On a recent Thursday morning, while other students were in school for another day of the usual academic fare, six children sat excitedly raising their hands, each trying to be the first one to answer a question on a subject that could save their lives: managing their asthma.
“Before I begin, I want to hear the five steps to asthma management,” said Mike Lapsansky, a respiratory-care practitioner from South Suburban Hospital in Hazel Crest.
“I know, I know!” responded the kids, who are 3rd through 6th graders at Chateaux School, near the hospital. The students then proudly reported the steps: Know your asthma and symptoms; tell an adult; take your medication; rest and relax; and take a deep cough.
It was their last of six classes on managing asthma, and they were ready for Lapsansky’s questions, although a bit sad about the classes coming to an end. They were able to tell Lapsansky that children with asthma must always follow their doctor’s instructions on taking medication, even if they are feeling well, and should tell their parents or a teacher if they feel sick.
They had learned that asthma often is hereditary, that dust and cigarettes can exacerbate it and that they need to stay home from school if they have difficulty breathing, are overly tired or have a respiratory infection or sore throat.
Certainly most lessons taught in school should be important, but this one can be a matter of life and death.
Asthma is the most common chronic illness in children. Of the nearly 14.5 million Americans who have asthma, about a third are children under age 18. In Illinois, about 213,056 children have asthma, according to the American Lung Association, and more than half of those, or 136,098, are in Chicago.
That makes teaching asthmatic children how to take care of themselves perhaps the most important thing they will ever learn.
Upon looking at a large, colorful picture of a pair of lungs during an asthma attack, the pupils in Lapsansky’s class gasped at the bright red swollen muscles around the lungs. Together with Lapsansky, they recounted two ways of avoiding such an attack: Stay away from smoke and take your medication.
“Dang, I hate that picture,” said Lamonte Lay, a 3rd grader from Country Club Hills.
“I can’t look anymore,” added Chisheekah Freeman, a 6th grader, also from Country Club Hills.
The students were part of Open Airways for Schools, a program sponsored by the lung association that strives to help children learn to manage their asthma better, thereby avoiding unnecessary emergency room visits and absences from school. The program was developed by Columbia University in 1977 and adapted by the lung association nationally for schoolchildren in 1986.
The program has been used in 38 Chicago schools and 22 suburban Cook County schools, plus four community health agencies in areas of the city. South Suburban Hospital has been a pioneer in the school project, sending four of its respiratory therapists to elementary schools over the last five years to teach the program.
“Part of what we try to do is have them become aware of what to do for themselves, how to identify what they need to do,” Lapsansky said. “I feel confident and optimistic that by providing this class we can be successful in treating their asthma, maintaining good lung health, reducing the amount of school days they miss. And they can also help educate and increase awareness of those around them.”
The importance of spreading the word is huge, because not only can parents unwittingly be an impediment to proper treatment, but even many primary-care physicians need enlightenment.
Dr. Jim Moy, director of the allergy division in pediatrics at Cook County Hospital, said compliance with treatment is sometimes a problem because parents associate the steroids that could help their kids with the steroids that athletes take.
Too, primary-care physicians may not prescribe them as much as specialists do because of the same fear and because they are less familiar with them, said Moy and Dr. Marc Hershenson, associate professor of pediatrics and chief of pulmonary biology and critical care in pediatrics at the University of Chicago Children’s Hospital.
Not the same steroids
Corticosteroids, not the muscle-building steroids sometimes misused by athletes, are widely prescribed for persistent asthma and generally have been found to be safe, although they can be associated with short-term growth suppression.
Small doses in school-age children before puberty don’t tend to cause significant side effects, although studies of the drug’s effect in higher doses and over a long period in this age group are being recommended by experts.
Some of asthma’s triggers include upper-respiratory infections, cigarette smoke, wood smoke, scented or cleaning products, air pollution, dust mites, pet dander, exercise, emotional stress and changes in weather or temperature.
Certainly it’s important to alert parents to these problems, but reaching kids with the information is just as important.
