Teen's Guide to Living with Asthma

LIVING with ASTHMA ilwa$$all.indd i 10/24/07 8:16:13 AM Also in the Teen’s Guides Series Living with Anxiety Disor...

Author: William E. | M.D. Berger

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LIVING with

ASTHMA

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Also in the Teen’s Guides Series Living with Anxiety Disorders Living with Cancer Living with Depression Living with Diabetes

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LIVING

with

ASTHMA William E. Berger, M.D.

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Living with Asthma Copyright © 2008 by William E. Berger, M.D. All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. For information contact: Facts On File, Inc. An imprint of Infobase Publishing, Inc. 132 West 31st Street New York NY 10001 Library of Congress Cataloging-in-Publication Data Berger, William E. Living with asthma / by William E. Berger. p. cm. — (Teen’s guides) Includes index. ISBN-13: 978-0-8160-6483-0 ISBN-10: 0-8160-6483-0 1. Asthma in children—Juvenile literature. 2. Asthma—Juvenile literature. I. Title. RJ436.A8B47 2007 618.92'238—dc22

2007003664

Facts On File books are available at special discounts when purchased in bulk quantities for businesses, associations, institutions, or sales promotions. Please call our Special Sales Department in New York at (212) 967-8800 or (800) 322-8755. You can find Facts On File on the World Wide Web at http://www.factsonfile.com Text design by Annie O’Donnell Cover design by Jooyoung An Printed in the United States of America Sheridan CGI 10 9 8 7 6 5 4 3 2 1 This book is printed on acid-free paper.

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CONTENTS ■■

1 What Is Asthma?

1

■■

2 Getting a Diagnosis

8

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3 Figuring Out Your Asthma Triggers

■■

4 Putting Out Your Asthma Flare: Treating Asthma Attacks

15 30

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5 Heading Off an Attack

45

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6 Coping with Asthma at School

51

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7 Asthma and Sports

64

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8 Asthma and Your Social Life

75

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9 Coping with Asthma When Traveling

83

■ ■ 10

Helping Others Cope with Asthma

94

■ ■ 11

Paying for Care

99

Appendix 1. Associations and Resources

105

Appendix 2. Famous People with Asthma

115

Appendix 3. International Health Insurance

Companies

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125

Appendix 4. Asthma Camps

129

Glossary

159

Read More About It

173

Index

175

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1 What Is Asthma?

J

Janet coughed a lot as a kid and was constantly being given antibiotics. When she and her two brothers got colds, she seemed to be much sicker than they were and for a much longer time. Although she was given many different antibiotics, none of them ever seemed to work very well. She’d start to cough when she exercised, her nose was always running, and she seemed to be taking cold medicine all the time. Then one night, when she was about 13, Janet woke up and couldn’t breathe. None of the cough syrups helped, and as her breathing began to worsen, her panicked parents rushed her to the emergency room. That was when the ER doctor recognized that Janet didn’t have an infection at all—she was having an asthma attack. Now on asthma medications, Janet doesn’t get sick as often or as severely, and she just won the long jump in her middle school competition. Just like Janet, you may have only recently been diagnosed, although you may have been struggling with symptoms for years. Or maybe you’ve known that you’ve had asthma for quite a while now. In any case, you’re certainly not alone. Asthma is a chronic life-threatening lung disease that affects nearly 5 million kids just like you, causing episodes of wheezing, coughing, and difficulty breathing. It affects about one or two students out of 10, which means that if there are 30 kids in your class, three to eight of them may have asthma. In fact, so many teens have asthma that it’s the most common reason for missing school in this country.

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2

Living with Asthma

Yet common as it is, it’s not always easy to recognize, especially in kids who just cough without the characteristic asthma wheeze. That’s what happened to Sue, 15, who struggled with a deep, hacking cough intermittently for six months while her family doctor was unable to pinpoint the cause. Countless antibiotics later, she was eventually diagnosed by an asthma specialist—but not before she broke a rib from coughing so hard. That’s why an accurate diagnosis is so important. The more you know about asthma and your own particular “triggers” (things that set off an asthma attack), the better. The good news is that doctors are coming up with new medications and treatments all the time, and if you’re careful about following your doctor’s instructions, you should be able to live a full and active life.

WHAT HAPPENS DURING AN ASTHMA FLARE? Normally, when you breathe in, your nose and airways trap dust, pollen, molds, bacteria, and chemicals. Tiny whiplike hairs called cilia move the mucus and foreign particles up toward your throat and nose, so you can cough or sneeze them out. Then the air, now warmed, moistened, and cleaned, moves through smaller branching airways, carrying oxygen to the tiny air sacs in your lungs. The airways are surrounded by muscles that help air move along. When everything is working properly, you probably don’t notice your breathing at all. It’s just automatic. But if you have asthma, certain triggers—such as pollens, pet dander, molds, viral infections, or even a strong smell—will set off a cascade of reactions that narrow your airways and make it hard for you to breathe. This reaction (called an asthma flare) usually begins days before symptoms suddenly appear. As the lining of your airways starts to swell and become inflamed, the bands of smooth muscles that surround the airways tighten. Excess mucus pours into the airways, causing congestion. As your airways tighten, you have a harder time breathing, you start to wheeze, and the level of oxygen in your blood might begin to drop. Together, the swelling, excess mucus, and bronchoconstriction continue to narrow the airways so that it’s hard for you to breathe air out of the lungs. Experts believe that the changes that occur in your airways during an asthma flare happen in two phases: First comes the obvious, immediate response to the trigger, which causes your airways to swell and narrow. Then there can be a later response up to eight hours after the initial trigger, which can lead to even more inflammation and tightening.

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What Is Asthma?

3

Some kids with asthma experience just a slight tightening of the airways once in a while; others notice symptoms when they play sports, especially in cold weather. Still others have very serious asthma that changes how well their lungs function and limits their everyday activities. Because the symptoms of asthma may look like other medical conditions, you may need to seek the opinion of an allergist or a pulmonologist who can make the diagnosis.

SYMPTOMS If you have asthma, you’ll probably have days when you can breathe effortlessly. This means that your asthma is under control. However, everyone with asthma has a built-in early warning system that tips you off that a flare is impending—symptoms that can be seen, heard, and felt. You probably have your own pattern of signals that you’ll learn to recognize, which may be different from those of any of your friends with asthma. The four most common symptoms are wheezing, chronic cough, shortness of breath, and tight chest. Wheezing. Odds are you won’t miss this symptom—it’s a character-

istic high-pitched, whistling sound that occurs as you try to breathe (especially when you breathe out). Not all people who wheeze have asthma, and not everyone who has asthma wheezes. In fact, if your asthma is severe, you may not be able to move enough air through your airways to produce this sound at all. Even if you don’t normally wheeze during an asthma flare, you may be able to produce this sound if you take a deep breath in, hold for one beat, and then explosively breathe out as hard as you can, pushing every bit of air out of your lungs. Healthy teens will just breathe out, but those who have asthma typically will end up wheezing and coughing as the last of the air is forced out of their lungs. Cough. Some kids who never experience the characteristic wheeze of asthma will cough instead. The typical asthma cough can sound very harsh—a deep, racking, and unproductive cough that may get so severe it can trigger vomiting. During severe flares, a teen with asthma may cough in a series of three, four, five, or more coughs without being able to breathe in between. An asthma cough may be either constant or intermittent, but without treatment it may persist for months. The chronic cough of asthma is especially obvious at night, after exercise, or after exposure to cold air. Any teen who has frequent coughing or respiratory infections should be tested for asthma.

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4

Living with Asthma

Emergency! If you experience any of these signs, you need to see a doctor right away. M Wheeze, cough, or shortness of breath gets worse. M Symptoms don’t fade after five or 10 minutes following your rescue medications, or they return again quickly. M You must struggle to breathe. M You have trouble walking or talking. M Your lips or fingernails are gray or blue.

Shortness of breath. If you have trouble catching your breath

(especially during exercise), this is another possible sign of asthma. Of course, everyone gets short of breath after exercise, but healthy people can resume normal breathing very quickly afterward. Teens with asthma do not. Chest tightness. Some kids with asthma report that they feel as if an elephant was sitting on their chest. This feeling may be more common when you lie flat and is eased when you sit upright. Other symptoms. Other symptoms that also may appear include

pallor, sweating, fast breathing, restless sleep, and fatigue. An asthma flare can get worse if you don’t use rescue asthma medicine. After taking your asthma medicine, the airways eventually return to the way they were before, and your breathing will return to normal—but you must remain on your prescribed controller medications.

IS IT AN ALLERGY OR ASTHMA? Most teens with asthma also suffer from allergies that affect their nose and eyes. Do your eyes itch and water in the spring or fall? Can you feel a constant dripping down the back of your throat? Do you have to clear your throat a lot at certain times of the year? Do you feel stuffy and headachy? People who have allergies like these that affect the nose and

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What Is Asthma?

5

eyes are more likely to have asthma too. Of course, not everyone who has allergies has asthma, and not all people with asthma have allergies. But more than 75 percent of kids with asthma also have allergies. Allergies and asthma often occur together because both are influenced by the immune system. If you have allergic asthma, it’s important to understand how these conditions influence each other and how to tell the symptoms apart. It may help to keep this in mind: Basically, asthma is a disease of the lungs. Allergies are hypersensitivities that trigger reactions in certain individuals. Normally, it’s your immune system’s responsibility to protect your body from invaders (such as viruses or bacteria) by producing antibodies—specialized proteins that recognize foreign invaders and fight them off. You may not realize it, but your immune system is on duty 24 hours a day patrolling the body, distinguishing between agents that should be in the body and foreign agents that could spell trouble. Anything the immune system detects as foreign will be attacked. These foreign substances are called antigens, and antigens that trigger an allergic response are called allergens. Examples of allergens include molds, pollens, and pet dander. If you’ve inherited a tendency to develop allergies, your immune system will overreact to an allergen. Pollen is one allergen that causes problems for many people. When you breathe in pollen, your immune system immediately recognizes that a foreign substance (the allergen) has entered the body. When the allergen binds with IgE antibodies located on cell surfaces, it triggers the release of histamine and other chemicals from the mast cells. Histamine and other inflammatory chemicals can cause allergic symptoms that affect the throat and lungs, such as itching, sneezing, nasal congestion, and inflammation. Allergy-prone people produce far too many IgE antibodies, which leads to many IgE-sensitized cells that release large amounts of histamine. It’s the histamine that makes you sneeze and causes a runny nose and watery eyes as your body tries to get rid of the pollen. Histamine can cause symptoms that affect the throat, lungs, skin, or gastrointestinal tract. Your immune system rarely forgets an allergen. Once sensitized, your body will probably react to that allergen for the rest of your life. This means that once sensitized to pollen, or mold, or pet dander, you’ll react with an allergic response again and again. Teens who have allergic asthma develop asthma symptoms when they inhale substances to which they’re allergic, such as pet dander, pollens, molds, and dust mites. In these cases, the immune system overreacts, triggering inflammation of the airways and various asthma symptoms.

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6

Living with Asthma

Nonallergic asthma is triggered not by an allergic process but by things such as exercise (especially in cold weather), viral infections, smoke, strong perfume, or strong chemical odors.

WHO’S AT RISK? Anyone can develop asthma, but some people are more likely than others to develop the condition. Some teens have asthma episodes only a few times a year (usually when they get a cold), while others have episodes just about every day during spring and fall, when the pollen counts and outdoor pollution are high. Heredity. If you have asthma, you may very well have a parent, sibling, or other relative who also has asthma (or who had it as a child). If both your parents have asthma, your risk is higher than if only one parent has it. (For some reason, your risk seems to be greater if your mother has asthma than if your father does.) Allergies. Certain types of allergies seem to increase a teen’s risk

of developing asthma. The tendency to develop allergies is inherited. One way to test a person for allergies is to perform skin tests with extracts of the allergens or do blood tests for IgE antibodies to these allergens. Race. Race is also a factor: Asthma is 26 percent more common in

African-American than in Caucasian children, and African-American children with asthma typically have more severe conditions and are hospitalized more often.

Is There an Asthma Gene? Experts have focused on a number of genes that contribute to a person’s susceptibility to asthma, located on chromosomes 5, 6, 11, 14, and 12. While they don’t really know how these genes cause a tendency to develop asthma, they have identified chromosome 5 as the most likely site for an asthma gene. This chromosome is a suspect because it’s a region rich in genes that influence a person’s inflammatory response.

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What Is Asthma?

7

YOU CAN TAKE CONTROL As you read on in this book, you’ll learn more about how to take control of your asthma. The good news is that most teens can control their asthma very well. In many cases, you may be able to control it so well that you experience only a few rare asthma flares. That’s the goal of treatment. Although you can’t cure asthma, it’s possible to reduce its frequency and severity so that it doesn’t interfere with your normal activities. How long it will take to get your asthma under control depends on how severe your symptoms are, how often you have flares, how long it’s been untreated, and how well you can follow the treatment plan your doctor designs.

WHAT YOU NEED TO KNOW M Asthma is a chronic life-threatening lung disease causing wheezing, coughing, and difficulty breathing. M Most people with asthma also have allergies. M Asthma can be either allergic or nonallergic depending on the major triggers of the symptoms. M If you take your asthma seriously and follow your doctor’s treatment plans, you can get on with the important business of having fun.

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2 Getting a Diagnosis

D

David, 14, was never much for athletics at school. He ended up being captain of the chess team since he couldn’t run fast enough to play football. Everyone just assumed that he wasn’t a good athlete. But David was also troubled with a constant cough, which cough medicine didn’t seem to help. Finally, his parents went to the doctor with a bag of seven antibiotics that David had been prescribed within the last six months—none of which helped relieve the cough. “We really want to find out what’s going on,” they said. David was referred to an allergist, who performed pulmonary function tests and diagnosed asthma. In addition, the allergist also was able to identify that David was allergic to the family cat and that he was very allergic to dust and pollen. Now on the right medication and having removed the cat from his room, David is able to sleep through the whole night without coughing. “We kept checking on him,” his parents said, “because he was sleeping so quietly, we were worried he might not be breathing!” Wheezing, coughing, and shortness of breath are all symptoms that need to be checked by a doctor. Diagnosing asthma can be tricky and time-consuming because different patients with asthma can have very different patterns of symptoms. If your family doctor or pediatrician suspects asthma, you may be sent to a specialist to help with the diagnosis. Physicians who specialize in treating asthma include those trained in the fields of allergy, asthma and immunology (how the respiratory and immune systems works), and pulmonology (conditions that affect the lungs).

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Getting a Diagnosis

9

Some cases of asthma seem fairly straightforward, but others aren’t so clear-cut. For example, some kids cough constantly at night but seem fine during the day, while others seem to wheeze all the time. Some experience symptoms only in a smoke-filled room or after playing with a pet. Others have so many allergies that the specific cause of asthma may not be recognized. Unfortunately, it’s not unusual for kids to have asthma symptoms for a long time before being seen by an asthma specialist.

ON YOUR FIRST APPOINTMENT When you go for your first appointment, the doctor will likely use a combination of medical history, physical examination, and lab tests to diagnose asthma and make sure that you’re not suffering from some other related lung disorder or infection. Most likely, the doctor will evaluate your lung function, probably by using spirometry, one of the simplest, most common pulmonary function tests. In addition, the doctor may measure the baseline amount of air you can blow out of your lungs by using a device called a peak-flow meter. In some cases, the doctor may order chest X-rays, blood tests, and allergy tests. Medical history. At that first visit, your doctor may ask you to

describe your symptoms in detail. Think carefully about when and where your symptoms occur, so you can help the doctor track down the source of your problems. Do your symptoms occur more often in the spring and fall? Do they seem to appear after you’ve exercised, or are they related to colds or infections? Specifically, the doctor will ask if you’ve had any recurrent episodes of coughing, wheezing, shortness of breath, chest tightening, or rapid breathing. You should mention any family history of asthma or allergic disorders such as hay fever, eczema, or hives, because any of these conditions can increase your risk of asthma. In addition, your doctor will probably ask you about your general health, your family’s health, any medications you’re taking, and any other allergies you have. You should tell the doctor how often you get colds, how severe they are, and how long they last. The doctor also may ask you about exposure to irritants and allergens or about any recent life changes or stressful events, such as a change in schools. Pulmonary function tests. To confirm the diagnosis of asthma,

most doctors will request pulmonary function studies. These tests can help determine the severity of your airway obstruction and whether it

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10

Living with Asthma

can be reversed with medications. These tests are usually performed using a machine called a spirometer that analyzes your airflow through both large and small airways. A spirometer also can be used to see if your breathing problems can be improved with medication, a primary characteristic of asthma. The doctor may take a spirometer reading, give you an inhaled medication to open the airways, and then take another reading to see if your breathing improves with medication. Challenge test. This is a test done to determine whether your

bronchial tubes are hypersensitive. During the test, you’ll breathe in air containing a substance known to cause bronchoconstriction, such as methacholine or histamine. If you have asthma, you’ll respond to much smaller amounts of the substance. This test is often used to confirm a diagnosis of asthma if there is uncertainty. Exercise tests. Because many teens have exercise-induced asthma,

your doctor may request special exercise tests to see whether your asthma symptoms are brought on by physical activity. Skin tests. If the doctor suspects allergies as a cause of your asthma,

you may be asked to have an allergy skin test or blood test. Knowing what substances you are allergic to can help identify your asthma triggers and help you avoid them in the future. These tests are usually performed by an allergist, who can determine what triggers your allergic asthma and whether allergy shots would help you. Chest X-rays. Doctors occasionally use chest X-rays while diagnos-

ing asthma as a way of ruling out other possible lung conditions.

WHAT DOES IT ALL MEAN? Once all the tests are in, your doctor will outline the factors that are important in your asthma. The four main categories of asthma based on symptoms include mild intermittent, mild persistent, moderate persistent, or severe persistent asthma. Of course, you need to keep in mind that your condition can get better or worse as the years progress, which would put you in a different asthma category requiring different treatment. If you wheeze, cough, or get short of breath no more than twice a week, your doctor will diagnose mild intermittent asthma. In this case, you probably don’t usually have symptoms between episodes, although you may occasionally have mild symptoms at night once or

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Getting a Diagnosis

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twice a month. This may seem harmless, but you shouldn’t ignore these symptoms, because even though your breathing seems normal between flares, your airways are still slightly inflamed. If you find that you’re wheezing, coughing, or getting short of breath more than twice a week (but less than once a day), you’ll be diagnosed with mild persistent asthma. People with this type usually notice symptoms at least twice a month at night. In these cases, symptoms may interfere with normal physical activity. Teens with moderate persistent asthma have some level of symptoms every day (and nighttime symptoms more than once a week) and need daily medication. Episodes of wheezing, coughing, or shortness of breath occur more than twice a week and may last for several days. These symptoms will interfere with your day-to-day activities. If you have symptoms all the time, you’ll be diagnosed with severe persistent asthma. You may have needed to rush to the emergency room with episodes of wheezing, coughing, or shortness of breath, and you even may have needed to be hospitalized sometimes. Many kids with severe persistent asthma often have symptoms almost every night and can handle only limited physical activity.

USING YOUR PEAK-FLOW METER Now that you’ve been diagnosed, your doctor will probably give you a peak-flow meter right away so you can monitor the status of your airways at home. One of the difficult things about persistent asthma is that you probably have inflamed airways even if you aren’t having any trouble breathing. This low-grade inflammation can build up over time, which can make you vulnerable to unexpected asthma flares. You may feel perfectly healthy, never realizing that your airways are swelling and narrowing. To help you get a better idea about the inner state of your health, you can use the peak-flow meter, a portable device that can measure how well your lungs are working. Tracking this information can help you avoid severe flares: When peak-flow readings drop, it’s a sign that your airways are getting inflamed. You may have first used a peak-flow meter when you were being tested to see if you had asthma. Basically, a peak-flow meter measures how quickly you are able to blow the air out from your lungs as you breathe out, which identifies whether there is obstruction in the airways. To do this, you simply blow into the meter as if you were blowing out candles. The meter records the peak flow—that is, how much air you were able to quickly blow out of your lungs.

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12 Living with Asthma

Using a Peak-Flow Meter Using a peak-flow meter is simple. 1. First, set the meter to zero. 2. Stand up and take a deep breath, and then hold it. 3. Now blow as quickly and strongly into the meter as you can. 4. Record the reading. 5. Repeat three times and record the highest reading (not an average). 6. Compare the highest reading to your personal best, the best peak-flow meter reading you’ve ever gotten.

A peak-flow meter can tell you how severe your asthma is, how well you’re responding to medications during a flare, and whether your asthma is getting worse. If the peak-flow reading is lower than usual, this means your airways are inflamed and an asthma flare could be developing. It may be two or three more days before you notice the flare, which gives you time to take your medicine to head off the attack. Your doctor will help you establish three zones of peak-flow meter readings based on your personal best—green (normal), yellow (warning), and red (danger). Any reading in the green safety zone means your airways are open, because your peak flow is 80 percent or better of your personal best. A reading in the yellow caution zone means that you’re at risk for a flare, because your peak flow is between 50 and 80 percent of your personal best. Any reading in the red danger zone means that you’re probably already having symptoms, because your peak flow is less than 50 percent of your personal best. If you’re in the red zone, you need medication immediately and you should consult your doctor.

PUTTING TOGETHER AN ACTION PLAN Once you’ve been diagnosed with asthma, your doctor will probably prepare an asthma action plan that includes a set of individualized

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Getting a Diagnosis

13

written instructions explaining how you should manage your asthma at home. If you keep the plan current and you follow it carefully, you can prevent or treat your symptoms and control your condition very well. Typically, this plan outlines both a daily program for preventive care and a rescue program that describes how to handle flares. This step-by-step plan outlines exactly how to recognize and manage flares when they occur and what to do between flares. Your daily program may include a description of your triggers, a peak-flow meter chart, and the long-term preventive medicines and short-term “rescue” drugs your doctor has prescribed. A key part of any action plan typically describes the steps to take if you have an asthma attack and may include details about taking rescue medication at school. Most important, the plan should describe when to call the doctor or go to the emergency room. Although there are all sorts of ways to organize the plan, many doctors use the zone system based on the red, yellow, and green colors of a traffic light—the same color system used on peak-flow meters. You can figure out what zone you’re in by checking your symptoms and peak-flow readings. On your action plan, the green safety zone explains how to manage your asthma on a daily basis, when you’re feeling good. The yellow caution zone explains how to look for signs that your asthma is getting worse and explains which medications to add to get your asthma back under control. The red danger zone explains what to do when you’re having a severe flare. This color system makes it easy for you to figure out which instructions to follow depending on your peak-flow meter reading. The plan also must include your personal best peak-flow reading, so that you’ll have something with which to compare the new numbers. You’ll get the most out of your action plan if you’re very familiar with it before you have a flare. You should keep a copy at home, and your parents should give one to the school nurse and to your teachers. Of course, as you get older, your situation may change, and your asthma may improve. You’ll need to keep your plan updated as the dosages for your medicines change, so it’s a good idea to review the plan with your doctor at least every six months. Any time your action plan changes, you should give new copies to anyone who has one.

WHAT YOU NEED TO KNOW M Diagnosing asthma can be tricky, because not every person experiences the same symptoms. M Asthma is diagnosed on the basis of history, symptoms, and results of pulmonary function tests and other assessments.

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M Your asthma may be diagnosed as either mild intermittent, mild persistent, moderate persistent, or severe persistent. M A peak-flow meter can help you assess your airway health on a daily basis. M Your doctor will give you an asthma action plan that includes a set of individualized written instructions explaining how you should manage your asthma at home.

