Asthma Management

Asthma Truths and Myths

Asthma is a serious health concern:

Yes, it is. People with Asthma should see a doctor at least twice a year to help keep it under control. There are many medications that can be prescribed to do this.

No one dies from Asthma nowadays:

Yes, they do. Approximately 400 people die every year, in Australia from Asthma.

Asthma is due to nerves or anxiety:

No, it is not. Calming someone down will not stop Asthma symptoms. Only medication will but trying to keep them calm is always recommended.

Exercise is bad for people with Asthma:

Some Olympic athletes have Asthma but it needs to be under control and advice from a doctor is essential. Warming up and cooling down and using prescribed medication means that asthmatics can have a normal healthy life, including doing regular exercise.

Taking steroids for Asthma is dangerous:

Steroid treatment for Asthma is different from the anabolic steroids that people sometimes illegally take to increase performance in sports. With doctors’ advice, these medications can be life-saving and keep them under control.

Over 2 million Australians have Asthma:

This is a true fact. Australasia leads the world in incidence and varieties of asthma. 1 in every 10 Adults, 1 in every 7 adolescents, 1 in every 4 primary school-aged children.

Asthma is one of the most common reasons for hospital admissions in children:

True. As we have mentioned before, Asthma is a serious health concern

 

What happens in an Asthma Attack?

Asthma is a respiratory condition in which the casualty suffers the onset of constricted passages in the lower airway and it becomes progressively more difficult to breathe.

• Muscle spasm – The layer of muscles surrounding the airways (including those small ones in the lungs) constricts or tightens
• Inflammation – The inside of the airways swell up and make the tubes for breathing smaller
• Excess mucus – More than usual amounts of mucus are made in each airway and also makes the tubes for breathing smaller

What Causes Asthma? (TRIGGERS)

In asthma, symptoms are made worse by ‘triggers’.

Triggers can be something that you:

• Catch: eg. flu, cold
• Breathe in
• Do: eg. exercise
• Feel
• Take in, eat or drink

It is important to know what triggers set off a person’s asthma symptoms

Every person’s asthma is different and not all people will have the same triggers. Triggers can include:

• Viral respiratory infections
• Exposure to known allergens, eg: dust mites, pollens, animal dander, moulds
• Exposure to chemicals or other occupational sensitisers
• Exposure to irritants, eg: cigarette smoke, perfume
• Reflux
• Drugs, eg: aspirin, ibuprofen, and beta-blockers
• Foods, eg: nuts, seafood
• Food additives – sulphite preservatives, colourings, metabisulphite, monosodium glutamate (msg)
• Changes in the weather, exposure to cool air
• Exercise
• Emotion

ALLERGIC TRIGGERS

Pollens

Pollens are in the air and come from plants. People with Asthma are more affected during springtime.

House Dust Mites, Dust and Mould

Dust mites are in our bedding. Cleaning dust and mould should be done away from those affected and microfibre cloths can be used so little dust is put into the air.

Animal Dander

This is not the fur on the animal that causes Asthma. It is the dead skin coming off and the presence of urine and saliva that causes signs and symptoms.

Food Preservatives/Additives

Fresh food is always best.

Food additives that may trigger asthma include:

• Metabisulfite/Sulphur dioxide (220-228)
• Tartrazine (synthetic yellow dye [102])
• Monosodium glutamate (621)
• Acetylsalicylic acid (ASA)

Some of these additives may also occur naturally in some foods.

NON-ALLERGIC TRIGGERS

Smoke

Could be in the air from:

Bush Fire

Unless advised to evacuate, stay indoors when there is smoke; close all windows and doors, and block air vents. Use an air conditioner if available.

Cigarettes

Almost 40% of children with asthma live with people who smoke. Smoking is one of the biggest triggers for people with asthma.

Factories

Air pollution includes gases, chemicals fumes, particulates, and odours that can cause discomfort or harm to a person

Asthma sufferers must be moved away from these hazards.

Infections

Colds and flu (viral infections) are common triggers causing Asthma signs and symptoms. The doctor’s advice will help.

Emotions

Strong emotions such as laughing, crying and yelling as well as anxiety and stress. Laughing is a common trigger for wheezing in children but should not be avoided. If wheezing happens frequently, then a change in asthma reliever medication may be required.

