Typical components of school asthma care include asthma action plans (AAPs), medication administration policies, and emergency response measures. GINA 2025 references AAPs 103 times and stresses that every patient should have an AAP appropriate for their health literacy [11]. Written AAPs can be printed, digital, or pictorial, but are essential for providing translational care to help parents and schools appropriately treat children with asthma using the best evidence in asthma care (Fig. 1). Asthma action plans help improve communication between providers, families, and patients. They lead to improved outcomes, better quality of life, fewer exacerbations, improved attendance and learning, and more equitable care [11].

Framework for implementing updated asthma guidelines into school based care

Depending on when a provider sees a patient, AAPs may become outdated midyear. This makes it hard for the nurse to track expiration dates for both medications and action plans. One solution is to date AAPs like sports physicals, using the student’s current academic year (e.g., 2026–2027). Dating the form for both semesters also eases families’ burden.

School nurses and approved personnel have provided asthma care for many years. However, new guidelines add a key component to school asthma policies: effective medication administration (Table 1). Often, medication administration staff are unaware that the 2-in-1 inhaler (ICS-formoterol) can serve as both an asthma reliever and a maintenance medication if needed. There is also confusion about how many pre-exercise or rescue inhalations are needed. ICS-formoterol is dosed as one puff for pretreatment or rescue. SABA, by contrast, is dosed from 2 to 6 puffs depending on the situation and provider [11]. Additionally, SABA is usually dosed every 4–6 h as needed. ICS-formoterol is given as needed, not on an assigned interval. The onset of action for both ICS-formoterol and albuterol is comparable: effects begin within minutes of inhalation, with bronchodilation in 5–15 min.

The maximum recommended daily dosage of albuterol is up to 12 inhalations. Using more than 8–12 puffs per day signals poor asthma control and the need for medical evaluation [11]. IICS-formoterol use is guided by age-specific thresholds for total daily inhalations rather than strict maximum limits. In children aged 6-11 years, use of more than 8 inhalations in 24 hours, and in those aged ≥ 12 years, use of more than 12 inhalations in 24 hours (both maintenance and as-needed doses) means the patient should contact medical providers. Frequent use of ICS–formoterol does not cause tolerance or loss of effectiveness, which may happen with repeated unopposed albuterol use. Some schools and families do not want to use ICS-formoterol as a rescue therapy because it is not FDA-approved for this use, despite support from both asthma guidelines [11, 13].

Many U.S. action plans, including those from the American Academy of Pediatrics (AAP) and the American Academy of Allergy, Asthma & Immunology (AAAAI), still rely on scheduled rescue dosing, such as “every 4 hours.” This differs from the GINA-recommended approach of as-needed reliever use [14, 15]. The American Lung Association action plan allows for separate dosing of ICS-formoterol and SABAs [16]. Although GINA 2025 provides clear criteria for what constitutes a high-quality asthma action plan, it does not offer a standardized template and instead references Australian action plans, such as the nationally endorsed SMART plan. This plan leaves the rescue dosing section customizable, letting clinicians specify individualized as-needed ICS–formoterol instructions [17]. Some U.S. states have begun modernizing their templates. Virginia’s state action plan, for example, includes both ICS–formoterol as reliever therapy and traditional SABA-based tracks [18]. Some large school districts across the country have implemented simplified action plans for schools that list only the rescue inhaler. These plans treat albuterol and ICS–formoterol as interchangeable, commonly recommending two pretreatment puffs before exercise. Rescue puffs are then allowed without distinguishing between the medications; if symptoms persist, staff are told to give four more puffs of the same rescue inhaler. Some states make an undesignated SABA inhaler available to any student who needs bronchodilation. Albuterol in acute settings can help, but it reinforces albuterol use among asthmatics. This may hinder the transition to the single-inhaler, anti-inflammatory reliever strategy promoted by GINA. These differences between national guidance, state policies, and school practices create a key gap. This gap must be addressed to bring improved evidence-based asthma management into U.S. schools.

School nurses and staff are responsible for implementing updated asthma guidelines. Staffing and resources, though, differ greatly among districts. For non-medical staff, simplified, symptom-based instructions are essential. Ongoing education is important not only for school nurses but also for teachers, coaches, administrators, students, and caregivers. This helps ensure safe and consistent asthma management. Pediatricians, subspecialists, families, and schools must communicate effectively. This ensures properly labeled medications, spacers, and current action plans reach the school. Families also face medication expiration issues—albuterol and mometasone-formoterol usually expire 12 months after pharmacy labeling. Budesonide-formoterol is labeled to expire 3 months after opening the foil pouch. Guidance relating to this labeled expiration date will need to be addressed nationwide. Clear processes keep current supplies in schools. These points stress the need for streamlined support and coordinated systems when using new asthma guidelines in schools.

The legal aspects of medication administration at school are also important. Since 2012, most states have passed laws requiring public schools to stock undesignated epinephrine for anaphylaxis. This is not true for albuterol. State laws regarding the stocking and administration of albuterol vary widely, according to the Asthma and Allergy Foundation of America (AAFA). Currently, twenty-five states allow schools to stock emergency asthma medications [19]. These laws differ by state regarding training mandates, liability protections, documentation requirements, and personnel administration. The states that allow usage of stock emergency asthma medicines are Arizona, Arkansas, California, District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Missouri, Nebraska, New Hampshire, New Mexico, New York, Ohio, Oklahoma, South Carolina, Texas, Utah, Virginia, and Wisconsin. The School-Based Allergies and Asthma Management Program Act (HR 2468), signed in January 2021, encourages states to improve asthma care in schools [19]. It prioritizes federal grants for schools that adopt best management practices. While it does not require stock albuterol, it asks for comprehensive school asthma programs. These programs should: identify affected students, use individualized action plans, ensure staff are trained to give medication, educate school personnel, reduce triggers, and support families. See the wording for each state law at the Asthma and Allergy Foundation of America website [19].