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3 Figuring Out Your Asthma Triggers

E

Elise loves field hockey, but when she was diagnosed with severe exercise-induced asthma, she was afraid she’d have to hang up her hockey stick. But then she got together with her doctor, and they figured out that if she regularly used her controller medication and used her inhaler just before every game, she could keep her asthma under control. Jason’s sensitivity to dust and mold triggered his asthma symptoms, so his parents helped him move his bedroom from the basement to the second floor guest room. His mom also replaced the wall-to-wall carpeting with tile in his new bedroom. He’s been sleeping better ever since. Kara and Becky are best friends, and they love sleepovers. But because Becky has allergic asthma and Kara has cats, they stay at Becky’s house to avoid the potential triggers of her asthma flares. Becky, Elise, and Jason all have asthma, and each one of them has managed to find a way to live a normal life by managing his or her own particular triggers—the substances or situations that set off their symptoms. Of course, different people will have different triggers. For example, Becky can’t pet a cat, but she can run for miles without having an asthma flare. Elise doesn’t seem to be affected by mold, but any exercise makes her sick. Jason can cuddle dogs without a wheeze, but a whiff of dust or mold sends him into a coughing fit. No matter what causes your asthma, the goal is to prevent a flare from occurring. The way to do that is to figure out what sets off your symptoms and then avoid those triggers.

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FIGURING OUT YOUR TRIGGERS Once you’re diagnosed with asthma, you’ll have to do a bit of detective work to figure out what sets off your symptoms. Of course, no matter how good you are at avoiding those situations or substances, you’ll still have asthma—but your everyday condition will most likely be much less severe. To figure out your triggers, think about what happens during some of the first symptoms of an asthma flare. Pay attention the next time you develop symptoms, and note when they occur. Don’t try to ignore the signs and pretend that a flare isn’t happening—ignoring them won’t make them go away. Some kids notice that their chest feels tighter and tighter; others say it gets harder to catch their breath. Some say they just feel very tired, and others report a cough that just won’t go away. Most kids report that trying to breathe during an asthma flare feels a lot like breathing through a straw. In the very early stages of a flare, it may be hard to detect symptoms. That’s why some kids use a peak-flow meter to help them determine if a flare may be developing. Becoming aware of exactly when your symptoms begin can help you figure out what’s causing them. Think about where you were and what you were doing when your breathing problems started. Different kids will react to different substances or situations. It may be smoke from a fireplace or a cigarette, dust in the air, or the dander from your pets. Maybe it’s the strong cleaning products your mom just used to disinfect your shower, the sulfites in the salad bar at your favorite restaurant, or the cold winter air when you went ice-skating on your pond. No matter what the trigger, finding out what’s causing your asthma flares will help you avoid those triggers the next time. The number and types of triggers you may have will probably be different from other kids’. Some teens react to only a few triggers, but others seem to be sensitive to just about everything in their environment. Kyle has exercise-induced asthma, and pretty much any sport he tries brings on severe symptoms. But he doesn’t have a problem with pollen, smog, strong smells, molds, or any of the other asthma triggers some of his friends have to watch out for. His best friend Luke, on the other hand, is a walking allergy magnet. He can’t handle pet dander, dust, pollens, grasses, or molds. He gets a flare during hot muggy weather or icy cold weather, or when he just strolls along the beach at the seashore. Some kids get asthma symptoms only when more than one trigger occurs at once; others notice that the more triggers, the more severe the flare. This can make it tough to figure out exactly what’s causing problems.

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Figuring Out Your Asthma Triggers

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What can make it particularly difficult to pinpoint your triggers is that asthma flares don’t always occur right after exposure to a trigger. You might be exposed to pet dander but not react for several hours, so it can be hard to figure out on your own that the neighbor’s cat was responsible for your symptoms. Moreover, triggers can vary from season to season, which is why figuring out what your triggers are can take time and some good detective work. Nevertheless, it’s important to figure out all of your allergic triggers, because some substances can cause a severe reaction while others cause only a mild problem. If you have allergic asthma and are having a hard time figuring out exactly what you’re allergic to, skin testing by an allergist might be a good way to determine all of your allergic sensitivities.

TYPES OF TRIGGERS Allergies. Many teens have allergic asthma that make them sensi-

tive to indoor or outdoor inhaled allergens. Common indoor inhalants include molds, cockroach allergen, dust and dust mites, and the animal dander of cats and dogs. Mold growing on the inside of your house can produce allergenic substances released in spores during any season, as long as you’ve got a warm, dark, humid, musty environment such as a damp basement, bathroom, or laundry room. Indoor molds also can grow in refrigerator drip trays, garbage pails, air conditioners, and humidifiers. Cockroaches are one of the most common indoor pests that bother people with asthma, because of the allergenic proteins in cockroach saliva as well as in their body and droppings. Researchers have found a significant link between cockroaches and more severe asthma symptoms in people sensitive to these allergens. But cockroaches don’t just live in poverty-stricken areas; you can find cockroaches even in the cleanest urban apartments and older homes in just about any neighborhood. Dust mites are tiny creatures related to ticks and spiders that are found in every house, no matter how clean—but some homes have much higher numbers than others. Your mite population is probably higher if your house is humid and you live in a temperate climate at normal altitude. There tend to be fewer mites at higher altitudes and in drier climates. The mites eat the dead skin cells that we shed and leave droppings that contain asthma-causing allergens. Sounds disgusting, but almost every home has them. If you’re allergic to cats or dogs, it’s not the fur itself that causes the problem but proteins in the pet’s dander and saliva that stick to

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Living with Asthma

the fur when animals lick themselves. These proteins are also found in tiny particles in rodent or guinea pig urine that is introduced into the air. Even if your pet isn’t in the same room with you, it’s a good bet that their allergens are—circulating in the air and lingering in the rugs and on sofas and chairs for weeks. Allergens even may be found in public buildings or schools where there aren’t any pets at all. Outdoor allergic inhalants include outdoor molds as well as pollens from trees, grass, and weeds. Outdoor molds grow in moist, shady areas, producing spores in early spring that continue to grow until the first frost. You can find these molds in soil, decaying vegetation, compost piles, fallen leaves, and rotting wood. Weed pollens such as ragweed, curly dock, lambs quarters, pigweed, plantain, sheep sorrel, and sagebrush produce huge amounts of pollen allergens. The ragweed pollen season runs from August to November, but it peaks in mid-September in many parts of the country. Pollen counts are highest between 5 A.M. and 10 A.M. and on dry, hot, and windy days. Trees produce pollen earlier than other plants, first releasing pollen as early as January in the south and as late as May or June in the north. Even if they aren’t near your house, trees can aggravate your asthma, because the huge amounts of pollen they release can travel miles from the original source. Luckily, less than 100 of the 50,000 kinds of trees cause allergic asthma, and most people have problems with only a few—cottonwood, elm, hickory, olive, pecan, sycamore, or walnut—or to the male cultivar (a plant variety developed through cultivation) of certain trees. There are individuals who occasionally do show some cross-reactivity among trees in the alder, beech, birch, and oak family and in the juniper and cedar family. Grass pollen levels vary depending on the part of the country in which you live and the time of year. Grass pollen levels also are affected by weather (especially rain), temperature, and time of day.

Food Triggers A few teens are sensitive to foods such as peanuts, shellfish, and tree nuts, although foods are much less likely to trigger an asthma flare in teens than in younger kids.

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Of the 1,200 species of grass that grow in North America, only a small percentage of these cause allergies. The most common grasses that can cause allergies are Bermuda, orchard, Johnson, sweet vernal, and timothy grasses, as well as Kentucky bluegrass. Irritants. Some substances that you breathe in act like allergens,

triggering flares because they physically irritate the airways. These inhaled irritants include cigarette smoke, air pollution, perfume, strong odors, aerosol sprays, chalk dust, and paint fumes. If you’re sensitive to any of these substances or smells, exposure may trigger a cough, wheeze, runny nose, or watery eyes—symptoms that look just like those produced by allergens. Cigarette smoke is one of the most irritating asthma triggers. In fact, as many as 1 million asthmatic kids experience asthma flares as a result of inhaling secondhand smoke. For obvious reasons, if you have asthma you shouldn’t smoke, but you also should avoid being around other people who are smoking. This secondhand smoke can trigger asthma symptoms that are just as severe as if you were smoking yourself. In fact, studies have found a clear link between secondhand smoke and the development of asthma in young people. Secondhand smoke also worsens asthma in teens and may cause up to 26,000 new cases of asthma each year. But cigarette smoking isn’t the only irritant that causes problems. Some research studies have found that high levels of air pollutants such as ozone may irritate the sensitive tissues in the bronchial tubes and possibly aggravate the symptoms of asthma in some people with the condition. Strong smells also can cause symptoms; you should avoid breathing in cleaning products, hairspray, perfumes and colognes, fresh paint, gasoline, tar, insect sprays, and potpourris and room deodorizers. Infections. Do you start wheezing as soon as you get a cold? That’s just what Max discovered; in fact, he told his doctor that sometimes he gets asthma symptoms a day or so before he develops symptoms of a cold. This is probably because viruses incubate in the body a few days before symptoms of a cold infection appear—but in people with extremely sensitive airways, an asthma flare is triggered within the very first hours of a viral invasion, long before cold symptoms begin. These infection-related asthma flares are hard to prevent, because if you go to school, you can guarantee that you’ll be surrounded by other kids with all kinds of germs. Respiratory infections often trigger severe episodes of asthma, especially if they are caused by viruses

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Living with Asthma

(although bacterial infections also can cause an asthma flare). Even an ear infection can trigger an asthma flare. Exercise. If you develop symptoms after only a few minutes of

almost any sustained, vigorous activity, such as team sports or biking, you probably have exercise-induced asthma. In particular, running seems to be a problem; it can trigger an episode in more than 80 percent of teens with asthma. If this sounds like you, it doesn’t mean you’ll be given a permanent pass to get out of gym. All teens need to exercise. But if exercise is triggering your symptoms, you’ll need to talk to your doctor so the two of you can figure out which medications you can take to prevent a flare. With proper treatment, you won’t need to curb your activities (except perhaps for prolonged running, especially during cold weather and during pollen season in the spring and fall). You’ll learn more about exercise-induced asthma in chapter 7. Additives. Some teens with asthma find that attacks can be triggered by certain food additives (especially sulfites, which are sulfurbased preservatives). Other food additives that can be associated with asthma include benzoates, artificial colors, nitrates, BHA, BHT, and MSG. The U.S. Food and Drug Administration (FDA) estimates that about five percent of kids with asthma are sensitive to sulfites. Some experts think sulfite sensitivity occurs in many more kids. People tend to react most quickly when sulfites are sprayed onto food or if they’re contained in a beverage, but the most severe reactions occur when sulfites are part of the food itself. If you’re highly sensitive to sulfites, you’ll react within about 15 minutes. Less sensitive teens, exposed often to sulfites, may experience a very mild chronic lung inflammation that erupts into an asthma flare after exposure to other triggers, such as a virus or exercise. When this occurs, the person tends to blame the obvious trigger, overlooking the underlying lung inflammation that was caused by sulfites. Sulfites are used to preserve lots of cooked and processed foods and beverages, including tuna; shrimp; lemon juice; baked goods; condiments; dried fruit; jam; gravy; dehydrated, precut, or prepeeled potatoes; molasses; and soup mixes. You’ll also often find sulfites in food on salad bars and in beverages such as beer, wine (especially white wine), hard cider, fruit and vegetable juices, and tea. The FDA requires that food manufacturers and processors identify sulfites in their products in concentrations of at least 10 parts per million (that’s about as much as a drop of water in a full bathtub). Sulfites

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What’s in Your Tuna? You should not eat canned white albacore tuna or light tuna if you’re sensitive to sulfites, according to the FDA, because most canned tuna contains this preservative even if it’s not listed on the label. If you’re wondering about the level of sulfites in your favorite tuna products, you can call (800) 283-1112 to find out.

have been used around the world for centuries to slow the browning of light-colored fruits and vegetables, prevent black spots on shrimp and lobster, discourage bacterial growth as wine ferments, and condition dough. In 1958 the government decided sulfites were “generally recognized as safe,” but by 1982 people exposed to sulfites began reporting health problems ranging from chest tightness and breathing problems to hives and fatal anaphylactic shock. In 1985 the government decided that sulfites were safe for most people, but that they caused unpredictable problems in people with asthma. As a result, in 1986 the FDA banned sulfites on raw fruits and vegetables (such as would be found on a salad bar). In addition, the government decided that unpackaged bulk food (such as barrels of dried fruit or loose raw shrimp) must carry a sign or label that lists the food’s ingredients so that consumers can see if the product was treated with a sulfiting agent. Since 1985 the government has been tracking reactions to sulfites and has logged 1,097 reports over 10 years, but by the mid-1990s the number of reported sulfite-related health incidents has been dropping steadily. In 1995 just six cases were reported. Drugs. Some medications can trigger asthma symptoms and should therefore be avoided by people with asthma. One of the best-known classes of drugs that causes problems in people with asthma are the beta blockers, which aren’t usually prescribed for people with asthma, because they block the bronchodilation of the airways. Beta blockers include

M atenolol (Tenormin) M metoprolol (Lopressor, Toprol XL) M propranolol (Inderal)

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Beta blockers are used to treat high blood pressure and heart problems and to prevent migraine headaches in people who get them frequently. Beta blockers aren’t the only type of medicine that can trigger an asthma flare. Between three and 22 percent of people with asthma can’t take aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or COX-2 inhibitors, because these medicines also may trigger asthma. NSAIDS include M ibuprofen (Advil, Motrin) M ketoprofen (Actoron, Orudis) M naproxen (Aleve) COX-2 inhibitors include M celecoxib (Celebrex) M rofecoxib (Vioxx) In sensitive individuals, an asthma flare will occur between one and three hours after taking one of these drugs and may be life-threatening. Experts don’t really know why some people with asthma are sensitive to these medications, but those who are tend to be more likely to have nasal polyps and chronic sinus problems as well as asthma. Researchers suspect that aspirin triggers the release of excess amounts of leukotrienes, which are chemical mediators that constrict the muscles surrounding the bronchial tubes, resulting in wheezing and shortness of breath. Keep in mind that many other nonprescription cough and cold, allergy, and pain medicines contain aspirin or other NSAIDs, so you should read product labels carefully. If it’s not clear whether a medicine includes a drug to which you’re sensitive, ask your doctor or pharmacist. If you’re not sure whether you’re sensitive to aspirin or other NSAIDs, you should probably avoid these drugs or check with your doctor before taking them. If you have asthma and you need to take a painkiller, you can probably choose acetaminophen (Tylenol). If necessary, your doctor can prescribe other pain medicines such as salsalate (Disalcid) or tramadol (Ultram). Weather. Many teens with asthma find that breathing in cold air alone is enough to cause an asthma flare. Other kids notice that many other types of weather, such as wind or rain or sudden weather changes, may trigger symptoms. In addition, the weather can influ-

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ence other asthma triggers; for example, on a windy day more pollen might be scattered in the air. This means that if you have allergic asthma, on a windy day you might experience an asthma flare not because you have a problem with wind but because of how the wind affects the pollen to which you’re sensitive. Sometimes a heavy rainfall might wash all the allergens out of the air but increase the concentration of mold. Although some people believe that western climates are asthma-safe zones, in fact there isn’t really one safe climate for everybody with asthma. Emotions. Many people used to think that kids developed asthma as

a result of psychological problems. Today experts know that this just isn’t true. However, your asthma might flare up if you cry, laugh, or yell in response to an emotional situation. These normal emotional responses involve deep rapid breathing, which in turn can trigger asthma, as it does after running. It’s not the emotion itself that causes symptoms but the physical aspect of laughing, crying, or yelling that irritates sensitive airways. Emotions themselves, such as anxiety or anger, may occasionally trigger asthma, but only in kids who already have asthma. The emotion itself doesn’t cause the condition. In addition, stress may occasionally trigger symptoms. It’s not surprising that in the past, emotions have been linked to asthma. It can be scary to find that you can’t breathe, and anxiety or panic can lead to rapid breathing that makes the asthma even worse. That’s why it’s important to try to control your anxiety during a flare. Of course, that’s not to say that nobody with asthma will ever have a psychological problem. Any chronic illness can cause psychological problems. If you’re experiencing psychological problems related to your asthma, it’s a good idea to talk to your parents, a trusted teacher, or maybe a counselor at school about consulting a mental health specialist to help you deal with the situation.

MANAGING YOUR TRIGGERS Once you’ve figured out what your triggers are, you’ll need to try to avoid them as much as you can. This can be fairly challenging, but altering your environment is one of the first steps you and your family can take in managing your condition. Infections. There isn’t a pill you can take to prevent getting a cold, but there are some things you can do to limit the likelihood that you’ll get sick. The most important thing is to wash your hands as often as you can, because that’s how most colds are transmitted. Wash your

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Living with Asthma

hands in the morning, before lunch, after going to the bathroom, when you get home from school, before dinner, and before bedtime. Think about taking a soapless antibacterial handwash to school, and use it as often as you can. Other times, plain soap and hot water will do just fine, as long as you wash long enough (mentally sing the song “Happy Birthday,” and don’t stop washing until you reach the end). Take a vitamin pill each day, and drink plenty of orange juice or any other fruit juices with vitamin C. Also drink lots of water and other fluids, eat sensibly, and get plenty of rest. An annual flu shot is imperative for anyone with chronic lung problems, so you should be sure to get your shot each November. No matter how careful you are, you’ll still get sick sometimes. If you begin to notice cold symptoms, many doctors would recommend that you make sure you’re taking your asthma preventive medications and have an action plan to increase the frequency or dose at the first sneeze or tickle in your throat to prevent a bad asthma flare. Check with your doctor to see what he or she recommends for you. Smoke. Anyone with asthma should never smoke cigarettes, cigars,

or a pipe, but you also need to avoid spending time with anyone who smokes, because this could trigger an asthma flare as well. Other sources of smoke in the house are also a problem. Try to avoid breathing in smoke from stoves and fireplaces. Because broiling and toasting food can produce smoke, it’s a good idea to have a good hood fan over the stove. Even lighting matches can be a problem for people with asthma, because they produce sulfur dioxide as they burn, which can severely aggravate your condition. If necessary, use a butane lighter instead. Exercise. Exercise-induced asthma can be a problem for athletes, as

is discussed at length in chapter 7. If you’re a sports nut and your sport is one that involves a lot of running, such as soccer or lacrosse, your doctor may recommend that you use an inhaled medication before exercise to prevent flares. However, some teens find that even the slightest exercise (such as climbing stairs) makes them wheeze. In that case, you may also need daily medication to bring the situation under control. If you have asthma and you just want to find a sport that allows you to exercise without triggering a flare, consider taking up swimming, which seems to be the least problematic sport for kids with asthma. Cockroaches. Studies have shown that the presence of cockroaches

in the home is linked to many cases of asthma. If you’ve got roaches at

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your house, talk to your parents about ways to get rid of them. Use bait stations and other environmentally safe pesticides to reduce cockroach infestation; these are much less likely to affect your lungs than sprays or foggers. Be sure to use pesticides as directed on the label. Once you’ve gotten rid of roaches, you’ll need to prevent their return. To do this, be sure to keep food and garbage in closed, tightlidded containers and never leave food out uncovered. Keeping the kitchen clean also will help. Mop the floor and wash countertops at least once a week. Keep crumbs, dirty dishes, and food waste cleaned up. If you tend to stash food around your bedroom, this can only encourage roaches. Limit snacking to the kitchen and dining room. Plug up any openings to the outdoors through which cockroaches can get in. You’ll also want to clean out your pet’s food bowls each day. Water also attracts roaches, so be sure your parents fix leaky faucets and drainpipes. Molds. To vanquish indoor mold, talk to your parents about using a dehumidifier or air conditioner in the house to keep relative humidity below 50 percent. The basement in particular may need a dehumidifier—and remember, the water in the dehumidifier must be emptied and the container cleaned often to prevent mildew and mold from developing. Keeping the indoors cool with an air conditioner will also discourage mold, because air-conditioned air is dry. However, don’t turn your air conditioning on full blast; air in the room should be comfortable. Some kids with asthma can’t tolerate a dramatic change in temperature, especially when moving from warm to cold. If your family has air-conditioning at home, you’ll also be able to keep the windows and doors closed, which will help cut down on outdoor mold wafting indoors. When your parents first turn on an air conditioner in your home or in the car after it’s been off for a few weeks, leave the room or drive with the windows open for several minutes to allow mold spores to disperse. Make sure that your family’s bathrooms and clothes dryer are vented to the outside, and don’t forget to turn on the fan when you’re taking a bath or shower or during cooking. You’ll also want to make sure that damp areas have good air circulation and are cleaned often. Because molds may form on foam pillows when you perspire, you should wash and dry pillows thoroughly every week and change them every year. Molds also grow in houseplants, so check them often. If you’re having a serious problem with mold-induced asthma, your family may have to keep all plants outdoors.

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Outdoor molds appear in early spring and thrive until the first frost, especially in moist, shady areas in soil, decaying vegetation, compost piles, rotting wood, and fallen leaves. To prevent mold from building up, be sure that your parents get rid of decaying debris from the yard, roof, and gutters. And you’ll need to avoid raking leaves, mowing lawns, or working with peat, mulch, hay, or dead wood, because all of these activities will make your asthma worse. If your parents insist that you do yard work, wear a mask and don’t work on hot, humid days. Indoor dust. Breathing in dust can aggravate asthma, so you and your family should keep your home as dust-free as possible. One way to do that is to see if your parents can choose hardwood floors over carpeting and vacuum often. Your parents should use a vacuum equipped with high-efficiency filters such as a micro filter or HEPA filter, good suction, and sealed construction. If your parents are buying a new vacuum, they should ask for data from the manufacturer about what percentage of dust particles are captured by the vacuum and at what size (such as 98% at 1.0 micron). Some families of asthma patients install a central vacuum that collects the dust in a chamber in the basement, which eliminates the need for emptying a canister or removing bags of dust and throwing them out. Vacuums with bags are a better choice than bagless machines because they better control loose dust. Sulfites. Many kids with asthma are sensitive to sulfites, which are added to many foods as a way to preserve them. When buying food, read all of the package labels. If the item is sold in bulk, ask the store manager or waiter to check the ingredient list on the product’s original packaging. Be aware that processed foods such as dried fruits, canned vegetables, maraschino cherries, and guacamole often contain sulfites. If you’re in a restaurant, order a baked potato rather than hash browns, fries, or any dish that involves peeling the potato first. Keep your inhaler with you when you eat out, so that in case you accidentally consume sulfites you’ll be prepared. If you’ve experienced a severe reaction (such as breaking out in hives or going into anaphylactic shock) to sulfites in the past, make sure you have an injectable epinephrine, such as EpiPen. This way, if you have a reaction you can stabilize your condition until you get to an emergency room. Pets. Pets are often a problem for kids with asthma. It’s best if you can remove pets from your home, but if that’s out of the question, at

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Did You Know? The first hypoallergenic cats have been bred by the San Diego–based pet company Allerca. At no harm to the cats themselves, the company bred the cats to eliminate the protein in cat saliva that can trigger allergic reactions. The first cats were offered for sale in 2007, at a cost of $3,950 each.

least try to keep them out of your bedroom. Ideally, they should stay only in uncarpeted areas or in rooms without upholstered furniture. Your pet should be washed every week to lower the pet dander and saliva on its fur. After playing with your pet, wash your hands and clean your clothes to remove pet allergens. Your parents should dust often with a damp cloth in any rooms where pets live. If you’re doing the dusting, wear a mask. If you have hamsters, gerbils, mice, or rats, you’ll need to wear a mask and gloves when you clean their cage, and try to avoid touching soiled litter. Although some breeds of dog or cat may cause fewer asthma symptoms than others, technically there is no such thing as a nonallergenic cat or dog (other than the special breed mentioned above), especially if the pet leaves dander and saliva in the home. However, some people with asthma have found that they can handle certain dog breeds with hair instead of fur, such as poodles, bichon frieses, or Portuguese water dogs, or hairless cats. Goldfish and other tropical fish also may be a good substitute. Pollens. If your symptoms are aggravated by weed pollens, you’ll

want to avoid being outdoors between 5 a.m. and 10 a.m. Plan to go outside in late afternoon or after a heavy rain, when pollen levels are lower. Keep the windows in your house and car closed, and use air conditioners, not window fans. Remember that pollen can be tracked into the house on clothing or pet fur, and don’t hang clothes or bedding outdoors where they can collect pollen. Instead, dry your clothes in a dryer. If grass pollens trigger asthma flares, you’ll need to avoid mowing—or if you can’t get out of it, at least wear a mask and keep the grass on your lawn cut short. You might talk to your parents about

