Assessing the acceptability and perceived effectiveness of disposable holding chambers among school health staff responding to students in respiratory distress




Winn, Andi
Fulda, Kimberly
Chamblee, Tracy
Allsopp, Leslie C.


Journal Title

Journal ISSN

Volume Title



Purpose: Quick-relief medication (albuterol) for respiratory distress is a critical component of asthma care. For two decades, standing delegation orders (SDOs) for unassigned-albuterol at school have been recommended to ensure students have access to this potentially life-saving medication, but widespread implementation has been limited. Asthma 411 is an evidence-based model for school-based asthma programs that includes unassigned-albuterol within a framework of education and community resources. The Asthma 411 in Consortium in Tarrant County currently supports the implementation of this model with 11 partner school districts. Between 2002-2020, Asthma 411 used nebulizers as the delivery mechanism for albuterol. Due to concern about COVID-19 spread, an alternative delivery system was required beginning in 2020. The efficacy of Metered Dose Inhalers (MDIs) in combination with conventional holding chambers (spacers) is well-supported in the literature, but they are prohibitively expensive for this application. MDIs in combination with disposable spacers were identified as an affordable alternative. Disposable spacers are approved for use in schools based on effective medication delivery under laboratory conditions. No evidence is available about user experience when used for respiratory emergencies at school. Importantly, disposable spacers vary substantively from conventional spacers in design and materials. This study provides preliminary evidence of user experience with disposable spacers and their effectiveness in school-health settings. Methods: Semi-structured questions addressing user experience were embedded within a larger, annual survey regarding satisfaction with Asthma 411; specifically ease of use for school health staff, ease of use for students, and perceived effectiveness. A four-point Likert scale was employed to avoid neutral responses. Where health staff indicated somewhat or very negative experiences, an open-ended prompt requested additional information. Survey questions were reviewed by an interprofessional team with expertise in survey and evaluation research, Quality-Improvement, and the Asthma 411 program. Anonymous surveys were distributed to seven school districts (an estimated 176 school health staff) that had implemented disposable spacers for at least four months. This survey was conducted under North Texas Regional IRB protocol #2017-056. Results: Complete responses regarding MDI/spacer use were received from 146 staff (82.9%). Among these, 62.3% reported use of the disposable spacer for at least one instance of respiratory distress. Among users, 98% reported the MDI/disposable spacer was easy or somewhat easy for them to administer, 94% reported it was easy or somewhat easy for students and effective in relieving symptoms. Challenges were reported among students unfamiliar with spacers and more severe symptoms, and 71% indicated nebulizers should continue to be available for severe distress or children challenged to use the disposable spacer effectively. Conclusions:A strong majority of staff reported the disposable spacers were easy to use and effective for themselves and students. However, a majority also expressed a preference for having a nebulizer available for emergencies. This analysis is ongoing. Despite limitations, the study provides preliminary insights and a foundation for further research to support the effective implementation of national guidelines for school asthma programs.