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Is breathing trouble or cough during or after exercise holding your child back? |
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Is your child "very tired," "out of shape" or unable to keep up in the playground or on the field? |
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Does your child avoid physical exertion? |
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BREATHE EASY, PLAY HARD is an awareness program that seeks to educate parents and children, and also professionals who are involved with kids on a daily basis (gym teachers, coaches, school nurses, etc.) about:
1) The basics of asthma
2) The signs and symptoms of asthma not presently being recognized
3) Evaluation and proper treatment
4) How to respect asthma but not let it prevent any child from exercising or competing with the rest or the best. |
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We want all kids - whether or not they have asthma - to exercise and reap the myriad long-term benefits of exercise, including:
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Long-term cardiovascular health from aerobic conditioning |
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Weight control |
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Improved asthma control |
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Improved hand-eye coordination |
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Improvement in motor skills and coordination |
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Increased self-esteem |
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Improvement in mood (elevated endorphins) |
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Stress relief |
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Development of anger management skills |
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Decreased use of recreational drugs |
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EXERCISE PRODUCES HEALTHY CHILDREN AND HEALTHY CHILDREN BECOME HEALTHIER ADULTS!!
Guide for kids and parents: Every child or teen with asthma - from the couch potato (the frustrated or discouraged athlete), to the recreational athlete, to the elite, competitive athlete - has the ability to reach his or her fullest potential. We must all find our inner athlete and exercise to become healthier in the long run. This educational and inspirational mini-course can help you thrive despite a diagnosis-just like some of the world's top sports stars and Olympic athletes have.
Guide for school and athletic professionals: "Breathe Easy Play Hard" will heighten your awareness of a condition that occurs today in at least 1 in 10 children in the U.S. It will help you recognize the signs and symptoms in undiagnosed children who have asthma - the many "kids flying under the radar". It will also raise your index of suspicion for exercise-induced asthma or bronchospasm in the more competitive, elite athlete.
This site will also give you a quick, complete course in all aspects of Asthma, and an understanding that, with proper Evaluation and Treatment, no child should be sidelined because of it. When symptoms are treated and controlled, a child with asthma can be just as active as anyone else: the sky's the limit.
What is exercise-induced asthma (EIA) and exercise-induced bronchospasm (EIB)?
EIA is asthma triggered by physical activity, especially aerobic exercise. Up to 90% of children and teens with asthma experience significant worsening of their symptoms with exercise. For kids with mild asthma, the appearance of exercise-related symptoms may be the only indication that the child has asthma. These symptoms include shortness of breath, chest tightness and/or cough during or soon after physical exertion. EIB refers to the spasm and resulting obstruction or narrowing of the airways that occurs with or without previously diagnosed asthma.
What causes the airway spasm and symptoms in EIA and EIB?
Normally, when we exercise, our respiratory rate, or number of breaths per minute, significantly increases. We also take in a greater percentage of air through our mouths, bypassing the body's protective mechanism (the nose) that usually warms and humidifies the air that we breathe in before it reaches our lungs. Breathing through the nose actually warms and moistens air to about 80% humidity, making it well-tolerated by the lungs. The inhalation (breathing in) of cold and/or dry air that comes with exercise triggers spasm in the irritable and hypersensitive airways of children and teens with asthma. This leads to symptoms. It is likely that spasm occurs as a result of changes in the water content of the airways, and the release of chemicals from inflammatory cells in the airways.
Recognizing the child with asthma: What symptoms should you look out for?
At first, it may seem confusing or difficult to differentiate between a child or teen who is poorly conditioned or "out of shape," and one who is experiencing respiratory symptoms or avoiding exercise due to asthma. But looking for the following signs and symptoms - and asking the right questions - will help you identify those who are struggling with underlying asthma. Remember: Symptoms of exercise-induced asthma generally last for 30 to 60 minutes while breathlessness from deconditioning, or "being out of shape," last for less than two minutes.
Typical symptoms of asthma include:
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Coughing (audio) |
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Chest tightness |
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Shortness of breath |
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Difficulty breathing |
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Wheezing, a high-pitched whistling sound (audio) |
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These symptoms develop within several minutes of initiating exercise, or soon after the completion of the aerobic exercise.
Other associated symptoms of asthma can include:
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Tiring easily, not being able to "keep up," or being "out of shape" |
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Appearing shaky, pale or very flushed following exercise |
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Avoiding physical exertion |
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Holding the chest while running |
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Chest pain or bad headache during or after exertion |
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Poor or inconsistent performance at any level of conditioning |
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Observing a child and asking direct, specific questions about the existence of any of these symptoms is very important. Many children and teens are reluctant to report symptoms because they are embarrassed or frightened, and they don't realize what is happening to them. Athletes may be afraid that they will no longer be able to play.