“There’s something interesting that once you have asthma and you spend a lot of time with obstruction to air flow, you become sort of insensitive to it,” Hershenson said. “They begin to not really feel it anymore, even when they’re having bad air flow.
Toughing it out
“The other problem, of course, is that kids don’t like to admit there’s a problem, and they like to keep playing and exercising,” Hershenson said.
In the Open Airways classes, emphasis is on the children using their peak-flow meter, a small device that measures how much air can be blown out in one quick breath. This is important because it provides an objective reading of how well their lungs are functioning, telling them whether they need medication even if their symptoms don’t.
Each child receives a free peak-flow meter and spacer, a device attached to an inhaler that holds medicine in suspension to be inhaled at the patient’s own pace.
Children also receive informational handouts to look over with their parents at home.
Hershenson and two other pulmonologists see 3,000 to 4,000 children with asthma yearly. Many of them have severe asthma, with some on ventilators and some requiring admission to intensive care.
Most of the children they see are from the inner city and are African-American. Hershenson said the incidence of asthma in inner-city schools is as high as 24 percent, compared with 10 percent in other city schools and 5 percent in suburban ones.
High city death rate
Although asthma deaths in Chicago children up to age 14 declined during the 1990s, they are still twice as high as national mortality rates, according to Dr. Sandra Thomas, Chicago Department of Public Health.
From 1990 to 1998, 69 children died from asthma, and 65 of them were African-American, according to Thomas.
“In the inner city, you have a problem with just who is watching the kids. Sometimes the parents are so busy they can’t check on them,” Hershenson said.
Although Hershenson has had only one patient die of an asthma attack in his work with them since he came to the university in 1989, many of his patients have mentioned relatives who have died of the disease. He said one of the reasons for a higher death rate in African-Americans is because they might not be getting appropriate medical care.
“What that says is if you really pay attention and are obsessive-compulsive with the medications, you see the patient back regularly, they buy into the system, then they tend not to die. But the problem is that unfortunately a lot of patients don’t get that care,” Hershenson said.
Studying triggers
In addition to fighting the public-relations battle for asthma, Hershenson also is working on the clinical side, doing research on the protein found in cockroach feces, a known asthma trigger that is thought to cause airway inflammation.
Once the protein is identified, scientists hopefully could discover how to block the protein’s effect, thereby blocking the allergic effect of cockroaches.
Although there is no cure for asthma, Moy said, many children who have symptoms before age 3 may grow out of it, but if they get it after age 6 they most likely will have it all their lives. Some children who wheeze early in life, however, may stop for a while only to have the wheezing start again.
“That’s why it’s not taken real seriously, because there are a lot of kids who wheeze but they don’t wheeze for quite a few years and start again,” Moy said. “We still don’t think of asthma as a chronic illness. We think of it as an acute illness like an ear infection.
“Unlike in diabetes, where everyone looks at it as a chronic illness, in asthma even if you don’t take your medications every day, you might go a few days or a week without symptoms. It’s not hard to monitor, I think it’s just a mind-set that it’s not a chronic illness.”
Moy has been an investigator on a number of clinical trials for asthma medications and is researching a new inhaled steroid that is expected to cause fewer side effects than other steroids.
Good results
The results of Open Airways have been impressive, according to Claudia Baier, director of health education at the American Lung Association of Metropolitan Chicago.
A 1998 evaluation of the program in New York schools found there was a decrease in doctor’s visits, a significant decrease in emergency room visits and hospital stays as well as a decrease in the number of work days missed by parents of children in the program.
“We would suspect they were able to do more self-care, self-management at home, so there wasn’t the need to run to the doctor every time they had a symptom,” Baier said.
Parents of the pupils at Chateaux School who took part in the program called it a resounding success, saying they were impressed with how much their children learned.
Patrice Turner of Country Club Hills said her 3rd-grade daughter, Mishaun, constantly talked about it, telling her mother how to use a peak-flow meter and trying to discourage her from smoking.
