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
INTRODUCTION
WHAT IS ASTHMA?
HELPING STUDENTS CONTROL THEIR
ASTHMA
RECOGNIZING SYMPTOMS AND TAKING
APPROPRIATE ACTIONS
APPENDIX 1: Peak Flow
Monitoring
APPENDIX 2: Using a Metered-Dose
Inhaler
APPENDIX 3: 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
INTRODUCTION
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
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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.
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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.
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Recognize Asthma 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
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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.
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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.
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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 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.
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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 3) 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 3)
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"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 2). 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.
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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.
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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
medallists 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 warm-up 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.
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"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.
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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.
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.
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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.
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):
- 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.
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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.
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.
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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.
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.
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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.
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APPENDIX 1: Peak Flow
Monitoring
There are different types of peak flow meters
available.
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.
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APPENDIX 2: 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 |
- Take off the cap. Shake the inhaler.
- Stand up. Breathe out.
- Use the inhaler in any one of these
ways:
A. Open Mouth: Hold inhaler 1 to
2 inches in front of your mouth (about the width of two fingers). |
B. Spacer: Use a spacer/ holding
chamber. These come in many shapes and can be useful to any patient. |
C. In the Mouth: Put the inhaler
in your mouth. Do not use for steroids. |
- As you start to breathe in, push down
on the top of the inhaler and keep breathing in slowly for 3 to 5 seconds.
- 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.
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APPENDIX 3: 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
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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
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