Asthma & Physical Activity in the School

Making a Difference

National Heart, Lung, and Blood Institute

National Institutes of Health

National Asthma Education and Prevention Program (NAEPP)

School Asthma Education Subcommittee

Paul Williams, M.D.

Chair, NAEPP School Subcommittee Working Group on

Physical Activity and School

American Medical Association

Mary Worstell, M.P.H.

Chair, NAEPP School Subcommittee

Asthma and Allergy Foundation of America

Ellie Goldberg, M.Ed.

Allergy and Asthma Network/Mothers of Asthmatics, Inc.

Sarah Kaluzny-Petroff

American Academy of Allergy, Asthma, and Immunology

Judy Golding, M.A.

American Lung Association

Pamela Luna, Dr.P.H.

American Public Health Association

Lani Majer, M.D.

American School Health Association

James Joy, Ed.D.

National Association of Elementary School Principals

Vivian Hanes, R.N., M.A., S.N.P.

National Association of School Nurses

Charlene Burgeson, M.A.

National Association for Sport and Physical Education

Rena Large, M.E.

National Education Association

Adria Thomas

National School Boards Association

Rose Cardinal, Consultant

National Heart, Lung, and Blood Institute:

Robinson Fulwood, M.S.P.H.

Virginia S. Taggart, M.P.H.

Chris Krutszch

Table of Contents

Introduction

What is Asthma?

Helping Students Control Their Asthma

      Recognize Asthma Triggers

      Avoid or Control Asthma Triggers

      Follow the Asthma Management Plan

      Ensure That Students With Asthma Have Convenient

        Access to Their Medications

      Modify Physical Activities to Match Current

         Asthma Symptoms

Recognizing Symptoms and Taking Appropriate Actions

      Symptoms That Require Prompt Action

      Signs That May Indicate Poorly Controlled Asthma

      Confusing Signs: Is it an Asthma Episode or a Need

         For More Support?

Appendix 1

      Student Asthma Action Card

Appendix 2

      Peak Flow Monitoring

Appendix 3

      Using a Metered-Dose Inhaler

Appendix 4

      Organizations That Can Help You Learn More About

         Asthma in the Schools

"I'm unstoppable...

If I take my medicine,

I'm fine."

-Student

"Asthma...something that

we can do something about.

You can deal with it.

You can actually

make a difference."

-Leonard Latronica

School Principal, New York City

Lifelong physical fitness is an important goal for all

students.

Yet students with asthma frequently restrict their physical

activities--and about 1 child in every 15 has asthma.

Much of this restriction is unnecessary--children with

asthma can and should be physically active. This presents a

challenge to classroom teachers, physical education teachers

and coaches. The National Heart, Lung, and Blood Institute's

National Asthma Education and Prevention Program encourages

a partnership among students, families, physicians, and

school personnel in managing and controlling asthma so that

students can be active.

It is our hope that this booklet and its companion video,

"Managing Asthma at School: Making a Difference," will help

classroom teachers, physical education teachers, and coaches

help their students participate fully and safely in sports

and physical activities.  

Claude Lenfant, M.D., Director

National Heart, Lung, and Blood Institute

What is Asthma?

Asthma is a chronic lung condition with ongoing airway

inflammation that results in recurring acute episodes

(attacks) of breathing problems such as coughing, wheezing,

chest tightness, and shortness of breath. These symptoms

occur because the inflammation makes the airways overreact

to a variety of stimuli including physical activity, upper

respiratory infections, allergens, and irritants. Exposure

to these stimuli--often called triggers--creates more

swelling and blocking of the airways. Asthma episodes can be

mild, moderate, or even life threatening. Vigorous exercise

will cause symptoms for most students with asthma if their

asthma is not well controlled. Some students experience

symptoms only when they exercise. However, today's

treatments can successfully control asthma so that students

can participate fully in physical activities most of the

time. 