“She was telling me how many chemicals are in cigarettes and everyone needs to stop smoking; it should be against the law,” said Turner, who added that she has cut down on smoking significantly because of her daughter’s advice.
Added Turner, who also has asthma: “She might be the one to help me if I have an asthma attack.”
Education is the best weapon against asthma
Asthma is a chronic disease in which the bronchial tubes, or the main air passages of the lungs, become inflamed and the muscles of the bronchial walls tighten. Extra mucus is produced and the airways narrow, leading to wheezing and difficulty in breathing.
Children can develop asthma as early as the first year of life. Although the cause is unknown, researchers believe family history and sensitivity to allergens or irritants in the environment probably cause it. It is more common in boys than girls, although after puberty, it becomes more common in girls.
Warning signs are wheezing, frequent coughing, awakening at night coughing or wheezing, shortness of breath and a tight feeling in the child’s chest. Although wheezing usually is present, sometimes it may not be heard without a stethoscope. Other times a cough may be the patient’s only obvious symptom.
Pulmonary function tests that measure a patient’s breathing ability and lung capacity also are used to diagnose asthma, although they are not usually considered helpful in preschool-age children.
Chest X-rays (to look for causes of cough or wheezing other than asthma), sweat chloride testing (to rule out cystic fibrosis) and allergy skin testing (rash is often associated with asthma) are recommended in children under age 3, according to Dr. Robert Strunk of the Washington University School of Medicine.
A patient’s history also is key in determining a diagnosis.
“You have to look at their signs and symptoms and how severe they are, how many times they actually are getting sick, how many times they are wheezing or coughing,” said Valerie Prajka, a family practitioner with South Suburban Hospital, who sees four or five asthma patients, ages 4 to 18, a month. “The main thing is getting them away from irritants, get parents to smoke outside and pets out of the bedroom.”
That is the kind of information passed along through asthma education. In addition to the Open Airways for Schools program, other efforts are being made.
Doctors involved with asthma say that educating patients and physicians about asthma management is paramount in getting the disease under better control.
Dr. Jim Moy, director of the allergy division in pediatrics at Cook County Hospital, said his department is part of a campaign to try to educate primary-care physicians about the usefulness of corticosteroids and other facets of good asthma management. In a federally funded project called Asthma Champions, Moy invites primary-care doctors to visit the hospital’s specialty asthma clinic once a week on a three-month basis to work with him and two other pulmonologists.
They see about 2,000 children with moderate to severe asthma yearly, most of whom also are from the inner city.
The University of Chicago Asthma Center does community outreach education and some research. The center staff soon will be talking to Chicago Public Schools faculty and staff about managing asthma in children and recently went to the Robert Taylor Homes housing development to do asthma education with residents. Some of its members also have trained for the Open Airways project. The center is led by Dr. Julian Solway, a pulmonologist, and was founded by Solway and Hershenson in 1998.
The Chicago Asthma Consortium, which comprises 300 physicians, nurses, educators, researchers, community leaders, asthma advocates, patients and families, does education outreach on a larger scale. It was formed by the American Lung Association of Metropolitan Chicago and the American College of Chest Physicians in 1996 to coordinate the activities of institutions and individuals engaged in asthma diagnosis, treatment and education.
— Janice Neumann
Law lets kids carry medicine in school
Last August Gov. George Ryan signed into law a measure requiring schools to permit asthmatic children to carry their own medication and to administer it themselves.
The legislation resulted from the death of a student in Chicago several years ago.
“If a child is capable of administering his own medication, they can carry by law their own medication during school hours,” said Claudia Baier, director of health education at the American Lung Association of Metropolitan Chicago.
This requires a parental signature and a letter from the doctor who prescribed the medication, with the understanding by all concerned that the child is capable of self-administering the drugs.
Conceivably, this could mean a kindergartner, but “I think that’s quite young,” Baier added.
“A school cannot be held liable unless they knowingly interfere,” she said.