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replacing lawns with ground covers that don’t produce much pollen, such as Irish moss, bunch, and dichondra. Some trees produce a lot of pollen, so if your parents are going to be planting trees, choose some of the pollen-free varieties: crape myrtle, dogwood, fig, fir, palm, pear, plum, redbud, and redwood trees or the female cultivars of ash, box elder, cottonwood, red and silver maple, palm, poplar, or willow trees. However, be aware that tree pollens can travel many miles, and you may be affected by pollens from far away from your home. Weather. One of the worst problems with weather-related triggers is very cold air. If you have to go outside in winter, try to avoid inhaling very cold air. Wear a special ski mask designed for this purpose, or wrap a heavy scarf loosely over your nose and mouth. Dust mites. As soon as you’re diagnosed and you’ve identified dust mites as a trigger, see if your parents can buy you a new bed or mattress, a new set of pillows, and a new duvet. Cover these with mite-proof bedding before they’re ever used, covering not only the pillow but also the mattress and box spring. Once they’re installed, you should vacuum or wipe the dustproof bedding covers regularly and wash them according to the manufacturer’s instructions. Adding benzyl benzoate in a cold-temperature wash can kill mites in bedclothes and other washable items. Some experts suggest that airing beds thoroughly helps lessen mites, since mites love moisture and hate light. Vacuuming the mattress will remove some of the skin cells on which the mites feed and a little of their droppings. However, if you’ve got allergic asthma, you shouldn’t be doing the vacuuming. In fact, you shouldn’t even be in the same room when the mattress is being vacuumed, because even machines with good filters remove dust from surfaces and blow a surprisingly large amount of mite dust back into the air. If you have asthma and you must vacuum and make your own bed, you should wear a good filter breathing mask, although it may be uncomfortable. If your vacuum cleaner is old and leaks, talk to your parents about replacing it. But beware of bagless vacuums, which can spread a lot of dust into the air when the canister is emptied; any mites in the dust will spread. No matter how good the vacuum, there’s a limit to how well it will remove dust mites. Getting rid of carpets is a better idea. Every time someone walks over a carpet, the mite dust is spread into the air, and wall-to-wall carpets can’t be cleaned thoroughly enough, although some experts believe that steaming carpets thoroughly may

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help. Instead, most experts recommend replacing carpets with sanded and varnished hardwood floors or a vinyl, linoleum, or tiled floor. A few area rugs are okay, as long as they can be washed frequently. If you can’t remove the carpets, the next best thing is to use a topquality vacuum cleaner and apply mite-killing chemicals occasionally (liquid nitrogen treatment of carpets kills mites). Cover the most highly traveled parts of the carpet with area rugs that can be washed. Don’t allow your bedding to touch the carpet. Remember that mite dust takes about two hours to land on surfaces in an undisturbed room. You also should control humidity. If your parents insist on carpeting, have them buy a lower quality carpet and replace it more often. It’s better to walk around in socks, soft slippers, or bare feet instead of any kind of shoes, no matter how soft they are. If possible, soft upholstered furniture should be replaced with wood, plastic, or leather furniture. If your asthma condition is quite severe and you live in an old, damp, or extremely dusty home, your parents may need to consider moving to a modern house with excellent ventilation. Air conditioning also can help keep the mite population under control, especially if you ventilate well so that the humidity is not too high. Your parents also might want to invest in a dehumidifier to remove excess amounts of water from the air. Because your clothes (especially your sweaters and bathrobe) can have lots of dust mites, wash or clean your clothes often. Keeping humidity to a minimum is another important way to get rid of dust mites. Although house dust mites feed on dead skin cells, they also live on a microscopic fungus in house dust called Aspergillus repens. This fungus needs moisture in the air to grow. To lessen your mite population, you must keep humidity below 40 percent for weeks or months. Air filters in a ducted-air central heating system will help. If you really want to get rid of mites, you’ll need to be thorough.

WHAT YOU NEED TO KNOW M Asthma triggers are the substances or situations that set off symptoms and may be different in different people. Triggers may include allergens, irritants, additives, strong M smells, drugs, exercise, emotions, and weather. M Controlling these triggers can help greatly reduce your asthma symptoms.

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4 Putting Out Your Asthma Flare: Treating Asthma Attacks

J

Jason has been using daily inhaled medication for several years, but when he entered high school he got tired of lugging around his rescue inhaler. It was a pain to remember to take his regular medications, and he started to resent having to be different from his friends. Gradually, he started “forgetting” his rescue inhaler, leaving it at home or in his locker at school. On a particularly rainy, cold winter day, he was over at his friend’s house when his asthma suddenly flared, probably as a result of the combination of the weather and his friend’s dog. Because he hadn’t been taking his controller medication, his underlying asthma had been worsening, and he experienced a very severe attack. His friends’ parents had to rush him to the hospital since he didn’t have his rescue inhaler with him. Luckily for Jason, everything turned out okay, but he learned a very important lesson: Not paying attention to prescribed treatment can cause major problems. In chapter 3 you read how Becky, Elise, and Jason tried to prevent asthma flares by avoiding their triggers. But if you have severe asthma, that’s probably not enough to keep you from having problems; most teens with moderate to severe asthma also need to take preventive medication to remain symptom free. Unfortunately, taking medication (especially every day) can be a pain. But you need to understand that relying only on your quick-relief inhaler can be dangerous. Just as everybody’s asthma is a little bit different, there also are different medicines for treating it. If you have asthma, your doctor will discuss your triggers with you, how fast the flares develop, and

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Putting Out Your Asthma Flare: Treating Asthma Attacks 31

how serious they are. Then your doctor will decide on the best kind of treatment for your particular condition. It may take some experimentation to come up with the most effective medication plan. Both the type and dosage of medication that you need are likely to change, but your doctor should always try to make sure you’re taking the least amount of medication necessary for effective asthma management. In addition, your asthma medicine may need to be adjusted if you’re having symptoms such as wheezing or coughing with exercise, at rest, at night, or early in the morning. If this happens, talk to your doctor about changing the dose or type of medicine. Your doctor may increase the dose of medicine, decrease the time between doses, or prescribe a second medicine, if necessary.

TWO TYPES OF MEDICATION There are two basic types of asthma medications available in either inhaled or pill form—the quick-relief medications (also called rescue drugs) and the long-term preventive (or controller) medications. Luckily, various asthma medications can control asthma in almost every case, since they treat both your symptoms and the underlying causes. If you have mild intermittent asthma, you may need to take your asthma medication only occasionally, during a flare. In this case, you’d use your rescue medicine, because it works fast to open the airways so you can breathe. Other kids with persistent asthma may need to take preventive medicine every day to keep flares from starting. New guidelines from the National Institutes of Health advise that you should treat asthma using the lowest effective dose of medication, increasing the dose and its frequency if your asthma gets worse. Once your asthma is under control, you can slowly decrease the medicines under your doctor’s supervision.

QUICK-RELIEF MEDICATIONS Rescue medications work right away to relieve asthma symptoms and are usually inhaled directly into the lungs, relaxing the muscles around the airways to relieve wheezing, coughing, and shortness of breath. They begin to work within minutes after they are used, and their effects may last up to six hours. Although they’re extremely effective, they won’t alleviate the cause of asthma symptoms over the long run. Most of the rescue medications are inhaled through a pocket-sized device that you can use when you feel symptoms coming on. These

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medications also can be used before exercise to help prevent asthma symptoms if you have exercise-induced asthma. The most commonly used rescue treatments for asthma are shortacting beta-agonists, which relax the smooth muscles around the airways. These medications are related to adrenaline and usually work within minutes to provide temporary relief of symptoms. If the inhaled bronchodilator alone doesn’t resolve a severe flare-up, other medications may be given by mouth or injection to help treat it. Side effects of beta-agonists may include increased heart rate, shakiness, and a nervous, jittery feeling. These drugs include M M M M M M

albuterol (Proventil, Ventolin) bitolterol (Tornalate) levalbuterol (Xopenex) metaproterenol (Alupent) pirbuterol (Maxair and Maxair Autohaler) terbutaline (Brethine; Bricanyl)

Ipratropium bromide (Atrovent) is an inhaled asthma medication that works more slowly than the other medications listed above, and it isn’t effective for exercise-induced asthma. Atrovent opens the airways by blocking reflexes through nerves that control the smooth muscle around the airways. It can take 15 to 20 minutes to show a significant effect. Some teens use Atrovent in addition to inhaling one of the drugs listed above to achieve a greater effect, especially during an acute attack. Combivent is a medication that combines albuterol and Atrovent. If you’ve been prescribed rescue medication, it’s important to keep these medicines with you—at home and school, at the mall, at sports practice, and even on vacation. If you don’t use your rescue medications during an asthma flare, the airways can continue to tighten until you end up in the emergency room. So it’s important for you to always have your rescue medication available and to take it as directed by your doctor. Remember, too, that rescue medications can be overused. Talk with your doctor about how often you use the rescue medication. If it’s too frequently, the doctor also may prescribe a controller medicine designed to prevent asthma flares. Oral corticosteroids. Corticosteroid pills or syrups are often used

to treat severe asthma because they reduce swelling and mucus pro-

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duction in the airways and help other quick-relief asthma medicines work better. These medications include M methylprednisolone (Medrol) M prednisolone (Pediapred, Prelone) M prednisone (Deltasone) They are taken by mouth for short periods of time to get initial control when you’re first diagnosed or to control symptoms during a period when your asthma is worsening. The corticosteroids used to treat asthma are not the same as the anabolic steroids (such as testosterone) used illegally by some bodybuilders. Corticosteroids do not affect the liver or cause sterility. This doesn’t mean there are no side effects. Side effects with shortterm corticosteroids may include increased appetite, fluid retention, moodiness, and upset stomach. Side effects with long-term use can include glaucoma, cataracts, acne, high blood pressure, and osteoporosis (bone loss).

LONG-TERM CONTROL MEDICATIONS While it’s important to have rescue medications handy, you need to control your asthma over the long term and prevent future attacks. Controller medications, also called preventive or maintenance medications, reduce airway inflammation and help prevent asthma

What’s an Epi-Pen? When a severe allergic asthma attack occurs, the hormone epinephrine is often given as an injection in the emergency room to treat anaphylaxis (a very severe allergic reaction). Doctors also prescribe epinephrine, in the form of the Epi-Pen, to allergic asthma sufferers for use during a severe asthma flare. The individual injects him- or herself using the Epi-Pen, which relaxes the airways until emergency treatment can be obtained. Individuals must carry the Epi-Pen at all times, as anaphylaxis can be fatal.

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symptoms. Long-term control medication is an important part of a treatment program for teens with persistent asthma. Daily medication to prevent asthma should be used even if you don’t have symptoms. The medicines reduce airway swelling and make it less likely that another episode will occur. The list of long-term medications for asthma include both oral and inhaled drugs. Unlike the rescue medications, long-term medicines can’t help you if you’re in the midst of an asthma episode. Instead, they work over the long term to reduce the frequency and severity of attacks. Many of these medications can take several weeks of regular use to work fully, and they must be used consistently if they’re going to work at all. You should take “as needed” (rescue) medicines within five minutes after symptoms begin, because it takes less medicine to stop an episode in the early phases of asthma. In some cases, your doctor might recommend that you take your medicine at the first sign of a cold or flu even if you aren’t wheezing or coughing. Continue taking medicine until all signs of the cold or flu are gone. The long-term controller medications can be divided into four broad categories: M Inhaled anti-inflammatory agents cromolyn (Intal) nedocromil (Tilade) M Inhaled corticosteroids beclomethasone HFA (Qvar) budesonide (Pulmicort) flunisolide (Aerobid) fluticasone (Flovent) fluticasone and salmeterol combination (Advair) fluticasone propionate (Flovent) and salmeterol (Serevent is a long-acting beta-agonist) mometasone (Asmanex) triamcinolone (Azmacort) M Long-acting bronchodilators formoterol (Foradil) salmeterol (Serevent) M Oral leukotriene modifiers montelukast (Singulair) zafirlukast (Accolate) zileuton (Zyflo)

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M Anti-IgE omalizumab (Xolair) Anti-inflammatory agents. Cromolyn and nedocromil, when taken routinely, can prevent and reduce airway inflammation and make airways less sensitive to asthma triggers. They help prevent asthma symptoms, especially symptoms caused by exercise, cold air, and allergies. Because cromolyn and nedocromil are preventive, they must be taken on a regular basis to be effective. Usually prescribed to be taken two to four times a day, they are very effective and safe. However, they should always be taken with a spacer device in the recommended dose to improve drug delivery and prevent side effects, such as throat irritation. Both of these anti-inflammatory medications must be taken regularly to be effective; their beneficial effects occur gradually over weeks and months of consistent use. However, they are less effective than inhaled steroids and leukotriene modifiers. Corticosteroids. Corticosteroids are very effective in the control of allergies and asthma. In fact, inhaled corticosteroids are the preferred long-term treatment for teens with frequent asthma symptoms. Inhaled steroids are usually prescribed as a long-term control medicine, to be used every day to maintain control of asthma and prevent symptoms. An inhaled steroid prevents and reduces swelling inside the airways, making them less sensitive, and also can decrease mucus production. However, an inhaled steroid won’t provide quick relief for asthma symptoms. Most patients with persistent asthma take inhaled corticosteroids daily. Inhaled steroids have much less potential for systemic side effects than oral steroids. The most common side effects with inhaled steroids are cough, hoarseness, or thrush (a yeast infection of the mouth or throat with white patches on the tongue and throat). You can reduce your risk of thrush by rinsing your mouth and spitting out the water after inhaling the medicine and by using a spacer with a metered-dose inhaler. When asthma is not controlled despite high doses of bronchodilator and inhaled steroid medication, additional oral corticosteroids might be given. Oral corticosteroids begin to work within a few hours. They are given for a few days to control severe asthma episodes and to speed recovery, and they’re given for longer periods for people with very severe and recurrent asthma attacks. A short course of systemic corticosteroids for less than two weeks is rarely associated with significant side effects.

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Long-term oral corticosteroids can have serious side effects throughout your body, but because severe uncontrolled asthma is potentially fatal, the asthma is a much greater risk than one or two weeks of systemic corticosteroid. You must never stop using these medications all at once, because this can cause side effects. Instead, they often must be tapered off over a period of days. It’s especially important to take these medications exactly as prescribed by your doctor. Long-acting bronchodilators. These inhaled medications relax

the muscles around the airways, making breathing easier. Their effects last up to 12 hours, and like the inhaled anti-inflammatory agents, they continue to work only if they are taken regularly. These medications can be taken either through a metered-dose inhaler or with a dry powder inhaler. Their side effects may include nervousness, dry mouth, or rapid heartbeat. These medications are highly effective in opening airways narrowed by asthma, and they have few severe side effects when used in the recommended dose. Some recent studies suggest that overuse of these medications in some patients may worsen the asthmatic condition and increase the possibility of death from asthma. However, many experts believe that undertreating is more likely to cause severe asthma and death than overmedication. Oral leukotriene modifiers. This new class of asthma medica-

tions, taken in pill form, is used to prevent and reduce airway inflammation and constriction of the airway muscles. They also make airways less sensitive to asthma triggers and can reduce the need for short-acting reliever medications. They are effective at improving asthma symptoms and lung function, but not to the same extent as inhaled steroids. Leukotriene modifiers seem to have fewer side effects than other asthma treatments. Depending on what type of leukotriene modifier is used, side effects may include upset stomach or diarrhea. Anti-IgE. This new form of treatment for allergic diseases has been

approved for the treatment of poorly controlled moderate to severe persistent asthma and year-round allergies and for those who are taking routine inhaled steroids. Anti-IgE blocks the action of IgE, an antibody in the immune system that tells immune cells to begin allergic reactions that may bring on symptoms such as coughing, wheezing, and nasal congestion. Anti-IgE attaches to IgE in the blood and prevents the allergic reaction.

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Xolair (omalizumab) is a new anti-IgE medicine that has been shown to decrease asthma episodes. It is given by injection once or twice a month. The injections are usually given in the doctor’s office. The dosage varies depending on your weight and IgE blood level. Xolair is a long-term control medicine, not a quick-relief medicine. Its reported few side effects include a reaction at the injection site, viral infections, upper respiratory tract infection, sinusitis, headache, and sore throat.

USING INHALED MEDICATION Your doctor will help you select the proper equipment and show you how to use your inhaled medication, metered-dose inhaler, spacer, and nebulizer. Be sure to follow carefully his or her instruction for use and cleaning. Using an inhaler. If your doctor prescribes inhaled medications for

your asthma, you’ll take the drugs using an inhaler—a plastic cover encasing a small aerosol container of medicine—that you hold up to your mouth and breathe in. The medicine sprays out in a mist that you inhale into your lungs. Inhalers are portable, hand-held devices that are available in two types: metered-dose inhalers (MDI) and dry powder inhalers. MDIs emit a premeasured puff of medicine when you squeeze the inhaler. The newer dry powder inhalers deliver medicine in powder form, but it doesn’t spray out. You’ve got to do more of the work, inhaling the powdered medicine quickly and forcefully. Dry powder inhalers include the Aerolizer, Handihaler, Diskus, Rotahaler, Turbuhaler, and Twisthaler. Using a spacer. If you use a metered-dose inhaler, you also may

use a spacer, which attaches to the inhaler and makes it easier to use. A spacer is a plastic tube with a hole for the inhaler at one end and

Don’t Run Out! Check your inhaler occasionally to make sure it still has medicine in it. You don’t want to run out.

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a mouthpiece at the other. The spacer holds the mist in one place, between the inhaler and your mouth. Spacers allow the metered-dose inhaler first to be sprayed into this container; then you breathe in the inhaled medication from the spacer. It lets you breathe in when you’re ready, which makes it easier to inhale all the medication. A spacer is a holding chamber for the medicine, so that you don’t have to closely coordinate squeezing the inhaler and inhaling the medicine. Spacers also make inhalers more effective. If you use an inhaler without a spacer, you may inhale the medicine into the back of the throat but not down into the lower airways. A spacer helps deliver the medicine down deep, where it needs to go to work properly. The spacer is also a good idea because about half of all asthma patients don’t properly use their inhaler alone. Spacers should always be used with inhaled corticosteroids or MDIs to reduce any yeast overgrowth (thrush) in your mouth and throat. Using a nebulizer. Some asthma medications also can be inhaled

through a nebulizer—a machine that turns the medication into a vapor that is inhaled deeply into the lungs. Nebulizers are electric- or battery-powered machines that come in different sizes and shapes, but they can be a bit bulky and noisy. It usually takes about five or 10 minutes to give medication by nebulizer. They can be used by anyone having a severe asthma episode and are the best delivery system to deliver high doses of bronchodilator medication to the lungs.

ALLERGY SHOTS Allergy shots are given to help reduce a person’s sensitivity to unavoidable allergens. In this type of treatment, you begin with skin tests to determine the allergens that cause you the most trouble. This is followed by a series of therapeutic injections containing small doses of those allergens in slowly increasing amounts until you can better tolerate the allergies. You’ll usually get injections once or twice a week for a few months and then decrease the frequency to once a month for three to five years. Typically, after one year of allergy injections, the patient is evaluated to see if they’re working. Over time, you should lose your sensitivity to the allergens. You’re most likely to benefit if you have allergic asthma. However, you should still continue to avoid the things you’re allergic to, even if your asthma is controlled.

USING YOUR PEAK-FLOW METER If you have asthma you’re probably used to feeling winded, so you may not always recognize when you’re having serious breathing

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problems. That’s why your doctor wants you to use your peak-flow meter, twice a day and before and after you use a rescue inhaler, to measure the amount of air your lungs can blow out. Be sure to write down any peak flows that are different from your usual daily readings. Record the date, time, and peak-flow numbers, and note any changes in how you feel or in your medicines. You should check your peak-flow number more often when you M M M M

wake at night with asthma symptoms have more daytime asthma symptoms have a cold need to use a rescue inhaler (If you can, check your peak flow before taking the rescue medicine. Then check it again 20 or 30 minutes later.)

National guidelines recommend that if your peak flow falls below 80 percent of your personal best, you may need to take an additional dose of a rescue inhaler and call your doctor. Airflow below 50 percent of your personal best means that you should get immediate medical care.

DON’T FORGET TO TAKE YOUR MEDICATION When you’re feeling well, it’s easy to start thinking that daily medicine isn’t necessary—but you may be doing so well because of those daily medications. Many teens take less than half of their medications on a regular basis, which can lead to a worsening of asthma symptoms. In fact, not taking medication correctly is the single greatest cause of emergency room visits for asthma patients. If you’re honest with yourself, you know that if you’re not taking your medication it probably isn’t because you’re just forgetting. You may doubt that the medicine is really going to work, or you may resent having to take it each day. Some people deny the significance of their condition and tell themselves that taking medication is an unnecessary chore. Some patients are afraid of the side effects or worry about how much the drugs cost. Once you’ve figured out exactly why you’re not taking your medication, you should talk about your thoughts with your doctor. Bring a list of detailed questions to your next visit and be honest about your real feelings. There’s nothing you can say that will shock or surprise your doctor, who’s probably heard it all. If you confide in him or her, your doctor can help you better understand your condition and medications. If necessary, your doctor can adjust the treatment to reduce side effects or alleviate other concerns.

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Once you’ve made a commitment to get serious about taking your medication every day, there are some things you can do to make sure you don’t forget. First of all, take your medicine during everyday activities. Put your inhaler next to your silverware or keep it in the bathroom next to your toothbrush and take it when you brush your teeth. Placing your medicine where you perform everyday activities will make you less likely to forget. Another way to remember to take your medication is to set an alarm on your cell phone or pager. This way, even when you’re having a busy day, taking your medication won’t slip your mind. Although not taking medication is a big problem, lots of teens start thinking that if some medicine is good, more might be better. However, taking more asthma medicine than you’re prescribed can be dangerous. Resist the temptation to self-adjust your dosages either higher or lower. If you seem to be doing better or worse, talk with the doctor about whether to change your medicine. You should also check with the doctor if you’re experiencing any side effects. Your doctor may adjust the dosage or prescribe a different medication.

HOME REMEDIES FOR ASTHMA SYMPTOMS Of course, it’s most important that you take your asthma medications as prescribed. But in addition to taking your medicine correctly, if you’re having symptoms, there are some home remedies you can try to help make yourself feel better too. But remember—these tips should never replace your regular asthma medications. Cough. If your cough is getting annoying, it might help to sip roomtemperature water (not cold). The fluids can help quiet a cough and thin the mucus coating your airways, making it easier to breathe. Drinking plenty of fluids is also a good idea to help you prevent future flares. If you’re bothered by a nighttime cough, as many kids with asthma are, you can help prevent a cough by raising the head of your bed. You can do so by either putting a block of wood under the headboard or simply adding a few extra pillows. Although cold air during exercise can trigger an asthma flare, many people have found that breathing cool air can ease a bad asthma cough. In the winter, you can simply step outside and slowly inhale a few breaths. In the summer, your cough might improve if you breathe air from an air conditioner. Sucking on hard candy or a Popsicle also can ease coughs. Some people find sipping on hot tea can ease a

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cough, although pure mint tea should be avoided. (The menthol in mint and catnip tea can create an unpleasant numbing sensation in the throat.) Acid reflux. Also called heartburn, this common problem in teens

with asthma happens when stomach acid backs up into the esophagus. You can help prevent it by making sure the head of your bed is propped up and by not eating right before bed. You also can try to avoid acid reflux by taking acid-suppressing drugs such as nonprescription Pepcid AC, or Prilosec, or your doctor may prescribe medications such as Nexium. Tight chest. Many patients find that when sleeping flat on their

back worsens the chest tightness, sleeping on their side helps ease breathing. Some patients find that standing in a steamy shower and breathing in the warm mist can help ease chest tightness.

UNCONTROLLED ASTHMA Unfortunately, as many as 11 million Americans have uncontrolled asthma—mostly because they aren’t following their doctors’ treatment plans. This results in missed school days, more emergency room visits and hospitalizations, and life-threatening asthma attacks. However, although there’s no cure for asthma, it can be managed if you work with your doctor to control symptoms. The first step toward control is to recognize the signs of uncontrolled asthma. If you need to use a rescue inhaler more than twice a week or you’re having asthma symptoms often during the day or night, your asthma is not being controlled well enough. To get your condition under control, you need to talk to your doctor and follow an asthma control action plan.