Asthma varies from student to student and often from season

to season. This is why physical education teachers and

coaches need to understand what asthma is and what the

individual needs of their students are. At times, programs

for students with asthma may need temporary modification,

such as varying the type, length, and/or frequency of

activity. At all times, students with asthma should be

included in activities as much as possible. Remaining behind

in the gym or library or frequently sitting on the bench can

set the stage for teasing, loss of self-esteem, unnecessary

restriction of activity, and low levels of physical fitness.

Helping Students Control their Asthma

Getting control of asthma means recognizing asthma triggers

(the factors that make asthma worse or cause an asthma

episode), avoiding or controlling these triggers, following

an asthma management plan, and having convenient access to

asthma medications.  It also means modifying physical

activities to match the students' current asthma status.

Recognize Asthma Triggers

Each student with asthma has a list of triggers that can

make his or her condition worse--that is, that increase

airway inflammation and/or make the airways constrict, which

makes breathing difficult. Table 1 lists the most common

triggers.

Table 1. Asthma Triggers

*    Exercise--running or playing hard--especially in

     cold weather

*    Upper respiratory infections--colds or flu

*    Laughing or crying hard

*    Allergens

     -  Pollens--from trees, plants and grasses,

        including freshly cut grass

     -  Animal dander from pets with fur or feathers

     -  Dust and dust mites--in carpeting, pillows and

        upholstery

     -  Cockroach droppings

     -  Molds

*    Irritants

     -  Cold air

     -  Strong smells and chemical sprays, including

        perfumes, paint and cleaning solutions, chalk

        dust, lawn and turf treatments

     -  Weather changes

     -  Cigarette and other tobacco smoke

Avoid Or Control Asthma Triggers

Some asthma triggers--like pets with fur or feathers--

can be avoided. 

Others--like physical exercise--are important for good

health and should be controlled rather than avoided.

Actions To Consider 

*    Identify students' known asthma triggers and eliminate

     as many as possible.  For example, keep animals with

     fur out of the classroom.  Consult the students' asthma

     management plans for guidance (see the next section).

*    Use wood, tile or vinyl floor coverings instead of

     carpeting.

*    Schedule maintenance or pest control that involves

     strong irritants and odors for times when students are

     not in the area and the area can be well ventilated.

*    Adjust schedules for students whose asthma is worsened

     by pollen or cold air.  A midday or indoor physical

     education class may allow more active participation.

*    Help students follow their asthma management plans. 

     These plans are designed to keep asthma under

     control.

Follow the Asthma Management Plan

A student's asthma management plan is developed by the

student, parent/guardian, and health care provider.

Depending on the student's needs, the plan (see Appendix 1

for a sample) may be a brief information card or a more

extensive individualized health plan (IHP).  Table 2 lists

what asthma plans typically contain.  A copy of the plan

should be on file in the school office or health services

office, with additional copies for the student's teachers

and coaches.  The plan--as well as the student's asthma

medications--should be easily available for all on- and

off-site activities before, during and after school.

Table 2.  Asthma Management Plan Contents

*     Brief history of the student's asthma

*     Asthma symptoms

*     Information on how to contact the student's health

      care provider, parent/guardian

*     Physician and parent/guardian signature

*     List of factors that make the student's asthma worse

*     The student's personal best peak flow reading if the

      student uses peak flow monitoring (see Appendix 2).

*     List of the student's asthma medications

*     A description of the student's treatment plan, based

      on symptoms or peak flow readings, including

      recommended actions for school personnel to help

      handle asthma episodes.

Winners With Exercise-Induced Asthma

What do Nancy Hogshead, Jackie Joyner-Kersee, Bill Koch,

Greg Louganis, Dominique Wilkins, and Jim Ryun all have in

common?

Each is a famous athlete who has asthma. They come from

diverse fields: swimming, track and field, cross-country

skiing, diving, basketball, and long-distance

running.

Following their asthma management plans helped these

athletes become winners.

Supporting and encouraging each student's efforts to follow

his or her asthma management plan is essential for the

student's active participation in physical activities.

Students with asthma need understanding from both teachers

and students in dealing with their asthma. If students with

asthma are teased about their condition, they may be

embarrassed, avoid using their medication, or cut class.

If students with asthma are encouraged to "tough it out,"

they may risk health problems or just give up.

