Updates in School-Based Asthma Management

Abstract

PURPOSE OF REVIEW:

School-based asthma management is an important component of pediatric asthma care that has the potential to provide more universal evidence-based asthma care to children and mitigate asthma-related health inequities. The purpose of this review is to highlight relevant developments in school-based asthma management over the past 2 years.

RECENT FINDINGS:

There have been considerable recent scientific advances in school-based asthma management including robust clinical trials of environmental interventions in the classroom setting, school-nurse led interventions, stock albuterol policy changes, school-based telemedicine approaches and innovative methods to engage community stakeholders in research that have pushed the frontiers of school-based asthma care.

SUMMARY:

Recent scientific work in school-based asthma management demonstrates the potential power of schools in providing access to guideline-based asthma care for all children with asthma and in improving their health outcomes. Future work should focus on the evaluation of methods to promote the adoption of school-based asthma management strategies in real-world practice and support evidence-based policy change and strategic partnerships to improve asthma health outcomes and produce meaningful public health impact for diverse children and families.

INTRODUCTION:

Over 4.2 million school-aged children in the United States (U.S.) have asthma leading to significant morbidity. (1–3) Asthma is a leading cause of school absenteeism contributing to 10 million absences each year. (4) Despite significant pharmaceutical advances for asthma in the last decade, pediatric asthma health inequities persist and children from low-income and minority backgrounds continue to experience disproportionate morbidity from asthma, including learning loss, chronic school absenteeism, emergency department visits and hospitalizations. (5, 6) Much of this morbidity and child health inequities are due to poor adherence and access to guideline-based asthma care. (7, 8)

School-based asthma management is a powerful approach to asthma care that has the potential to provide more universal evidence-based care to children with asthma and to mitigate the persistent health inequities in childhood asthma. Moreover, delivering asthma care in schools is attractive due to the ability to identify children at high risk for morbidity, to provide asthma education to children and families, improve medication adherence and reduce environmental exposures during much of the daytime hours. (9) In recognition of this, several expert organizations including the National Asthma Education Prevention Program (NAEPP) and American Lung Association (ALA) provide asthma management guidelines and resources for schools, including evidence-based curricula for school such as Open Airways for Schools and the Asthma Friendly Schools Toolkit and the School-Based Asthma Management Program. (10–15) A recent review across 36 U.S. states does suggest that the majority of schools have improved their efforts to identify and track students with asthma; however, health policies and practices vary across states and there is a need to improve asthma-related health education and professional development for teachers, school nurses and school health professionals. (*16)

Over the last two years there have been considerable scientific advances in school-based asthma management including robust clinical trials of environmental interventions in the classroom setting, school-nurse led interventions, stock albuterol policy changes, and school-based telemedicine approaches that have pushed the frontiers of school-based asthma care. Herein, we describe the most recent relevant studies in school-based asthma management over the last two years.

Classroom-based Strategies

Given the sheer number of hours that children spend in the classroom setting, classroom-based strategies can provide excellent access to asthma care. Many classroom-based programs use a multi-faceted approach to improve asthma outcomes which include environmental strategies to reduce exposure to asthma triggers as well as evidence-based approaches such as education and medication therapy. Several recently studied classroom interventions have shown improvements in asthma outcomes. Educational curricula for school staff and students with asthma were associated with sustained improvements in knowledge, skills, and self-efficacy, along with improved adherence, and fewer missed school days due to asthma. (*,*,**,**17–20) Implementation of Integrated Pest Management systems and High Efficiency Particulate Absorbing (HEPA) filters did not improve overall symptom days throughout the school year but did reduce asthma symptoms earlier in the school year and produced fewer school absences due to asthma. (**21, *22) An assessment of molds in the classroom showed that there were significantly higher levels found in schools compared to student homes, and the presence of air-conditioning in the school was associated with lower asthma prevalence. (*23) A study examining the feasibility of classroom-based short intermittent physical activity was shown to be safe in students with asthma and participating children experienced increased confidence in their ability to participate in physical activity. (**24) Each of these strategies are important considerations for schools looking to implement classroom-based strategies for asthma management. More research is needed in understanding the cost-effectiveness of classroom-based strategies and ways in which policy change could allow for low-resourced schools to adopt these evidence-based approaches to produce meaningful health impact for its students.

