Exercise, once discouraged for asthmatic children but a goal in treatment today, can be managed if care is taken to minimize problematic factors and to incorporate proper medication administration and a good action plan.

 Asthma is a significant health problem for millions of Americans. It is estimated that 17.3 million Americans had a diagnosis of asthma in 1998.1 This compares to 6.7 million in 1980, showing an increase of 158% over that time period. As recently as 1999, it was estimated that 24.7 million people in the United States have been diagnosed with asthma at some point in their lifetimes.2 The figures for asthma rates in children are even more dramatic. The American Thoracic Society reported that 4.8 million children in the United States under the age of 18 were affected by asthma in 1998.3 This makes it the most prevalent chronic illness in children in the United States. In addition, asthma rates in children under the age of 5 increased more than 160% from 1980 to 1994.4 Children in the United States miss more than 14 million school days per year due to asthma,5 and the lost productivity of adults caring for those children results in the largest single indirect cost related to asthma, nearly $1.5 billion per year.6

Goals of Asthma Treatment
Decades ago, many children with asthma were encouraged to lead a fairly sedentary life, and were discouraged from participating in exercise and organized sports to prevent asthma flare-ups. With the advent of today’s effective asthma medications, this is no longer the case. The document Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma,7 released in 1997 by the National Asthma Education and Prevention Program (NAEPP) of the National Institutes of Health, lists the following goals for effective asthma therapy:

  • Prevent chronic and troublesome symptoms (eg, coughing or breathlessness in the night, in the early morning, or after exertion)
  • Maintain (near) “normal” pulmonary function
  • Maintain normal activity levels (including exercise and other physical activity)
  • Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations
  • Provide optimal pharmacotherapy with minimal or no adverse effects
  • Meet patients’ and families’ expectations of and satisfaction with asthma care

“It should be the goal of every parent of an asthmatic child to be sure they are able to participate as fully as possible in sports and other physical activities,” says Janine R.E. Vintch, MD, FCCP, a member of the Respiratory and Critical Care faculty at Harbor-UCLA Medical Center in Torrance, Calif, herself the mother of two young children with asthma. “This is an important part of a normal childhood and helps children to develop self-confidence, discipline, teamwork, and a sense of fun and achievement. In fact, children who exercise regularly tend to be more physically fit and manage their asthma better than those who are inactive.”

Physical Factors Affecting EIB
• Cold air and/or low humidity, particularly during the winter
• Airborne particles and pollutants
• Inhaled seasonal allergens, such as grass, weeds, and trees, especially during heavy pollen periods
• Dust
• Irritants such as strong fumes from smoke, paint, or cleaning compounds
• Automobile exhaust and commercial pollutants, especially sulfur dioxide, nitrogen dioxide, and ozone
• Respiratory infection from a recent cold or asthma episode
• Fatigue and/or emotional stress

The Connection Between Asthma and Exercise
It is well known that exercise can trigger asthma symptoms such as coughing, wheezing, tightness in the chest, and shortness of breath. A susceptible individual with hypersensitive airways is likely to react to vigorous exercise with these symptoms. As children exercise, they tend to breathe more rapidly and deeply, usually through the mouth. This means that cooler and dryer air enters the respiratory tree, triggering a narrowing of the airways and bronchospasm. Typically, this reaction starts during or just a few minutes after exercise, reaches its peak 5 to 10 minutes after stopping exercise, and resolves 20 to 30 minutes later. Exercise-induced bronchospasm (EIB) is very common, occurring in 80% to 90% of individuals diagnosed with asthma.8 In addition, a number of individuals without a formal diagnosis of asthma develop breathing problems with exercise. As many as 50% of people who have allergic rhinitis or “hay fever” and even 10% of “normal” athletes have been found to develop EIB under certain circumstances. EIB is usually categorized by the degree of reduction in the FEV1 or peak expiratory flow rate after 6 to 8 minutes of exercise. A decrease of 15% to 20% is categorized as mild; 20% to 40% is moderately severe; and 40% or greater is considered severe.

Vintch notes that detecting EIB may be a matter of reading subtle clues. “Not every child will display classic symptoms of wheezing with exercise,” she says. “Frequently, the most common symptom may be coughing, especially after exercise is completed. If a child complains that he can’t keep up with the others, or can’t run as far and doesn’t wish to participate, he may be signaling that EIB may be a factor.”

Other clues such as chest congestion, susceptibility to cold, tiring easily, lack of energy, dizziness, frequent colds, or throat clearing may all indicate a possible problem related to exercise.

Factors Affecting EIB
One of the most important factors affecting exercise-induced asthma in children is how well their asthma is controlled. As stated in the NAEPP Guidelines,7 the child should be symptom-free with exercise. Children having difficulty keeping up in gym class, on the playground, or during team sports may not have their asthma under good control. Making sure that they are on effective medication regimens, and that these regimens are being followed during times of physical activity, is extremely important.

Second, consider the physical conditions present during exercise. Such factors as air quality, respiratory infections, or stress can contribute to EIB. (See sidebar.)

The exercise itself also is a factor in EIB. Exercise variables include:

  • The type of exercise. EIB is more likely to be caused by aerobic sports that involve continuous exercise over a longer period of time, resulting in deep and rapid breathing. These include activities such as long-distance running, cycling, soccer, and basketball. An activity that is more intermittent, such as baseball or weight training, might be preferable.
  • The intensity of the exercise. The general rule is that the higher the level of intensity in the activity, the more severe the bronchospasm.
  • The duration of the exercise. Generally speaking, the longer the activity lasts, the greater the EIB. However, 50% of children exercising may have a latent period after the first instance of EIB. They can therefore eliminate some of the problem with adequate warm-up.

