Annex A: Guidance For Education Authorities, NHS Boards and Schools in Scotland on the Use of Emergency Salbutamol Inhalers
1. This annex provides guidance to education authorities, NHS boards and schools in Scotland on the use of emergency salbutamol inhalers. This guidance is not statutory, but has been developed by the Scottish Government to accompany the guidance to NHS boards, education authorities and schools on "Supporting the healthcare needs of children and young people at school" provided for earlier in this document.
2. The Human Medicines (Amendment) (No. 2) Regulations 2014  , which amended the Human Medicines Regulations 2012  , provides schools across the UK with discretionary powers to buy and hold salbutamol inhalers, without a prescription, for use in emergencies  . The 2014 regulations only applies to salbutamol inhalers. The Human Medicines (Amendment) Regulations 2017 allows schools discretionary powers to buy and hold adrenaline auto-injectors, this is covered at Annex B. There are no other medications which can be held in schools for emergency use which can be purchased by a school.
3. All medications should be provided to schools by children and young people or their families for storage in line with "Supporting the healthcare needs of children and young people at school", including salbutamol inhalers and adrenaline auto-injectors, the spare devices held by the school are only for use in emergencies e.g. if the pupil's own device fails.
4. As stated in paragraph 1 of this annex, the guidance on the use of salbutamol inhalers in schools is for education authorities, NHS boards and applies to schools  .
5. Once purchased, the salbutamol inhalers may only be administered to or used by children or young people who have been diagnosed with asthma, or who have been prescribed a salbutamol inhaler as a reliever medication. The salbutamol inhaler will only be used in an emergency when the child's own inhaler isn't available.
6. While schools are not required to hold a salbutamol inhaler for use in emergency situations, they should be aware that there are many benefits of doing so. For example, it might help to reduce the time a child or young person misses class, and the level of response required when a child has an asthma attack in school. It might provide reassurance to children, young people, parents/carers and school staff to know that there is an salbutamol inhaler on site that may be used in an emergency situation. Importantly, it might help to save the life of a child and young person.
General information in regard to the use of emergency salbutamol in schools in Scotland
Purchase of inhalers/asthma kits
8. Regulation 27 of the Human Medicines (Amendment) (No. 2) Regulations 2014 amends Schedule 17 of the Human Medicines Regulations 2012, and sets out the principles of supply to schools  . The Regulation which provides the power for schools to buy and hold salbutamol inhalers for use in emergencies, is clear that it is for individual head teachers and schools to purchase. Education authorities in Scotland may wish to consider whether they wish to have a local policy on whether the schools in their area are encouraged to hold salbutamol inhalers for use in emergencies and if they wish to secure a supplier from which individual schools can purchase them. Emergency salbutamol inhalers may only be purchased on receipt of an order (ideally on appropriately headed paper) signed by the head teacher of the school. They can be purchased from a pharmaceutical supplier such as a community pharmacy.
The signed order should state:
- the name of the school for which the product is required;
- the purpose for which the product is required;
- the total quantity required.
9. Salbutamol inhalers and spacers for use in emergencies in schools may be bought and/or kept as part of an asthma kit, which may include:
- one salbutamol metered dose inhaler;
- two plastic spacers compatible with the inhaler;
- instructions on using, cleaning, testing and storing the inhaler and spacer;
- manufacturer's information and a checklist of inhalers, identified by their batch
- number and expiry date, on which monthly checks recorded;
- a note of the arrangements for replacing the inhaler and spacers;
- a form to record when the inhaler has been used;
- a physical and up to date list of children permitted to use the emergency inhaler (see paragraph 14 for more information about asthma registers).
Schools may wish to discuss with a community pharmacist the different spacer devices available and what is most appropriate for the age-group in the school. Pharmacists can also provide advice on the use of the inhaler and spacer.
Who can use the emergency inhaler?
10. Emergency salbutamol inhalers must only be used by children and young people who are diagnosed with asthma and/ or for whom a reliever inhaler has been prescribed when their own inhaler isn't available. The emergency salbutamol inhaler must be retained by the school. It cannot be given to the child or young person to take home. If a child or young person requires a replacement inhaler it must be obtained by prescription. It is recommended that at least two named volunteers amongst school staff should have responsibility for ensuring that the plastic inhaler housing (which holds the canister) has been cleaned, dried and returned to storage following use, or that replacements are available if necessary.
11. Written consent from parents/carers of children diagnosed with asthma and/or for whom a reliever inhaler has been prescribed, and, where appropriate, from children and young people themselves, must be sought to ensure that there is agreement in place that the salbutamol inhaler may be administered or used in an emergency situation.
12. This may be handled via any form that obtains consent for a child's own inhaler to be administered at school, or as part of the development of an individual healthcare plan. Consent should be updated regularly, to ensure that any changes to a child or young person's condition can be managed. Therefore, consent may also be obtained at the start of an academic year or when seeking consent for flu or other vaccinations.