School Nurse-led Approaches

School nurse-led approaches are an important form of asthma management as school nurses are uniquely positioned health professionals with daily exposure and access to a child with asthma. A recent trial showed that school-aged children participating in educational sessions led by a school nurse on asthma pathophysiology, measurement and monitoring of asthma symptoms, asthma medication use, demonstration of correct inhaler and spacer technique and goal setting for asthma, experienced statistically significant improvements in reported asthma symptoms (p<.001), Asthma Control Questionnaire scores (p<.001) and interruptions in daily activities (p<.001) at 12 weeks as compared to children receiving usual care. (**25) In another study of the Easy Breathing for Schools Program, school nurses assessed asthma risk and asthma control, provided asthma education, and reviewed medication therapy using a pediatrician communication tool and enrolled children experienced a 25% decrease in school absences as compared to those not enrolled in this program. (26). Such school-nurse led strategies have great potential to improve asthma outcomes, (27) and future directions of this work should consider how schools without full-time school nurses could participate in such approaches and whether existing school nurses would accept these types of responsibilities as part of their routine practice, outside of a research context.

School-based Health Centers

School-based health care centers (SBHC) provide both acute and preventive services in the school setting, obviating the need for children to travel to an outside healthcare entity for asthma care. SBHCs are associated with improved health and academic outcomes (28) including asthma outcomes, (29–32) and most are provisioned with a full-time registered nurse who manages the health needs of students. (**33) For children with asthma, SBHCs can provide acute asthma care and an array of preventative services such as asthma screening, asthma education and supervised asthma medication therapy, allowing for access to care for children that are disconnected with the healthcare system or have challenges traveling to or accessing traditional healthcare settings.

A recent study examined the cost-savings for acute asthma care in SBHCs located in Connecticut. (**33) Researchers tracked the time of each asthma visit, the treatment provided, and disposition status of the visit. Over the course of the school year, 166-plus hours of classroom instruction time were saved among students who received asthma care at the SBHC. Data demonstrated acute asthma management required less time compared with when the child was sent to the emergency department (i.e., usual care). SBHCs have the capacity to decrease costs for families, schools, and state resources while improving educational outcomes. (**33)

SBHCs also play an important role in adherence to controller medications. In a pilot study involving 3 SBHCs located in Buffalo, New York, students with asthma were randomized to receive directly observed therapy of their asthma controller medication under the guidance of trained SBHC advanced practice providers, and outcomes were compared to children randomized to receive usual asthma care through their primary care provider. (*34) Students who were randomized to the intervention received their controller medication on 92% of the days they attended school. While Asthma Control Test scores did not differ between the intervention and usual care groups, there were improvements within groups. SBHCs may provide a potentially efficient way to ensure medication adherence among student with asthma, however further research examining the effectiveness of SBHCS on improving asthma outcomes as well as the cost-effectiveness of SBHCs remains necessary. (*34)

Stakeholder Partnerships / Multi-level Programs

Given that most U.S. schools operate with limited monetary resources and without a full-time, registered nurse who manages the health needs of students with asthma, stakeholder collaborations remain essential to increasing resource capacity and successful operation of school-based programs. (35) School staff and administration are tasked with ensuring evidenced-based programs are adopted and implemented in schools, but their input is often left out of pre-program planning which ultimately guides the intervention’s design and implementation processes. Barriers to program implementation occur at the personal, interpersonal, family, systems and policy levels which ultimately impact program effectiveness and sustainability. (*36) Qualitative findings have demonstrated a hierarchy of needs across systems when implementing asthma care in schools. Given resource restraints, a need for resolving issues across multiple systems remains necessary for effective school-based asthma management. (*36)

Researchers have noted not only the importance of identifying the barriers and facilitators at the individual-level of school-based interventions (e.g., from families that receive and school health staff that deliver them), but also the need to go beyond this and address barriers at the systems-level (e.g., level of the school administrators, practice managers, payors or policy makers) before implementation and scalability are tested in real world settings, like schools. (**37, **38) As an example, the Asthma Link^™ intervention, which provides daily school-supervised administration of asthma controllers to children with poorly controlled asthma, was adapted for real-world use by eliciting input from both individuals involved (children, families, providers, school nurses) as well as systems-level stakeholders. Input from individuals involved as well as school administrators, practice managers, payors and pharmacists allowed for the refinement of Asthma Link^™ intervention itself and guided the choice of outcome measurement for a clinical trial. This stakeholder input has supported the uptake of Asthma Link^™ in real-world practice. (39) For school-based research to effectively be translated into practice, experts have noted that stakeholder priorities should be assessed during each step of the research process. (**37)

