Supervising inhaler use may not improve asthma symptoms among school children

Supervising the use of inhaled corticosteroids (ICS) in elementary school children with asthma may not improve asthma symptoms, prevent school absences or reduce health care use, according to new research presented at the ATS 2017 International Conference.

Researchers conducted a randomized controlled trial of a comprehensive school-based asthma program among 361 children, most of whom were from Hispanic and low-income families, living in Tucson, Arizona. Of these children, 73 percent had asthma that was not well controlled when evaluated by a study physician, but only 36 percent reported taking an ICS to control their asthma. All the children participated in the American Lung Association's Open Airways for Schools program that educates students about asthma, its triggers and its treatment.

The children were randomized into two groups: those who would begin taking their asthma control medication under school supervision immediately and those who would start in the supervised program a year later.

"Adherence to daily controller medication is quite poor," said lead study author Joe K. Gerald. MD, PhD, assistant professor at the University of Arizona College of Public Health, who noted national statistics showing that only about one-fourth of the asthma medicines prescribed for children are filled. "Although there are many reasons for this, we have found affordability and inconvenience to be the most important."

Because children are required to attend school, Dr. Gerald and colleagues hypothesized that providing children with their medicines and then making sure they took the medicine once each day during school would not only increase adherence, but also improve their asthma control.

Students completed the Juniper Asthma Control questionnaire. The questionnaire asks six questions about asthma symptoms, including one about rescue inhaler use. Despite the fact that the study achieved 95 percent adherence at school, the researchers found no difference in questionnaire scores, the primary outcome, between those who took ICS under supervision and those who did not. There was also no difference in secondary outcomes, including quality of life, school absences or health care utilization as measured by use of oral corticosteroids, the emergency department or hospitalization.

Previously, the researchers conducted a similar study in Birmingham, Alabama. That study showed that school-based treatment reduced episodes of poor asthma control in a student population that was mostly low-income and African American. The current study was designed to replicate those findings in another school system with a different student population.

Dr. Gerald said two factors may help explain why the current study did not confirm previous results. Students in the current study had a high rate of absenteeism and their measure of asthma control, based on the Juniper questionnaire, was more stringent that the asthma control measure used in the Birmingham study.

Still, Dr. Gerald noted, both studies demonstrate the feasibility of using schools to ensure medication compliance near 100 percent during school days.

"More study is needed," he said. "Just because this study did not find a difference does not mean that school-based programs cannot be effective."​