%), hot weather (5.6%), upper respiratory tract infections (4.8%), and no exposures (4.8%) were also common.

Incidents. Most students presented with shortness of breath (70.2%). Many reported chest tightness (40.3%), wheezing (38.7%), coughing (36.3%), and anxiety/restlessness (22.6%). Rapid breathing was the most common severe symptom (26.6%), followed by difficulty speaking (16.9%), nostril flaring (8.1%), retractions (4.8%), and blue lips or fingertips (1.6%). Most received stock inhalers due to asthma symptoms (96.8%) vs preventively. Of the 120 uses for symptoms, 112 documented mild to moderate respiratory distress, 6 severe, and 2 unsure. After the incident, 83 recipients (69.2%) returned to class, 28 (23.3%) left school with a caregiver, and 9 (7.5%) required Emergency Medical Services (EMS). Out of 110 incidents with available data, nurses believed that 59 (49.2%) students would have had to go home and 38 (31.7%) would require EMS if the stock inhaler was not available, representing a better outcome for 77.4% of students.

Adoption

Program Scale-up (Figure 3)

Due to the success of the pilot and funding and supplies becoming available through RESCUE-IL, 302 additional schools adopted stock inhaler programming. Ninety-five schools scaled up in February 2024 and 207 in April 2024. By June 2024, 154 149 additional students had access, totaling 160 181 students reached with the stock inhaler program in 2023–2024. Of these, 49 732 (31%) identified as Black, 19 581 (12%) as white, 73 397 (46%) as Hispanic/Latinx, and 10 797 (7%) as another race or ethnicity. A total of 39 498 identified as English learners (25.6%) and 25 164 as diverse learners or children with special education needs (16.3%). A total of 104 809 (68.0%) were low-income students.4

Guided implementation was well received. One nurse reported: “I found… the post-meetings to be very helpful… sometimes when you’re in a situation…you think you have it under control or you think …you’ve done the right thing, but that feedback is so helpful. Because … when you get that reassurance, you know, collectively… okay good to know, you know…” A district administrator described, “A lot of times in, in school settings, you’re kinda on an island by yourself, especially the nurses. So I think having that post-meeting does help, like… And it’s also not to say, “Hey, you didn’t do this,” but,“What was your rationale? Was there anything preventing you from doing it this way? Is there any feedback that then we could share with other people?”

Implementation

Protocol Fidelity

Out of 103 incidents with full data, 97 (89.8%) incidents were described as mild to moderate, whereas 6 (5.6%) were described as severe. Forty trained personnel (37.0%) selected the incorrect protocol pathway (ie, mild to moderate or severe based on reported symptoms). Specifically, 40 (88.9%) incidents were incorrectly characterized as mild to moderate instead of severe.

Of the 124 stock inhaler uses, 61.3% administered a dose consistent with their assigned respiratory distress severity. Two-thirds of incidents that should have been designated as mild to moderate based on symptoms reported the administration of 4 or 8 puffs as required by protocol, with 22 (31.9%) receiving fewer puffs than recommended. Forty recipients (90.9%) whose symptoms placed their asthma event in the severe category received fewer puffs than recommended. Only 3 of these recipients (6.8%) received the recommended starting dose for severe asthma incidents (8 puffs), and only 1 (2.3%) received a higher dose than recommended.

Prepilot Interviews and Surveys

Three district administrators, 8 nurse managers, 12 nurses, 5 school principals/vice principals, and 3 other school staff participated in interviews (n = 31). No staff declined to participate in interviews, but 5 were lost to follow-up. Six nurses, 6 school administrators, and 2 district administrators completed the presurvey out of 9 nurses, 6 administrators, and 2 district administrators invited.

Postpilot Interviews and Surveys

Eleven individuals participated in the close-out interview and only 4 in postpilot surveys.