Medications

Non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, and aspirin which are frequently used to reduce fever or treat pain affect between 10% to 20% of adults with asthma. These medications should be totally avoided by known medication asthma sufferers as the results could be severe or even fatal.

Weather changes

Certain weather conditions, from extreme heat to extreme cold, from rain to thunderstorms, humidity, and air pressure fluctuations can prompt an asthma attack. Although it’s not possible to control the weather, a person can take steps to limit asthma attacks. Identify the weather triggers and then do what you can to protect yourself from the elements.

Thunderstorm Asthma

Epidemic Thunderstorm Asthma is a phenomenon where a large number of people develop asthma symptoms over a short period of time. It is thought to be triggered by an uncommon combination of high pollen levels and a certain type of thunderstorm.

This occurs when pollen grains from grasses get swept up in the wind and carried for long distances. Just before the storm, some burst open and release tiny particles that are concentrated in the wind, and blown down to the ground, where people can breathe them in. They are small enough to go deep into the lungs and can trigger asthma.

They are not yearly events and mainly occur from October through to December in the southeast region of Australia.

The above excerpt is from Asthma Australia: asthma.org.au

Industrial chemicals and odours

Fragrances and strong odors have been characterized as triggers that may aggravate asthma symptoms. These may include car exhaust fumes, perfumes, paint, aerosol sprays such as hair lacquer or furniture polish, and cooking smells.

Known triggers should be readily avoided.

Reflux

Asthma and acid reflux often occur together. Acid reflux can worsen asthma and asthma can worsen acid reflux — especially severe acid

reflux, a condition known as gastroesophageal reflux disease (GERD).

Exercise

The Asthma sufferer needs to warm up and cool down before and after exercise. Also, they may need to use a reliever before exercising.

Asthma Action Plans

These should be completed by a doctor or nurse and kept with the casualty’s medication.

They should be followed when treating the casualty as everyone’s asthma is different.

They should be updated every 12 months, when there is a moderate or severe attack, if any details change or if they need a reliever 3 times a week. Children should see a doctor every 6 months to update their Action Plan.

After a person has had a moderate or severe Asthma attack, you should recommend that they go back to their doctor and update their Action Plan and get their medication checked in case they need something else or more medication.

Please read through the following Action Plans so that you are familiar with them when you come to your course. Either one may be used and provided for a child suffering from Asthma:

• First Action Plan by Asthma Australia
• Second Action Plan by National Asthma Council Australia

Good Asthma Control

If a person’s Asthma is under control, they are well and they will:

• Not be waking at night
• Be able to exercise normally
• Be free of symptoms when waking and when going to sleep
• Have hardly any symptoms during the day
• Be using a reliever less than 3 times a week

Asthma Risk Minimisation and Management Plan

They are PREVENTATIVE which means they are filled out to try and prevent Asthma attacks, and signs and symptoms from happening in the first place. They show what can be done to reduce the risks and prevent Asthma.

Relievers and Preventative

Relievers:

• Used in Asthma Emergencies, works in minutes.
• Blue inhaler colour is known as Bronchodilators
• Used to relieve symptoms, can be called puffers or inhalers. You can use someone else’s but they can’t touch it with their mouth. Use a rolled-up piece of paper to separate the puffer from the mouth or use a spacer
• Relaxes the tight muscles around the airways
• Medications inside could be: Ventolin, Asmol, Bricanyl, Airomir, Atrovent

Preventers:

Not to be used in Asthma Emergencies, taken regularly every day to prevent Asthma

• Brown, orange, yellow or white inhaler
• Used to reduce the severity of attacks
• Reduces inflammation and mucus in airways
• Medications inside could be: Pulmicort, Intal Forte, Qvar, Alvesco, Flixotide, Singulair (tablets), Tilade

Symptom Controllers:

• Not to be used in Asthma Emergencies, taken regularly every day to control Asthma
• Green, Light Blue
• Long-acting Relievers (for up to 12 hours) used with preventers
• Relaxes tight muscles around the airways
• Medications inside could be: Oxis and Serevent (green), Foradile (light blue)

Combination Medication

Contain two medicines within one inhaler, known as a ‘fixed-dose combination’ inhaler. The fixed-dose combination enables the accurate and safe delivery of the right dose of the two medicines in combination.