GOING TO THE EMERGENCY ROOM Each year, there are more than 1.8 million visits to the emergency room (ER) because of asthma. Of course, the goal of treating asthma is to avoid the emergency department—but if your asthma is out of control you’ve got to get emergency help right away. It’s important to know when you can treat your own symptoms and when you need emergency help. The first step is to check ahead of time and know where the closest emergency room is located. You should discuss with your doctor how to make the decision to go to the emergency room before you have a severe flare. Your instructions should be spelled out in your asthma action plan, which

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also should list peak-flow meter readings and specific symptoms you can use as a guideline for when to go to the ER. In general, you should get help very quickly by getting to an ER or calling an ambulance if M M M M

you feel very tight in your chest you have trouble talking because of rapid breathing your heart starts beating very fast you use your rescue medications repeatedly but the symptoms don’t improve after five or 10 minutes—or they return again quickly M your peak-flow reading falls below 50 percent of your personal best and doesn’t improve with medication M your coloring changes (you become pale, or worse—your lips or fingernails are turning blue) If you must go to the ER, take along a copy of your asthma action plan or a note with the names and dosages of any medications you’re taking, so that you can tell the medical staff at the emergency room. At the hospital ER, a nurse will check your pulse, blood pressure, temperature, and respiratory rate and the oxygen saturation in your blood. The nurse will also look to see if you’re pale, perspiring, wheezing, or turning blue. The nurse may draw blood for blood work, and you may be given oxygen or put on a heart monitor. Emergency treatment often begins with nebulized rescue medications that contain bronchodilators to relax the band of muscles that surround the airways, and anti-inflammatory drugs to reduce swelling in the lungs. An IV may be started to deliver quick-acting corticosteroids. Chest X-rays and blood tests can rule out other conditions, such as an infection or pneumonia. Another type of blood test will also reveal how much oxygen and carbon dioxide you have in your blood. Nurses will continue to assess your condition. If your condition is improving, you’ll likely be monitored for another three to six hours to be sure that you aren’t going to experience another flare and that your asthma is under control before you go home. If you’re not any better, you may be admitted to the hospital with a diagnosis of status asthmaticus. This is a life-threatening condition in which your asthma is not responding to treatment. Although it occurs mostly in patients with very severe disease and in those who have had previous severe attacks, any asthma patient can experience a severe asthma attack like this.

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As an inpatient, you’ll continue to receive IV medications, nebulizers, and oxygen, and a respiratory therapist will monitor your breathing pattern, listen to your chest, and check your oxygen saturation. When you are better able to use a peak-flow meter, the doctor or therapist will use the readings to assess the effectiveness of your treatment. When you no longer need IV medications and can use oral medications to maintain control of your symptoms, you can go home.

BE RESPONSIBLE ABOUT YOUR ASTHMA You should know which medications you’re taking—both the brand name and generic name. You also should understand how the medication works, what the dose is, when to take it, and what side effects to watch for. When your doctor first prescribes a new drug, ask about any drug, food, or herbal interactions. Be sure to keep your medications in the original bottle, which has the correct label and instructions. School health policies usually require that all medications have an original pharmacy label. You should never substitute nonprescription medications for those your doctor has prescribed. For example, nonprescription bronchodilators such as Primatene Mist or Bronkaid may contain epinephrine and/or theophylline, which can interact with the medications your doctor has prescribed. However, you can probably use nonprescription decongestants and antihistamines safely, but first check with your doctor.

Know Your Asthma Score Want to find out how well your asthma is controlled? Take the online Asthma Control Test (http://www.asthmacontrol.com) offered by the American Lung Association (ALA). Your answers to this five-question quiz give you a score that may help you and your doctor determine if your treatment plan is working or if it might be time for a change. The ALA recommends that if you’re aged 12 or older with asthma you should take the test no matter how well controlled you think your asthma is.

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WHAT YOU NEED TO KNOW M There are two basic types of asthma medications available: the quick-relief (rescue) medications and the long-term preventive (controller) medications. M A combination of rescue and controller medications can almost always control asthma, since together they treat symptoms as well as underlying causes. M Rescue medications usually work within minutes to provide temporary relief of symptoms and should always be kept with you. M Using a peak-flow meter can help you decide if your condition isn’t responding to treatment. M If you need to use a rescue inhaler more than twice a week or you’re having asthma symptoms often during the day or night, your asthma is not being controlled well enough. M You should seek emergency care if your color changes, you have trouble talking, your rescue medications don’t work, or your peak-flow reading falls below 50 percent of your personal best and doesn’t improve with medication.

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5 Heading Off an Attack

L

Liz was sitting with her family, enjoying a holiday performance of The Nutcracker in New York City. She noticed that someone in her row was wearing extremely strong aftershave lotion. She didn’t think much of it until suddenly, in the middle of the pas de deux, she felt her throat tighten. Liz has asthma, and one of her triggers is strong odors. She didn’t want to create a scene and disturb the others in the audience, and she hoped she could just wait out the flare. But every second that passed only worsened the symptoms, and soon Liz knew she had to leave the theater and use her rescue inhaler. Liz knew very well what her triggers were, but she had very little warning between the smell of the aftershave and the onset of symptoms. Still, she realized that at the very first whiff, she should have left the area, which probably would have minimized the flare. Liz had taken the first step in heading off an attack—she knew what her triggers were. The more you know about your asthma triggers and what your symptoms are, the less your symptoms will interfere with your daily activities. Liz was also very aware of her symptoms—the familiar experience of coughing, wheezing, and her chest getting tight were clear signals that a flare was occurring. If you can pick up on trouble early, you can use medication to stop things from getting worse.

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MANAGING YOUR ASTHMA You may have heard scary stories about kids who have died from severe asthma attacks, but the truth is, if you control your asthma by carefully following all the steps in this chapter, your chances of experiencing a severe asthma flare are significantly decreased. Wellmanaged asthma is rarely life threatening. Fatal asthma cases usually occur because people have stopped taking their prescribed medication or ignore their condition. People with uncontrolled asthma usually have a long history of repeated severe asthma flares and ER visits. However, even people with mild asthma can experience a severe flare. If you take your condition seriously and closely adhere to the following tips, you can reduce the risk that you’ll ever need to go to the emergency room. Follow your asthma action plan. It’s vital that you monitor your condition by following the action plan you and your doctor created. This plan outlines your daily treatment and symptoms and provides detailed, step-by-step instructions to follow when you have a flare. Use your peak-flow meter. Exposure to triggers on a daily basis

increases airway inflammation for many teens, but they’re not aware of it. Just listening to how you’re breathing won’t give you an accurate sense of what’s really happening, so you need a more objective way to measure breathing. Your breathing may sound normal even as your airways are getting narrower and inflamed. This makes your airways prone to an asthma flare. The best way to track what’s going on is to measure your lung function by using your peak-flow meter every day. A peak-flow meter is a quick, easy way to measure how well you’re breathing and to find out right away if you’re heading for a flare. Because you may not even be aware that you’re slowly getting worse, using a peak-flow meter is a great way to let you know what’s going on inside. When your peak-flow reading drops, it’s a warning that your airways are getting inflamed. Your meter can pick up even subtle indications of airway inflammation and obstruction, even if you feel fine. Sometimes, your peak-flow readings may drop two to three days before a flare occurs, which gives you plenty of time to treat and prevent breathing problems. Recording your peak flow two or three times a day also can help you and your doctor figure out if you need to take more or less medication. If your peak flow fluctuates a lot, this means you’re not able to control your asthma as well as you might; in this case, you should ask the doctor to adjust your medication. If your peak flow drops and doesn’t improve very much when you use your inhaled bronchodila-

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Heading Off an Attack

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tor medication, more aggressive treatment is needed. But remember, don’t take more medication on your own. You should only increase doses by yourself if you and your doctor have already discussed how to do this; otherwise you must talk to your doctor first. Avoid triggers. Once you’ve identified your triggers (see chapter 3)

that can cause flares, you’ll be able to avoid them. You and your parents should control dust mites, mold, animal dander, and cockroaches in your house (especially in your bedroom). Take your medications. Take your control medications exactly as

you’re supposed to, even when you can breathe normally. Skipping your medication makes you vulnerable for more frequent and severe flares. And no matter how good you’re feeling, always keep your rescue medications with you. Many kids must go to the emergency room simply because their rescue inhaler is at home on their bedside table instead of in their pocket or purse. Visit the doctor regularly. If you have asthma, you should see

your doctor every three to four months, according to the National Institutes of Health. This lets your doctor check how you’re doing, refill prescriptions, track your symptoms, and make any changes in your medicine or your asthma action plan. Because you’ll probably have an asthma flare if you get the flu, you should get an annual flu shot before November. Your family members also should get the shot. At the first sign of a flare, be sure to call your doctor if you have any concerns. It’s better to take a trip to your doctor’s office instead of the emergency room. Check for early warning signs. Another way to know when a

flare is developing is to check for slight changes that indicate that your medication may need to be adjusted to prevent a flare. These signs may not definitively mean that a flare will happen, but they can help you plan ahead. Some kids notice that their mood or breathing changes. Other kids say they just feel “funny.” These symptoms don’t always mean you’re definitely going to have a flare—as a teenager, your mood can change radically without having anything to do with asthma. But over time, you may learn how your body responds to an impending asthma flare, and recognizing these slight symptoms gets easier. Early warning signs can help you learn how your body responds to asthma. Your asthma action plan should detail how you can adjust your medication by yourself when you spot these slight changes.

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48 Living with Asthma Recognize an impending severe flare. Most kids with asthma have mild flares much more often than severe attacks. The severity of asthma flares will vary from one attack to the next. Sometimes flares seem to occur without warning—suddenly you can’t catch your breath, or you start coughing and wheezing. It’s important that you know the warning signs of a severe flare. Because they can be life threatening, asthma flares demand attention. You might need to take rescue medication or go to the emergency room. Your asthma action plan can help you figure out what to do when you experience warning signs of a severe asthma flare. Watch your diet. Try eating six smaller meals instead of three big

ones. Experts typically recommend smaller, more frequent meals for people with chronic lung problems, because many of these patients feel more short of breath with a full stomach. This is because the diaphragm doesn’t work as well when the stomach is bulging with food. By eating smaller, more frequent meals, you can still get the nutrition you need while making your stomach feel better and allowing your diaphragm to move. Small, frequent meals also reduce the chance of acid reflux (heartburn), which is a common problem with asthma patients. Also, don’t wait to eat until you’re starving or very tired. As you chew, try to breathe evenly, and stop eating if you have to catch your breath.

Warning Signs of a Severe Flare M constant, severe cough without having a cold M fatigue M problems speaking M having to use chest muscles to help breathing M pale or bluish skin M peak-flow meter readings below 80 percent of personal best M rescue medications not working

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Heading Off an Attack

49

Steroids and Your Diet Regular oral corticosteroids (prednisone or methylprednisolone) can help shrink swollen airways, but they may interfere with the way your body uses calcium, potassium, sodium, protein, and vitamins C and D. If you take these drugs, it’s very important to M eat a well balanced diet, including foods from each food group M eat calcium-rich foods such as dairy products, because steroid pills increase the risk of osteoporosis (loss of calcium in the bones) M limit the use of salt and salty foods M lower your fat and cholesterol intake; calcium supplements and a multivitamin may help

Another way to avoid an uncomfortably full stomach is to avoid eating a lot of foods that cause gas, such as: M M M M M M M M M M M M M M

asparagus beans (pinto, kidney, navy, black) broccoli brussels sprouts cabbage carbonated drinks cauliflower cucumbers garlic peppers radishes raw onions sausage spicy foods

Make lifestyle changes. If you have asthma, there are other lifestyle modifications you can make to leave you less vulnerable to

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Living with Asthma

allergens. This means leading a healthy lifestyle by getting enough sleep, eating well, and getting lots of regular exercise. You might consider losing excess weight, too, if you have asthma. Some scientists believe there is a link between being overweight and having a higher risk of asthma symptoms. Finally, watch out for stress. The average teenager has a lot to cope with—doing well in school, keeping up grades, friends, dating, driving, getting into college, parent or sibling squabbles, increasing independence, sports, after-school jobs—so is it any wonder you’re feeling stressed? But feeling anxious and stressed can make you tired, which can trigger asthma symptoms. Try to get a handle on stress and talk to your parents, a trusted teacher, or school counselor if you feel overwhelmed.

WHAT YOU NEED TO KNOW M Well-managed asthma is usually not life threatening. M To avoid a flare, follow your asthma action plan, use your peak-flow meter, and avoid triggers. Never skip medications and always keep a rescue inhaler with M you. M Visit your doctor every three to four months. M Know your early warning signs. M Severe flare symptoms include severe cough, fatigue, speech problems, using chest muscles to breathe, pale/bluish skin, and peak-flow meter readings below 80 percent of your personal best. M Eat six small meals, and consider taking a multivitamin and calcium supplement if you take steroids. Get plenty of rest and avoid stress. M

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6 Coping with Asthma at School

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Nearly 5 million children under age 18 have asthma, which leads to 10 million school absences a year—three times as many as any other cause. Because you spend so many hours a day at school, asthma usually affects your life there in one way or another. But the good news is that if you manage your asthma symptoms properly, you can still handle both sports and school easily. Although most schools require that elementary-school students go to the school nurse to get their asthma medication, most high schools assume that teens are mature enough to handle their own treatment. It may seem like a pain to interrupt your day to take your medicine during school hours, but it’s important. Certainly, having to live with a chronic disease can be so stressful sometimes that it may affect how well you do in school. But skipping your asthma medication will only cause problems for you later on.

INFORMING THE SCHOOL Your school should know as much about your condition—and asthma in general—as possible, because staff members must be able to recognize asthma symptoms and handle an acute asthma episode. At the beginning of each school year, you and your parents should meet with your teachers or the school nurse to review your medical information, including the medications you take, possible side effects, how you’ll be taking medication during school hours, how you should handle

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gym classes, when you should visit the school nurse, and when your parents must be called. You or your parents also should give your school nurse a copy of your asthma action plan, along with all the medications you’ll need—all clearly labeled. Your plan should clearly indicate which short-term, fast-acting rescue medications you use if your condition suddenly worsens. Your action plan also should clearly spell out how to adjust your medications in response to your symptoms and at what point to call for help. You and your parents should make sure that the asthma action plan you give to all school officials lists your doctor’s phone number, your preferred hospital emergency room, and contact numbers for your parents and a trusted friend. Cell phone numbers are also helpful. You should keep track of your inhalers and replace the medicines at school on a regular basis. If your school shares a nurse with other schools, make an appointment to see the nurse when he or she is in the school and find out who will be in charge when he or she is not around.

Emergency Treatment of Asthma Flare at School If a student begins to have trouble breathing because of an asthma flare: M The student must immediately stop all activity. M The student must remain in an upright position—do not let him or her lie down. M Stay calm. M Make sure the student uses the appropriate rescue inhaler immediately—it is much worse to withhold medication when needed than to provide medication if not needed. M Notify the proper person if the student’s condition does not improve or gets worse after 10 to 15 minutes. This may include calling 911 for an ambulance.

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Coping with Asthma at School 53

You and your parents should check your classroom and other school areas to see if you can uncover any triggers, such as animals in the classroom, strong odors, or significant chalk dust. If you identify possible triggers for your asthma, work with your teacher to lessen your exposure. In addition, you’ll want to give the school a list of your asthma triggers. Because of medical confidentiality laws, you and your parents—not your doctor—must tell your school that you have asthma. You can probably get a form letter for this purpose from your doctor. Tell your teachers. Be sure to let as many teachers and other adults at school know about your asthma as possible—not just the school nurse. You could have an asthma flare while the school nurse is not around, so each of your teachers should know about your condition. One of them will probably be nearby, and the more your teachers know about you, the more likely you’ll get the care you’ll need in case of emergency. If you have exercise-induced asthma (and many teens do), it’s especially important that your gym teacher knows about your situation. This way, your teacher can keep a sharp eye out while you’re exercising to make sure you’re okay. At the same time, it’s important that your gym teacher understands that kids with asthma need exercise, and as long as your asthma is under control you should never be left on the sidelines while the other kids participate. Many parents forget about substitute teachers, but the regular classroom teacher should alert the substitute to your condition. Medications. Schools have different policies about children bringing medications to school. Your parents should contact your school and find out its policy. Some schools don’t allow any student to carry medication of any kind; if this is the case at your school, you’ll need to store your medication with the school nurse. Many school districts require that your doctor fill out a form listing medications you’ll need during school hours. If this is the case at your school, make sure your parents have your doctor fill out the form before you start school in the fall. Because school starts during the height of the fall allergy season, asthma symptoms often increase soon after school starts. In addition, attending classes along with lots of other kids in enclosed spaces exposes you to viruses and to animal dander carried on the clothes of classmates with pets. Stress. New classes, new teachers, new schedules, and higher aca-

demic expectations can pile on the stress. The first weeks of the new

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school year can be so anxiety-provoking that your asthma is triggered. Talk to your doctor about ways to ease stress, and if you’re really feeling burdened, talk to your parents or school counselor about getting some short-term counseling. Exercise. Exercise is a common trigger for asthma symptoms, as

you’ll read about in chapter 7. If you have this type of asthma, make sure that you follow your doctor’s orders, perhaps using a bronchodilator such as albuterol before gym class or other physical activities (especially outdoors during cold weather). If you’re having symptoms, don’t hesitate to have your parents call or send a note to the physical education teacher. And keep in mind that exercising outdoors during the high pollen season (spring and fall) can make your asthma worse. Pretreatment with antihistamines and inhaled steroids can reduce those symptoms. If you have exercise-induced asthma, read chapter 7 carefully for more detailed information.

YOUR SCHOOL’S ASTHMA ACTION PLAN You know that you’ve got your own asthma action plan, but you may be surprised to hear that many schools have asthma action plans of their own as a way to provide clear guidelines for how they’ll handle all of their students with asthma. (In many schools, that may be as many as one of every 13 kids.) Many school districts develop a generalized asthma management plan, which individual schools in the district can then tailor to meet their specific needs. The overall asthma management plan should include school policies on the use of inhalers and medications, actions or emergency procedures school staff should take when a student has an asthma attack, and student asthma action cards. Handling medication. A good asthma action plan should address

schoolwide policies for handling students’ medications, including whether students are allowed to carry or use medication outside the school nurse’s office. Recognizing symptoms. The school’s action plan also should describe how to recognize severe symptoms requiring prompt action. Student asthma action cards. The student asthma action card is an individual management plan your school keeps for each student with asthma. It provides information to school officials on each

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student’s asthma condition, along with medical information, asthma triggers, emergency procedures, and phone numbers. This action card should be signed by a physician and parent and kept on file at school. It should include M M M M M

how severe each student’s asthma is potential triggers medications to use and how to give them properly how to use a peak-flow meter what to do in case of an asthma flare

Teachers should have a separate asthma action plan for every student in the class who has asthma. The plan also should discuss how to keep students with asthma away from potential triggers, such as mold, dust, chemicals, strong odors, or furry or feathered animals, and how to make sure students take their medication at regular intervals, as prescribed. The plan must guarantee easy access to medications in case of an asthma episode and allow students to pretreat with medications before exercise to prevent breathing problems associated with exercise-induced asthma. Action and emergency plans. For each student with asthma, the

school should have a clear plan for when to call the student’s doctor and when to call 911. Staff training. In addition, your school should provide regular staff

training sessions about asthma for teachers, instructional assistants, substitute teachers, physical education teachers, coaches, food service workers, janitors, administrators, administrative staff, school nurses, clinic aides, bus drivers, and after-school staff. How to care for someone with asthma should be written down and distributed to school officials and your teachers.

HOW ASTHMA-FRIENDLY IS YOUR SCHOOL? You may have thought of your school as a safe place to be, but many indoor air quality problems in schools can affect your health, especially if you have asthma. Some of the indoor air quality problems that schools struggle with include chemical pollutants from cleaning products, chemical pollutants from science and art classes, poorly maintained ventilation systems, and allergens from classroom animals or pets. Many schools struggle with indoor mold problems, which can be related to standing water in maintenance rooms or pipes, or from

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Grade Your School’s Asthma Friendliness Take the following quiz to find out how well your school helps kids with asthma. This quiz is provided by the NHLBI’s National Asthma Education and Prevention Program: ■ Is your school free of tobacco smoke all of the time, includ-

ing during school-sponsored events? ■ Does your school maintain good indoor air quality? Does

it reduce or eliminate allergens and irritants that can make asthma worse? Check if any of the following are present: M cockroaches M dust mites (commonly found in humid climates in pillows, carpets, upholstery, and stuffed toys) M mold M pets with fur or feathers M strong odors or fumes from art and craft supplies, pesticides, paint, perfumes, air fresheners, and cleaning chemicals ■ Is there a school nurse in your school all day, every day?

If not, is a nurse regularly available to the school to help write plans for and give guidance regarding medicines, physical education, and field trips to students with asthma?

dampness in ceiling tiles, carpets, and furniture. Outdoor air pollutants and pollens may seep into the school through ventilation systems or open doors and windows. If you have asthma, your school should be willing to offer support to help you keep your asthma under control so you can participate fully. The National Heart, Lung, and Blood Institute (NHLBI) recommends that school staff, health professionals, and parents work together to remove obstacles and to promote your health and education.

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■ Can you take medicine at school as recommended by your

doctor and parents? Are you allowed to carry your own asthma medicines? ■ Does your school have an emergency plan for taking care

of you if you have a severe asthma flare? Is the plan clear about what to do, whom to call, and when to call? ■ Does someone teach school staff about asthma, asthma

action plans, and asthma medicines? Does someone teach all students about asthma and how to help a classmate who has it? ■ Do you have good options for fully and safely participating

in physical education class and recess? For example, do you have access to your medicine before exercise? Can you choose modified or alternative activities when medically necessary? If the answer to any question above is no, the NHLBI warns that you may be facing obstacles to asthma control. Uncontrolled asthma can interfere with your attendance, participation, and progress in school.

Another way to help your school deal with potential problems is to ask them to obtain the Indoor Air Quality (IAQ) Tools for Schools Action Kit, provided by the U.S. Environmental Protection Agency. This kit helps school staffers identify, solve, and even prevent problems with indoor air at school. The kit includes a 19-step management plan and checklists for the entire building, including the ventilation system, maintenance procedures, classrooms, and cafeteria areas. The kits also include a coordinator’s guide that explains the basics of indoor air quality and how to improve air inside your school. The kit

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also contains background information about the problem and a 30minute video covering the ventilation checklist and how to implement the IAQ Tools for Schools. Most schools form an IAQ coordinating team to implement the kit. Pets in school. Many kids with asthma are sensitive to animal aller-

gens—and you’d be surprised how many schools keep warm-blooded creatures on site that can aggravate students’ asthma, including gerbils, birds, cats, dogs, mice, and rats. Proteins that act as allergens in the dander, urine, or saliva of warm-blooded animals may trigger asthma episodes in students sensitive to animal allergens. If your school has animals, you may be exposed every day to the animal’s dander, saliva, and/or urine. The most effective way to control exposure to animal allergens in schools is to avoid bringing animals into the building. Alternatively, staff may keep animals in one area, away from upholstered furniture, carpets, and stuffed toys, and keep sensitive students away from animals as much as possible. Animals should be kept away from ventilation system vents so that allergens aren’t circulated throughout the room or building. Schools that do have animals should make sure to clean classrooms where the animals live thoroughly. In addition, properly maintained air cleaners may reduce animal dander in small areas as well, as long as they are the correct size and efficiently remove particles. In addition, the school should be aware that some air-cleaning devices marketed as air purifiers emit ozone, which may be harmful to students with asthma.

YOUR RIGHTS IN SCHOOL As an asthma patient, you have a certain number of rights guaranteed to you by the federal government. Although schools are generally getting much more sophisticated in their understanding of the needs of asthmatic students, there are still some occasional problems. You already may be missing school for medical appointments, preventive evaluations, treatments, and illness. Having to leave the room to take your medicine is more disruptive than it needs to be. Most high schools allow their students to medicate themselves and to carry their inhalers with them. However, if your school doesn’t, this can mean that you must leave your class every time you need medication. Some kids must use medication three or four times a day; even if you leave your class for just one dose of medication a day, you’re losing an extra 11 days over the course of the school year.