Acceptability

The average AIM score was 4.7. School nurses’ average AIM score was 4.3 and administrators 5.0, indicating high acceptability, especially among administrators. Postsurveys demonstrated an average AIM score of 4.4, with nurses reporting 4.2 and administrators 5.0.21

Feasibility

The average pre-FIM score was 4.6 to 4.3 for nurses and 4.9 for administrators—indicating high feasibility. However, fewer participants reported that they agree or highly agree with the statement “stocking inhalers is easy.” Post-FIM scores were 4.3 overall, with 5.0 for administrators and 4.0 for nurses.21

Adaptations

Extra materials were ordered for schools with multiple buildings and/or decentralized nursing stations to facilitate access. Some schools had difficulty with school-wide parental notification, as inhalers were implemented after enrollment. Also, additional education was needed regarding medication dosage.

Satisfaction

In presurveys, 5 (83.3%) nurse respondents reported being satisfied/very satisfied with their ability to treat asthma-related emergencies, with 6 (100%) satisfied/very satisfied with their ability to treat mild to moderate asthma symptoms. After implementation, all 6 nurses (100%) surveyed were very satisfied/satisfied with their ability to treat asthma-related emergencies and mild to moderate asthma symptoms.

Maintenance

All schools expressed interest in maintaining a stock inhaler program in the next school year. Over the 2024–2025 school year, all district-run schools implemented a stock inhaler program. One nurse explained:

“It not only helps students stay in school and miss less instruction time, which is the whole point of school nursing, but it also saves lives. So, really just a lot of positives. No reason not to do it. It’s a very cost-effective program as well.”

DISCUSSION

We planned, implemented, and evaluated a mixed-methods stock inhaler pilot program using IS to advance health equity in a district facing persistent asthma-related health disparities.4,8–10,22–24 Due to the strength of collaboration from policymakers, public health agencies, advocacy and professional groups, academic and community partnerships, administrative leadership, school nurses, and a stock inhaler coalition, the program quickly upscaled from 4 to 306 schools by the end of the 2023–2024 school year. Health equity was at the forefront of the implementation process and programmatic execution.

Health policy must be first advocated for, enacted, and then implemented equitably and sustainably.21,25,26 This multilevel intervention demonstrated considerable success in addressing asthma-related health disparities by managing symptoms, reducing educational disruptions, and strengthening infrastructure. The effectiveness of the program’s structure in delivering timely care is evident through its outcomes. Although more than two-thirds (67.5%) of students were able to return to class after receiving a stock inhaler, preventing educational disruption, this was a lower percentage than the 83.9% observed by Lowe et al in their Arizona pilot.9 This may be explained by differences in the asthma landscape or longstanding policies to always call 911 in case of an asthma emergency.4 Fidelity to protocols may be a focus of future programming, as nurses reported that they were hesitant to give 4 to 8 puffs. Overall, the stock inhaler program was highly acceptable, feasible, and satisfactory and reached many historically marginalized children.4,20,21 Health policy is most effective when implemented collaboratively and systematically through evidence-based approaches. Other models, such as the School-Based Asthma Therapy (SBAT) program, incorporate daily controller medication delivery to address persistent asthma among students, demonstrating a reduction in ED visits and hospitalizations.27 SBAT, school-based telemedicine, or mobile care vans can provide long-term follow-up to maintain asthma management.27–29

The pilot phase reached more than 6000 students, 65.8% of whom were classified as low-income. Then, the program quickly expanded to 306 schools, reaching 160 181 students, 68.0% of whom were low-income.4 Notably, 56.5% of the stock inhaler incidents involved students who identified as non-Hispanic Black, a population disproportionately affected by asthma-related ED visits and inpatient hospitalizations.2 More than one-quarter of stock inhaler recipients had no formal asthma diagnosis, and only 33.8% of recipients had a current asthma action plan. Stock inhaler use prompted asthma recognition and follow-up for proper diagnosis, management, acquisition of personal inhalers, and documentation at school.

