Asthma, activity and athletics: what should we expect our children with well-controlled asthma to be able to do?

In this issue, we were fortunate to have interviewed Dr. Michael Bowman, a tireless advocate for respiratory health and mentor for other caregivers, for over 20 years, to provide insights on some of the challenges surrounding children and asthma.

Routine use of albuterol before exercise is often used for adult exercise-induced bronchospasm. However, it may not be the best approach for a child with asthma as there may often be additional subtle signs of poor asthma control.

Children with asthma have a variety of symptoms. Wheezing is often associated with the condition.  But when the child suffers a coughing fit, chest tightness or is observed having problems playing during recess, there can be greater uncertainty for the care provider and the family. It may be called “bronchitis” or something else. Clearly, there are many reasons―including asthma―why a child may have exercise intolerance. The challenge for everyone, the child, the parent, the provider, the school nurse and Physical Education (PE) teacher, is to figure out why a child is not able to exercise and then what to do about it. It has been said that the very best way to find a child not yet recognized as having asthma is to ask a PE teacher who he or she perceives as being “lazy.”

Activity can frequently trigger symptoms of asthma in children. If that is a cough or wheeze, adults can hear it. However, if it is merely chest tightness or dyspnea, it is likely to go unrecognized. The child may not recognize the uncomfortable sensation as being abnormal, and may not mention it to their parents or teachers. When asking the parent of a newly-diagnosed child with asthma how they do with exercise, the answer is often “fine”. However, if asked what the child does for activity, the parent may say “she likes to play with dolls” or “he spends a lot of time playing video games”. The problem can be magnified in children who are overweight, where vigorous activity is often the best solution. Care providers should not accept a stance from a parent that their child “has asthma and, therefore, needs an excuse from recess or physical education class.”

Where to start

Try to figure out in as much detail as possible exactly what happens when the child exercises. What are the symptoms and how severe are they? Do they happen with only heavy exercise for a long time or do they happen with mild exercise?  Be sure to ask the school nurse for input as to what the PE teachers and coaches see in terms of the child’s exercise tolerance. Also, be sure to ultimately tell the school nurse via an Asthma Action Plan (AAP) exactly how you want the child’s asthma managed.

Two approaches

The hallmark of bronchospasm triggered by activity is responsiveness to albuterol. If a therapeutic trial with albuterol reduces symptoms for the child, there is a strong suggestion that bronchospasm plays a role in exercise intolerance.

Often the child will be treated with albuterol prior to recess or exercise. The challenge here is how to quantify and anticipate whether it is going to be an episode of light or heavy exercise. Does rough-housing with a sibling constitute light or heavy exercise? Bottom line: it can be very hard to know exactly when to give a pretreatment with albuterol.

Alternatively, utilizing a controller medication may be indicated. If the child were on a travel team with hard play and workouts every day, they would likely have daily symptoms. That would "qualify" (EPR-3) them for a daily controller with inhaled corticosteroids (ICS) and perhaps a long-acting beta-agonist (LABA). However, if they were restricted from vigorous exercise, they would not have the symptoms. Their rare symptoms would actually be misleading.

It is also essential that children with asthma receive the inhaled medication down into their lungs where they need it. Therefore, it is also important that the families know the correct delivery technique for the inhaled medications, whether by nebulizer or inhaler with spacer.

The timing of medication delivery is also important. If prescribing a short-acting beta2-agonists such as albuterol, these medications should be administered 10-15 minutes prior to exercise. Alternatively, if management of exercise-induced symptoms with the short-acting agent isn’t effective, a long-acting beta2-agonists with inhaled corticosteroid medication may be required. These combination controller medications are generally used twice daily (10-12 hours apart) and the child’s medication schedule may need to be adjusted to allow the medication enough time (30-60 minutes) to reach maximum effectiveness before activity. For example, if the child has a soccer game at 6pm, then evening dose of the combination controller may be moved up to 5:30 pm to allow time for the long-acting beta2-agonists to work. 

Control

A patient with asthma who is under excellent control should be able to do essentially anything they want activity-wise at any time or place. Their colds should be short and they should rarely have symptoms of asthma.

That means they should rarely need albuterol rescue (other than when they have a virus) and they should only need prednisone once or at most twice in a full year.

Encouragement through role modeling

Children with asthma may choose not to exercise or participate in sports out of fear of an asthma flare-up. Healthcare educators may keep a list of prominent male and female athletes with asthma who have achieved asthma control which enabled them to excel in various sports. Professional and Olympic sports figures such as Michael Phelps¹ and Jackie Joyner Kersee¹ can serve as role models to encourage children to stay on top of their asthma and achieve success in sports whether on the track, field, court or in the swimming pool.

Ultimately, managing exercise intolerance in children is a major challenge, especially when obesity is present. Merely avoiding exercise is not the answer. Proper management of the asthma requires a team effort between the care provider, the patient and family, the school nurse and the school PE teachers and coaches, as well as any other adults responsible for the welfare of the child.