• Not to be used in Asthma Emergencies, taken regularly every day to control Asthma
• Purple, Red
• Combination of preventer and symptom controller
• Medications inside could be: Seretide (purple) and Symbicort (red)

Accuhalers

An Accuhaler is a breath-activated device – this means that it will release a dose of medication when you inhale on the mouthpiece. Doses of the medicine are preloaded in foil-covered blister packets inside the device

• Has a dose counter
• Can be used by adults and children over 8
• You need to be able to breathe in strongly so it’s not suitable for young children

Why Use a Spacer?

With a puffer or inhaler, medication shoots to the back of the throat, and the casualty swallows some, breathes some in and medication is found all around inside the body. This does not harm the casualty but a lot more medication enters the lungs with a spacer. Reliever or preventer medication is taken directly with the puffer approximately 10% of the medication ends up in the lungs. 10% stays in the mouth on the tongue or back of the throat 80% ends up in the stomach. You can see this in the ultrasound pictures below.

When taken through a spacer approximately 80% of the medication ends up in the lungs where it is needed.

Types of Asthma Spacers

A spacer is usually made out of plastic and is shaped like a cylinder or a football. It has a mouthpiece at one end and a hole at the other end where the puffer can be inserted.

Spacers come in two sizes, small volume and large volume. Children under five should not be using a large Volumatic spacer. 

Spacers can have a mask attached to them for young children. This makes it easier for them to breathe in the medication, and therefore more effective.

For someone who does not have their spacer, they can use a spare that is brand new. Once a spacer has been used, it is owned by the user. Even when cleaned, the spacer may not be used by anyone else at all.

If an asthma sufferer has been given a spare spacer to use (e.g. the schools), it can be purchased as it is theirs from then on.

Spacer Care

Clean the spacer before its first use and then regularly to prevent it from discolouring or getting mouldy. A spacer should be replaced annually if used daily, or earlier if deterioration has occurred.

• Spacers should be cleaned once a week.
• Take the spacer apart and wash it in warm water containing a little dishwashing detergent or mild soap.
• Do not rinse the spacer. It is important to leave residual soap on the inside lining of the spacer, to minimise static electricity in the spacer. Static electricity causes the medicine to get trapped in the walls of the spacer, instead of entering the child’s lungs.
• Allow the spacer to drip dry. Do not wipe the spacer dry with a tea towel or kitchen paper – it should air dry. This can be done overnight.
• Put the spacer back together.
• Do not allow anyone else to use the child’s spacer.

The above excerpt is from The Royal Children’s Hospital Melbourne: rch.org.au

Correct Usage

• Shake the puffer every time before firing a puff into the spacer
• Put only one puff into a spacer at a time
• Breathe in from the spacer as soon as puff is released so that medication does not settle to the bottom

Nebulisers

These are air-pump-driven devices that deliver medication through a mask or mouthpiece. They are useful for the elderly, or children under two, who have difficulty with a puffer, spacer, and mask.

They are also useful for people with severe life-threatening asthma.

Types of Asthma

MILD ASTHMA

• Cough
• Wheeze
• Minor difficulty breathing
• Little to no difficulty speaking in sentences (less breath getting in and out – less able to talk)

MODERATE ASTHMA

• Persistent cough
• Moderate to loud wheeze
• Obvious difficulty breathing
• Able to speak in short sentences only

SEVERE ASTHMA

• Gasping for breath (may have little or no wheeze due to little movement of air)
• Severe chest tightness
• Inability to speak more than one or two words per breath
• Feeling distressed and anxious
• Little or no improvement after using “reliever” medication
• ‘Sucking in’ of the throat and rib muscles, use of shoulder muscles, or bracing with arms to help to breathe
• Blue discolouration around the lips (can be hard to see if skin colour also changes)
• Pale and sweaty skin
• Symptoms rapidly get worse when using a reliever more than every two hours.

As well as the previous symptoms, young children can appear restless, unable to settle or become drowsy.

A child may also ‘suck’ in muscles around the ribs and may have problems eating or drinking due to shortness of breath. A child also may have severe coughing and vomiting.

An asthma attack can take anything from a few minutes (quite suddenly after being exposed to an allergy trigger) to a few days to develop (e.g. the person gets a cold).

An asthma attack can become life-threatening (an asthma emergency) if not treated properly, even in someone whose asthma is usually mild or well controlled.