Actions to Consider

*     Get a copy of each student's asthma management plan.

      Review the plan to identify the role of the teacher

      and coach in the student's asthma management plan.

*     Teach asthma awareness and peer sensitivity. For

      example, use the activities in the Asthma Awareness

      curriculum (see "NHLBI" in Appendix 4) to teach K-6

      students about asthma. As students learn more about

      asthma, they can more easily offer support instead of

      barriers to their classmates with asthma.

*     Consult "Managing Asthma: A Guide for Schools" for

      suggested activities for all grades. (See "NHLBI" in

      Appendix 4)

"The role of physical education teachers is in some ways

probably the first line of recognition of children who have

problems with their asthma...They can really help these

children."

-Dr. David Evans

Columbia University

Ensure That Students With Asthma Have Convenient Access to

Their Medications

Many students with asthma require two different medications:

one for daily control and prevention, the other to treat and

relieve symptoms. These medications are usually taken by

metered-dose inhaler (see Appendix 3). Preventive asthma

medications are taken daily and usually can be scheduled for

before and after school hours. However, some students may

need to take preventive daily medication during school

hours.  All students with asthma need to have their

medication that relieves symptoms available at school in

case of unexpected exposure to asthma triggers, or an asthma

episode.  In addition, students with asthma often benefit

from using their inhaled medication 5-10 minutes before

exercise.  If accessing the medication is difficult,

inconvenient, or embarrassing, the student may be

discouraged and fail to use the inhaler as needed. 

The student's asthma may become unnecessarily worse and his

or her activities needlessly limited.

Actions to Consider

*    Provide students with asthma convenient access to their

     medications for all on- and off-site activities before,

     during and after school. These medications prevent as

     well as treat symptoms and enable the student to

     participate safely and vigorously in physical

     activities.

*    Enable students to carry and administer their own

     medications if the parent/guardian, health care

     provider, and school nurse so advise.

Modify Physical Activities To Match Current Asthma Status

Students who follow their asthma management plans and keep

their asthma under control can usually participate

vigorously in the full range of sports and physical

activities.  Activities that are more intense and

sustained--such as long periods of running, basketball,

and soccer--are more likely to provoke asthma symptoms or

an asthma episode. However, Olympic medalists with serious

asthma have demonstrated that these activities are possible

with good asthma management.

When a student experiences asthma symptoms, or is recovering

from a recent asthma episode, exercise should be temporarily

modified in type, length, and/or frequency to help reduce

the risk of further symptoms. The student also needs

convenient access to his or her medications.

Actions to Consider

*    Include adequate warmup and cool-down periods.  These

     help prevent or lessen episodes of exercise-induced

     asthma.

*    Consult the student's asthma management plan,

     parent/guardian, or health care provider on the type

     and length of any limitations. Assess the student and

     school resources to determine how the student can

     participate most fully.

*    Remember that a student who experiences symptoms or who

     has just recovered from an asthma episode is at even

     greater risk for additional asthma problems. Take extra

     care. Observe for asthma symptoms, and check the

     student's peak flow if he or she uses a peak flow

     meter. Review the student's asthma management plan if

     there are any questions. 

*    Monitor the environment for potential allergens and

     irritants, for example, a recently mowed field or

     refinished gym floor. If an allergen or irritant is

     present, consider a temporary change in location.

*    Make exercise modifications as necessary to get

     appropriate levels of participation. For example, if

     running is scheduled, the student could walk the whole

     distance, run part of the distance, alternate running

     and walking.

*    Keep the student involved when any temporary but major

     modification is required. Ask the student to act, for

     example, as a scorekeeper, timer, or equipment handler

     until he or she can return to full participation.

     Dressing for a physical education class and

     participating at any level is better than being left

     out or left behind.

"Every spring my asthma gets real bad. I couldn't even

finish the Presidential Physical Fitness Tests! But this

year my teacher let me do the run inside before the air got

so bad. I got a badge!"

-Student

Recognizing Symptoms and Taking Appropriate Action

Recognizing asthma symptoms and taking appropriate action in

response to the symptoms is crucial to asthma treatment and

control.

