Asthma411: Integrating Evidence Based Medicine and Rapid Review Methodology into a School Health Collaboration

Purpose: Asthma411 is a school program that provides resources and asthma education to families and school nurses in Tarrant County. Asthma411 includes the provision of stock albuterol in schools to aid students experiencing acute asthma exacerbations. For decades, accepted practice for the management of mild-intermittent asthma was largely based on short-acting beta-2 agonists (SABA), primarily albuterol. This changed in 2019 when recommendations from the Global Initiative for Asthma (GINA) no longer supported the use of SABA-only treatment. In 2020, the National Institute of Health Expert Panel Report 4 (EPR-4) also scaled back recommendations for SABA monotherapy. Additionally, there was concern that COVID-19 might be spread by the nebulizers previously used for the administration of albuterol at school. Instead, metered-dose inhalers (MDIs) with spacers were recommended, which also required the use of a common canister (shared MDI) and disposable spacer. The objective for this project was to review the best available evidence to answer three questions: (Q1) Is the provision of short-acting beta-2 agonists (SABA), through standing delegation orders, a best practice given the most recent guidelines from the EPR-4 and GINA (Q2) Does the evidence suggest there may be instances that a nebulizer should be available in addition to an MDI and spacer, to assure effective administration of medication? (Q3) Does sanitizing common canisters with alcohol pads in between users provide acceptable protection against the transmission of infectious agents in school settings? Methods: We conducted a rapid, systematic review using 3 major databases: PubMed, SCOPUS, and CINAHL. Search terms, inclusion, and exclusion criteria were developed and applied for each question. We also conducted an expanded search of national recommendations, from the National Heart, Lung, and Blood Institute, American Academy of Allergy, Asthma, and Immunology, and the American Lung Association. Results: Our initial search yielded 381 articles. After removing duplicates and screening the articles, 31 unique and relevant articles remained. 15 of these articles were applicable to Q1. 21 articles were applicable to Q2, and 6 articles were applicable to Q3. Conclusion: For Q1) regarding the use of stock albuterol and the recent guideline changes, evidence supports the continued use of SABA in the school setting for isolated acute exacerbations as a best practice. For Q2) regarding MDI with a spacer vs. nebulizers, evidence supports the use of MDIs with a spacer as best practice. However, the spacers used in published studies differ substantially from those available for administration of SABA at school. The latter devices are disposable, collapsible chambers constructed of cardboard. A 2021 survey of Asthma411 school nurses indicated that some students had difficulty using disposable devices. Therefore, nebulizers may be considered in emergencies where disposable spacers cannot be effectively used by a student. For Q3) evidence supports the use of 70% isopropyl alcohol to sanitize a common canister used in a school setting. This application of evidence-based medicine and rapid-review methodology has informed Asthma 411 policies and exemplifies approaches to strengthen best practices in school health.