Although all 50 states permit children with asthma to self-carry personal inhalers, access to emergency inhalers may be as low as 14%.1 Every child could have access when needed if albuterol were allowed to be stocked at schools.1 This problem affects all children: rich or poor, private-schooled or public-schooled, urban or rural. There are many reasons why a child might not have an inhaler at school: they forgot it, they could not afford it, they unexpectedly ran out, or it might have expired. When children do not have albuterol, schools have few options. A parent may not be immediately accessible or able to respond promptly. Even if they can, the attack often worsens with delays. Generally, the school must call 911. This may lead to an ambulance transport and an emergency department visit; furthermore, such events take children out of the classroom and impede their learning. In a study of asthma-related deaths in the school setting between 1990 and 2003, authors cited 38 reported asthma school deaths, which the authors believe was an underestimate.2 Thirty-one percent of these children died while waiting for medical intervention.2 These adverse events are likely avoidable with stock inhalers because access to rescue medications is a key component of guideline-based response in asthma emergencies.3,4 Schools can purchase a single inhaler containing albuterol to administer to anyone who experiences the sudden onset of cough, shortness of breath, and chest tightness that signals an asthma attack.

Each of the states that have adopted stock albuterol policies did so by amending their stock epinephrine laws to include albuterol. Currently, stock albuterol legislation exists in 12 states: Arizona, Georgia, Illinois, Indiana, Missouri, Nebraska, New Hampshire, New Jersey, New Mexico, New York, Ohio, and West Virginia. This strategy was employed because amending an active policy or legislation is often easier than creating a new legislation. In addition, the advocacy and impact for stock epinephrine laws in schools are prime examples of how motivated parents and physicians collaborated to pass public health policy. Between March 2012 and July 2016, the number of states with stock epinephrine laws increased from 7 to 49.5 This demonstrates clearly that when one state adopts a health policy, other states can quickly follow, using the inaugural policy as a model. The Illinois Department of Public Health reported that within the first year of implementation of the policy in 2014–2015, there were 65 epinephrine administrations recorded, with 58% being persons without a previously known severe allergy.6 Schools transferred fewer children to the emergency department because of anaphylaxis.6 The same opportunity to adopt policies to allow stock albuterol inhalers at schools currently exists.

Considering the lack of nurses in most schools, an important aspect of stock albuterol legislation is determining who can administer the drug and how that is worded in the legislation. The stock inhaler policies mostly allow any trained personnel to administer the drug, but few of these policies included a clause that waived liability.7 We strongly urge inclusion of the waiver of liability because this is a major barrier to implementation.7,9 Other components important in designing legislation include (1) the ability of school contractors to be indemnified, (2) use of the word “agent” instead of “employee or nurse” so that chaperones and volunteers may be covered, (3) pharmacy and prescribing laws allowing inhalers to be written and dispensed to schools, and (4) open wording such as “general respiratory distress” so that those without a known diagnosis of asthma may also benefit. Prescribers of the stock albuterol may vary, but the lead physician at the health department is a common solution for who will prescribe albuterol to the district. Administration of medications also varies by school but is generally done by a nurse or a designated school representative in a nurse’s absence.

Advocacy for stock inhaler policy in Illinois was organized by Illinois-based respiratory advocacy and legal aid organizations with the help of the Arizona counterpart organizations. In Arizona, local lung advocacy associations were also the primary organizers with physician advocates. Concerns fielded by these groups included those of liability, potential allergic reactions to albuterol, and concern for the inability of lay personnel to recognize asthma symptoms or miss another illness, such as pneumonia, among others. In Illinois, these groups published a policy brief informed by multiple provider organizations, stakeholders, and leaders in the field of asthma in which they highlighted the need for stock albuterol and addressed concerns.7 Concerns were further addressed via conference calls regarding the low risk of side effects and allergic reactions to albuterol, promising an active role of clinicians in the implementation of stock albuterol laws, with special regard to inhaler technique and recognition of respiratory distress. In Arizona, the groups had multiple in-person meetings with stakeholders and used physician and expert testimony at the House and Senate health committees to address these concerns. There have been no documented adverse events to stock albuterol in schools. Details of the timeline of stock albuterol passage in Arizona are publicly available.9 Health care providers seeking to support such laws in their home states can contact such advocacy organizations for assistance.

Stock albuterol has the potential for great impact by allowing children access to this life-saving medication. In the urban Sunnyside Unified School District in Arizona, a stock albuterol program demonstrated 222 stock albuterol administrations in 55 children among 20 schools during a 1-year timeframe. The district saw a 20% reduction in emergency calls and 40% fewer emergency medical services transports in the same year; however, these differences were not statistically significant.8,9 Missouri also reports, through their Resources for Every School Confronting Unexpected Emergencies program, 1720 stock albuterol uses in 2014–2015, with 84.5% of children returning to class.10 Stock albuterol is not only being implemented in Arizona but is highly used. Barriers to stocking albuterol include funding and presence of certified staff to properly administer. The cost of an inhaler and a few holding chambers is ∼$100. We recommend portable spacers, which may be easier for schools to store. Implementation strategies to disseminate and fund stock albuterol are underway in Illinois. Nursing administration within the school districts leads these efforts. In the state of Illinois, the Illinois State Board of Education is creating a protocol to help guide districts.

Stock albuterol legislation allows schools to have access to rescue asthma medications that can be available to all students who may be experiencing an acute asthma exacerbation. Many children lack the diagnosis of asthma, asthma management plans, and albuterol at school, posing a significant risk to the health of children and youth with asthma. Stock albuterol can be a solution. We strongly urge our colleagues to undertake such actions in other states to ensure such policies are universal.

Drs Pappalardo and Gerald both drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Pappalardo has worked with Boehringer-Ingelheim on their Speaker’s Bureau and in consultation in the past, starting in 2016 and ending August 2017. From August 2014 to July 2017, Dr Pappalardo met with pharmaceutical representatives who provided lunch. Dr Gerald received a product donation from Thayer Medical Corporation for the LiteAire Spacer for projects conducted in 2014 and in 2018.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.