Symptoms That Require Prompt Action

Acute symptoms require prompt action to help students resume

their activities as soon as possible.  Prompt action is also

required to prevent an episode from becoming more serious or

even life threatening.  Table 3 lists the symptoms that

indicate an acute asthma episode and the need for immediate

action.  The student's asthma plan and the school's

emergency plan should be easily accessible so that all

staff, substitutes, volunteers, and aides know what to do. 

Symptoms of exercise-induced asthma (coughing, wheezing,

pain or chest tightness) may last several minutes to an hour

or more.  These symptoms are quite different from

breathlessness (deep, rapid breathing) that quickly returns

to normal after aerobic exercise.

Table 3. Acute Symptoms Requiring Prompt Action

*     Coughing or wheezing

*     Difficulty in breathing

*     Chest tightness or pressure--reported by the

      student

*     Other signs, such as low peak flow readings as

      indicated on the asthma management plan.

Actions to Take

*     Stop the student's current activity.

*     Follow the student's asthma management/action plan.

*     Help the student use his or her inhaled medication.

*     Observe for effect.

*     Get Emergency Help

      -   If the student fails to improve.

      -   If any of the symptoms listed on the student's

          asthma plan as emergency indicators are

          present.

      -   If any of the following symptoms are present

          (consider calling 911):

          o   The student is hunched over, with shoulders

              lifted, and straining to breathe.

          o   The student has difficulty completing a

              sentence without pausing for breath.

          o   The student's lips or fingernails turn

              blue.

Signs That May Indicate Poorly Controlled Asthma

Students may have symptoms that do not indicate an acute

episode needing immediate treatment, but instead indicate

that their asthma is not under complete control. Table 4

lists these signs.

The teachers and coaches who supervise students' physical

activities are in a unique position to notice signs that a

child who struggles with physical activity might in fact

have asthma. Because exercise provokes symptoms in most

children with poorly controlled asthma, the student may need

to be evaluated by his or her health care provider. It may

also be that the student simply needs to follow his or her

asthma management plan more carefully.

Table 4. Signs That May Indicate Poorly Controlled Asthma

*     A persistent cough

*     Coughing, wheezing, chest tightness, or shortness of

      breath after vigorous physical activity, on a

      recurring basis

*     Low level of stamina during physical activity or

      reluctance to participate.

Actions to Consider

*     Share observations of the symptoms with the school

      nurse and the student's parents or guardians. Helping

      students get the medical attention they need is an

      important way to help children become active and take

      control of their condition.

*     Provide students convenient access to their asthma

      medication.

Confusing Signs:  Is It an Asthma Episode or a Need for More

Support? 

At some times teachers and coaches may wonder if a student's

reported symptoms indicate a desire for attention or a

desire not to participate in an activity. At other times it

may seem that students are overreacting to minimal symptoms.

It is always essential to respect the student's report of

his or her own condition. If a student regularly asks to be

excused from recess or avoids physical activity, a real

physical problem may be present. It also may be that the

student needs more assistance and support from his or her

teacher and coach in order to become an active participant.

Actions to Consider

*     Talk with the student to:

      -   learn his or her concerns about asthma

          and activity.

      -   offer reassurance that you understand

          the importance of appropriate modifications or

          activity limits.

      -   develop a shared understanding about the

          conditions that require activity

          modifications or medications.

*     Consult with the school nurse, parent/guardian, or

      health care provider to find ways to ensure that the

      student is safe, feels safe, and is encouraged to

      participate actively.

*     If the student uses a peak flow meter, remind him or

      her to use it. This may help the student appreciate

      his or her asthma status and appropriate levels of

      activity.

Appendix 1

Student Asthma Action Card

Graphic omitted:  Student Asthma Action Card

Appendix 2

Peak Flow Monitoring

There are different types of peak flow meters available.

Graphic omitted:  Different flow meters

A peak flow meter is a small device that measures how well

air moves out of the airways. Monitoring peak flow helps a

student determine changes in his or her asthma and identify

appropriate actions to take.

Each student has his or her personal best peak flow reading.