This program revealed critical insights into Chicago Public Schools’ asthma burden assessment. Traditionally, they estimate asthma prevalence through active 504 plans.30 However, many children with asthma do not have 504 plans, making this metric unreliable.31 Some districts use asthma action plans as an alternative, but our study revealed that reliance on these documented plans underestimates true asthma prevalence, consistent with the literature.32 Future research should focus on identification and care coordination for children with asthma, potentially involving screening.17–19

Although the stock inhaler program achieved many successes, continuous evaluation is essential for addressing variability in protocol adherence and ensuring its scalability.15,16 Utilization rates were lower than previously reported in other district-wide programs, which ranged from 3.8 to 13 uses per 1000 students annually.9,33 Lowe et al also saw more recipients return to class than our study.9 This may be influenced by differences in asthma prevalence and diagnosis, ramp-up time (for 6 months, only our 4 pilot schools stocked inhalers), school nurse presence, or identification and escalation of asthma symptoms. Delays in program initiation allowed time for protocol refinement, but these challenges underscore the importance of real-time monitoring and iterative improvements for future program expansions.14 We encountered difficulty recruiting school administrators for interviews and surveys due to competing demands, which may have biased the feedback and required more directed recruitment methods.34 School nurses’ availability for ramp-up schools also varied.

Chicago Public Schools’ rapidly upscaled stock inhaler program, guided by IS methodologies, successfully reduced educational disruptions and enhanced asthma management through asthma symptom de-escalation. Its scalability, its positive reception, and the collaborative nature of the intervention suggest the program’s potential to serve as a model for other school districts.19,21 Future research is critical to understanding long-term impact and sustainability within Chicago and beyond.

WHAT’S KNOWN ON THIS SUBJECT:

Twenty-three states allow schools to stock undesignated asthma medication for respiratory distress, which has been shown to reduce Emergency Medical Services calls to schools and early dismissals due to asthma.

WHAT THIS STUDY ADDS:

An implementation science–based mixed-methods approach to a stock inhaler pilot program in the fourth-largest US school district results in a mid-year scale-up to approximately half of the district.

ACKNOWLEDGMENTS

We would like to thank Chris Martinez and Naomi Soto of the Allergy and Asthma Foundation of America and Erica Salem from the Respiratory Health Association for their tireless efforts resulting in the RESCUE-IL program and its ramp-up in Chicago Public Schools. We would like to thank the following individuals for their assistance in the thematic analysis that was represented in this manuscript: Ana Ongtengco, Aastha Saggar, Emily Wilt, Krista Edenfield, and Oscar Tellez. This program would not be possible without the assistance of all the front desk staff, school health staff, nursing, data team, and administrators at Chicago Public Schools.

FUNDING:

American Lung Association Public Policy Award PP-824034, AHRQ K-12 Grant 5K12HS026385–04.

ABBREVIATIONS

AIM

Acceptability of Implementation

CPS-SIAT

Chicago Public Schools Stock Inhaler Assessment Tool

ED

emergency department

EMS

Emergency Medical Services

FIM

Feasibility of Implementation

IS

implementation science

ISBE

Illinois State Board of Education

RE-AIM

Reach, Effectiveness, Adoption, Implementation, and Maintenance

RESCUE-IL

Resources for Every School for Combating Unexpected Emergencies-IL

SBAT

School-Based Asthma Therapy

Footnotes

CONFLICT OF INTEREST DISCLOSURES: Dr Pappalardo reports current grant funding from the National Institutes of Health, Respiratory Health Association, Food Allergy Research and Education, and American College of Allergy, Asthma and Immunology; recent funding from Northwestern University, Agency for Health Research and Quality, and the American Lung Association; and consulting for the Food Allergy Research and Education, Northwestern University, and OptumRx/UHG (no active consult for >24 months). She has received speaking honoraria from the American Academy of Pediatrics, American Academy of Allergy, Asthma and Immunology, and the Wisconsin Allergy Society. Dr Gerald reports current grant funding from the National Institutes of Health, Respiratory Health Association, and the American Lung Association. She consults for Up-to-Date and UMass Medical School. All other authors report no conflicts of interest.

REFERENCES

RESOURCES