physical activity 

&

in the school

Making 

a

Difference

National Heart, Lung, and Blood Institute

NATIONAL INSTITUTES OF HEALTH
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

National Asthma

Education and

Prevention Program
Introduction....................................................................1

What Is Asthma?............................................................2

Helping Students Control Their Asthma...................3

Recognize Asthma Triggers ............................................3

Avoid or Control Asthma Triggers ..................................4

Follow the Asthma Management Plan ............................4

Ensure That Students With Asthma Have

Convenient Access to Their Medications ......................7

Modify Physical Activities to Match Current

Asthma Symptoms........................................................8

Recognizing Symptoms and Taking 

Appropriate Actions..............................................10

Symptoms That Require Prompt Action........................10

Signs That May Indicate Poorly Controlled Asthma......12

Confusing Signs: Is it an Asthma Episode or a Need

For More Support? .....................................................13

Appendix 1

Student Asthma Action Card ........................................14

Appendix 2

Peak Flow Monitoring ..................................................16

Appendix 3

Using a Metered-Dose Inhaler .........................................17

Appendix 4

Organizations That Can Help You Learn More About

Asthma in the Schools ...............................................18
“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
1

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
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. 

2
3

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

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.
4

Others —like

physical exercise—are 

important for

good health 

and should 

be controlled

rather than

avoided.

■ 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.
5

■ 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 longdistance running.

Following their asthma

management plans 

helped these athletes

become winners.
6

dents 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.

■ 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)

ACTIONS TO CONSIDER

“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
7

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 peventive 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.

■ Provide students with asthma convenient

access to their medications for all on- and offsite 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/guar-dian,

health care provider, and school nurse so

advise.

ACTIONS TO CONSIDER
8

gp

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.
9

■ 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
10

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. 
11

■ Follow the students 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):

— The student is hunched over, with shoulders lifted, and 

straining to breathe.

— The student has difficulty completing a sentence without 

pausing for breath.

— The student’s lips or fingernails turn blue.
12

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.

■ 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.

ACTIONS TO CONSIDER
13

dent’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. 

■ 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.

ACTIONS TO CONSIDER
14
15
16

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.

There are different types of peak flow meters

available.
17

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:

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. 

A. Open Mouth B. Spacer C. In the Mouth
18

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

61 Broadway, 6th Floor

New York, NY 10006

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
(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