13. Arrangements in place for obtaining consent should take account of how the information about the children will be held and used.
14. Maintaining an up to date register or list of children and young people with asthma or a prescribed salbutamol inhaler will help ensure the easy identification of children who may require support with their condition and/or have consent in place to use the emergency salbutamol inhaler. This will be particularly important in larger schools or high schools where the individual health needs of children and young people are not known by school staff. While schools may wish to manage this information via a flagging system on the school management information system, a separate asthma register may also be held. A hard copy of the list or asthma register should be kept with the emergency salbutamol inhaler or asthma kit.
Children and young people who have not been diagnosed with asthma or prescribed a reliever inhaler
15. The salbutamol inhaler should not be used if there is no consent in place or the child or young person has not been diagnosed with asthma or prescribed a reliever inhaler. If any member of staff has reason to suspect a child has asthma or a respiratory condition, they should either speak to the child or young person concerned or notify their parents/carers, so they may seek further medical advice. Any ongoing health or wellbeing concerns may be flagged up to the individual's named person and/or school health team.
16. Where any child or young person is experiencing breathing difficulties – staff should follow their own emergency protocols.
17. Although salbutamol is a relatively safe medicine, as with all medicines, it can have some adverse effects. The adverse effects of salbutamol are generally mild and temporary and are not likely to cause serious harm. Children may feel a bit shaky or experience an increased heart rate. Side effects are very rare but may include dizziness or passing out, muscle pain or weakness or a very bad headache. Where side effects develop, the school health team should be notified immediately.
18. The arrangements in place for obtaining consent for an inhaler to be used in an emergency situation (see paragraph 11-13 of this annex) will help ensure that any risks are appropriately identified and managed. This may be managed, for example, via the questions in the consent forms or via the planning arrangements of an individual healthcare plan.
Storage of the emergency salbutamol inhalers/asthma kit
19. All salbutamol inhalers should be stored as per the manufacturer's guidelines. These usually indicate that inhalers are stored at room temperature and are kept away from direct sunlight and heat.
20. The emergency salbutamol inhalers/asthma kits should be stored in a safe and central location in the school. Larger schools may want to consider having these in more than one location for emergency use ( i.e. in a school with split sites or in the physical education department). The location of the emergency salbutamol inhaler or asthma kit should be known to all staff in the school and accessible at all times. While the salbutamol inhaler or asthma kit should not be locked away, it shouldn't be accessible by children and young people.
21. An emergency salbutamol inhaler or asthma kit should be kept separately to Children's own inhalers (which children will normally carry with them) or any spare inhalers held for individual children and young people. As with all other inhalers, the emergency salbutamol inhaler or asthma kit should be clearly labelled.
Care of the emergency inhalers/asthma kits
22. As part of the arrangements in place at school level, there should be at least 2 allocated members of staff who are clear about their responsibility for the care of the emergency salbutamol inhaler or asthma kit. It is recommended:
inhalers and spacers are used in line with the manufacturers' instructions; the emergency salbutamol inhaler or asthma kit is checked once a month to check whether the salbutamol inhaler and spacer is present and in working order; the salbutamol inhaler has a sufficient number of doses available, this could be done by keeping a form recording the number of doses administered; replacement salbutamol inhalers/spacers/mouthpieces and other kit items are ordered in good time and are available for use.
Disposal of the emergency inhaler/asthma kits
23. Manufacturers' guidelines will usually make recommendations about the disposal of inhalers, although this will normally be every 2 years. It is recommended that spent inhalers are taken to a pharmacy. To do this legally, schools should register as a professional carrier and transporter of waste with the Scottish Environment Protection Agency ( SEPA). Registration is free and can be done online on the SEPA website  .
Early learning and childcare settings
24. Some young children in early learning and childcare settings and the early stages of primary school may not be able to indicate when they need their inhaler or use the inhaler without assistance. Staff in such settings need to be able to identify when children will be required to use their inhaler and the procedures in place for the individual child should be captured in an individual learning plan.
Staff and training
25. All staff working in schools should have a general awareness of providing support to children and young people with asthma. All staff should be aware of:
- whether or not the school holds an inhaler for use in the event of an emergency.
- the signs and symptoms of an asthma attack;
- how to check if a child is diagnosed with asthma, is on the asthma register and holds their own inhaler, how to access information from a child's individual care plan or other written record about the management of their condition;
- where the child's own inhaler should be kept and how to access the emergency inhaler if there is one;
- who to contact for further help and advice;
- know who the contact(s) are for administering an inhaler.
26. There should also be staff trained to support children and young people in managing their asthma, including how to respond in the event of an emergency. Those staff should undertake specific training to be able to:
- be able to recognise when emergency action is required;
- respond to a request for help from another member of staff;
- administer (or support an individual to administer) salbutamol inhalers;
- clean the mouthpiece of the inhaler after each use (spacers should not normally be reused to reduce the risk of cross infection and may be given to the child to take home);
- undertake specific training regularly;
- maintain the emergency inhaler or asthma kit;
- update records regarding the use of an inhaler and pass on this information onto parents and carers.