Recently, a school-based, comprehensive asthma care program led by pharmacists and an interdisciplinary team of stakeholders was implemented in Pittsburgh Pennsylvania. (40) Children with asthma were assessed by a physician and a pharmacist reviewed the child’s drug therapy, provided asthma self-management education, reinforcement of appropriate inhaler technique and reviewed the importance of medication adherence, with additional support given for insurance problems and home and school delivery of asthma medications. Enrolled children experienced significant improvements in asthma knowledge (p<.001), asthma-related quality of life (p<.001) and asthma control (p=.001). (40) This study demonstrates the potential for partnerships with non-traditional stakeholders to improve asthma health outcomes.

Stock Albuterol Inhaler Programs

Stock albuterol inhaler use in schools is safe and effective, ensuring that all children have access to their rescue medication while at school, with important recent scientific advances. (**41, **42) Stock albuterol use has been shown to avoid the need for escalated care such as summoning the emergency medical system and allows children to remain in school when experiencing asthma symptoms. (**41, 43, 44)

Approximately 18 U.S. States have passed legislation that allows schools to procure, stock and administer stock albuterol to students; however, these laws vary widely across states. (**45) Expert organizations have created policy recommendations that guides states on lobbying for stock inhaler legislation and provides recommendations for program implementation on a state level. (**42) Recently, stock inhaler events were examined among 228 schools located in Tucson, Arizona, and data suggested that not only were stock inhalers used by all schools across the socio-economic spectrum, but all children can benefit from having a stock inhaler at their school (with no adverse events reported). (46) There is national momentum for legislation to be passed across all states so that all children will have access to rescue medication at school.

Supervised Asthma Medication Therapy

Rescue Medication Use in Schools.

Because stock albuterol laws are not universal in the U.S., some researchers have used partnerships to send asthma medications directly from the pharmacy to the school. One such program, the Asthma Scripts for Schools Program sent albuterol inhalers from local pharmacies in Washington D.C. directly to area schools at no cost to families. (*47) This study highlighted the ability for pharmacies to directly courier medication to schools, as many pharmacies offer free or reduced cost courier services. (*47) By demonstrating the feasibility of direct courier of medications to schools, states that have passed stock albuterol laws may be able to have stock medications delivered from local pharmacies as well.

Preventive Medication Use in Schools.

While predominant asthma medications prescribed for school use are rescue medications, there is a strong body of research to support the daily supervision of preventive controller asthma medications at school. These can be administered by the school nurse (licensed or unlicensed) and are often combined with asthma education, assessing environmental triggers and facilitating communication between the medical home, family and school. (48, **49) A 3-armed randomized trial to examine a school-based asthma intervention in Rochester, New York used 2 main components, directly observed therapy (DOT) of preventative medications and motivational interviewing with teens to discuss the potential benefits of DOT. (**49) Findings suggested that the teens did not show improvements in asthma symptoms, but short-term improvements in adherence to medication therapy were observed. In another recent study in central Massachusetts, children with poorly controlled asthma were identified in their pediatric clinic and set up to receive their daily controller at school. Enrolled children experienced long-term improvements in asthma health outcomes for up to 4 years, including reductions in emergency room visits, hospital admissions, rescue medication use and school absences. (**50, 51) These recent studies included children from predominantly low-income and racial ethnic minority backgrounds. School supervision of medication use has great promise for improving health equity in asthma and further work should be done to promote the translation and uptake of this strategy into real-world practice.

School-based Telemedicine / Telehealth Strategies

School-based telehealth can overcome many barriers to asthma care for high-risk populations, particularly those related to access, travel and transportation, providing telehealth in a location where children inherently spend time. (52) School-based telehealth has improved medication adherence monitoring, personalization of therapy, and asthma-related emergent visits among children from low-income and minority households. (53, 54)

With school-based asthma telehealth, we must consider the facilitators and barriers experienced by schools during implementation, including capacity building among key stakeholders, (55) as well as marketing, technological assistance, and education. (55) Schools with a strong nursing leadership remain an important indicator of program success. (55)