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Being allowed to medicate yourself and carry your inhaled medications will end this problem. Discuss this with school officials and your doctor; if the school won’t reconsider, ask your doctor about longer-lasting medication options that require fewer doses per day than others. When talking to your school, it should help to know that if you have asthma, you are protected by three laws with very big names: M Title II of the American Disabilities Act of 1990 M Section 504 of the Rehabilitation Act of 1973 M the Individuals with Disabilities Education Improvement Act (IDEIA) The first two ensure access to federally funded services for any handicapped person. IDEIA gives money to help schools serve these students. (You may not think of yourself as traditionally handicapped, but the IDEIA does. It states that for the purposes of the law, handicapped means “any person who . . . has a physical or mental impairment which substantially limits one or more major life activities . . . [such as] breathing.”) The applicable part of Section 504 of the Rehabilitation Act of 1973 reads, “No qualified handicapped person shall, on the basis of handicap, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives Federal financial assistance.” Among other things, this means your school can’t stop you from playing sports just for having asthma. Section 504 says your school must follow procedures to safeguard the rights of parents, students, and school employees and to make sure decisions about your needs are fair. These regulations also require that schools and parents act as partners in making decisions about your welfare. Your state and the local Board of Education have resource staff members who can provide specific guidelines for you and your parents. For more information about any of these laws, you or your parents can contact the U.S. Department of Education Office for Civil Rights at (800) 421-3481, or visit their Web site at http://www. ed.gov/offices/OCR.

TO GO TO SCHOOL—OR STAY HOME? Sometimes it can be hard to figure out whether to stay home from school if your asthma is acting up or whether to go in. Typically, experts suggest that you should be able to go to school if

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M M M M

your nose is stuffed up but you’re not wheezing you’re wheezing a little bit, but it clears after medication you can participate in everyday activities you have no coughing or chest tightness

You should probably stay home if M you have a sore throat or swollen, painful neck glands M you have a fever over 100 degrees F and your face is hot and flushed M you’re still wheezing an hour after you take your medicine M you’re feeling weak or tired, which makes it hard to take part in usual daily activities M you’re having trouble breathing If your peak-flow meter reading is lower than normal and you have a few other early warning signs (you’re coughing and pale), an asthma flare may be near. You should take your medication and see if you respond; if your symptoms don’t respond, you should stay home. If you go in to school, you might want to mention to the school nurse that you are in a pre–asthma attack stage, but that so far it’s being controlled with medications. During school, you might want to take a quick puff on your peak-flow meter to see how you’re doing. Many teens notice that their asthma is worse in the morning than at noon; if you’re having trouble in the morning, you may be able to get back to school by lunchtime.

BEFORE YOU LEAVE FOR COLLEGE You may have been coping with asthma for years now, or perhaps you’ve been recently diagnosed. As you head off to college, you’ll be faced with lots of new responsibilities as you live on your own, probably for the first time. Taking good care of your asthma is just one more of those responsibilities you need to take very seriously. If you do, there’s no reason that you should have any problems in handling your condition while away from home. Don’t be surprised if your asthma acts up when you first go away to college. You may find yourself living in an old building with poor dust mite control—and living so close to other students means you’re much more likely to pick up colds and flu. In addition, dorms are often filled with bacteria, viruses, perfumes, hair sprays, cigarette smoke, incense, and other irritants. College students are also much

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more likely to attend class, participate in sports, or go out at night despite having infections or an asthma flare, which can make your condition worse. You’ll also probably be staying up later and not getting quite enough sleep at times. Finally, money might be so tight that you neglect your health care or medications, and not having your parents around to get you to the doctor or fill your prescriptions might contribute to the problem. Of course, most kids with asthma do perfectly fine while living away from home at college. But you should expect to make a few lifestyle adjustments as a result of having a chronic disease. Call the college’s health service. Before you leave home, call the student health service at your college to find out what their policy is if you’re receiving allergy injections. This may require special arrangements that you’ll need to take care of ahead of time. Make a final doctor appointment. Before you leave home, you’ll

want to make one last appointment with your doctor to explain that you’ll be going to college and living temporarily out of the area. Discuss the need to transfer care, such as medication prescriptions or allergy injections, to the school’s health center. Locate a drug store near your college so you can continue to get refills of your prescriptions while living away from home. Discuss with your doctor whether you need to revise your asthma action plan; you should give a copy to your roommate and to your residence hall director or the resident assistant who lives on your floor. This plan should list your doctor’s phone number in case of an emergency and any medications you’re taking. Fill your prescriptions. Before you leave home, be sure to fill your prescriptions for both long-term and rescue medications. Dorm arrangements. Request a nonsmoking room and roommate. Ideally, ask for a nonsmoking dorm, if your college offers one. Also ask for a dorm room without carpeting (most aren’t carpeted anyway, but it never hurts to ask). Because you’ll be spending so much time there, it’s important to reduce dust mites. You and your roommate can bring simple throw rugs, but be sure to wash them weekly in hot water.

WHILE YOU’RE AT COLLEGE Moving into the dorm. If your college dorm has bunks, choose

the top one—you’ll be exposed to less room dust. Try to avoid dust-

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collectors, such as excess clutter, upholstered furniture, or secondhand rugs (these can be filled with allergens). It may look tidy when you arrive, but as soon as possible, thoroughly clean your dorm room or apartment. This will help you control dust mites and uncover any mold or cockroaches. Zip up your mattress, box spring, and pillows in airtight, zippered plastic or special allergen-proof fabric covers. Vacuum your dust mite–proof covers once a month with a vacuum equipped with a HEPA filter to trap allergens. Consider using a HEPA air filter as well. Wash your bedding weekly in hot water and dry it in a hot dryer to reduce dust mites. You can get rid of indoor mold and mildew with a cleaning solution of bleach and a small amount of detergent. Never put carpeting on concrete or damp floors, and don’t store your clothes in damp areas. To avoid roaches, keep food in tightly covered containers with lids, clean your floor or rugs after meals, and take out your garbage regularly. Wash dishes right away in hot, soapy water. Check out the campus health center. As soon as you arrive on

campus, track down the health center so you know where it is. If symptoms should flare up, you may need to visit the student health center. Also, if you take allergy shots, arrange to receive them if needed from a local allergist or, if possible, from the student health service. Carry your inhaler at all times. Never leave your dorm room

without your inhaler. You may be less aware of conditions that trigger an asthma flare while you’re getting used to a new living situation. Personal prevention. The better you’re able to avoid getting sick, the less likely you’ll have an asthma flare. You can cut your risk by getting an annual flu shot, washing your hands often (especially in winter), eating a balanced diet, and getting at least eight hours of sleep each night. Cut down on airborne allergens. As the weather gets warmer,

and if you have air conditioning, you might keep your windows closed to cut down on pollens and other airborne allergens. Monitor mold and pollen conditions. If your asthma gets worse during seasonal allergy periods, listen to the radio, watch TV, or check the Internet to monitor high pollen and mold counts in your area each day.

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Coping with Asthma at School 63 If you have exercise-induced asthma. If you play on a college

team or intramural sport, let friends and coaches know if you have exercise-induced asthma, and always bring your inhaler along to practices and games. Going back home. Some people with allergic asthma lose their

tolerance of their pets during their time away. On your first visit back home, you may have a flare so severe that you need emergency care. Discuss this possibility with your doctor beforehand.

WHAT YOU NEED TO KNOW M Most schools will allow you to carry your inhaler with you and medicate yourself—but check to make sure you know what your school allows. M At the start of each school year, make sure to tell teaching staff and the nurse about your condition; also give them a copy of your asthma action plan. M When you get to college, be sure to clean your room regularly, check for dust mites, and don’t have too much dust-collecting clutter around.

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7 Asthma and Sports

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Every year Janet dreaded the blooming of new spring plants and flowers, because her allergies made her eyes itch and her nose run. But when she entered middle school, she began to notice new problems that occurred in the spring. Her seventh grade gym teacher liked to take the class outdoors for exercise, and after just a few minutes of running or exercise around the field, Janet would start to wheeze and cough. Luckily for Janet, her teacher quickly recognized the signs of exercise-induced asthma. Instead of yelling at her to get moving or making her sit on the sidelines, the teacher sent Janet to the school nurse. The nurse agreed with the gym teacher and contacted Janet’s parents with the suggestion that she see a doctor. It turned out that Janet had indeed developed exercise-induced asthma (also called exercise-induced broncho-spasm). Exercise-induced asthma (EIA for short) isn’t a distinct type of asthma. Instead, it is likely to occur in anyone who has the sensitive airways that underlie asthma. Often, EIA occurs in teens who have chronic asthma but who don’t know that their symptoms during exercise are a part of their asthma. In some kids, however, exercise can induce an asthma flare even if they have no other triggers and don’t experience asthma under any other circumstances. Between 5 and 10 percent of kids with asthma have symptoms only when they exercise. Pet dander, colds, allergies, mold—none of these other common triggers cause asthma symptoms in this small group.

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Asthma and Sports

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Janet was an avid field hockey player, and she was happy to learn that with the proper medications, she’d still be able to play on the team along with her friends. Asthma doesn’t need to stop you from having fun and getting exercise. If you’ve been diagnosed with EIA, you don’t need to worry that this might spell the end of your sports career either. You can still be part of a team and do just about anything that anyone else can do. In fact, more than 20 percent of Olympic athletes (especially girls) have exercise-induced asthma (EIA) they’ve learned to control, just like Janet. Research shows that everyone can benefit from exercise—it can improve your physical health, boost your self-esteem, and ease stress. When asthma is well controlled, students with exercise-induced asthma should be able to participate in any sport. Moreover, exercise will improve conditioning, reduce excess weight, and reduce the work of your heart and lungs, so that asthma becomes more difficult to trigger. Research shows that people with asthma who exercise can take in more oxygen and transfer more air in and out of their lungs; regular exercise can increase oxygen intake by up to 20 percent. Kids with EIA often give up playing sports, which is unfortunate, since the condition is very rarely dangerous and it shouldn’t stop you from exercising as long as you take your medications and follow your doctor’s orders.

Asthma and the Olympics At least one in six U.S. Olympic athletes in 1996 had asthma; it was most common among cyclists and mountain bikers and least common in athletes competing in badminton, beach volleyball, table tennis, and volleyball. Although 4 to 7 percent of the general population has asthma, 16.7 percent of 1966 Olympic athletes had asthma. But statistics showed that athletes with asthma won as many medals as did those without.

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CAUSE OF EIA People with EIA have airways that are overly sensitive to sudden changes in temperature and humidity, especially when breathing colder, drier air. EIA occurs in almost 90 percent of people with chronic asthma and in 40 percent of individuals with allergic rhinitis or atopic dermatitis. The reason for this is fairly clear. As you exercise and you start to breathe more quickly, the air you take in isn’t warm enough. Normally, when you’re at rest you’re breathing in through your nose, which warms and moistens the air you breathe in to make it more like the air in the lungs. In general, the air you inhale is warmed and moistened up to 90 percent humidity before reaching your lungs. But when you exercise, you tend to breathe through your mouth, which allows cold, dry air to reach your lower airways without being warmed and moistened in the nose. Breathing through the mouth means that the air may only reach about 70 percent humidity. As you draw in this cooler, drier air, the contrast between the warm air in your lungs and the cold inhaled air can trigger an asthma flare. As the flare begins, your airways swell, the airway muscles contract, and extra mucus is produced, all of which narrows the breathing passageway. This makes it more difficult to exhale. The triggers responsible for exercise-induced asthma differ from person to person. For some kids with EIA, exercise alone triggers asthma symptoms. Most often, EIA occurs during prolonged, intense exercise in a cool, dry environment. Air pollution also may affect people with EIA. In addition, if you know that pollen is one of your triggers, exercising on a cool spring day in a grassy field may boost the likelihood of an asthma flare. In some cases, pollutants can trigger bronchospasm—or they may increase your sensitivity to another trigger that would not normally cause a reaction alone. If you run on a busy city street, you may be breathing air pollutants that increase the chance of bronchoconstriction or an asthma attack.

SYMPTOMS OF EIA Exercise-induced asthma symptoms are usually identical to those of asthma caused by other triggers—but asthma flares caused by exercise don’t usually last as long as other asthma flares. They may improve all by themselves after about a half hour, even without medication, but it’s always best to prevent symptoms if possible. Different people, different symptoms. Almost all young adults

with asthma have some degree of EIA, but different athletes can

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tolerate different amounts of exercise before symptoms appear. One student with very well-controlled asthma might not experience any problems at all unless undergoing intensive exercise. Another student fighting off a cold might only require a slight amount of activity before symptoms appear. Although the main trigger for EIA is exercise, other factors—such as infection, weather changes, or allergies—can make a person more sensitive to exercise. On the whole, exercise can trigger asthma symptoms in up to 80 percent of people with asthma, typically within five to 20 minutes after they start to exercise, peaking about five to 10 minutes after exercise is over. The most common symptoms of exercise-induced asthma include coughing, wheezing, shortness of breath, and chest tightness. Some kids may just feel very tired during exercise, and they’ll notice they have trouble keeping up with their teammates. Prolonged shortness of breath may not begin until five to 10 minutes after brief exercise. EIA-related symptoms of wheezing or coughing usually get better with rest, but they may last for more than an hour—or even progress to a severe asthma attack. It’s important to recognize the difference between being out of condition and exercise-induced asthma. In well-conditioned athletes, symptoms of exercise-induced asthma may only occur after the most vigorous exercise.

GETTING A DIAGNOSIS OF EIA Determining a diagnosis is the most important part of getting a handle on EIA. It made all the difference in the world for Bobby, whose parents had noticed for years that he had a nagging cough, which got worse when he ran or got upset. In particular, he seemed completely uninvolved in sports, and he hated gym class. When he was finally brought in for testing because of his persistent coughing, he was finally diagnosed with EIA and put on medications. This only triggered new concerns with his parents. “I think those medications are making him crazy,” his parents told the doctor. “All he wants to do is run around and play and do sports!” Of course, there wasn’t anything wrong with the medications or with Bobby— it’s just that for the first time in his life, now that his asthma was under control, he was finally behaving like a normal, active kid. His life changed dramatically once his asthma was properly diagnosed. Your doctor usually can diagnose EIA just from listening to your medical history. Think about how you feel when you exercise. Do you get tired easily or cough a lot when you run? It may be hard to notice some of your symptoms or when they occur. That’s why it’s a

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good idea to keep a diary to chart your activities and any symptoms a couple of weeks before your visit to the doctor. Write down what you were doing when you experienced asthma symptoms, what those symptoms were, and what you did about them. Share this information with your doctor. In addition to asking questions about your symptoms, your doctor will probably do a physical exam and order further tests (such as pulmonary function tests) to confirm a diagnosis. Your doctor may want to find out how you tolerate a particular type of exercise, since not every kind of exercise affects kids with EIA the same way. An exercise challenge may be done in your doctor’s office or the hospital. First, your doctor may perform a breathing test when you’re at rest to ensure that you don’t have chronic asthma. Then, during an exercise challenge, you’ll walk or run on a treadmill or ride an exercise bicycle and then have your breathing tested with a machine called a spirometer, which measures your ability to breathe out. Your breathing will be tested at rest and again after six to eight minutes of exercise. You’ll need to exercise enough to maintain a heart rate at 80 to 90 percent of your age-related maximal predicted value. The last test will come at least 30 minutes after you’ve finished the exercise. By examining the results, your doctor can assess how exercise affects your ability to breathe and whether exercise triggers asthma symptoms. EIA is diagnosed if there is a drop of at least 12 to 15 percent in the value of your FEV1 (the “forced expiratory volume in one second”—a comparison between the volume of air blown out in the first second after exercise compared with the starting value before exercise). Even if your doctor suspects exercise-induced asthma, he or she will want to rule out other conditions. For example, shortness of breath during exercise could mean that you have a heart condition, another type of pulmonary problem, or you’re just out of shape. If these are suspected, your doctor may perform additional tests to rule out potential heart ailments or other conditions.

TREATMENT The benefits of regular physical activity almost always outweigh the risks associated with exercise-induced asthma, as long as you follow your doctor’s recommendations. Every kid with EIA should have an asthma action plan to provide the necessary guidelines in case of an asthma flare. Ideally, this will help you prevent asthma flares, live a normal life, and play the sports you enjoy—all while maintaining near-normal lung function.

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Treatment of exercise-induced asthma focuses on preventing asthma flares. There’s no way to cure exercise-induced asthma, but certain medications can help you manage the symptoms of the disorder. Because EIA has the same symptoms and is caused by the same airway reaction as is regular asthma, the same asthma medications are used for both. If you take your prescribed medication as directed, you should be able to exercise without symptoms. Even Olympic champions with EIA can compete at the international level with appropriate treatment. In fact, most people should be able to control asthma completely while participating in sports—if they work with their doctor and follow their treatment regimen carefully. Of course, just because people with asthma can be successful doesn’t mean you can ignore your condition. If your asthma isn’t well controlled, it can hinder your performance. Many students with asthma take inhaled maintenance medications to help keep their asthma under control. But often, maintenance medications alone aren’t enough to provide complete control of exerciseinduced asthma, especially if you’re very active or if you’re exposed to pollution or allergens as you exercise. In this case, you should also take your rescue inhaled bronchodilator medication about 15 to 30 minutes before exercising to prevent your airways from tightening. This is called pretreatment, and it can help you participate safely in sports or exercise. Many athletes find that it helps to take one of these medications right before working out and to use deep breathing to control symptoms while exercising. Most doctors prescribe the following medications for pretreatment: M inhaled short-acting beta 2-agonist bronchodilators: Puffs of drugs such as albuterol (Proventil, Ventolin) or pirbuterol (Maxair), 15 to 30 minutes before exercise, can prevent your airways from contracting for up to four to six hours. These medications are effective in 80 to 90 percent of patients and can also be used to relieve EIA symptoms after they occur. M long-acting bronchodilators: Sometimes, your doctor may prescribe a medication to provide 12-hour control of symptoms, such as salmeterol (Serevent Diskus) or formoterol (Foradil) in addition to your other controller medications (inhaled steroids). By using this before school, many children can participate in gym class and other sports throughout the day without needing short-acting sprays. It’s still important for you to carry a short-acting bronchodilator in case symptoms suddenly appear, however.

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M mast-cell stabilizers: These drugs, such as cromolyn sodium (Intal) or nedocromil sodium (Tilade), are another type of medication sometimes used as pretreatment. They should not be used to treat acute symptoms, but when given about 20 minutes before exercise, they prevent asthma symptoms in up to 85 percent of patients with EIA. M inhaled corticosteroids: For patients with only EIA, inhaled corticosteroids don’t help when used only before exercise. However, research suggests that inhaled corticosteroids such as budesonide (Pulmicort) or fluticasone (Flovent) may help on a long-term basis. Starting on a regular schedule of inhaled corticosteroids may be effective when combined with inhaled beta 2-agonists for some patients. M leukotriene modifiers: These long-term control drugs, such as montelukast sodium (Singulair) or zafirlukast (Accolate), appear to protect against EIA in many patients with chronic asthma, reducing airway sensitivity to allergic triggers. Warm-up and cool-down. A warm-up period before exercise may ease the chest tightness that occurs during or after exercise. Try to spend 30 minutes for each warm-up period. By doing warm-ups, you may avoid asthma symptoms that usually occur during the first 15 minutes of exercise. When you’re finished exercising, cool down slowly rather than stopping exercise abruptly. A 30-minute cool-down period, including stretching and jogging after strenuous activity, may prevent the air in your lungs from changing quickly from cold to warm and may prevent EIA symptoms that occur after exercise. Other strategies. There are a number of other things you can do

to help prevent EIA flares: M Drink liquids. Don’t forget to drink plenty of fluids when you exercise, especially if it’s hot outside. Aim for drinking eight ounces of water before exercise, and then another eight ounces every 30 minutes while you exercise. M Stay healthy. Do your best to avoid colds and other respiratory infections (wash your hands often during cold and flu season, eat healthy foods, and get lots of rest), and don’t do any strenuous exercise when you have a cold. M Think humid. When you’re exercising, choose a humid environment; try to avoid cold, dry air.

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Don’t Exercise If . . . M you have a viral or bacterial respiratory infection M it’s very cold outside M t’s very dry outside M pollen counts and air pollution levels are high and you have allergies

M Treat allergies. If allergies contribute to your asthma, use allergy medication and avoid allergens while you exercise. M Breathe right. To keep cold air from blasting your lungs, learn how to breathe through your nose or through pursed lips as much as possible while exercising.

IF YOU HAVE A FLARE . . . Of course, premedicating doesn’t mean that you’ll never have an asthma flare. Exercise-induced asthma can be prevented most of the time, but a treatment regimen that usually works great may fail once in a while. That’s why you always have to carry your rescue medication to every practice and every game. You’ll also need to be alert for symptoms that appear in the middle of a game or a workout so you can promptly treat them with bronchodilators. Your asthma action plan should outline what to do if your symptoms get worse while you exercise. When you’re playing a sport and you experience mild asthma symptoms, try to keep playing—your symptoms may remain mild. If they continue and your doctor has prescribed an inhaler with a short-acting bronchodilator, pause and inhale two puffs, even if you have pretreated. Typically, a doctor may prescribe two puffs of an inhaled rescue medication (such as a beta 2-agonist), with one minute between puffs. You should breathe more easily within a few minutes. If you don’t, stop exercising and take an additional two puffs every 10 minutes for two more additional doses. You might have to end practice early or stop playing

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Living with Asthma

in a game and sit on the sidelines. If there is no response, call your doctor. If you find that you’re having frequent EIA flares despite using your premedication, or if you’re having attacks when you’re not exercising, you should see your doctor right away. Your doctor may need to prescribe daily medication to control the underlying inflammation that is causing your frequent asthma flares.

BEST AND WORST EXERCISES Not all sports involve the same amount of physical exertion, which is why some sports are easier for students with asthma to handle than others. Swimming is usually the least likely to cause problems for kids with EIA. In fact, if you have asthma, the best exercise you can choose is swimming, because you’ll be breathing in warm, humid air as you swim and your throat won’t dry out. In addition, the horizontal position in which you swim may help move mucus from the bottom of the lungs. Other good choices. Sports or activities with bursts of activity fol-

lowed by brief rest periods are other good choices, because they are least likely to cause asthma symptoms and you can regain control of your breathing in between. Baseball or softball, football, wrestling, gymnastics, volleyball, tennis, free downhill skiing, walking, leisure biking, hiking, golf, surfing, and short-term track and field events are less likely to trigger asthma. Repeated cycles of a few minutes of exercise followed by several minutes of rest are ideal. More likely to cause asthma. Vigorous running for more than six consecutive minutes is the most likely to induce wheezing, and sports that require constant motion, such as soccer, basketball, cycling, field hockey, distance running, or lacrosse, can be tough to handle if

Swim Your Way to Better Health! Swimming is the best exercise for people with EIA; sports with endless running or exercising in the cold are the worst.

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you have asthma. But if you really love one of these more strenuous sports, you’ll probably be able to work with your doctor to figure out how to keep on playing, despite your condition. Winter sports sometimes cause more problems for students with asthma, because cross-country skiing, snowboarding, ice hockey, and ice skating all involve continual exercise in cold air and are more likely to aggravate airways. Wearing a ski mask or scarf to warm cold air before you breathe it in may help. And even in these higher-risk sports, many athletes with asthma have found that with proper training and medical treatment, they are able to succeed as runners, skiers, or even basketball or hockey players.

WHAT TO EXPECT Kids react in different ways to having EIA. Some kids don’t want to participate in any type of physical activity—even if their doctor says it’s okay—because they’re scared they might have a flare. Other kids figure that having asthma will be a free ticket to get out of gym class—permanently. Others just worry they won’t be able to play a sport they love. It’s reasonable to expect that you won’t experience any symptoms and that you’ll be able to participate in all activities you desire. If your fears about having a flare are so severe that they’re interfering with your ability to play sports or get exercise, you may want to talk to your doctor or a therapist. Having a chronic disease can make living your life more difficult sometimes, and talking about your feelings can help. On the other hand, some kids try to use their illness to get out of doing things they don’t really want to do. That’s not healthy, either, and in the long run it isn’t good for you.