If someone is getting an asthma attack, follow the instructions in their personalised asthma action plan

Asthma First Aid

Asthma First Aid Charts

Please read through the following two Asthma First Aid Charts. Place either of these around the school or childcare centre so that everyone knows how to treat Asthma.

When treating an Asthma sufferer, follow their personalised Asthma Action Plan. If it doesn’t work or if it is the first time they have had Asthma, follow the 4 x 4 x 4 Management Plan as per the following Asthma First Aid Charts:

• 1st – Asthma First Aid Chart by Asthma Australia
• 2nd – Asthma First Aid Chart by National Asthma Council Australia

Preliminary Step:

When starting DRS ABCD, check for all possible dangers to the first aider or casualty. Also, check for Environmental Dangers (triggers) like:

• Windy, Cold Weather, or Thunderstorm
• Smoke or Industrial Pollution
• Pollens

You may need to move the casualty away from these Dangers (e.g. take them inside a building or away from some plants). If there are no dangers, don’t move them. Take their medication to them.

Step 1:

• Confirm the casualty’s history of asthma episodes and follow their personalised Asthma Action Plan
• Sit the casualty comfortably upright
• Be calm and reassuring
• Do not leave the casualty alone

Step 2: Emergency procedure with spacer and puffer (4 x 4 x 4 Management):

1. Check the expiry date on the blue/grey puffer
2. Remove the cap
3. Shake the puffer, then insert the puffer into the spacer
4. Place the mouthpiece of the  spacer into the mouth and close the lips
5. Press the button on top of the puffer
6. One puff, 4 breaths in and out through spacer
7. Repeat points 3 to 6. One puff, 4 breaths in and out through spacer
8. Repeat points 3 to 6. One puff, 4 breaths in and out through spacer
9. Repeat points 3 to 6. One puff, 4 breaths in and out through spacer

 This equals a total of four puffs and sixteen breaths  

Step 3:

• Wait 4 minutes
• If the casualty has not improved and still cannot breathe properly, give four more separate puffs (repeat points 2 to 9 as per Step 2)

Step 4:

• If they are still no better, immediately ring 000 for an ambulance and say someone is having an Asthma attack
• Keep giving 4 x 4 x 4 Management until the ambulance arrives and the paramedics take over
• In a timely manner, accurately convey to relieving emergency services:
  o Asthma management steps undertaken
  o Signs and symptoms that were observed
  o If known, the casualty’s name and age

Step 5:

• Contact parent/guardian or other emergency contacts
• Document in a timely manner, presenting all relevant facts and report the incident
• Follow workplace debriefing procedures for emergency asthma incidents

Once you have provided first aid to a casualty and handed over responsibility to the paramedics, it is recommended that you undergo a debriefing.

• Talk through your actions with your manager, other first aiders, psychologists, doctors, family, or friends.
• Take time to calm down and reflect on your actions, don’t go straight back to work if the incident occurred in a workplace setting.

Note: Anyone around the incident such as the casualty, the first aiders, and onlookers which may include children can be affected by stress from the trauma that had occurred. Psychological stress can badly affect people of all ages either during or after the incident. For example, talk with children about their emotions and responses to the incident. Provide support as required.

If the person is known to have Anaphylaxis, give an adrenaline autoinjector FIRST (Anaphylaxis Action Plan), then an asthma reliever (Asthma First Aid)

Immediately phone (Triple Zero) 000 for emergency assistance:

• If the person becomes unresponsive and not breathing normally, commence resuscitation – CPR
• If the person’s asthma suddenly becomes worse or is not improving
• If the person is having an asthma attack and a puffer/reliever is not available
• If you are unsure if it is asthma

Immediately elicit support, especially for an asthma emergency. Have bystanders fetch the personalised asthma plan, reliever medication & spacer, and ring 000 while you stay with the casualty. As applicable, additional emergency support can be provided by a doctor, nurse, or designated first aid officer.