Information for parents or carers
27. At both education authority and school level, consideration will need to be given to the information available for parents or carers about the use of emergency inhalers in schools. As set out in paragraph 54 of the Guidance on supporting children and young people with healthcare needs in schools, education authorities must publish information about their arrangements in place for additional support for learning so schools may wish to include their policy in schools buying and holding salbutamol inhalers for use in emergencies. Schools may wish to include its arrangements in their school handbook or website.
Summary checklist for education authorities and NHS boards in putting in place a policy on the use of emergency salbutamol inhalers in schools
28. Education authorities and NHS Boards in Scotland may wish to consider whether they wish to have a local policy in place about the use of salbutamol inhalers in emergencies as part of the policy framework in place for supporting the healthcare If so, they may wish to include, for example:
- a clear statement about whether it encourages and supports schools to hold a salbutamol inhaler for use in emergencies;
- the arrangements in place for the purchase, storage, care, use and disposal of the emergency inhalers or asthma kit (subject to manufacturer's guidelines);
- the number of the emergency inhalers or asthma kits that a school might consider holding (depending on the size of the school and the number of sites the school is spread across);
- how and when written consent should be sought in regard to use of the emergency salbutamol inhaler;
- whether information on what to do in an emergency should be specified in a child or young person's individual healthcare plan or captured within another relevant document such as the form that obtain written consent;
- general information on how to recognise and respond to an asthma attack and what to do in the event of an emergency (see page 43); the training that staff in school should expect in regard to the use of any emergency salbutamol inhalers it holds;
- the arrangements in place in schools to maintain an up to date register or list of children and young people who have been diagnosed with asthma and/or prescribed an inhaler including how this reflects whether or not consent is in place for regarding the use of an emergency salbutamol inhaler;
- how schools should record the use of the emergency salbutamol inhaler; how schools inform parents/carers that their child has used an emergency inhaler;
- a point of contact in regard to any queries.
Summary checklist for schools in the use of emergency inhalers in schools
29. In line with Chapter 4 of the Guidance on supporting the healthcare needs of children and young people in schools, when a school chooses to hold an asthma inhaler in school, the school management team will need to refer to any policy arrangement agreed by the NHS board and education authority. They should consider whether it can deliver the procedures set out in this policy framework, and/or whether local adaptions are required that meet the local context of that school (or cluster of schools).
30. In putting in place arrangements about the use of emergency inhalers in schools, the school management team should work with the school health team to ensure:
- staff in school are aware that there is an inhaler held centrally for use in emergencies and the protocol for using the inhaler;
- that there are training arrangements in place for all staff in schools in recognising and responding to an emergency situation, and that staff training is up to date;
- there are arrangements in place for seeking consent from parents or carers, and where appropriate children and young people themselves, about the use of emergency salbutamol inhalers in schools, and how they will ensure that this information is kept up to date;
- someone is responsible for ensuring that the asthma register is up to date, for maintaining the salbutamol inhaler or asthma kits and for ensuring that an up to date asthma register is kept alongside the kits, and the disposal of the components of the asthma kit.
Guidance for school staff on how to respond if a child or young person is having an asthma attack - checklist
Signs of an asthma attack
The child's reliever inhaler (usually blue) isn't helping, and/or any of the following:
- they are coughing, wheezing or short of breath;
- they say their chest feels tight or if a younger child reports that they have
- they are unusually quiet;
- pale skin tone on face;
- they are unable to talk or complete sentences.
STEP 1: If a child is having an asthma attack the following steps should be taken:
Send someone to get the child's own inhaler and spacer. If a child does not have their reliever inhaler in school, use the spare emergency inhaler if there is one available on the school premises (check that the child is confirmed as having asthma and is on the school's asthma register). Stay with the child. If possible do not move the child but allow space and privacy.
STEP 2: Stay calm and help them to take their inhaler
Encourage the child to sit in an upright position. Stay calm and reassure the child. Prime the inhaler (2 puffs into the air). Help the child to take two doses (2 puffs) of their inhaler, one dose at a time separated by at least 30-60 seconds, shaking inhaler between doses. It is recommended the child hold their breath for around 10 seconds, if possible, after inhaling the medicine. A spacer may be used to help ensure that the medicine reaches the lungs. If no better repeat a dose every 30-60 seconds up to 10 doses.
STEP 3: Call 999 for an ambulance if:
Their symptoms are getting worse or they are becoming exhausted. They don't feel better after 10 doses. If you are worried at any time, even if they haven't yet taken 10 puffs.
When calling ambulance give clear details and confirm the entrance to the school if there is more than one entrance. Record all information including the time inhalers were given.
If the ambulance takes longer than 15 minutes, repeat STEP 2 and call emergency services again.
Useful information about the management of asthma
Asthma UK Website https://www.asthma.org.uk/advice/asthma-attacks/
My Lungs, My Life http://mylungsmylife.org/