How can a parent or coach recognize when a child with asthma is having difficulty?
A child with exercise-induced asthma (EIA) is in trouble when:
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There is no symptom improvement within 15 minutes of using a rescue inhaler |
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The child/athlete is bent over with shoulders lifted and is struggling to breathe |
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The child/athlete is extremely breathless and has difficulty speaking |
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There is pulling in of the chest or neck muscles |
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There is a gray or blue discoloration of lips/nail beds |
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What should a parent or coach do when a child with asthma is having difficulty?
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Stay calm |
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Encourage slow, deep breaths |
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Stay with the child but ask someone to CALL 911 |
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Suggest an initial evaluation or reevaluation by an asthma specialist after the child is stabilized and before returning to competition. |
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But please remember to suggest this evaluation as a matter of appropriate management and safety, not as a punishment. When the child/teen athlete is improved and free of symptoms, he or she should be encouraged to return to action as soon as possible.
It is always important to reassure kids and teens that:
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Asthma is more common than they think |
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Asthma is not a stigma |
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With an accurate diagnosis and proper treatment, they can play and compete at the highest levels. |
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How prevalent are EIA and EIB, and can children and teens become successful athletes even if they have it?
Asthma affects approximately 9 million children in the U.S. - or 1 out of every 10. We know that exercise-induced asthma (EIA) occurs in up to 90% of these already-diagnosed children and teens. But since asthma is under recognized or misdiagnosed, the total number of kids affected by EIA in this country is probably higher than 9 million.
Who else suffers from breathing difficulties due to exercise-induced bronchospasm (EIB)?
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Up to 10% of the general population |
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An average of 30% of elite and competitive high school, college and Olympic athletes without a diagnosis of asthma (a range of 12-50% depending on the sport) |
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These are alarming statistics. However, children with EIA and EIB can absolutely participate successfully in sports.
Kids can compete at the highest level in almost all sports if the condition is properly diagnosed and treated and if certain important precautions are taken. Many professional athletes - basketball, ice hockey and football stars, for example - have stayed at the top of their game for years despite EIA. And a significant number of gold medal-winning Olympians have asthma too.
What is the proper way to evaluate a child whom you suspect has exercise-induced asthma (EIA)?
Referral to a pediatric pulmonologist or asthma specialist familiar with EIA is advised. The doctor will begin by performing a complete asthma evaluation.
First, a family and patient medical history is taken. Questions will then focus on the activities which most frequently trigger symptoms as well as the athletic goals of the patient and the parents. Then, after a thorough physical examination is completed, one or more of the following pulmonary function tests will be performed to confirm or rule out a diagnosis of EIA:
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Resting spirometry, before and after bronchodilator |
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A field or treadmill exercise-challenge study |
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Bronchoprovocation test with methacholine (See Evaluation section for more detail) |
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Bronchoprovocation test with cold air inhalation |
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Bronchoprovocation with a 5% CO2 mixture (eucapnic voluntary hyperventilation). This test is currently used by the International Olympic Committee to document EIB in Olympic athletes. |
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Exciting new tests on the horizon:
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Osmotic challenge testing with mannitol (dry-powder) has been demonstrated to have both a high sensitivity and specificity for EIB |
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Nitric oxide (NO) measurements in exhaled air: Nitric oxide is formed by the lining cells in the airways and is a marker of airway inflammation. NO is found in much higher concentrations in the exhaled air of people with asthma. |
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How is a child or teen with EIA treated? What precautions or tips can be followed to assure improved success in both recreational activities and competitive sports?
Successful participation in physical activity for children with EIA or EIB depends, first and foremost, on an appropriate maintenance treatment plan, which leads to good asthma control.
Preventative Medications:
Use a fast-acting beta-agonist bronchodilator (such as albuterol, maxair, proair, proventil, ventolin, xopenex) 15 to 20 minutes prior to starting exercise. This is a very effective method of preventing or lessening the bronchoconstriction triggered by exertion.
Other inhaler medications taken prior to exercise may be useful as well. Certain anti-inflammatory drugs such as mast cell stabilizers (intal, tilade) may offer additional exercise protection, especially when used in combination with a fast-acting bronchodilator 15-20 minutes prior to the initiation of exercise.
With any inhaler regimen, it is essential to utilize the correct inhaler delivery device and proper technique for maximum benefit.
Although it is not an FDA-approved indication thus far, there is evidence that when taken daily, a leukotriene modifier (singulair), another type of anti-inflammatory medication, is effective in preventing EIB.
A pediatric pulmonologist will be able to determine which medication regimen is best for each individual child.