MONITORING EXERCISE-INDUCED ASTHMA You’ll need to be on the lookout for symptoms while you exercise. This is where your peak-flow meter can help. Remember that your peak-flow meter measures how fast you can exhale. When your airways get narrower during an asthma flare, your peak-flow number will drop. If your symptoms are appearing more often during exercise or you notice a significant drop in your peak-flow number, this is a signal that you should talk with your doctor. A peak-flow meter is helpful not just to let you measure your asthma symptoms—it can also be used as an objective way to make decisions about your participation in sports, or gym class. Sometimes,

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gym teachers and coaches may be confused about asthma and exercise. Some may try to stop you from participating; others may push you to keep up with your classmates without giving you time to monitor or treat your condition properly. A peak-flow meter can help your teachers make objective decisions about your situation.

WORKING WITH YOUR SCHOOL As discussed in chapter 6, your school should have a copy of your asthma action plan on file. There may be some specific things you or your parents need to discuss with the school if you have EIA. If your condition is made worse by pollen or cold air, see if your school will allow you to adjust your physical education schedule. Taking gym at noon, or taking an indoor gym class, may help you avoid EIA. Make sure your gym teacher knows that if you’re experiencing asthma symptoms or you’re recovering from a recent flare, the teacher may need to modify temporarily the type, length, or frequency of exercise to reduce the risk of further symptoms. Your teacher needs to understand that a student who has just recovered from an asthma flare is at greater risk for more asthma problems. You or your parents might ask your teacher to modify exercise as necessary so you can participate. For example, if your gym class is running, see if your teacher will let you walk the whole distance, or alternate running and walking.

WHAT YOU NEED TO KNOW M You can still exercise and play sports with EIA—in fact, exercise may even help cut down on the number of flares. M EIA may be the result of airways that are overly sensitive to sudden changes in temperature and humidity, especially when you breathe colder, drier air. M EIA also may be affected by air quality. M EIA symptoms usually appear five to 10 minutes after exercise stops, but they may appear during intense exercise. M EIA can be diagnosed by exercising and then testing your breathing. M EIA is treated by premedicating before exercise.

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8 Asthma and Your Social Life

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Josh has had asthma since he was in elementary school, but by the time he got to high school he was pretty sick of taking medications and lugging his inhaler everywhere he went. Plus he really got ticked off when his parents hassled him about whether he’d taken his daily medication or whether he remembered to take his rescue medication when he went over to his friend’s house. He started leaving his inhaler behind, partly because he just didn’t want to carry it, but, he also admits, partly to show he was the boss of himself. So when he had a sudden, unexpected flare when he was playing pool at the home of his best friend, Jordan, he didn’t have his rescue inhaler along. Luckily, Jordan only lived a couple of miles away, and Josh’s mom happened to be home when Jordan’s mom called her in a panic to see if she could bring over the inhaler. Josh was also lucky that his flare was not severe and was quickly controlled by the inhaler. But he’d gotten a scare when he realized what might have happened if his inhaler hadn’t been close by. Because of the restrictions asthma can place on your life, you may feel different from your friends and classmates. That’s never a good way to feel, but it’s important to keep your asthma under control.

ISSUES WITH PARENTS Now that you’re a teenager, you’re starting to become more independent, so you probably know just how Josh felt about his parents

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nagging him about asthma. Your parents probably have been worried about you and your asthma for years, and it’s not easy for them to stop suddenly. It often takes parents a while to recognize and accept their children’s growing independence. The best way to deal with this is to show them how well you can manage your asthma on your own. It may be hard for you to realize, but most parents want their kids to grow up and be successful, independent people. Most of the time they aren’t bugging you because they enjoy wielding power, they bug you because they’re scared something might happen to you when they aren’t around to help. If you can show them that you’re responsible, they’ll feel more reassured and will probably back off a bit. If it’s getting to be a problem, talk to your doctor and see if he or she can speak to your parents.

ISSUES WITH FRIENDS Battles with parents over asthma are only one common problem in adolescence. Many kids also don’t like to stick out from the crowd, and they may be embarrassed at having to take medication. The last thing most kids want is for their friends to think they’re different. Maybe you’ve had asthma for years, and your friends have all known about those daily visits to the school nurse since elementary school. But if you’ve been diagnosed more recently, you may want to share your condition with at least a few close friends or the person you’ve started dating. You probably won’t just want to blurt it out, especially on a first date, but sharing this information with people you’re going to spend time with can help. First of all, if you ever do have an attack, it may be less scary for them, and they’ll know how to help. Some kids say their friends don’t seem to understand the seriousness of asthma; some say their friends tease them or accuse them of being wimps, looking for an excuse to get out of gym. If your friends do tease you or treat you differently for having asthma, they aren’t very good friends. Would you make fun of someone for having cancer? Asthma is a disease like any other health condition. Asthma is so common that finding friends who will accept you shouldn’t be a problem. Dating can bring a whole unique set of problems and worries to teens with asthma. First of all, every time you go out on a date, you should take your quick-relief medicine with you. (It’s better than going out without it and ending up in the emergency room because you had an unexpected flare.) When you’re planning a date, think

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Finding the Time Maybe your friends are great and supportive, and you don’t mind taking the medication in front of them—it’s just that it can be tough to follow a treatment schedule when you’re going in a million directions at once. If you’ve got basketball practice, play practice, church, volunteer activities, homework, and a weekend job—you just don’t have a lot of spare time. It’s important to talk to your parents and your doctor and come up with a plan that fits your lifestyle before you move out on your own or leave for college.

about possible triggers. For example, before you go out, you might need to ask your date not to wear cologne or aftershave or not to smoke around you. If you don’t want to mention your asthma, just say, “I’m sensitive to certain cologne” or “smoke just really bothers me.” If you’re uncomfortable taking your medication in front of your friends, talk to your parents and your doctor to find out if you can take your daily preventive medication at home in the morning and at night, just like brushing your teeth or taking a shower. If the problem is that your friends don’t understand the seriousness of asthma, you might talk to your principal, school counselor, or a favorite teacher and ask if you could have someone present a health lesson on asthma. If you explain that some of your friends are hassling you, odds are the teachers will be happy to educate the class. If your asthma is aggravated by pets, you might have to turn down invitations to visit or sleep over at your friends’ homes, which can make you feel left out. If you explain the situation to your friends, maybe you can all accept the fact that sleepovers will have to take place at your house—or at the home of another friend without pets.

EMOTIONAL ISSUES For some kids, their parents and friends aren’t the problem—asthma itself is. Having a chronic life-threatening condition isn’t like dealing with a case of dandruff or a new blemish. Dealing with asthma can

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cause emotional and psychological distress, no matter how upbeat you think you are. Burden of medication. You might be upset at having to drag three

kinds of controller medications around with you. If this is your problem, talk to your doctor to see if it might be possible to take a single long-term control medicine once or twice a day, so you can leave it at home. Loss of pets. Others who are newly diagnosed with allergic asthma

may be devastated at having to give away a favorite pet. If this is your situation and you’re allergic to a pet, there are some alternatives you can try before you have to give your furry friend away. 1. Isolation: See if it helps to keep the pet away from where you sleep and the furniture you use. Ban the pet permanently from your bedroom. 2. Washing: Sometimes giving the pet a weekly bath can help, although studies have reached conflicting conclusions on this. Weekly washings can be traumatic for a cat, but one study demonstrated significant reductions in airborne cat allergen by filtering the air, washing the cat, vacuuming, and removing furnishings. 3. Medicate: Talk to your doctor to see if you can just increase your medicine a little bit. 4. Tidy up: Remove bedroom carpets, upholstered furniture, and heavy drapes that can’t be washed—even if the pet isn’t allowed in the room. 5. Filter it: Use HEPA or electrostatic air cleaners, especially in your bedroom. If none of this works and your parents say you really must give your pet away, see if you can replace the furry pet with an animal that doesn’t trigger allergies so often, such as a Cornish rex or a sphynx cat (they’re hairless) or one of the dogs with hair, not fur (such as a poodle, bichon friese, or bearded collie). Remember, there’s no such thing as a truly nonallergenic cat or dog—but some breeds trigger problems far less often than most. Fear of flares. Some kids may be haunted by the fact that—while

it’s rare—there is a serious risk to this disease; some people do die from a severe asthma flare. Many kids with asthma might not like to admit it, but they’re just plain scared, wondering when the next flare

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will occur and remembering how frightening it is to have to struggle to breathe. One of the scariest things for Warren was that he never knew when the flare would stop—a slight chest tightness wasn’t too bad, but sometimes the flare would continue to get worse until he and his parents had to decide if he needed to go to the ER. While asthma is a very serious disease, there is really no reason that anyone should die from it. If you’re scared about having an asthma attack, the best thing you can do is to follow your asthma action plan, avoid your triggers, and take your medications as directed. Be willing to talk to your doctor about your fears and concerns. Depression. For some teens, adolescence is difficult enough without a chronic disease thrown into the mix. Especially if your asthma is uncontrolled or unstable, you may experience depression or low self-esteem. You may start having trouble getting up in the morning or you might do badly in school. Occasional low moods are normal, and fluctuating emotions are also a normal part of being a teenager. More than half of teenagers feel sad for a day or so at least once a month. When you’re sad, life may seem drab or hopeless, as if you don’t have anything to look forward to. You may feel empty or emotionless. When you’re in a sad mood, it may feel like it will last forever, but if you think about it clearly, feelings of sadness usually don’t last very long—a few hours, or maybe a day or two. You may feel like crying, and when you do, it might make you feel better. You might feel like shutting yourself into your bedroom, which sometimes upsets your family. Or maybe you share your unhappy feelings with a friend; if you do, you may find that talking about your asthma and how it makes you feel sad helps you feel better. Serious, unrelieved depression is quite another matter. Those feelings make it hard to live your life. True clinical depression is a far more intense kind of sadness that lasts much longer—weeks or months at a time. Those feelings aren’t normal, even if they are triggered by the fact that you have a chronic disease. It may seem hard to believe that there’s any good news involved in dealing with clinical depression, but the fact is that even if your depression is terribly severe, a combination of psychotherapy and antidepressant medication is almost always effective. The sooner you find a caring therapist—and, if necessary, start medication—the sooner you’ll feel like your old self again. Remember that depression is in part a psychological response and also in part a biological condition and that there’s no more reason to be embarrassed or ashamed at needing treatment for depression than there is for asthma itself.

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TIPS FOR TEENS There are some things that teens should keep in mind to manage asthma effectively. Don’t smoke! First of all, whatever you do, don’t start smoking— and if you are smoking, please try to quit. You’ve already got major problems with your lungs. You’ve got to know that inhaling hot, poisonous smoke into your lungs isn’t going to help the situation. Odds are you can’t really inhale anything without coughing and choking—which is your lungs sending you an important message. If you don’t smoke but your friends do, remember that secondhand smoke is just about as dangerous for your lungs as if you were puffing on that cigarette yourself. In fact, smoky areas of any kind are going to be hard for your lungs to handle. If someone in your family or a good friend of yours smokes, it can be a tricky situation. You may feel uncomfortable asking them not to smoke around you, but remember—you have a health condition that is made worse by this smoke. At the very least, ask them not to smoke when you’re in their car or during meals. If your friends smoke, explain to them that their smoking makes your asthma worse and can even trigger a flare. If a family member smokes, you need to understand that it’s an addiction and can be extraordinarily hard to stop. You may find that asking your family member to stop smoking as a birthday present is effective. If the person really can’t stop lighting up, ask him or her to smoke outside instead. These days, it’s far more acceptable to put your foot down about smoking than it used to be. Dancing is exercise too. If you have exercise-induced asthma,

remember that dancing is exercise too. You should pretreat with your medication before getting out on the dance floor, if your doctor recommends it. (This is especially true if you’re dancing in a hot, smoky club.) If you do have EIA, remember that it shouldn’t be an excuse for turning into a couch potato; an active lifestyle will really keep you healthier in the long run and lessen the chance of having flares. A healthy, nutritious diet also can help keep you healthy and help control asthma.

JOIN A SUPPORT GROUP There’s nothing like getting together with a bunch of kids your own age who have similar interests—and this is especially true if you’re with a bunch of kids who also have asthma. It should be a relief to be able to discuss all of your fears with other kids who know exactly

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what you’re talking about. To find a local support group, call your local community health center, community hospital, or visiting nurse association.

CAN’T FIND A SUPPORT GROUP? One of the great things about the Internet is that a worldwide community of experts and help is available to you at the click of a mouse. If you have asthma, one place to learn more is the Web site of the Allergy and Asthma Network Mothers of Asthmatics at: http://www. aanma.org/breatherville.htm. Here you’ll find information on managing asthma and dealing with emergencies, details on medications and devices, the latest news on asthma, and how to handle pets and allergic asthma. You can even order books and videos about asthma. There’s also information about famous people with asthma, how to show your friends what having asthma is like, kids making a difference, and much more. If you want to find a support group but can’t find one nearby for teens with asthma, you can start your own with the help of the Asthma and Allergy Foundation of America (AAFA). AAFA is a private nonprofit organization based in Washington, D.C., that believes that educational support groups are one of the most important ways to help people with asthma and allergies. If you’ve got the energy and the drive, you can reach out to other teens just like you, through local doctors, hospitals and medical centers, and libraries, to form a group. Of course, you could start a group completely on your own, but affiliating with AAFA gives you credibility, since you’ll be associated with a national organization. What’s more, affiliating with AAFA is free. As an affiliated group, you’ll be able to get referrals for new members from AAFA’s hotline (800-7ASTHMA). Your group will also be included in a searchable database of affiliated groups on AAFA’s Web site.

Don’t Rely on Rescue Medication It’s common for teens to stop taking their daily medication and instead rely on rescue inhalers to get them out of a breathing jam. This can be dangerous to your health—prevention is always preferable to rescue.

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When you affiliate as a teen group, you’ll receive M a “Sample Pac” selection of products including peak-flow meters, spacers, demo-inhalers, and written information M 25 copies of the Teens Talk to Teens brochure M a free interactive game on CD-ROM called Quest for the Code M free subscriptions to Leaders Link, AAFA’s support group leader/advisor newsletter M a free resource guide (Starting Strong, Staying Strong) along with a companion CD-ROM M free technical assistance M free resources and special mailings throughout the year Your first meeting may bring only a couple of teens together, but you’ll be surprised at how quickly the word will get around. Soon you’ll find that your informal get-togethers have gained momentum. Anyone can lead a group—a nonmedical person, a professional, or a team of both. To affiliate with AAFA, your support group must meet at least four times a year, find a doctor to serve as medical advisor, have at least 10 members, and complete the affiliation forms and submit semiannual reports on the group’s activities. You’ll find the forms at AAFA’s Web site at http://aafa.org/pdfs/affiliation_forms.pdf.

WHAT YOU NEED TO KNOW M If you can show your parents that you can handle your asthma responsibly, they’ll probably be much less controlling about giving you more independence. M Using a peak-flow meter to gauge your condition is a good way for teens and parents to deal with asthma medication issues and power struggles. M Sharing information about your condition with your close friends and classmates makes sense. M Asthma can cause a number of emotional issues, including grief at the loss of a pet or having to deal with a chronic illness, depression, and fears. M Don’t smoke, avoid secondhand smoke, and don’t rely on your rescue medication instead of control drugs. M Join a support group to help you cope, or start your own.

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9 Coping with Asthma When Traveling

K

Karen was diagnosed with asthma two years ago, and by now her condition was very well controlled. She had mild allergic asthma, and she was careful to avoid her triggers: strong smells, pollen, dusty places, and fireplace smoke. Asthma was the farthest thing from her mind when she arrived at the beach—her first visit to the ocean since she was a little girl. As she ran along the beach at dusk, she began to feel the old familiar tightening in her chest. Slowing down, she was alarmed to recognize the first signs of a severe asthma flare, which appeared to begin out of nowhere. Although she didn’t have her rescue inhaler with her at the beach, her mother had remembered to pack it, and it was quickly available back at their condo. Karen hadn’t realized that the cold, damp air at the seashore would be one more trigger that she needed to prepare for. Had she not been prepared, she might have had to visit the emergency room to get her flare under control—not something anyone wants to deal with on vacation. If you and your family are planning a trip, the most important thing to remember is to be aware of your asthma triggers and avoid situations or substances that may cause you problems. At the same time, you’ll need to realize that if you’re venturing into unknown territory, you might react to something you’ve never encountered before. Even if your asthma is fairly mild, you can’t always be sure what reactions you might have in an unfamiliar environment. Make sure you are armed with the medications you will need if you have a reaction.

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If you have asthma—especially if it’s severe—it might require that you and your family accept some extra work beforehand so you can travel safely. Learn as much as you can about potential hazards so you can prevent problems and have a happy, safe trip.

BEFORE YOU LEAVE There’s a lot you and your family can do before you walk out the door to prepare for an asthma-free vacation. If you have allergic asthma, remember that the climate at your vacation spot and the season when you go may affect the sorts of allergens you’ll be exposed to. If you’re heading to the dry southwest, you’ll probably have fewer problems than if the tropics are your ultimate destination, where the dampness virtually guarantees lots of airborne molds. Warm, humid climates may boost your chances of being exposed to house dust mites and indoor molds, whereas cold dry air can be irritating to breathing passages. Pretrip checkup. If you have active allergy symptoms or unstable

asthma, consider asking your parents to schedule a doctor visit before you leave on vacation. Discuss what you’ll be doing and where you’ll be going, and find out if your doctor thinks you should adjust your medication. Consider MedicAlert. If you have severe or unstable asthma and

you’re going to be traveling (especially if you’re traveling alone or without your parents), you may want to think about wearing a medical alert bracelet (such as a MedicAlert bracelet or necklace) to help medical workers understand your problem if you have an asthma attack. In fact, a MedicAlert tag is the first thing emergency medical personnel look for when they respond to a call. The MedicAlert organization provides members with an easily recognizable emblem available as a bracelet or necklace, engraved with your medical condition and a toll-free number accessible from anywhere in the world. Any doctor can call the number for more information about the patient’s medical condition (available in more than 100 languages). If a call comes through, the MedicAlert staff also tries to reach the patient’s family to let them know about the emergency. Medications. Take along a medical kit that includes your asthma medications and your rescue medications, which may include antihistamines, bronchodilators, and a small amount of corticosteroids. Keep a complete separate set of medications in your purse, briefcase,

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Coping with Asthma When Traveling 85

MedicAlert MedicAlert bracelets are available from the MedicAlert Foundation, 2323 Colorado Avenue, Turlock, CA 95382, (888) 633-4298, or at their Web site at http://www.medicalert.org. Membership is $35 for the first year, with an annual renewal of $20.

or carry-on bag in case your checked luggage is delayed. (It’s a good idea to have a second set in your checked luggage in case you lose your briefcase or your purse is stolen.) It’s always a good idea to pack more than you think you’ll need. When flying abroad, you must have your medication in its original container, which identifies the medicine for custom officials. It’s always a good idea to keep medications in the original container anyway, in case someone besides you needs to administer your medication to you. If your asthma is particularly severe, your doctor might prescribe oral corticosteroids for you to take with you when you travel. Your doctor will discuss with you when you might have to use it or when to call for instructions. Don’t forget to pack your peak-flow meter so you can monitor your condition. Also include your asthma action plan and a copy of your doctor’s phone number. If you use a portable nebulizer and you’re traveling abroad, make sure you bring an adapter for electrical plugs in countries that use different electrical currents. Contact information. Take your physician’s phone number with

you, because you never know when you might need to call for information. Ask about travel medical insurance. Don’t forget to ask your parents about getting travel medical insurance (or check to see what your own health insurance policy covers) if you’re going abroad. You may need it if you must go to an emergency room while on vacation. See Appendix C for names of companies. If you’re traveling abroad. If you’re planning an overseas trip, you’ll need to be able to locate a hospital or a doctor in an emergency.

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You might write down before you leave how to ask for a doctor or hospital in the language of the country you’ll be visiting. Your parents should make sure that you have proper health insurance coverage. Most health insurance, HMOs, PPOs, and Medicare don’t offer such international coverage. If your parents’ policy doesn’t cover you when you’re traveling abroad, they might want to consider buying an international travel medical insurance policy. If your parents’ health insurance policy does provide coverage outside the United States, they should be sure to take their insurance policy identity card and a claim form and get copies of all medical bills and receipts from the trip. Doctors and hospitals overseas may want payment in cash for treating you, but they may accept a credit card. If an American citizen becomes seriously ill while abroad, a U.S. consular officer can help find appropriate medical services. If necessary, a consular officer can also help transfer money from the United States. Contact information for U.S. embassies and consulates abroad is included in Key Officers of Foreign Service Posts, which you can obtain through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402. Or you can call the State Department’s Hotline for American Travelers at (202) 647-5225, or visit the State Department Web site at http://www.state.gov. For lists of doctors and hospitals abroad, visit the Department of State’s Web site at http://travel.state.gov/travel/tips/emergencies/emergencies_ 1195.html. You or your parents might contact the American College of Allergy, Asthma & Immunology (ACAAI) at http://www.acaai.org to obtain the names of qualified English-speaking physicians around the world. Alternatively, you can obtain the name of a member allergist or immunologist practicing in your destination area from the American Academy of Allergy, Asthma and Immunology’s physician referral and information line, (800) 822-2762, or its physician referral system on the Web site: http://www.aaaai.org. Finally, you might check with the International Association for Medical Assistance to Travelers, a voluntary Canadian group that offers a listing of qualified English-speaking physicians in other countries. Before you leave the country, check with your physician for any immunizations you may need. Make sure to carry your physician’s phone number at all times. Take your asthma medications in their original containers, which are easier for customs officials to identify, and bring along a prescription signed by your doctor. If you use a nebulizer, be aware that you’ll probably need an electrical adapter because other countries’ electrical currents are usually different than

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those in the United States and Canada. The electric current in many other countries is 220 volts, as opposed to the 110-volt standard in the United States. And if you use a portable nebulizer, be sure to have plenty of batteries. Remember to complete the information page on the inside of your passport, providing the name, address, and telephone number of someone to be contacted in an emergency. Making hotel reservations. You probably won’t be surprised to

hear that hotel rooms often harbor large populations of dust mites and molds in carpeting, bedding, and upholstered furniture, which can make your asthma symptoms worse. When your parents make hotel reservations, make sure they ask if there are allergy-proof rooms available. A few hotels reserve a few hypoallergenic rooms that typically have fewer allergens than traditional rooms, because they are equipped with carpetless hardwood floors, blinds instead of drapes, hypoallergenic bedding, and allergy-free mite-proof pillow and mattress covers. If the hotel doesn’t offer those, have your parents ask for a nonsmoking room with air conditioning. You also can try to see if the hotel will replace the air conditioning filter before you arrive. If you’re sensitive to molds, a sunny, dry room away from indoor pools is a good idea. If you have pet allergies, find out about the hotel’s pet policy and ask for a room where pets have never stayed. If you’re extremely sensitive to dust mites, you can always pack your own dust-proof, zippered covers for pillows and your mattress and bring your own air filter. If you’re allergic to feathers, bring your own special pillow. Rental properties. If you and your family are staying at a cottage or cabin in a forest or at the shore, make sure it’s thoroughly cleaned and aired out before you get there for your vacation. This can reduce dust mite and mold concentrations. Staying at a private home. You may think you don’t have to

worry about allergies when you’re visiting friends or family, but that’s not necessarily the case. Animal allergens in pets’ dander, saliva, or urine can cause problems for some people even if the pet is moved outdoors for your arrival or barred from your room. If your friends or family members know about your asthma, they may be willing to take extra precautions, such as keeping the pets out of the room you’ll be using or isolating the pet. However, it takes months before the dander and residue of an indoor pet no longer triggers symptoms. If your friends have cats or dogs and you’re highly sensitive to pet allergens,

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88

Living with Asthma

you may want to talk to your doctor about taking medication or an inhaler before you go. Some thoughtful hosts make a special effort to vacuum and dust before your arrival. But some kids, such as Andrew, 14, are so sensitive to pets that simply walking into a room where a pet has been is enough to trigger a major flare. When Andrew’s family goes to visit his grandparents, they stay in a hotel because of the pet cats. He’s able to visit briefly at his grandparents’ house, because they keep a wing of their home permanently closed to the animals. Making your needs known beforehand isn’t rude—it’s vital for your health and comfort. And if it seems that staying at the house will probably trigger asthma attacks like it did for Andrew, and there’s nothing you can do to prevent them, consider having your family check into a hotel instead. Sometimes it’s just easiest to avoid staying in the homes of family or friends whose pets trigger your allergy symptoms. Check pollen counts. Remember that pollens and molds vary from one region to the next, depending on the weather and time of year. Check pollen counts and weather reports for the part of the country where you’ll be traveling. It’s a good idea to try to visit at a time when you’re least likely to experience symptoms. You’re probably less likely to have problems in very dry climates such as Arizona and New Mexico, but pollen counts are rising there as nonnative plants are being introduced. You may want to avoid traveling to the eastern half of the United States and Canada from mid-August through October if you’re sensitive to ragweed. If pollens are a concern, you might consult the National Allergy Bureau (NAB) of the American Academy of Allergy, Asthma and

National Allergy Bureau Pollen and Mold Counts You can check the pollen and mold counts at any time by visiting the National Allergy Bureau on the Web at http://www.aaaai.org/nab/ index.cfm?p=pollen.

