Asthma: Lessons that won’t take your breath away

On the back of every classroom door in St Brigid's Girls' National School in Killester, Dublin, there is a notice about the "Five-step rule" for managing asthma attacks.

The printed sheet is one of the visible signs that the north Dublin school has become the first in the capital to be deemed "asthma-friendly", having recently received a bronze award from the Asthma Society of Ireland.

One in five children in Ireland is diagnosed with asthma – and we have the fourth highest prevalence of asthma in the world, with more than 470,000 people affected. While no one cause can be pin-pointed, genetic, climatic and environmental factors all play a part.

Considering the incidence of asthma, it makes sense to tackle the problem early, which is why the society is keen to raise awareness through schools.

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Asthma is a chronic condition that can prevent children from fulfilling their potential at sport and study. At worst, it is fatal.

Every week, one person in Ireland dies from the condition. And every 26 minutes, somebody attends a hospital emergency department because of uncontrolled asthma.

One of the (many) “bad mother” moments etched in my memory is the sight of our elder son trailing wheezily in the wake of his exuberant younger brother up a misty Mount Leinster. The stark contrast between the two of them suddenly made me realise it was time to stop being blasé about the older boy’s suspected asthma. I couldn’t get home quick enough to go to the GP and start to get serious about managing the condition properly.

Over-sensitive airways

Asthma makes it hard to breathe because it affects the small tubes that carry air in and out of the lungs. In sufferers these airways are over-sensitive to allergens such as dust and animal hair; they swell and start to fill with mucus – some say it is like breathing through a straw. The muscles in the chest tighten as they struggle to get enough air in and out of the lungs.

Triggers for an asthma flare-up vary from individual to individual but common ones include: dust, pollen, cigarette smoke, perfume, infections such as the common cold and flu, and breathing in cold air, which is why there was a spike in calls to the asthma society’s advice line during the snow in March.

“The more information people have, the less likely you are to have a problem,” says the new chief executive of the Asthma Society of Ireland, Sarah O’Connor. Distributing information about how to recognise asthma and manage it better is core in the school awards scheme, for which there are bronze, silver and gold levels.

One incentive for such awareness-raising could be “so they are not the school that has an asthma attack”, she suggests. Apart from the danger to the affected child, watching somebody have an asthmatic attack is stressful and traumatic, she points out, so best avoided for other children and teachers.

Aside from averting or dealing with an emergency, a school community has other vested interests in doing everything possible to ensure asthma is well managed. On average, children with the condition miss 10 days of school a year.

“It is about minimising those, which any teacher or parent will want,” says O’Connor. Research by the society has found that 60 per cent of people with asthma do not have their condition under control.

Medication misunderstanding

She believes there is “often a fairly fundamental misunderstanding about asthma medication and how to take it”. There are two common types of inhalers – the controller and the reliever. People are using the reliever when they should instead be talking to health professionals about the controller, she says.

“If you are using the reliever more than two times above your prescribed level in a week, that means your asthma is not fully under control.”

St Brigid's school decided to embrace the scheme after an approach from Lorraine Nolan Daly, who is doing a Masters in Leadership at the Royal College of Surgeons in Ireland (RCSI), where she works as a programme manager for the science research network. She lives in Beaumont and grew up with asthma in the family – her mother, Sheila Nolan, suffers from the condition.

“I have been a witness to the impact it has had on her and her family,” she says. Researching the potential for better education on the condition, she found that while the asthma society had devised a schools’ programme in 2015, there had been little uptake, and no primary school in Dublin had signed up.

Nolan Daly believes some rural schools showed a little more interest because they are likely to be further away from emergency healthcare services. However, just six achieved awards between 2015 and 2017, according to the asthma society.

School programme

Apart from home, school is the place where a child will spend the most time, she points out. And one of the aims of the programme is to increase understanding among all children and teachers, to ensure a child with asthma can feel comfortable taking medication in the classroom.

Revitalising the schools scheme is one of the society’s key aims for 2018, says O’Connor, who was appointed chief executive in March. “We’ve been reliant on schools coming to us and we want to be more proactive this year.”

They want to tackle the stigma younger children with asthma can feel when taking their medication in the company of classmates. It’s equally important, she stresses, that teachers understand that someone with asthma has to take medication every day, at the time allocated, to prevent problems with breathing.

“Occasionally, there are teachers who think it’s looking for attention or it is intruding on school space.” The society, she says, would like to hear from parents and teachers with ideas on the best way to promote understanding of the condition among children, maybe something that worked for them.

O'Connor attended an education talk at St Brigid's for parents and children, given by a nurse from the society, Pam Quinn.

“There were quite a lot of parents there who were quite concerned about their kids and their kids’ health,” says O’Connor. These were parents who, in the absence of a definite diagnosis, hadn’t reported to the school that their child had asthma. Often children can not be formally diagnosed until they are about seven or eight.