With telemedicine, we must also be carefully not to exacerbate current health disparities by providing care to only those with advanced technological equipment and stable internet connections. To address the potential digital divide that could be encountered, our approaches must remain accessible for low-income children and families. With this in mind and considering that cell phone use remains nearly universal among low-income and limited English-proficient families, and that text message interventions are favored, (56) one recent study described the development and feasibility of the first school-linked text message intervention. (**57) This intervention provided daily two-way text message reminders for parents of children with poorly controlled asthma to give their child their asthma controller; parental text responses were shared with the child’s school nurse. This intervention was shown to be feasible and acceptable for low-income and minority children and families and for school nurses, with promising improvements in asthma medication adherence and asthma symptoms. (**57) School-based telemedicine is a feasible approach to bridging asthma care between specialists, primary care providers, and schools, but more work is needed to establish best practices for implementation. (52) Future strategies of school-based telehealth and telemedicine for asthma care should carefully merge the effective use of technology with culturally tailored and accessible interventions to avoid worsening the existing health disparities in asthma.

CONCLUSION:

There have been significant advances in school-based asthma management strategies over the last several years. Even amid remote school conditions during the COVID-19 pandemic, school-based approaches have remained a powerful and innovative method to reach and provide access to acute and preventive care for high-risk children with asthma. There is still much to learn about school-based asthma management strategies, specifically in methods to enable their operation in real-world practice, their impact on health inequities, and the ways policy change and strategic partnerships can support their sustained operation to improve asthma health outcomes for diverse children and families.

Table 1.

School-based Asthma Management Strategies, 2021–2022.