Taking Steps to Avoid EIB
The asthma-treatment team of child, parent, teacher, and coach can minimize exercise-related asthma symptoms in many ways. If a child is wheezing actively or showing other asthma symptoms, the exercise should be avoided. The asthma should be under control before attempting participation.

Appropriate medications are key. In a large number of young asthmatics, taking a short-acting bronchodilator (such as albuterol) 15 to 20 minutes before exercise can eliminate problems with EIB. Some may benefit from other medications such as cromolyn sodium taken 30 minutes or so before exercise, either alone or in conjunction with the bronchodilators. In teenage athletes, using a long-acting bronchodilator that can last up to 12 hours, such as salmeterol, may keep asthma symptoms from occurring. A child who has more persistent problems with asthma should be controlled with the use of inhaled corticosteroids to minimize flare-ups. In some cases, anti-leukotreine medication has proven very beneficial in minimizing EIB.

All of these asthma medications are allowed by the official governing bodies overseeing competitive sports, although officials should be informed of their use. However, cold remedies, decongestants, and some other allergy treatments may not be allowed. In addition, rescue medication such as an albuterol inhaler should be readily available to the child at the time of exercise.

Taking time to warm up adequately can make a big difference in reducing asthma symptoms. The young asthmatic can walk, stretch, and perform other low-level activities for 15 or 20 minutes to avoid symptoms. He or she also can run in place for 30 seconds or so, rest for 60 seconds, and repeat two or three times to minimize problems. Cooling down for at least 10 minutes after exercise is also important.

Try to find a good fit in choosing physical activities or sports. One can find champion athletes with asthma in almost every sport, but some present fewer problems than others. (See sidebar.)

It is important to try to avoid irritants that may make the EIB worse. These might include cold dry air (which can be minimized by wearing a scarf or mask) and inhaled irritants such as allergens and pollutants. Children who live in high pollution areas may need a higher level of anti-inflammatory treatment to avoid problems with exercise.

Pacing is very important. The child, parent, teacher, and coach must be alert to signals that EIB may be occurring. There may be quite a variance in exercise tolerance day to day, and exercise level should be tailored to accommodate this.

All members of the treatment team must be aware of the action plan for that youngster in case EIB develops. Knowing what steps need to be taken in an emergency makes it easier to enjoy participation for all concerned.

The Right Spot
Swimming and/or diving is one of the most popular sports for youngsters with asthma. It is generally performed in a warm, humid environment that is soothing to the airways. However, recent studies9 indicate that swimmers who spend a lot of time in that environment may have higher rates of asthma because the chlorine used in pool water combines with urea and ammonia from sweat and urine to form irritating substances such as nitrogen trichloride that irritate the airways. These studies have found that in the top competitive circles, the rate of asthma is nearly 21%, which is considered higher than expected.

Other recommended sports are football, tennis, baseball, volleyball, wrestling, short distance track-and-field events, golfing, and gymnastics. All of these activities require shorter bursts of energy with some periods of rest in between.

In contrast, activities that require longer periods of endurance exercise, or that are performed in a cold air environment, may cause problems with EIB. These include skiing (especially cross-country), skating, ice hockey, field hockey, long-distance running, soccer, and basketball. If the young asthmatic really wants to try any of these sports, it is sometimes possible to train up to the required level. After warming up, a level of exercise can be chosen that can be tolerated for 10 minutes or so. If the tolerance to exercise improves, the exercise period can be increased as tolerated.

Of special note: Scuba diving is not recommended under most circumstances. The cold dry air is very irritating to asthmatics, and participation in this sport is generally contraindicated.

Communication and education are essential components in meeting the goal of symptom-free exercise in young asthmatics. Asthma alliances and initiative groups across the country have been trying to increase understanding of effective treatment for asthma in children. New York City officials recently released results from the New York City Childhood Asthma Initiative, a group that has given intensive training to children, parents, teachers, school nurses, and coaches throughout the city on treating and controlling asthma. They found that rates of asthma hospitalizations for children in New York City declined 35.4% between 1997 and 2000 since implementing these new education strategies. A key component is the School Medication Form, which is filled out for each student by parents, school staff, and the child’s physician. Specific instructions are given on medications for a normal day; exercise and emergency procedures are outlined as well. Children deemed old enough are allowed to keep their medication with them to use as needed.

Andrea Van Hook, vice president of communications for the American Lung Association (ALA) of Los Angeles County, believes that respiratory therapists are key to the asthma education efforts taking place across the country. “We use respiratory therapists as facilitators for many of our community programs to educate children, parents, and others about asthma control,” she says. “Respiratory therapists are ideally suited for this type of patient education.” Nationwide, respiratory therapists go into schools with the ALA Open Airways programs for grades three, four, and five, which help children, teachers, and parents learn how to minimize asthma episodes at home and at school. Other opportunities include the Little Lungs Program for children of ages up to 5 and the A Is for Asthma program for preschoolers.

Respiratory therapists are frequently needed for “asthma camps,” where children learn how to participate in physical activities while effectively managing their asthma. They also can assist with Asthma and Allergy Foundation of America programs such as “Air Power” track-and-field events and “Splash and Dash” swimming and running programs. Many community health fairs and asthma fairs look for informed professionals to aid in educating families on issues such as asthma and sports. Some respiratory therapists make presentations to school boards, teacher meetings, parent-teacher meetings, and other forums to make participation in sports and physical exercise safe for all children with asthma. Materials are available through the National Heart, Lung, and Blood Institute, the American Lung Association, and the Asthma and Allergy Foundation of America to help in these efforts.

Peggy Walker, RCP, RRT-NPS, is a Research Associate at the Rehabilitation Clinical Trials Center, Harbor-UCLA Research and Education Institute, in Torrance, Calif.

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