Other precautions and tips:
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After taking the preventative inhaler, follow up with a 5 to 10 minute warm-up routine before beginning any vigorous exercise. This routine can perhaps be a slow jog or even running in place. This will serve to both warm up the muscles and open the airways prior to the start of more vigorous exertion. |
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As a general rule, remember to hydrate well prior to exercise. |
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If you're sensitive to outdoor pollen or mold-and you're exercising outdoors-be sure that seasonal allergen sensitivities are controlled, as this can be an additional trigger for symptoms. You can do this by taking preventative allergy medications (oral and/or nasal sprays), or finding another venue - such as an indoor facility - to exercise in during peak allergen periods. |
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Since cold air is a potent trigger for EIA and EIB, breathe through the nose as much as possible. Inhaled air will be warmed and humidified by the nose before reaching the lungs. Or, if possible, use a ski gator or scarf to cover the nose and mouth when exercising outdoors. |
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A cool-down period at the end of exercise is advisable. Stretching and jogging in place after vigorous exertion may slow the changeover of air in the lungs from cold back to warm, decreasing the chance of symptoms occurring after the completion of exercise. |
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Limit indoor and outdoor exercise during a cold or viral upper respiratory infection, and limit outdoor activity when air pollution levels (ozone, for example) are high. |
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And if symptoms do arise: stop exercising and take a break. |
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Are some sports better than others for children with EIA?
The degree to which exercise provokes airway narrowing or bronchoconstriction in asthma is influenced by both the intensity of activity (and how hard one breathes) and the temperature and humidity of the air. Therefore, the incidence of EIA and EIB is significantly higher in highly aerobic, high ventilation endurance sports - basketball, hockey, soccer and long-distance running, for example. Vigorous and sustained activity in cold-weather sports, such as ice hockey and cross-country skiing, is associated with an even higher incidence of EIA and EIB: As many as 50% of elite cross-country skiers have EIB. Meanwhile, stop-and-go sports that use short energy bursts such as baseball, football, volleyball, short track and field events, golfing, wrestling, and gymnastics are less likely to trigger asthma. And lower intensity activities such as jogging and recreational biking are even less difficult for children with asthma.
However, with the proper medical treatment, training and precautions, kids and teens with asthma can excel in many sports.
Swimming is frequently considered an excellent sport choice for anyone with asthma. As an activity, swimming offers great aerobic and lung conditioning, upper-body toning, year-round availability and an environment where the inhaled air is already warmed and humidified.
There is an important caveat, however, as it relates to children and teens who swim in chlorinated, poorly ventilated indoor pools. Researchers from Brussels have reported that regular indoor pool use by children is associated with an increased prevalence of asthma. This is likely due to the inhalation of an irritant that is generated when chlorine comes into contact with organic material such as urine or sweat. This may also account for a paradoxically higher incidence of asthma in elite, competitive swimmers who have been swimming since early childhood. Increasing public awareness about this issue and the use of pool disinfectants that do not contain chlorine will hopefully alleviate this concern.
A similar situation may occur for ice hockey players, and speed and figure skaters: Irritants from the chemicals used to resurface the ice may act as additional asthma triggers.
Finally, while scuba diving is not an aerobic exercise, it presents important issues and challenges to kids and teens with asthma. It has been traditionally recommended that children diagnosed with asthma should not dive because:
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There is a reduced breathing capacity or inability to expand the lungs related to the underwater depth, which may further compromise someone with asthma. |
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The narrowing of the airways and excess mucus that is present in asthma may cause an obstruction to airflow during ascent and exhalation, increasing the chance of a serious air pocket developing in the chest (pneumothorax, pneumomediastinum). |
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Scuba diving is usually done in an isolated location, removed from emergency medical care in the event that it is needed. |
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Recently, the Undersea and Hyperbaric Medical Society (UHMS) prepared more liberal guidelines that take into account the severity of asthma and how well it is controlled around the time of a dive. Further education about the potential risks - and consultation with a physician - is strongly advised.
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What are the ultimate goals of Breathe Easy Play Hard?
The BEPH program has been developed to heighten national awareness about youth asthma, specifically exercise-induced asthma. Phases of the program now in progress include:
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A comprehensive educational program for athletic directors, coaches, trainers, gym teachers, school nurses, and others involved with children on a daily basis |
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Assessment of all Middle School/High School athletes for EIA or EIB |
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Community-wide assessment for EIA or EIB of children in playgrounds |
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While these goals are ambitious, they will help us achieve the vital mission of Breath Easy Play Hard (LOGO) which is to ensure that all children and teens with asthma can:
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Exercise to their full potential |
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Do all the things they wish to do |
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Achieve their dreams |
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It is also our hope to better educate everyone about the facts of asthma - beginning with the fact that it is controllable!
Remember: Healthy children and teens become healthier adults. The better shape that kids are in, and the more control they have over their asthma, the more active they can become.
The sky's the limit: Even an Olympic gold medal or a professional championship is within reach!
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