Author	Title	Year	Location & Setting	Population (N)	Intervention / Program	Comparison Group(s)	Findings & Next Steps
Classroom-based Strategies
McGovern C, Arcoleo K, Melnyk B	Sustained Effects from a School-Based Intervention Pilot Study for Children with Asthma and Anxiety	2022	Columbus, Ohio Columbus City Schools	Elementary children aged 8–12 years and their primary caregivers N = 32	COPE for Asthma program, an integrated asthma education and cognitive behavioral skills-building program for with asthma and comorbid anxiety.	Convenience sample (i.e., no comparison group)	At 6-weeks postintervention, anxiety and CG-reported behavioral symptoms were significantly reduced, there were fewer missed doses of asthma controller medications, and asthma-related self-efficacy, personal beliefs, and the children’s understanding of asthma significantly increased. Next steps: Objective measurement of lung function, change in missed instructional time as well as academic performance in a randomized controlled trial design.
Arekapudi KL, Norris C, Updegrove S	Improving Self-Efficacy of Student Asthma Management in Elementary and Preschool Staff	2021	Connecticut Urban, underserved community public school	PreK-6th grade schoolteachers N = 35	Facilitated elementary and preschool staff with access to student AAPs to improve perceived self-efficacy regarding prevention and management of students’ asthma exacerbations.	Cross-sectional (i.e., no comparison group)	Education and facilitated access to AAPs significantly increased participant student asthma management self-efficacy both in the areas of asthma exacerbation prevention and management. Next steps: Improving the consistency and continuity of case across caregivers of students with asthma and supply schools with a foundation for enhanced guidelines on asthma management in the absence of a school nurse.
Bryant-Stephens T, Williams Y, Kanagasundaram J, Apter A, Kenyon CC, Shults J	The West Philadelphia asthma care implementation study (NHLBI# U01HL138687)	2021	Philadelphia, Pennsylvania Children’s Hospital of Philadelphia & School District of Philadelphia	Elementary-aged children 5–13 years with uncontrolled asthma.	A primary care-based invention, school-based intervention and combined primary- and school-based intervention as compared to usual care for improving asthma control among school-age children.	Factorial Design: Primary care-based intervention, School-based intervention & combined primary care and school-based intervention	Findings not yet reported/published.
Bruzzese JM, George M, Liu J, et al.	The Development and Preliminary Impact of CAMP Air: A Web-based Asthma Intervention to Improve Asthma Among Adolescents.	2021	New York City, New York New York City Public High Schools, clinics, and community-based organizations	High-school aged adolescents with uncontrolled asthma N = 30 (Intervention) N = 31 (Control)	Controlling Asthma Program for Adolescents (CAMP Air), a web-based intervention focusing on adolescents with uncontrolled asthma.	Information and referral intervention control group.	CAMP Air participants demonstrated significantly improved asthma knowledge, asthma control, night wakening and school absences, and less risk for urgent care visits. Adolescents enrolled in schools completed more modules and had significantly fewer nights woken and school absences than community enrollees. Next steps: Understanding the long-term effects of CAMP Air including factors associated with dissemination and implementation such as cost-effectiveness.
Phipatanakul W, Koutrakis P, Coull BA, et al.	Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students with Active Asthma: A Randomized Clinical Trial	2021	Northeastern United States	Students with active asthma N = 236 students across N = 41 elementary schools	School Inner-City Asthma Intervention Study A school-wide Integrated Pest Management (IPM) program consisting of application of rodenticide, sealing entry points, trap placement, targeted cleaning, and brief educational handouts for school staff.	Control schools received no IPM, cleaning, or education. Classroom portable sham HEPA filter purifiers were deployed and the filters were changed every 3 months.	School-wide IPM resulted in non-sustained improvements in asthma symptoms for children. Next steps: Examine allergen levels, particle exposures and asthma symptoms.
Busse WW, Jackson DJ	School Classrooms as Targets to Reduce Allergens and Improve Asthma	2021	NA	NA	An editorial on the clinical trial of Integrated Pest management (IPM) and HEPA air filters in classrooms of students with asthma describes the lessons gleaned from the school-based intervention conducted by Phipatanakul et al. (2021).	Editorial	Next steps: Future efforts should more fully phenotype both the environment and study participants and select environments with consistently higher concentrations of allergen exposure and children with greater levels of allergen sensitization and more symptomatic disease to allow for a greater likelihood of detecting a treatment effect. The environmental abatement should also be frequently monitored and reapplied if needed to ensure that the initial beneficial effects on asthma control are sustained.
Howard EJ, Vesper SJ, Guthrie BJ, et al.	Asthma Prevalence and Mold Levels in US Northeastern Schools	2021	Northeastern U.S. Schools and homes	N = 32 schools (Intervention) across N = 114 classrooms N = 33 homes (Control)	School Inner-City Asthma Intervention Study 2 (SICAS 2)	Independent group of Northwestern homes	Levels of outdoor group 2 molds were significantly greater in schools compared with homes. The presence of air-conditioning in school buildings correlated significantly with lower asthma prevalence. Next steps: Intervention studies like SICAS 2 and studies of other methods to improve school indoor air quality may be important to reducing asthma.