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Immunology’s (AAAAI) Aeroallergen Network. The NAB is responsible for reporting current pollen and mold spore levels to the public. The Aeroallergen Network monitors pollen and spore levels with volunteers at about 78 counting stations throughout the United States and three in Canada. At the stations, volunteers collect airborne pollen and spores for microscopic examination. Pollen and mold counts are electronically forwarded to local, regional, and national media. Also remember that very cold areas don’t usually have a big problem with dust mites, and snow kills mold spores. Prepare for the airplane. If your nose is stuffed up as a result of allergies when you have to fly, you’ll be more likely to have ear pressure problems during your flight. That’s why you should treat your allergy symptoms with decongestants and antihistamines before you leave. If you’re flying abroad, there may be some flights where smoking is allowed, so make sure to ask for a seat located as far as possible from the smoking section. If you have severe asthma and you think you might need supplemental oxygen, don’t wait to ask for oxygen as you’re taxiing down the runway. You’ve got to arrange for this with the airline long before you take off. The airline can’t refuse to let you board because you need supplemental oxygen, but you must make arrangements in advance. Many airlines will let you use a battery-operated nebulizer (except during takeoff and landing), but your parents should check this in advance. You should know that nebulizers aren’t typically included in aircraft emergency kits, because they’re so big. On the other hand, inhalers with spacers can be as effective as nebulizers in treating asthma, and they’re usually easier to carry around when traveling. Investigate the ship. If you’re taking a cruise, your parents should check ahead of time to find out about the ship’s doctor and staff and what type of health issues they’re prepared to handle. In general, the larger, reputable cruise lines will have some type of medical facilities on the ship. Have your parents ask for a smoke-free cabin on the ship. If you have severe asthma, your parents should tell the cruise operators ahead of time. If you’re traveling on a river cruise or barge trip, remember that these cruises can float through areas with heavy pollen and mold concentrations. For your room on the ship, you’ll want to follow the suggestions provided above for staying in a hotel.

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90 Living with Asthma Clean your car. If you’re taking a long car trip, don’t forget those pesky dust mites that could be lurking in the upholstery, carpeting, and ventilation system, along with molds and pollens. Before you leave on your trip, turn on the air conditioner or heater and open the windows for at least 10 minutes before you get into the car. Use a vacuum with a HEPA filter to clean up pollen, mite, and pet allergens. Air conditioners collect all kinds of allergens, so spray your air conditioner with a dust and mold allergy removal spray. If your parents are going to rent a car, ask them to request a nonsmoking car. You’d be amazed at how much smoke can cling to a car’s interior. Traveling solo. If you’re going to be traveling alone (especially if

you’re going abroad), give a copy of your asthma action plan and a list of your medications and emergency phone numbers to at least one adult you’ll be with. If you’re under age 18, have your parents provide written (and notarized) permission for another adult to provide you with emergency care.

ON THE MOVE In the car. On a car trip, do not dangle outside the window. You

should keep the car windows rolled up and the air conditioner running, especially if you’re driving through a polluted area, a large city, or an area with a high pollen count. Suggest to your parents that you set off early in the morning. There will be fewer cars and trucks on the road to clog up the air with exhaust. And, of course, no one in the car should be smoking cigarettes. If you use a nebulizer for your asthma, you can get a portable nebulizer that plugs into your car’s cigarette lighter or uses a portable battery pack. On the plane. The air in planes is notorious for being very dry and

filled with recycled germs. In fact, research has found that some of the highest concentrations of dust mites and animal dander is found on planes, because of their sealed environments with recycled air that is rarely well filtered. Every new planeload of travelers tracks in a whole new population of microscopic critters. To keep your nasal membranes moist, use a saline nasal spray once every hour. This will make you more comfortable during and after your flight. Drink plenty of water during the flight. Drinking water will help lessen the likelihood of an asthma problem and help you combat jet lag.

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In Flight, Drink Water! Drinking water during a flight will reduce the chance of having an asthma attack and help with jet lag too.

UPON ARRIVAL When you get to your hotel, have your parents check with reception to find out how close the nearest hospital is and whether the hotel has an in-house doctor. If the hotel room seems a little dry, turn on the shower to fill the room with steam and keep your sinuses moist, and keep squirting the saline nasal spray. If you’ve got allergic asthma and you’re sensitive to pollens, remember that pollen counts are highest in the morning, so schedule indoor vacation activities early and then move outdoors in the afternoon.

SPECIAL SITUATIONS Holidays. Winter holidays can be especially difficult for people with allergic asthma, because that’s when crates of items come out of storage in attics and basements, often loaded with dust, mildew, and mold. There can be molds on Christmas trees, damp leaves, and moldy logs piled up at fireplaces. If you’re sensitive to smoke, as most people with asthma are, breathing fireplace and wood stove smoke can trigger symptoms. Those who are sensitive to smells may have trouble with the pine, bayberry, and other strongly scented potpourri, candles, and air fresheners that are used during the winter holidays. Camping. There’s nothing like pitching a tent on the side of the mountain and sleeping out under the stars. But if you’ve got asthma, embracing the outdoors also will increase your contact with outdoor pollen and mold, inhalation of wood smoke from campfires, and so on. That doesn’t mean you can’t ever go camping. However, you may want to avoid hiking and camping during the high pollen season if you’ve got allergic asthma. And because campsites are usually in fairly remote areas, always bring along plenty of your medications, including rescue medications.

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Vacation sports. Combining a vacation with a sport you love can be a wonderful experience, and there’s no reason you can’t participate in activities that you love. But if you’re going to be going skiing, ice skating, snowboarding, or tobogganing, remember that cold air can trigger asthma episodes. Combining a cold-weather exercise such as skiing also means you may be at high altitudes, which might increase your risk even more. Sometimes, a particular sport is just too dangerous for people with asthma, and scuba diving is one of those. Imagine experiencing an asthma flare 30 feet beneath the ocean surface—you wouldn’t be able to use your rescue medication, and even in an emergency situation you can’t make a rapid ascent to the surface. If you’re going to scuba dive, you’ve got to be physically and mentally fit. In fact, some countries consider scuba diving just too risky for people with asthma. If you experience frequent symptoms or you have airway obstructions based on lung tests, you might make things worse if you try to scuba dive. On the other hand, if you have asthma but you have normal pulmonary function and only an occasional flare, you may be able to scuba dive—but you should talk to your doctor first. For many people, it’s just easier and safer to replace your scuba tanks with snorkel gear and enjoy exploring the ocean floor in shallow water instead, where you can easily reach the surface if you get into trouble. If you’re hoping to do some horseback riding on your trip—or if your family is planning a dude ranch vacation—make sure that you can tolerate exposure to horses and to the hay that they eat. If you’re going to be hiking, especially if it’s in the high mountains or in very rugged terrain, make sure you’re physically up to the challenge. For example, hiking the Grand Canyon might be challenging for someone with exercise-induced asthma and who hasn’t been well conditioned for the extremely challenging effort. If you’re going in the opposite direction—climbing up a mountain—you should take special care if you’re planning on hiking above 5,000 feet, where the oxygen in the atmosphere will be markedly thinner. Also remember that if you have asthma and airway obstruction, you may experience shortness of breath at higher altitudes, and the cooler, drier air plus the strenuous work of climbing at high altitude may trigger an asthma flare. On the other hand, you’ll encounter fewer allergens in the air at high altitude. Crossing time zones. If you’re going on a big trip, you may cross a number of time zones. Jet lag isn’t your only concern here—you’ll need to make allowances for time differences in figuring out your medication schedule.

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Coping with Asthma When Traveling 93 Allergy shots. If you’re taking allergy shots and you’re going to be

away for a long time—at least a month—you may want to continue this therapy. If you will be gone for this long, check with your doctor about getting a referral to a physician in your vacation spot. You can have that doctor give you your shot. Remember to keep your allergy vaccine containers in an insulated pack to stay cool. However, it’s better to get maintenance doses of allergy shots before you travel. If you’re traveling abroad and you need to carry your allergy extracts, make sure you label them clearly with your name as it appears on your passport.

WHAT YOU NEED TO KNOW M If you’re planning a trip, avoid your asthma triggers and those situations where you might be exposed to situations or substances that may cause you problems. Be sure to bring your medications if you have a reaction. M Schedule a doctor visit before you leave to see if you need to adjust your medication. Take along asthma and rescue medications, which may include M antihistamines, bronchodilators, or a small amount of corticosteroids. Keep a complete separate set of medications in your purse, briefcase, or carry-on bag in case your checked luggage is delayed. M Pack your peak-flow meter so that you can monitor your condition, in addition to your asthma action plan and a copy of your doctor’s phone number. If you use a portable nebulizer and you’re traveling abroad, make sure you bring an adapter for electrical plugs in countries that use different electrical currents. M Get travel medical insurance (or check to see what your own health insurance policy covers) if you’re going abroad. You might want to write down how to ask for a doctor or hospital in the language of the country you’ll be visiting. M If an American citizen becomes seriously ill while abroad, a U.S. consular officer can help find appropriate medical services. M If you’re going to be traveling alone (especially if you’re going abroad), give a copy of your asthma action plan and a list of your medications and emergency phone numbers to at least one adult. If you’re under age 18, have your parents provide written (and notarized) permission for another adult to provide you with emergency care.

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10 Helping Others Cope with Asthma

M

Most of this book discusses teens who have asthma and how they can deal with their condition. But some teens don’t have asthma themselves—instead, they must cope with the fact that their parent, sibling, or best friend has it. The odds are that someone you know has asthma, because according to the American Lung Association, nearly 4 million kids under age 18 have had at least one asthma attack. You may have some very special concerns if your close friend has this condition. You may be scared or worried about him or her, because you’ve heard that a severe asthma attack can lead to hospitalization. A lot of kids wonder whether people can die from asthma. Although very rare, it can happen. However, fatalities from asthma these days are infrequent, since most people have asthma management plans that can prevent or treat most of their attacks. Some kids worry that their friends might have an attack when they’re with them, but they wouldn’t know exactly how to help. Seeing someone have an asthma attack can be frightening, especially if you’re not used to it. So it’s important to find out what to expect if your friend has an attack, so that you’re prepared. For example, most people think that an asthma attack means that the person can’t breathe in, but in fact, the person can breathe in just fine. The problem comes in breathing out—it becomes harder and harder to force air out of constricted airways. Many kids with asthma say it’s like trying to breathe through a straw. You can do it, but it’s exhausting to try to get enough air that way for any length of time. 94

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Helping Others Cope with Asthma 95

Studies have found that how well family members and friends support the asthma patient can be a major factor in the success of the treatment—so it’s a good idea to try to learn as much as you can.

LEARN ABOUT THE MEDICATION If a close family member or friend has asthma, it may be important someday for you to know what kind of asthma medications the person takes. Take a few minutes now to find out whether the person uses a long-term control medication or a short-term rescue medication—or both. Many patients have two inhalers—one for control and one for rescue. It’s critical that you know the difference, because a control inhaler cannot help during an asthma attack. Learn the dosage and when the medication should be taken. How often does your friend need medication? Many people with asthma must inhale medication at least once a day; others, who have much milder cases, need to take rescue medication only if they are having an occasional flare. Find out what medication the person takes during a flare. Some of the person’s medications are for long-term control, and those won’t help in an emergency. You need to find out which medications are the rescue inhalers and where they are kept. You also should know how to administer them. Rescue medications work right away to relieve asthma symptoms and are usually inhaled directly into the lungs, relaxing the muscles around the airways to relieve wheezing, coughing, and shortness of breath. They begin to work within minutes after they are used, and their effects may last up to six hours. Most rescue medications are inhaled through a pocket-sized device that the person uses when a flare begins. Rescue medications include: M M M M M M

albuterol (Proventil, Ventolin) bitolterol (Tornalate) levalbuterol (Xopenex) metaproterenol (Alupent) pirbuterol (Maxair and Maxair Autohaler) terbutaline (Brethine, Bricanyl)

Whatever the situation, this information should be written down in the person’s asthma action plan. If someone in your family has asthma, you should know where a copy of this plan is kept. If a close friend has asthma, you should at least know where to find his or her rescue medication.

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WHAT TO DO IN AN EMERGENCY Would you know what to do if your friend or family member suddenly had a severe asthma flare? It can be scary to watch someone struggling to breathe. Every family member and close friend of a person with asthma should know what to do in an emergency like this. It can be especially difficult for a bystander to know, without prior education, when to take the person for emergency help and when the situation is under control. What to do first. If you think your loved one may be suffering a

severe attack, here’s what to do first: M Stay calm. If you panic, you could upset your friend. M Your friend will know what to do, so ask what she or he wants you to do. M Make sure the person immediately stops all activity. M Keep the person in an upright position—do not let him or her lie down. Loosen any tight clothing, but don’t hug the person, since this restricts breathing. Make sure the person uses his or her rescue inhaler immeM diately—don’t worry about whether it’s needed or not. It’s much worse to withhold medication when it’s needed than to provide medication if it’s not. M If your friend doesn’t improve right away, continue to give one puff of the rescue inhaler every minute for five minutes. If your friend needs to take additional medication after a few minutes and isn’t any better after five minutes, send someone for help or call 911. Do not worry about causing inconvenience or calling in a false alarm, even late at night. M Continue to give supportive treatment until help arrives. M Stay and talk quietly with your friend. Remember that if it’s a bad flare, your friend is probably scared too, and in many cases may not be able to communicate those fears to you. Try not to freak out. You can help your friend relax and let the medication take effect. You might try offering to watch a DVD with your friend or read a book out loud to help distract the person. Or put on some music the two of you like. When to call an ambulance. Long before an asthma flare appears,

you should discuss with your friend or family member how to decide if an ER visit is needed. Your instructions should be spelled out in the person’s asthma action plan, which also should list peak-flow meter

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Helping Others Cope with Asthma 97

readings and specific symptoms you can use as a guideline for when to go to the ER. When peak-flow readings drop, it’s a sign that airways are getting inflamed. If you and your friend or family member aren’t sure how serious the flare is, have the person blow into the peak-flow meter and check the readings against the person’s asthma action plan. You should get help quickly by getting to an ER or calling 911 if the person M M M M

has trouble breathing has trouble talking experiences a rapid heart rate uses rescue medications repeatedly but the symptoms don’t improve after five or 10 minutes—or they return again quickly M has a peak-flow reading that falls below 50 percent of personal best and doesn’t improve with medication M has blue lips or fingernails Even if you’re old enough to drive, it’s better to call 911 unless the emergency room is right down the end of the street. An ambulance is equipped to deal with a severe asthma flare immediately. What to take to the ER. If your friend or family member must go

to the emergency room, take along a copy of the person’s asthma action plan or a note with the names and dosages of any medications he or she is taking (or has already taken in the last hour or so), so that you can inform the medical staff at the emergency room. Also,

How You Can Help Encourage your friend to take his or her medication as prescribed, because even when the person isn’t having symptoms, the airways may be inflamed. Asthma requires a lifelong commitment to prevent a flare from happening. Make sure the person keeps quick-relief medication close by at all times, in a backpack, desk, car, or pocket.

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don’t forget to bring the patient’s insurance card to help speed up the process.

WHAT YOU NEED TO KNOW M Learn as much as you can about your friend’s triggers and symptoms, and know where the rescue inhaler is kept. M Learn the names of all your friend’s medications—especially which inhaler is the rescue drug and which is the long-term control medication. M During a flare: ● Have the person stop and sit upright, loosening clothing. ● Offer one puff of a rescue inhaler every minute for five minutes. ● Call 911 if ❍ the person has trouble talking ❍ the person experiences a rapid heart rate ❍ symptoms return again quickly ❍ a peak-flow reading falls below 50 percent and doesn’t improve with medication ❍ there’s no improvement after five minutes ❍ the person turns blue ● Continue to give one puff every minute until help arrives.

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11 Paying for Care

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Sarah, age 14, was recently diagnosed with asthma— which could not have come at a worse time. Her father had only recently been laid off from work, and her mom had to take care of her two little brothers at home. The family was shocked to find that Sarah’s medications would cost more than $300 a month—every month. Sarah was still a kid, but she had to face some adult problems. It’s bad enough to have a chronic health problem, but seeing her parents agonize over paying the bills for her care made it all that much worse. Paying for health care is a grownup problem, but there are many older teens who, just like Sarah, are fully aware of financial problems that their family may be having. If this is your situation, you know how unsettling it can feel. Or perhaps a friend of yours has confided in you, for example, that his medication is really expensive and he doesn’t know how he’s going to afford it. You may want to help—but what can you do? Unfortunately, today all too many families are finding that paying for good health care, emergency health care, and prescription medications for what may be a lifelong health problem can be difficult to afford. Some parents make too much money for Medicaid coverage but not enough to pay for doctor visits, therapy, and medications. Others just can’t afford health care coverage anymore. Fortunately, there are ways to get the care you, a family member, or a friend might need.

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EMERGENCY ROOM COVERAGE One of the biggest concerns for families having financial problems is how to cover emergency care for asthma. Even if you have no insurance and no money, anyone who comes to the emergency department asking for treatment for a medical condition must be examined to determine if it’s an emergency, according to the Federal Emergency Medical Treatment and Active Labor Act (EMTALA), also known as COBRA or the Patient Anti-Dumping Law. If it’s an emergency, the hospital is required either to provide free treatment until the person is stable or to transfer him or her to another hospital. Almost every hospital in the country (except some military hospitals and Shriner’s hospitals) must comply with this rule. This means that if you’re having a severe asthma attack, even if your family has no money or no insurance, don’t hesitate to go to the ER. They cannot turn you away. They are required by law to examine and treat you or transfer you for treatment to another hospital.

MEDICAID If your family is below a certain income limit, you may already be aware of Medicaid, the state-run public health program that covers health care and transportation. States must cover some benefits, including hospital and outpatient care, doctor services, and home health services. Your parents can get more information about eligibility at your local welfare and medical assistance offices to see exactly what’s covered where you live and what the income limits are. More information about Medicaid is available at http://www.CMS.gov.

Low-Cost Health Care Clinics The federal Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA) has a nationwide network of community-based health care centers that provide primary health care services at little or no cost. For information, visit http://www.ask.hrsa. gov/pc.

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MEDICATION COSTS By far the most expensive part about having asthma is the medication. Many kids need not one but three or four medications: There’s a daily, long-term medication (some kids take at least two), and then there’s your rescue inhaler, which must be replaced at least once a year. Spacers are another expensive item. Added to this is the occasional course of corticosteroids that your doctor may prescribe when you’re having a flare. This doesn’t mean you’re out of luck if you don’t have insurance or your parents’ plan doesn’t include a prescription drug benefit. You may be surprised to find that most drug companies offer free medications to patients who can’t afford them. You’ll usually have to get a doctor’s note to apply, along with proof of either financial need or a statement that your family has no health insurance or no prescription drug benefit. Patient assistance program Web sites. Individual drug companies often list their programs online, so you can Google a company’s name and check their Web site. To make things easier, you can visit any of the Web sites listed below, which provide information about many patient assistance programs that provide free prescription medications to eligible participants.

Free Medicine Foundation http://www.freemedicinefoundation.com Established by volunteers, the Free Medicine Foundation has helped countless families across the nation completely eliminate or substantially reduce their prescription drug bills. Last year, these programs helped an estimated 7.6 million patients fill more than 11 million prescriptions. The Free Medicine Foundation is designed to help patients nationwide obtain free prescription drugs. Those without prescription coverage or with a low income or maxed prescription benefits are encouraged to apply. Individuals with family incomes ranging from below the national poverty level up to $38,000 and, in some cases, families with annual incomes as high as $60,000 can receive free drugs. Each sponsored drug has its own eligibility criteria. The Medicine Program http://www.themedicineprogram.com Through a special discount available only to large groups and corporations, this program offers a unique free discount

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prescription drug program. Everyone is eligible. This prescription plan is absolutely free of charge and is available to anyone looking to lower the cost of their prescription bills. Visit the Web site to print a free prescription card, present it at more than 35,000 participating pharmacies, and save up to 60 percent on medication. NeedyMeds program http://www.needymeds.com NeedyMeds was founded by Libby Overly, M.Ed., MSW, and Richard J. Sagall, M.D., in 1997 as a source of information on patient assistance programs and other programs that help people obtain health supplies and equipment. The list of drug programs came from Overly, a home health social worker in Alabama at the time, who had a written database on patient assistance programs to help her patients obtain the medicine they needed but couldn’t afford. Information will always be available at this site at no cost. It continues to grow with new information and links. In response to requests for printed versions of the data, Overly and Sagall began selling the “NeedyMeds Manual,” which contains the information on the Web site for those who find it easier to use a printed version rather than access the Web site. Partnership for Prescription Assistance (888) 4PPA-NOW (477-2669) https://www.pparx.org/Intro.php The Partnership for Prescription Assistance combines pharmaceutical companies, doctors, other health care providers, patient advocacy organizations, and community groups to help qualifying patients who lack prescription coverage get the medicines they need through the public or private program that’s right for them. Many people qualify for free or nearly free medications. Among the organizations collaborating on this program are the American Academy of Family Physicians, the American Autoimmune Related Diseases Association, the Lupus Foundation of America, the NAACP, the National Alliance for Hispanic Health and the National Medical Association. RxAssist http://www.rxassist.org RxAssist offers a comprehensive database of patient assistance programs run by pharmaceutical companies to provide free

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medications to people who cannot afford to buy their medicine. The site also offers practical tools, news, and articles so that health care professionals and patients can find the information they need.

CANADIAN MEDICATIONS You may have heard that many Americans are buying less expensive drugs from Canada. It’s a bit of a controversy because the U.S. government doesn’t like it—they say there’s no way to ensure these drugs are safe—but consumer advocates say it’s a sensible choice. If you and your parents decide to go this route, you should get your medications from a reputable Web site. Several states have developed programs for their residents in which they can buy medications from Canada, and these are quite safe. Illinois, Kansas, Missouri, Vermont, and Wisconsin If you live in Illinois, Kansas, Missouri, Vermont, or Wisconsin, you can participate in I-SaveRx, an easy-to-use mail-order pharmacy program that can save you money. The program was developed by the governors of these states to provide mail-order access to lower-cost brand prescription drugs from Canada, the United Kingdom, and Ireland. For more information, visit the site at http://www.i-saverx. net. Minnesota The governor of Minnesota has set up a Web site to help residents of that state find less expensive drugs abroad. This Web site allows you to buy drugs from Canada and the United Kingdom at more affordable prices. For more information, contact Minnesota RXConnect online: http://www.state.mn.us/portal/mn/jsp/home. do?agency=Rx. New Hampshire The state of New Hampshire lists a number of helpful sites on their official Web site, at http://www.egov.nh.gov/medicine%2Dcabinet, and offers a link to CanadaDrugs.com. North Dakota This state’s Web page on Canadian drugs offers detailed explanations and links to Web sites to help you import medications. For more information, visit http://www.governor.state.nd.us/prescriptiondrug.html.