 REMEMBER

• Use the casualty’s own inhaler if possible. If not, use the first aid kit inhaler if available or borrow one from someone else. Use a rolled-up piece of paper between the casualty’s mouth and the puffer
• DO NOT use a spacer that has been touched by another person’s mouth, EVEN IF CLEANED!
• Blue reliever puffers are quite safe and unlikely to harm, even if the person does not have asthma
• Their use may be lifesaving
• An overdose cannot be given by following emergency instructions
• Keep some puffers and spaces spare in your First Aid Kit!
• Take them to activities and camps
• Keep them stocked and ready at all times

Asthma Video:

Asthma in Australian Childcare Services

• If a child has a first time Asthma attack, qualified (Asthma) staff can administer the puffer/reliever without ringing “000” for authorisation
• All staff must know the Workplace Asthma Emergency Management Plan at all times
• This also refers to Long Day Care, Family Day Care, OSHC and Pre-schools
• The Centre must have an Asthma Action Plan, for each child with a puffer, from the parents, which has been completed by a General Practitioner (Doctor) or specialist
• The Centre must show the policy and provide a copy to parents. This includes a Risk Minimisation, Communication Plan, and Asthma Emergency Management Plan
• Staff can give medication for Asthma and Anaphylaxis but must call “000” and a parent/guardian
• Procedures for incident, injury, trauma, and illness reporting to be followed
• An appropriate amount of First Aid kits must be fully stocked and available where the child is being educated

 Incident, injury, trauma and illness policies & procedures and reporting Law Section 174, Regulations 12, 85-87, 168, 177-178, 183

• Centres must have incident, injury, trauma, and illness policies and procedures in the event that a child:
  (a) is injured, or (b) becomes ill; or (c) suffers a trauma.
• A Centre must ensure that a parent of a child is notified as soon as practicable, but not later than 24 hours after an occurrence, if the child is involved in any incident, injury, trauma or illness
• The details of the occurrence must be correctly and accurately recorded within 24 hours
• The occurrence records are stored safely and securely until the child is aged 25 years
• That the Regulatory Authority is notified of a serious incident which includes:
  (b) death of a child; or (b) where medical assistance was required; or (c) attendance of emergency services at the education and care service premises was sought, or ought reasonably to have been sought.

It is important that all first aid incidents, inside or outside of work, be recorded in writing.

Each workplace should have appropriate documentation for the reporting of illness or injury.

These documents need to be completed in full and should not be altered.

Therefore, correction fluid or pencil should not be used on these documents. Outside of the workplace, if an incident occurs, first aiders should take accurate, brief, and clear notes and keep them on hand in case an investigation takes place.

Notes should include:

1. The time of the incident
2. The date of the incident
3. The location of the incident
4. What the first aider found upon arrival
5. What actions the first aider carried out
6. Any changes in the casualty’s condition
7. Any witness details
8. Handover to medical professional’s details
9. Did the casualty recover and relieve the first aider of their duty of care?

All documentation should be signed and dated by the first aider and stored securely to maintain confidentiality. Keep your notes clear and easy to understand and ensure you write down exactly how things are presented to you.

National Regulation 136 requires that your emergency Asthma management qualifications be current. All applicable staff must be trained in Asthma management every 3 years.

The Safe Work Australia First Aid in the Workplace Code of Practice recommends that first aiders should attend refresher training on a regular basis to maintain their first aid knowledge and skills, and to confirm their competence in providing first aid including Asthma.

In workplaces where children are in attendance, there is a regulatory requirement for a Working with Children check and/or Police Check to be conducted for any person working on the premises.

Asthma Risk Assessment

What are the five steps to risk assessment?

Step 1: Identify hazards, i.e. anything that may cause harm

Step 2: Decide who may be harmed, and how

Step 3: Assess the risks and take action

Step 4: Make a record of the findings

Step 5: Review the risk assessment

When conducting a risk assessment, ensure that all areas of the facility/premises are reviewed. Also, allow for:

• Off-site locations – conferences or meetings
• Off-site locations – excursions, field trips, camps
• Off-site locations – student placements

Examples of how to reduce asthma triggers at your workplace are:

• Reduce exposure to animal dander:
• Ensure that furred animals do not enter the workplace
• Use high-efficiency air cleaners
• Where possible have non-carpet flooring

Asthma Risk Minimisation

Reduce exposure to mould spores:

• Remove sources of dampness, make needed repairs
• Remove sources for mould such as old books and magazines
• Regularly clean and change all filters (building and equipment)
• Correctly ventilate and dry bathrooms

Reduce exposure to pollen:

• Mow grounds out of hours
• Plant a low allergen garden and away from windows
• Keep windows closed

Reduce exposure to dust mites:

• Where possible have non-carpet flooring
• Where possible use blinds instead of curtains
• Use dust-proof pillow wrap for any pillows and cushions, and pillow/cushion cases should be washed regularly
• Vacuum each week (after school hours) using a vacuum with a high-efficiency particulate air filter
• Dust regularly (after school hours) using an anti-static or damp cloth

Reduce non-allergy triggers for asthma:

• Avoid contact with others that have the flu or a cold
• Avoid physical activity on days with high air pollution e.g., bush fires, smoggy, dusty and stay indoors with windows and doors closed while using air conditioning
• Stay indoors for certain weather conditions, e.g., cold air or thunderstorms
• Avoid food additives, such as sulphites in food and drink, tartrazine, certain food colouring, monosodium glutamate
• Only use cleaning products and chemicals with strong odours after school hours
• Maintenance that may require the use of chemicals, such as painting, should be conducted during school holidays
• Avoid the use of strong perfume, cologne, aftershave, etc.
• Avoid all cigarette smoke inside or near the premises
• Use non aerosol-based pest control products

Asthma Risk Minimisation Strategy

Practice Activity 

Special Note:

You will be developing a ‘Risk Minimisation Strategy’ in the classroom as part of your practical assessment. This will be a group activity with each student contributing to the creation of the strategy.

For the following slides, you will a see sample of the assessment and be undertaking a practice session in completing some aspects for creating an Asthma Risk Minimisation Strategy.

Asthma Risk Minimisation Strategy – Sample of classroom assessment

A Workplace Asthma Emergency Management Plan (WAEMP) must be implemented if a child suffering from Asthma is enrolled at the school or centre.

The plan should incorporate:

• All Individuals’ Asthma Management Plans
• Emergency first aid management for asthma
• Identification of staff competencies and training requirements
• Identification and risk assessment of avoidable and manageable asthma triggers
• All relevant stakeholders, which may include: Carers/parents, workplace first aiders, management, students, teachers, nurses, casual staff, coaches, specialist staff, early childhood staff, food industry staff such as carers, canteen staff, school camp providers, volunteers, etc.
• Who to contact after an event;
  o Parent, guardian, or nominated emergency contact
  o Workplace supervisor, manager
  o School principal, centre director

Implement and establish a communication plan to raise awareness of Asthma and its first aid management in line with the WAEMP. Both the WAEMP and communication plans should be reviewed annually to maintain their effectiveness.

The effectiveness of a Workplace Asthma Emergency Management Plan (WAEMP) should be reviewed:

• Annually
• If the child’s medical condition, insofar as it relates to asthma, changes
• As soon as practicable after a child has a severe or life-threatening asthma attack at the school or centre
• After re-occurring asthma episodes

Special Note:

You will be completing a WAEMP in the classroom as part of your practical assessment. This will be a group activity with each student contributing to the creation of a WAEMP.

For the following series of slides, you will a see sample of the assessment.

Communication Plan:

The principal of a school/director of a centre is responsible for ensuring that a Communication Plan is developed in consultation with all relevant stakeholders and it must include strategies on how to respond to an anaphylactic reaction by a student in various environments including:

• During normal school activities including in the classroom, in the schoolyard, in all school buildings and sites including gymnasiums and halls
• During off-site or out-of-school activities, including excursions, school camps, and at special events conducted or organised by the school
• Students with a medical condition that relates to respiratory conditions and the potential for asthma triggers and their role in responding to an asthma episode by a student in their care

Stakeholders may include: Carers/parents, Workplace first aiders, Management, Students, Teachers, Nurses, Casual staff, Specialist staff, Early childhood staff, Food industry staff such as carers, canteen staff, School camp providers, Volunteers, etc.

The communication plan should be annually reviewed to maintain its effectiveness.

Special Note:

You will be completing a Communication Plan in the classroom as part of your practical assessment. This will be a group activity with each student contributing to the creation of a Communication Plan.

You will a see sample of the assessment in the following slide

Evaluate Incident Response

Once the documentation and reporting process has been completed it is vital that the following steps take place:

• Review and assess the first aider’s and organisation’s responses to the incident and adherence to the casualty’s Asthma Action Plan
• The effectiveness of risk minimisation strategies is reviewed
• The Workplace’s Asthma Emergency Management Plan (WAEMP) is reviewed
• Reviews can generate improvements for processes and procedures. If so:
  o Implement improvements as soon as possible
• Communicate improvements and updates to all stakeholders