This number should be noted in the student's asthma plan or

school health file. A peak flow reading less than 80 percent

of the student's personal best indicates the need for

action. A student should avoid running and playing until the

peak flow reading returns or exceeds 80 percent of the

personal best.

A peak flow reading is only one indicator of asthma

problems. Symptoms such as coughing, wheezing, and chest

tightness are also indicators of worsening asthma. Follow

the student's individual plan or the school plan if you

observe any of the signs or symptoms listed in the asthma

emergency section or in the student's own plan.

Appendix 3

Using a Metered Dose Inhaler

It is important that students take their medications

correctly. Many asthma medications are delivered by metered

dose inhalers, which are highly effective, but they can be

difficult to use.

The school nurse or health room technician should review

proper use of the inhaler with the student. These

instructions are provided for your information.

How to Use a Metered Dose Inhaler

1. Take off the cap. Shake the inhaler.

2. Stand up. Breathe out.

3. Use the inhaler in any one of these ways:

Graphic omitted:  Inhaler Action Pictures

A. Open Mouth      B. Spacer      C. In the Mouth

4. As you start to breathe in, push down on the top of the

   inhaler and keep breathing in slowly for 3 to 5 seconds.

5. Hold your breath for 10 seconds. Breathe out.

Note: Dry powder capsules are used differently. To use a dry

powder inhaler, close your mouth tightly around the

mouthpiece and breathe in very fast.

Appendix 4

Organizations That Can Help You Learn More About Asthma in

the Schools

National Heart, Lung, and Blood Institute

National Asthma Education and Prevention Program

PO Box 30105

Bethesda, MD 20824-0105

(301)251-1222

American Lung Association

1740 Broadway, 14th Floor

New York, NY 10019-4374

1-800-LUNG-USA

Asthma and Allergy Foundation of America

1125 15th Street, NW, Suite 502

Washington, DC 20005

(202)466-7643 or 1-800-7-ASTHMA

Allergy and Asthma Network/Mothers of Asthmatics

3554 Chain Bridge Road, Suite 200

Fairfax, VA 22030

(703)385-4403

American Association of Respiratory Care

11030 Ables Lane

Dallas, TX 75229-4593

(214)243-2272

U.S. Environmental Protection Agency

Indoor Air Division

"Indoor Air Quality: Tools for Schools"

401 M St., SW (6607J)

Washington, DC 20460

(202)233-9030

Healthy Kids: The Key to Basics

79 Elmore Street

Newton, MA 02159-1137

U.S. Department of Education

Office of Civil Rights

Washington DC 20202-1328

Civil Rights of Students With Hidden Disabilities Under

Section 504 of the Rehabilitation Act of 1973 Pub #91-3,

Appendix 1

The National Heart, Lung, and Blood Institute's (NHLBI)

National Asthma Education and Prevention Program has several

products on asthma in the school:

Managing Asthma At School: Making a Difference (videotape)

Managing Asthma: A Guide for Schools (booklet produced with

the U.S. Department of Education)

Asthma Awareness: Curriculum for the Elementary School

Classroom (booklet)

Managing Allergies and Asthma at School: Tips for School

Teachers and Staff (booklet produced with the National

Institute of Allergy and Infectious Diseases)

To order these and other publications about asthma, write:        

     

NHLBI Information Center

P.O. Box 30105

Bethesda, MD 20824-0105

DISCRIMINATION PROHIBITED: Under provisions of applicable

public laws enacted by Congress since 1964, no person shall,

on the grounds of race, color, national origin, handicap,

or age, be excluded from participation in, be denied the

benefits of, or be subjected to discrimination under any

program or activity (or, on the basis of sex, with respect

to any education program or activity) receiving Federal

financial assistance. In addition, Executive Order 11141

prohibits discrimination on the basis of age by contractors

and subcontractors in the performance of Federal contracts

and Executive Order 11246 states that no federally funded

contractor may discriminate against any employee or

applicant for employment because of race, color, religion,

sex, or national origin. Programs of the National Heart,

Lung, and Blood Institute are operated in compliance with

these laws and Executive Orders.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 95-3651

September 1995