But the parents were quite anxious, she says, a) about the prospect of diagnosis and b) that their child was in school without an inhaler, without the teacher knowing and without everybody being briefed.

Before the programme, only four out of 436 pupils at St Brigid’s were listed as having asthma, as identified by parents to the school. Now there are 11 on the register.

“Parents don’t realise they need to tell the school; they need to fill out forms,” says Nolan Daly, whose own three children have recently been diagnosed with borderline asthma. They have inhalers now and she has alerted their school.

She hopes other schools will sign up for the “asthma-friendly” designation. “It doesn’t seem a big ask and I don’t know why we shouldn’t have it in all schools.”

Having identified the gap in communications on the subject, she has also met the Minister for Education, Richard Bruton, to look for action on teaching children about asthma.

“It would reduce absenteeism and the knock-on effect would be [savings in] healthcare,” she says. The total economic cost to the State of asthma is estimated to be €533 million a year.

Resource pack

Paula Byrne, who is a member of the Parents' Association at St Brigid's and has a child with asthma, helped to champion the move towards "asthma-friendly" status, with the backing of the principal, Lorna Diffley. Materials in a resource pack from the asthma society were distributed around the school and children were given leaflets to take home to parents, as well as the education evening being organised.

Byrne’s older daughter, Emily (16), was seven when she was diagnosed. She used to attend St Brigid’s, where her younger sister, Megan (11), is in fifth class.

“I always thought asthma was not being able to catch your breath but my daughter had a dry, barky cough.” Byrne admits she was “absolutely shocked” at the diagnosis; it had never occurred to her, with no history of it in the family.

A part-time secretary at St Brigid’s, she is delighted the school has done this programme. “It wanted to make sure children who had asthma had an inhaler with them and were aware of how to use it. So, it’s a case of children informed, teachers informed, parents informed” – all for the good of the children.

Symptoms that parents should look out for include a persistent cough and coughing at night, says O’Connor. Also wheezing, shortness of breath and having trouble exercising.

Having asthma herself, she recalls being diagnosed when she was about eight, in the 1980s.

“I have really strong memories of it. My parents had gone out and we had a babysitter who was listening to me wheezing and I think she got a fright.

“She called my parents home and I got brought to the sitting room from bed, which was quite notable in my head because once bedtime happened, bedtime happened. I can actually recollect my dad making me hot chocolate from the saucepan – not with water – with proper boiled milk. I went to the doctor and was diagnosed almost straight away.”

She had it all through her teens and into college years, “especially if staying in damp houses”.

“I was very lucky that I never had an asthma attack but I would have had chest infections and steroids and antibiotics and inhalers. What I do as an adult now is take medication every single day that manages both the asthma and what would have been really significant hay fever or allergy symptoms for me.”

A change in medication within the past three years means asthma is something that has gone to the back of her mind, she says, rather than struggling with symptoms every day. She would encourage other chronic asthma sufferers to check if there is newer medicine that would bring more relief.

O’Connor adds that she is no longer suffering symptoms “that would have been a really daily annoyance, irritation and unhelpful from a work scenario – you can’t be sitting beside somebody who sneezes 200 times a day and find it in anyway enjoyable”.

To mark World Asthma Day (May 1st), the Asthma Society of Ireland is running a one-stop shop for asthma at Dublin's St Stephen's Green Shopping Centre, 10am-4pm, where people can meet a respiratory nurse to get support on how to manage their asthma. For more information see asthma.ie. The society's free advice line is tel 1800 44 54 64.

Asthma in Ireland: the numbers

- 1 person dies every week
- 1 child in every 5 diagnosed with asthma
- 6 in 10 of those children don't take medication correctly
- 1 person attends a hospital emergency department for uncontrolled asthma every 26 minutes
- 10 days of school a year missed, on average, by children with asthma
- €533 million is the estimated annual economic cost of the illness

Under attack: symptoms of an asthma attack

- Severe cough, wheeze, shortness of breath, chest tightness or any combination of these.

Five-step rule on how to deal with an attack

1. Take two puffs of reliever inhaler (usually blue) immediately.
2. Sit upright and stay calm.
3. Take slow steady breaths.
4. If there is no immediate improvement, take one puff of reliever inhaler every minute. (An adult can take up to 10 puffs in 10 minutes; children under six years can take up to six puffs in 10 minutes.)
5. Call 999 or 112 if symptoms do not improve after following steps 1 -4.
If an ambulance does not arrive within 10 minutes repeat Step 4.

For bystanders

DOs
- Do offer a spacer device (plastic cylinder) for use if one is available.
- Do listen to what the person having the asthma attack is saying; they have experienced attacks before.

DON'Ts
- Don't put your arm around or lie down someone having an asthma attack, this will make it harder for them to breathe.
- Don't worry about them using too much reliever; it is safe to take extra puffs of reliever during an asthma attack.
- Don't leave the person having the attack on their own.
- Don't take the person having the attack to hospital in your own car unless absolutely necessary; another adult should accompany you.