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March 1, 2000
Vol. 57
No. 6

Managing Asthma at School

Knowledge, understanding, and planning help schools minimize the impact of asthma on the social, emotional, and physical health of students.

What if a country experienced a terrible nuclear or chemical accident that seriously affected people's health? What if that accident caused the death of 5,000 citizens, the hospitalization of another 400,000, and acute emergency room visits for more than 1.5 million? What if one-third of the people affected were children under the age of 18, who lost 10 million school days to absences from illnesses related to this event? How would the country respond?
Certainly we would be outraged at this catastrophe: outraged that such an event could occur, outraged that better preventive measures weren't followed, outraged at the loss the nation suffered.
So why aren't we more outraged about asthma?
The prevalence and impact numbers for our hypothetical accident are the actual annual statistics for asthma. An estimated 15 million people in the United States have this chronic disease; about one-third of them are children. In fact, asthma is the most common chronic illness among children. Despite improvements in clinical treatment, asthma-related hospitalizations and emergency room visits are increasing, and poor, inner-city dwellers are the hardest hit.
The direct and indirect costs of this disease, in terms of school absences and degraded quality of life, are enormous. Yet asthma falls far behind other health-related topics that receive attention in schools, in the media, and from the public health community. But there is some promising news. Although there is no cure, medical, environmental, and behavioral interventions can keep asthma well under control. Children with asthma can live normal lives in which the disease has a minimal impact on their daily activities. So what exactly is asthma?

The Basics of Asthma Pathology

Asthma is a condition in which the air passages in the lungs, called bronchial tubes, are sensitive to certain substances. When a person with asthma is exposed to one of these substances, several things happen. The inside walls of the bronchial tubes become inflamed and swell. Muscles that surround the tubes contract, squeezing them even tighter. And mucus is produced in greater amounts within the tubes, adding to the clogging. The result is wheezing, coughing, increased difficulty in breathing, and tightness of the chest.
The disease has nothing to do with a person's physical strength or mental toughness. But try telling that to a classroom of peers when a student has to sit down during gym class, use an inhaler at lunch, or avoid petting the science class hamster because it may trigger an attack. Children with asthma have to deal with both the social and the physical aspects of the disease. Fitting in with the crowd is paramount to most children, and those with asthma are often labeled weak or different. They are embarrassed when others find out they have this disease. That's why it's so important for school educators to understand the disease and to reinforce positive messages about its management.

Asthma-Management Plan

Teachers, coaches, and administrators need to know which students have asthma, the warning signs of a problem, and appropriate actions to take in an emergency. Each student with asthma should have an asthma-management plan on file with the school. This one- or two-page document, developed by the student's physician, has vital information about routine and emergency medications, symptoms of an impending attack, and emergency contacts and procedures. The plan also indicates whether the student should carry his or her inhaler at all times, a recommendation that can run counter to a school's zero-tolerance drug policy.
Doctors commonly prescribe metered-dose inhalers for people with asthma. Two types of medications are administered through inhalers. One is for quick relief and reduces acute contractions of the muscles surrounding the bronchial tubes. The other is for long-term control of the inflammation of the bronchial tube lining. Quick-relief medicines are generally used as needed, whereas long-term control prescriptions have a specific daily dose. Because children can't predict when they are going to need quick relief from the symptoms of a possible asthma attack, ready access to these types of inhalers is essential. Drug-free school policies that have no flexibility toward prescription medications could have a detrimental effect on a child's health and self-confidence in his or her ability to manage the disease.
In April 1999, a mother who sued the Hanford, California, Elementary School District after her 11-year-old son died during an asthma attack was awarded $9 million in compensation for her loss. (The award was later reduced to $2.25 million.) Her son was a severe asthmatic who carried an inhaler at all times except when at school, where district policies required that medications be kept in staff offices. On the day he died, he went to the office to use a nebulizer—a special inhaler for severe asthma—and collapsed while waiting for a staff member to figure out how to assemble it. He died at the school. Such dramatic cases are certainly rare, but they serve as a clear reminder that schools need to be prepared to deal with asthma incidents.

Environmental Triggers

Although each person with asthma reacts to different substances, several common allergens and irritants can make asthma symptoms worse: mold, dust and dust mites, the skin and saliva of furry or feathered animals, cigarette smoke, odors from cleaning supplies or other aerosols, and cockroaches. Even chalk dust or fumes from cooking can be problematic. Reducing exposure to these triggers can go a long way toward effectively preventing attacks and successfully managing the disease.
Maintaining good indoor air quality is beneficial for everyone in a school environment, but it takes the active involvement of the custodial staff and a commitment from administrators to make it a priority. The Environmental Protection Agency (EPA) has developed a useful guide, Indoor Air Quality Tools for Schools Action Kit, which provides checklists and forms for implementing an indoor air-quality program at the school level.
It is important to remember that the school environment includes more than just the classroom. The school must take asthma into consideration on field trips, at sporting events, at pre- and after-school programs on school property, and during extracurricular social events.

Asthma Education

School curriculums are filled to the brim. It's not easy to add anything to the already crowded plate of topics. But depending on the severity of its asthma problem, a school or a district may find that sponsoring some short classes on asthma management is both economical and healthful. The American Lung Association (ALA) has prepared a comprehensive package called Open Airways for Schools, which focuses on children with asthma between the ages of 8 and 11.
The package has an instructor's guide, a curriculum book, and posters and handouts written in English and Spanish. Any local chapter of ALA will provide a train-the-trainer session and run interference on the program's promotion and logistics. Teachers are prime candidates to facilitate the six 45-minute sessions, but other volunteers, such as a nurse, a counselor, or a parent, can be effective. One key to the program's success is parental involvement. Children take work home and get parental input on such topics as medication, emergency situations, and triggers at home. The ALA also has programs for preschoolers and written materials for teenagers with asthma.


Because asthma is a complex disease, managing it requires a multifaceted approach. It's not just about using the right medicine or reducing triggers. Policymaking in the schools and workplace, legislative activities to ensure access to health care, efforts to improve substandard housing and to limit both indoor and outdoor air pollutants, and education at all levels are part of a comprehensive public health response. Asthma problems can't be solved in the school environment alone, but increased knowledge and understanding by school educators will go a long way toward reinforcing the kinds of behaviors needed to control the disease. And the benefits are many, including reducing the time that children miss school and improving their overall quality of life.
Consider what you can do to support a coordinated effort to reduce asthma's grasp on children. For more information, contact your local ALA, or check out these Web sites: the Journal of the American Medical Association Asthma Information Center (www.ama-assn.org/special/asthma/asthma.htm), Allergy and Asthma Network/Mothers of Asthmatics, Inc. (www.aanma.org), and the American Academy of Allergy, Asthma, and Immunology (www.aaaai.org).
Schools have a large role in shaping children's self-esteem and in giving them the tools they need to deal with the future. When it comes to children with asthma, let's make sure our role is one of enabler, not labeler.

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