Beemer LR, Lewis TC, Ajibewa TA, Dopp R, A BE, Hasson RE	Classroom-Based Strategies to Reduce Disparities in Physical Activity Among Children with Asthma	2022	Detroit, Michigan Public elementary school	3rd – 9th grade students across 9 classrooms N = 1 school	Classroom-based Physical Activity (PA) intervention, Interrupting Prolonged Sitting with Activity (InPACT), where teachers implement 5 × 4-min moderate-to-vigorous physical activity (MVPA) breaks throughout the school day. classroom-based physical activity intervention in preadolescent children with asthma and without asthma.	Observational (i.e., no comparison group)	Out of 294 observations, six instances of asthmatic symptoms (coughing) were observed in students with asthma 5–15 min following the PA break. Symptoms self-resolved within 15-min of the PA break and did not result in sustained exercise-induced bronchoconstriction. Next steps: Future research should continue to address parent perceptions in the intervention design when targeting children with asthma.
School Nurse-led Approaches
Isik E, Fredland NM, Young A, Schultz RJ	A School Nurse-Led Asthma Intervention for School-Age Children: A Randomized Control Trial to Improve Self-Management	2021	Undisclosed location Public schools	Elementary school-age children between the ages of 7–12 years N = 76 students across N = 8 schools	A school nurse-led intervention of educational sessions around asthma symptom monitoring, peak flow meter usage, inhaler and spacer teaching, and medication adherence counseling.	Usual asthma care	Differences in school absences was not statistically significant, but the treatment group missed fewer school days than the control group. Next steps: Similar interventions should be studied in older students with asthma (e.g., high school) and across geographical locations.
School-based Health Centers (SBHCs)
Goddard A, Konesky A, Borkowski V, Etcher L	Show Me the Money…Saved! Cost Savings from Acute Asthma Care in the School-Based Health Center	2022	New London County, Connecticut SBHCs and districts in 3 different communities	N = 14 SBHCs across N = 5 school districts	This quality improvement project demonstrated classroom seat time preserved through use of school-based health centers (SBHC).	Cross-sectional (i.e., no comparison group)	Acute asthma visits that returned to class saved an average classroom time of 3:42 hours per student resulting in a combined total of 166:07 hours saved. A minimum potential cost savings was estimated to be $67,770. Next steps: Demonstrate the fiscal implications and clinical impact of SBHCs and maintaining funding for these services.
Holmes LC, Orom H, Lehman HK, et al.	A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools	2022	Buffalo, New York SBHCs	Students aged 4–14 years N = 10 SBHCs	Project ASTHMA (Aligning with Schools to Help Manage Asthma): Directly observed therapy of controller medications through SBHCs for children with uncontrolled asthma.	Usual care	The multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Next steps: Measure the adherence and sustainability of the self-management component of Project ASTHMA. Future studies can assess this based on medication refills during and after the intervention period.
Stakeholder Partnerships / Multi-level Programs
Mammen JR, McGovern CM, Schoonmaker JD, Philibert A, Schlegel EC, Arcoleo K	A multilevel perspective on goals, barriers, and facilitators of school-based asthma management	2021	Undisclosed location Urban school districts and surrounding local community	N = 66 participants across N = 2 school districts	Interviews with school personnel, nurses, families, and children underscored the importance of including their perspectives of school-based asthma care.	Qualitative (i.e., no comparison group)	There is broad support for school-based asthma management. To optimize school-based programs, there is a need for greater systemic support for school-based care (i.e., resources, time, and training). Next steps: Future directions include allocating sufficient resources to realistically achieve proactive asthma care—including improving communication, access to care, care continuity, and relationships across the care community.
Trivedi M, Hoque S, Luther J, et al.	Incorporating systems-level stakeholder perspectives into the clinical trial design of school-supervised asthma therapy	2021	Central Massachusetts Schools and community	N = 18 stakeholders	Stakeholders were interviewed to identify priority areas for the clinical trial design of the intervention, including selection of study population and health outcomes for evaluation.	Qualitative (i.e., no comparison group)	Systems-level stakeholder input informed refinements to the clinical trial design of a school supervised therapy program including outcome and implementation measures and choice of study population. Next steps: Future research includes eliciting input from systems-level stakeholders before the implementation of interventions to facilitate adoption of research-tested interventions.
Trivedi M, Hoque S, Shillan H, et al.	CENTER-IT: a novel methodology for adapting multi-level interventions using the Consolidated Framework for Implementation Research-a case example of a school-supervised asthma intervention	2022	Central Massachusetts Schools and community	N = 22 stakeholders	An innovative stakeholder engagement methodology for school-based interventions, which moved the field of implementation science forward.	Qualitative (i.e., no comparison group)	Findings demonstrated an empirical use of the Consolidated Framework for Implementation Research (CFIR) and helped clarify the relationship between CFIR domains. Moreover, it showed the dynamic interplay between individuals involved in EBPs and the organization and context in which they worked. Next steps: Future work should evaluate the extent to which multi-level partner engagement, using the CENTER-IT methodology, produces intervention adaptations that improve implementation of evidenced-based practices.
Stock Albuterol Inhaler Programs
Lowe AA, Gerald JK, Clemens CJ, Stern DA, Gerald LB	Managing respiratory emergencies at school: A county-wide stock inhaler program	2021	Pima County, Arizona Schools	N = 229 schools	Described the largest implementation of the Pima County Stock Inhaler for Schools Program.	Cross-sectional (i.e., no comparison group)	Reaching 82% of students in the county, a total of 152 schools (66%) used a stock inhaler, accounting for 1038 events. Most events (83.9%) resulted in the student returning to class, 15.6% resulted in students being sent home. Only 6 events resulted in 911 calls, and 5 of these led to an ambulance transport. Next steps: Future research should examine pre- and post- 9–1-1 calls and EMS transports, school absenteeism and cost-savings.
