Background: School nurses play a central role in assisting elementary school children in managing their asthma, especially those in higher-risk school districts that are at increased risk of uncontrolled asthma. Study purposes are to (1) identify barriers to asthma management by school nurses in higher-risk school districts; and (2) assess the extent to which National Asthma Education and Prevention Program (NAEPP) recommendations are followed in these districts. Methods: School districts containing at least one zipcode with high asthma hospitalization rates among children (0-14?years) in a New York State county were identified. Nurses in 44 elementary schools were surveyed about asthma management during 2008. Both quantitative and qualitative data were collected. Results: Study nurses learned of children with asthma mainly through school records and when students presented with symptoms rather than through parents. The major obstacles to asthma management were communication with parents and parental support. Reluctance of some physicians to diagnose asthma in these children presented a barrier and contributed to the nurses' ability to gain parental cooperation. Adherence to the NAEPP school recommendations was inconsistent. Conclusions: Improvement in the communication among parents, school nurses, and providers is critical to the improvement of asthma management for children in high-risk school districts.