Volerman A, Lowe AA, Pappalardo AA, et al.	Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement	2021	United States	NA	Outlined the necessary actions that U.S. states must take to effectively pass stock albuterol legislation at the state level.	Policy Statement (i.e., no comparison group)	Albuterol is a safe and potentially life-saving medication that is recommended by guidelines, it is important that schools make quick-relief medications available to all school-aged children, both with and without a documented asthma diagnosis. Next steps: Future work should focus on passing legislation in all states and implementing policy in schools as well as on evaluating the impact of such programs on academic and health outcomes.
Lowe AA, Phan H, Hall-Lipsy E, et al.	School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review	2022	United States	N = 15 U.S. states	Discussed the variations in stock albuterol inhaler laws passed by 15 U.S. states.	Policy Statement (i.e., no comparison group)	There are differences in state laws regarding the types of schools that may implement stock inhalers, in the training requirements for those who are designated to administer stock inhalers and in civil liability protections for schools, trained personnel, prescribing authorities and dispensing pharmacists. Next steps: Stock inhaler programs should be evaluated to understand the impact of the programs on academic and health outcomes.
Supervised Asthma Medication Therapy
Gessner L, Thompson D, Torres R, Fu L	Implementing the Asthma Scripts to School Programs to Facilitate Student Access to Albuterol	2021	District of Columbia	N = 109 students	A pharmacy-school partnership in increasing access to asthma rescue medication for children in school, by sending the child’s rescue inhaler directly from the pharmacy to the school after an asthma-related hospitalization or primary care visit.	Cross-sectional (i.e., no comparison group)	Partnerships with health care providers, families, health plans and pharmacies that arrange medication delivery to children’s schools are feasible and improve at-school medication access. Next steps: Pharmacy-delivered medication programs should be replicated across geographic locations.
Halterman JS, Riekert KA, Fagnano M, et al.	Effect of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity: a 3-arm randomized controlled trial	2022	Rochester, New York Schools	N = 430 adolescents aged 12–16 years	School-Based Asthma Care for Teens (SB-ACT) program 1) Directly observed therapy (DOT) of preventive asthma medications, provided in school for at least 6–8 weeks for the teen to learn proper technique and experience the benefits of daily preventive therapy; 2) 4–6 weeks later, 3 sessions of motivational interviewing (MI) to discuss potential benefits from DOT and enhance motivation to take medication independently.	There were 2 comparison groups: 1) DOT-only for 6–8wks, and 2) asthma education (AE) attention control.	SB-ACT improved preventive medication availability and short-term adherence but did not impact asthma symptoms. Next steps: Further work is needed to create developmentally appropriate and effective interventions for this group.
Shillan HN, Luther JP, Ryan GW, et al.	School-supervised Asthma Therapy is Associated with Improved Long-Term Asthma Outcomes for Underrepresented Minority Children	2022	Central Massachusetts Schools	N = 83 children	Reported sustained improvements in asthma-related emergency department visits and hospital admissions for up to 4 years for children enrolled in Asthma Link™, a school nurse-supervised asthma therapy program for children with poorly controlled asthma in central Massachusetts.	Cross-sectional (i.e., no comparison group)	Participation in Asthma Link, a school nurse-supervised asthma therapy program, was associated with sustained improvements in asthma health outcomes for a study population of largely underrepresented minority and Medicaid-insured children. Next steps: Partnering pediatric practices with school nurses to deliver school-supervised therapy to children with asthma has the potential to make a long-term beneficial impact on reducing health disparities in pediatric asthma.
School-based Telemedicine / Telehealth Strategies
Arenas J, Becker S, Seay H, et al.	The feasibility of a school-linked text message intervention as an adaptation to school-supervised asthma therapy	2022	Central Massachusetts Schools	N = 26 children and their caregivers	Showed the feasibility of the first school-linked text message intervention for children with asthma.	Cross-sectional (i.e., no comparison group)	A school-linked text messaging intervention for pediatric asthma is feasible and acceptable. Children experienced significant improvements in asthma health outcomes. The intervention was well accepted by nurses and caregivers. Next steps: Text messaging interventions should be expanding in underserved communities to improve health equity.

KEY POINTS:

• School-based asthma management is a powerful approach for reaching high-risk children with asthma.

• School-based strategies increase access to guideline-based asthma care, ensure school children have access to their rescue medication and have effectively improved asthma outcomes.

• Novel approaches in school-based asthma management include environmental mitigation, telemedicine/telehealth strategies and supervised asthma medication therapies.

• Partnerships between community and academic partners throughout all steps of the research process can effectively bridge the research-to-practice gap and facilitate the adoption of evidence-based asthma care in schools.

ABBREVIATIONS

DOT

Directly Observed Therapy

IPM

Integrated Pest Management

NAEPP

National Asthma Education Prevention Program

PFM

Peak Flow Meter

SBHC

School-based Health Center

U.S.

United States