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WHAT YOU NEED TO KNOW M You must be examined and treated at an emergency room if you’re having an asthma attack, even if you can’t pay or don’t have insurance. M A number of companies offer free or reduced-priced medications if you don’t have health insurance or you meet income limits. M Certain states offer Web sites explaining how to obtain medications at lower prices from Canada.

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APPENDIX 1 Associations and Resources AIR QUALITY Children’s Environmental Health Network http://www.cehn.org The Children’s Environmental Health Network is a national multidisciplinary organization whose mission is to protect the fetus and the child from environmental health hazards and promote a healthy environment. The Web site provides information on the network and the issue of children’s environmental health and has links to sources of information and resources in the field. Children’s Health Environmental Coalition 12300 Wilshire Boulevard, Suite 410 Los Angeles, CA 90025 (310) 820-2030 http://www.checnet.org The coalition’s mission is to inform parents about preventable health and development problems caused by exposure to toxic substances in homes, schools, and communities and to encourage the public to protect children against these toxic threats. EPA Indoor Air Quality Information Clearinghouse (800) 438-4318 http://www.epa.gov/iaq The EPA Web site is dedicated to information about indoor pollution and indoor air quality and their relationship to asthma. U.S. Environmental Protection Agency (EPA) Indoor Environments Division 401 M Street, SW (6604J) Washington, DC 20460 (202) 233-9370 http://www.epa.gov/asthma

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Government agency whose mission is to protect human health and the environment. Since 1970 EPA has been working for a cleaner, healthier environment for U.S. citizens and residents, which includes indoor environmental air and its relationship to asthma.

ALLERGY Allergy & Asthma Network Mothers of Asthmatics (AANMA) 2751 Prosperity Avenue, Suite 150 Fairfax, VA 22031 (800) 878-4403 http://www.aanma.org A national nonprofit network of families whose desire is to overcome allergies and asthma. AANMA advocates for patient access to specialty care and appropriate treatments, promotes the importance of a school nurse in every school, and supports children’s rights to carry inhalers while at school after receiving appropriate training by medical professionals. American Academy of Allergy, Asthma & Immunology (AAAAI) 611 East Wells Street Milwaukee, WI 53202 (800) 822-ASMA (414) 272-6071 http://www.aaaai.org A professional medical specialty organization representing allergists, clinical immunologists, allied health professionals, and other physicians with a special interest in allergy. It was established in 1943 and has more than 6,000 members. American College of Allergy, Asthma & Immunology (ACAAI) 85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 (800) 842-7777 http://www.acaai.org ACAAI is a professional association of 4,900 allergists and immunologists established in 1942 to improve the quality of patient care in allergy and immunology through research, advocacy, and professional and public education. The ACAAI’s goals are to maintain and advance the diagnostic and therapeutic skills of members and foster their appropriate application, sponsor educational and scientific programs and publications, and

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provide educational information for members, patients, and other physicians and health professionals. Asthma and Allergy Foundation of America (AAFA) 1233 20th Street, NW, Suite 402 Washington, DC 20036 (202) 466-7643 http://www.aafa.org A nonprofit patient organization dedicated to improving the quality of life for children with asthma and allergies and their caregivers, through education, advocacy, and research. AAFA, founded in 1953, provides practical information, communitybased services, support, and referrals through a national network of chapters and educational support groups. AAFA also sponsors research toward better treatments and a cure for asthma and allergic diseases.

ASTHMA Allergy & Asthma Network Mothers of Asthmatics (AANMA) 2751 Prosperity Avenue, Suite 150 Fairfax, VA 22031 (800) 878-4403 http://www.aanma.org A national nonprofit network founded in 1985 whose mission is to overcome allergies and asthma. AANMA produces Allergy & Asthma Today magazine, The MA Report newsletter, and e-news updates; it operates a toll-free help line and community awareness programs. Allies Against Asthma University of Michigan School of Public Health 109 South Observatory Street Ann Arbor, MI 48109-2029 (734) 647-3179 http://www.asthma.umich.edu/index.html Allies Against Asthma is an initiative funded by The Robert Wood Johnson Foundation to improve efforts to control pediatric asthma. The National Program Office, based at the School of Public Health at the University of Michigan, works with seven asthma coalitions from around the country to develop, implement, and sustain community-based comprehensive asthma management systems.

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American Academy of Allergy, Asthma & Immunology 611 East Wells Street Milwaukee, WI 53202 (800) 822-ASMA (414) 272-6071 http://www.aaaai.org A professional medical specialty organization representing allergists, clinical immunologists, allied health professionals, and other physicians with a special interest in allergy. It was established in 1943 and includes more than 6,000 members. American Association for Respiratory Care 11030 Ables Lane Dallas, TX 75229-4593 (972) 243-2272 http://www.aarc.org American College of Allergy, Asthma & Immunology 85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 (800) 842-7777 (847) 427-1200 http://www.acaai.org Association of Asthma Educators (AAE) 1215 Anthony Avenue Columbia, SC 29201-1701 (888) 988-7747 http://www.asthmaeducators.org/default.htm The primary purpose of the Association of Asthma Educators is to promote asthma education as a comprehensive program, to raise the competence of health care professionals who educate individuals and families affected by asthma, and to raise the standard of care and quality of asthma education delivered to those with asthma. AAE recognizes that asthma education should reflect the recommendations of the national guidelines. Asthma and Allergy Foundation of America (AAFA) 1233 20th Street, NW, Suite 402 Washington, DC 20036 (202) 466-7643 http://www.aafa.org

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A nonprofit patient organization dedicated to improving the quality of life for people with asthma and allergies and their caregivers, through education, advocacy, and research. AAFA, founded in 1953, provides practical information, community-based services, support, and referrals through a national network of chapters and educational support groups. AAFA also sponsors research toward better treatments and a cure for asthma and allergic diseases. Global Initiative for Asthma (GINA) http://www.ginasthma.com Works with health care professionals and public health officials around the world to reduce asthma prevalence, morbidity, and mortality. Through resources such as evidence-based guidelines for asthma management and events such as the annual celebration of World Asthma Day, GINA is working to improve the lives of people with asthma in every corner of the globe. GINA was launched in 1993 in collaboration with the National Heart, Lung, and Blood Institute and the World Health Organization. GINA’s program is determined and its guidelines for asthma care are shaped by committees made up of leading asthma experts from around the world. Healthy Kids: The Key to Basics Educational Planning for Students with Asthma and Other Chronic Health Conditions 79 Elmore Street Newton, MA 02159-1137 (617) 965-9637 National Asthma Education and Prevention Program (NAEPP) National Heart, Lung, and Blood Institute Information Center P.O. Box 30105 Bethesda, MD 20824-0105 (301) 592-8573 http://www.nhlbi.nih.gov/about/naepp NAEPP materials include Managing Asthma: A Guide for Schools, Asthma Awareness Curriculum for the Elementary Classroom, Asthma and Physical Activity in the School, and Making a Difference: Asthma Management in the School (video).

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GOVERNMENT ORGANIZATIONS Centers for Disease Control and Prevention Asthma Program 1600 Clifton Road Atlanta, GA 30333 (800) 311-3435 (404) 639-3534 http://www.cdc.gov/asthma/default.htm The mission of the CDC is to promote health and quality of life by preventing and controlling disease, injury, and disability. This CDC Web site offers a wide array of helpful fact sheets, newsletters, and information about asthma and air pollution. It also offers the National Asthma Control Program. National Center for Complementary and Alternative Medicine NCCAM Clearinghouse P.O. Box 7923 Gaithersburg, MD 20898 (888) 644-6226 (866) 464-3615 (TTY) http://www.nccam.nih.gov One of the 27 institutes and centers that make up the National Institutes of Health (NIH), whose mission is to support rigorous research on complementary and alternative medicine (CAM), to train researchers in CAM, and to provide information about which CAM modalities work, which do not, and why. Information specialists at the NCCAM Clearinghouse can answer questions about the center and about complementary and alternative medicine. National Heart, Lung, and Blood Institute (NHLBI) NHLBI Health Information Center P.O. Box 30105 Bethesda, MD 20824-0105 (301) 592 8573 (240) 629 3255 (TTY) http://www.nhlbi.nih.gov NHLBI provides leadership for a national program in diseases of the heart, blood vessels, lungs, and blood; blood resources; and sleep disorders. Since October 1997 NHLBI has also had administrative responsibility for the NIH Woman’s Health Initiative.

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National Institute of Allergy and Infectious Diseases National Institutes of Health Building 31, Room 7A32 9000 Rockville Pike Bethesda, MD 20892 (301) 496-5717 Federal institute that supports research into and information about allergies and infectious diseases. National Institute of Child Health and Human Development Building 31, Room 2A32 9000 Rockville Pike Bethesda, MD 20892-2425 (301) 496-5133 http://www.nichd.nih.gov Institute that supports research into children’s health and offers information on a wide variety of topics relevant to children’s and maternal health. U.S. Food and Drug Administration (FDA) 5600 Fishers Lane Rockville, MD 20857 (301) 472-4750 http://www.fda.gov The FDA regulates drugs and medical devices to ensure that they are safe and effective. This government agency provides a number of publications for consumers.

HEALTH SERVICES HRSA Information Center Parklawn Building 5600 Fishers Lane Rockville, MD 20857 (888) 275-4772 http://www.ask.hrsa.gov Federal agency that provides publications and resources on health care services for low-income, uninsured individuals and those with special health care needs. Publications are available in Spanish, and a Spanish speaker is on staff.

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National Health Information Center (NHIC) P.O. Box 1133 Washington, DC 20013-1133 (800) 336-4797 (301) 565-4167 http://www.health.gov/nhic A federal health information referral service that puts health professionals and consumers who have health questions in touch with organizations that are best able to provide answers. NHIC was established in 1979 by the Office of Disease Prevention and Health Promotion (ODPHP), Office of Public Health and Science, Office of the Secretary, U.S. Department of Health and Human Services.

RESPIRATORY DISEASE American Lung Association (ALA) 1740 Broadway New York, NY 10019 (800) LUNG-USA or 586-4872 http://www.lungusa.org The oldest voluntary health organization in the United States, which was founded in 1904 to fight tuberculosis. Today ALA fights lung disease in all its forms, with special emphasis on asthma, tobacco control, and environmental health.

SCHOOL-BASED ASTHMA CONCERNS Asthma and Schools http://www.asthmaandschools.org Asthma and Schools consolidates information about asthma-related resources for school personnel working with grades K–12. The searchable database links to educational materials, medical information, Web sites, and other resources useful for anyone who works in a school serving children and youths. This site is funded by the Centers for Disease Control and is made possible by the National Education Association Health Information Network. Healthy Kids: The Key to Basics Educational Planning for Students with Asthma and Other Chronic Health Conditions 79 Elmore Street Newton, MA 02159-1137 (617) 965-9637

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http://www.healthy-kids.info/index.lasso Web site run by Ellie Goldberg, an educational consultant, advocate, author, speaker, workshop leader, and educational rights specialist devoted to promoting children’s environmental health. National Association of School Nurses (NASN) 111 Cantril Street Castle Rock, CO 80104 (303) 663-0403 http://www.nasn.org The National Association of School Nurses serves more than 12,000 members nationwide and abroad. NASN’s core purpose is to advance the delivery of professional school health services to promote optimal health and learning in students. National Education Association Health Information Network 1201 16th Street, NW, Suite 521 Washington, DC 20036 (202) 822-7570 http://www.nea.org The nation’s largest professional employee organization committed to public education, from preschool to university graduate programs. U.S. Department of Education Office for Civil Rights, Customer Service Team Mary E. Switzer Building 330 C Street, SW Washington, DC 20202-1328 (800) 421-3481 (202) 205-5413 http://www.ed.gov/about/offices/list/ocr/index.html?src=mr The mission of the Office for Civil Rights (OCR) is to ensure equal access to education and to promote educational excellence throughout the nation through vigorous enforcement of civil rights. The office serves students facing discrimination and the advocates and institutions promoting solutions to civil rights problems. An important responsibility is resolving complaints about discrimination. OCR also provides technical assistance to help institutions comply with the civil rights laws that OCR enforces. An important part of OCR’s technical assistance is its partnerships designed to develop creative approaches to preventing and addressing discrimination.

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APPENDIX 2 Famous People with Asthma ACTORS AND DIRECTORS Jason Alexander (1959– ) American actor who worked for the hit series Seinfeld, along with other plays, movies, and TV commercials, despite struggling with asthma. Steve Allen (1921–2000) American comedian and actor who enjoyed enormous success despite lifelong asthma; he wrote 7,000 songs, published 49 books, and recorded 52 music albums. He won a Grammy Award in 1963 and was inducted into the TV Hall of Fame in 1986. Dani (1997– ) Sesame Street Muppet specially created for the “Sesame Street A is for Asthma” Childhood Asthma Awareness Project. Morgan Fairchild (1950– ) American actress who suffered from asthma in childhood and found success acting in television movies, miniseries, and prime-time series such as Falcon Crest and Dallas. Moses Gunn (1929–1993) American actor nominated for a Tony and an Emmy for his work on stage and television, in addition to awards for his Off-Broadway theater performances. During his final years, he required annual hospitalizations for asthma and died of complications of the disease. Helen Hayes (1900–1993) American actress and author, often called the first lady of American theater, who was often sent to the hospital because of asthma attacks triggered by backstage dust. When asthma ended her theatrical career, Hayes wrote books and raised funds for organizations that fight asthma. Bob Hope (1903–2003) American comedian and actor who was born near London and grew up in Cleveland, Ohio. One of the most popular comedians on radio, on TV, and in the movies, despite his

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asthma Hope made more than 40 trips abroad to entertain U.S. troops throughout four wars and received distinguished service awards from every branch of the armed services. Diane Keaton (1946– ) American actress and director who also suffers from adult-onset asthma. She got her start in the Broadway production of Hair and was nominated for a Tony for her performance in Play It Again, Sam, opposite Woody Allen on Broadway. She subsequently starred in a number of popular films, including Lovers and Other Strangers, The Godfather, Love and Death, Manhattan, Annie Hall, Sleeper, Interiors, The Godfather Part II, Reds, Crimes of the Heart, Radio Days, Looking for Mr. Goodbar, and Something’s Gotta Give. Lindsay Lohan (1986– ) Actress and singer who was hospitalized in Florida in 2005 with a severe asthma attack, one of the first severe flares since childhood. Lohan nevertheless has enjoyed a successful acting and singing career, starring in films including Mean Girls, Confessions of a Teenage Drama Queen, Parent Trap, Herbie Fully Loaded, and Freaky Friday. Liza Minnelli (1946– ) American actress and singer born into a famous Hollywood family. Despite having asthma, she has earned three Tony awards, an Academy Award, and an Emmy for performances on stage, in film, and on television. Jim Nabors (1930– ) American entertainer with a rich classical baritone who combines the charm of a country gentleman with the ingenuousness of a country cousin. Suffering from asthma since childhood, he moved west for his health, ending up in Los Angeles. Eventually, he worked as a regular for the Andy Griffith Show and later was the star of his own show, Gomer Pyle USMC. Christopher Reeve (1952–2004) Reeve, an American actor best known for his 1978 role as Superman, is a hero by any definition. Before his near-death accident in 1995, he volunteered for a number of humanitarian and environmentalist causes. An asthma sufferer himself, Reeve also volunteered for the Asthma Foundation. Martin Scorsese (1942– ) American film director who dropped out of seminary school to study film. As a child with asthma, he watched movies on television and became an insatiable fan. Scorsese has received the American Film Institute’s Life Achievement Award and an Academy Award.

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Paul Sorvino (1930– ) American actor and opera tenor whose career early on was threatened when asthma interfered with his ability to talk and sing. However, the breathing exercises he learned years ago have helped him breathe normally ever since. Elizabeth Taylor (1932– ) British-born actress who first worked in films at age 10, going on to star in films for more than 30 years. Despite her asthma, she earned two Oscars for best actress and the Jean Hersholt Humanitarian Award for her work in support of AIDS research. Orson Welles (1915–1985) One of the greatest directors of film and the theater and a fine actor, screenwriter, broadcaster, and producer, despite suffering from asthma. Two of his films, Citizen Kane and Touch of Evil, are considered by critics to be among the finest films ever made. Welles, who was rejected by the army because of chronic asthma, made pioneering, influential films that were imaginative, ambitious, and technically daring.

ATHLETES Bruce Davidson (1949– ) American equestrian champion who manages his allergic asthma with medications so he can compete in equestrian events. Despite his chronic condition, he has won a silver and a gold Olympic medal, seven American championships, and two world championships. Tom Dolan (1976– ) American swimming champion and spokesperson for the American Lung Association who, despite severe chronic exercise-induced asthma, exhaustively trains to win gold medals. He holds the world record and is reigning world and Olympic champion in the individual medley (the first American to win the event since 1976). Kurt Grote (1973– ) American swimming champion who started swimming at age 15 as a way of easing chronic asthma. Now a medical student, he won an Olympic gold in 1996 in the breast stroke. Nancy Hogshead (1962– ) American swimming champion and spokesperson for asthma organizations who, despite breathing difficulties, won three gold medals and one silver in the 1984 Olympics. It was not until a bronchial spasm kept her from winning medal number five that a physician diagnosed her problem as asthma. Jim “Catfish” Hunter (1946– ) American professional baseball player who was born the son of North Carolina sharecroppers and

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who, despite having asthma, in 1968 pitched the American League’s first perfect game since 1922. He received the Cy Young Award for best pitcher in his league in 1974 and was elected to the Baseball Hall of Fame in 1987. Jackie Joyner-Kersee (1962– ) American Olympic medalist in track and field who became the world’s top woman athlete in the heptathlon and long jump competitions despite severe asthma. She retired from track competition after the 1996 Olympic Games. Bill Koch (1956– ) The only American to ever win an Olympic medal in cross-country skiing; he manages his asthma with medications. Greg Louganis (1960– ) U.S. Olympic medalist in diving who outgrew his childhood asthma and won an Olympic silver medal while still in high school. At his retirement from competition in 1988, he had earned four gold medals and three world championships. Debbie Meyer (1952– ) American swimming champion who, at age 16, was the first swimmer to win three gold medals in one Olympic Games. Despite suffering from asthma since childhood, she broke 20 world records and was inducted into the Olympic Hall of Fame. Art Monk (1958– ) NFL leading receiver for the Washington Redskins until 1995; during his career he set a variety of National Football League records. He was the first player to catch more than 900 passes, the first to catch 106 passes in a single season, and the first with at least one catch in 178 consecutive games. Dennis Rodman (1961– ) An American professional basketball player who also has asthma, Rodman is one of the great rebounders of all time and a formidable defensive player. Amy Van Dyken (1973– ) U.S. Olympic gold medalist in swimming who got her start in the sport when her doctor suggested she start swimming to ease her severe asthma. Diligent training and asthma medications helped her become the first American woman to win four gold medals in one Olympic Games.

MUSICIANS, SINGERS, COMPOSERS, DANCERS Ludwig von Beethoven (1770–1827) German composer. Tormented by chronic asthma and other debilitating diseases, Ludwig von

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Beethoven composed unforgettable music while railing against “bumbling doctors”—the best physicians in Vienna—who were unable to give him relief from asthma. Leonard Bernstein (1918–1990) American conductor, composer. As a sickly infant, Leonard Bernstein sometimes turned blue from asthma. He became a prodigious pianist, conductor, composer, and lecturer, although he suffered from asthma throughout his life. Audiences often heard him wheezing above the orchestra. Judy Collins (1939– ) American folk singer who was a child prodigy in classical piano, turning to folk music during high school in Denver. This asthma patient is best known for composing and performing social protest songs during the 1960s. Alice Cooper (1948– ) American rock singer whose family moved from Detroit to Phoenix when he was three years old in hopes of easing his asthma. He organized the Alice Cooper hard rock band and recorded 20 solo albums. Kenny G (1956– ) American sax player and musician whose asthma did not stop him from winning a Grammy award, selling millions of records, and playing a duet with President Bill Clinton. Billy Joel (1949– ) American singer who has sold more than 100 million records over the past quarter century, despite his struggles with asthma. Billy Joel ranks as one of most popular recording artists and respected entertainers in the world, with 33 Top 40 hits and 23 Grammy nominations since signing his first solo recording contract in 1972. In 1990 he won the Grammy Legend Award, he was inducted into the Songwriters Hall of Fame in 1992, and in 1999 he was inducted into the Rock & Roll Hall of Fame. His hits include “Uptown Girl,” “We Didn’t Start the Fire,” and “River of Dreams.” In 1998 he was forced to pull out of a tour with Elton John after what was described as a severe asthma attack. Robert Joffrey (1928–1988) American dancer, choreographer, producer, and teacher who began dancing at age six as a way of controlling his asthma. Founder of the Joffrey Ballet, a worldrenowned modern dance company, Joffrey battled lifelong asthma with acupuncture, herbs, and medications but rarely missed a performance.

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Wynonna Judd (1964– ) American singer diagnosed with asthma at age 12; by the time she signed with RCA Records at age 18, she’d been in and out of hospitals several times with asthma flares. Despite asthma symptoms, she kept performing by taking a dose from her inhaler between songs onstage, but it wasn’t until her son developed asthma that Wynonna found the discipline to get her own asthma under control. Today she is one of the most popular country singers in the world. Alyce King (1915–1996) American singer best known as one of the four King Sisters, who performed for 60 years with members of her musically gifted family. Asthma plagued her as a child and caused life-threatening attacks in her 60s and 70s. Antonio Vivaldi (1678–1741) Italian priest, composer, and conductor turned away by his church for neglecting his religious commitments because of his preoccupation with both his music and his disabling asthma. His lifelong struggle with asthma did not stop him from producing an astonishing body of music.

POLITICIANS Calvin Coolidge (1872–1933) The 30th president of the United States distrusted physicians, so he treated his asthma with patent medicines and by breathing chlorine released into the air of a closed room. None of these methods worked. Benjamin Disraeli (1804–1881) British statesman and author who struggled with disabling asthma. Queen Victoria’s physician prescribed mustard poultices and a change of scene, while other physicians recommended a popular new remedy called arsenic. Unfortunately, none of these treatments were successful. Che Guevara (1928–1967) Argentinean physician, Marxist revolutionary leader, and Cuban guerrilla who at age two developed asthma, which dogged him all his life. His condition was so severe that his family moved to the drier climate of Alta Gracia (Cordoba), but his health did not improve. He became interested in medicine because of his fight with asthma, and he was rejected from the Argentine army because of the disease. With his dashing romantic style and his dedication to violent, flamboyant action, Che became a legend and an idol for discontented and revolutionary youth of the 1960s and early 1970s.

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Rev. Jesse Jackson (1941– ) American political leader, Baptist minister, and civil rights activist who also struggles with asthma. He was the most successful African-American presidential candidate in U.S. history, receiving over 3 million votes in the 1984 election. John F. Kennedy (1928–1963) The 35th president, whose asthma was caused by allergies to dogs, horses, and dust, was the youngest man ever elected to the presidency and the youngest man to ever die as president. Steroids prescribed to treat his Addison’s disease probably also helped control his asthma. John Locke (1632–1704) British politician and philosopher who loved London, the seat of English government. Unfortunately, persistent asthma forced him to live in the country, away from the city’s polluted air and political life. Walter Mondale (1928– ) The 42nd vice president of the United States under President Jimmy Carter, Mondale was the first presidential candidate to choose a woman for a running mate, but they lost the election in 1984. Ernest (Dutch) Morial (1929–1989) African-American political, legal, and civil rights leader and twice mayor of his native New Orleans, who broke the color barrier throughout his municipal and national career. Twenty-five years of asthma led to his unexpected death at age 60. Peter the Great (1672–1725) This Russian czar was an ambitious ruler with an insatiable drive to reform Russia. Peter the Great seemed to ignore his many health problems, but during the last 10 years of his life, severe asthma and other diseases seriously affected his ability to function. Theodore Roosevelt (1858–1919) Twenty-sixth president of the United States whose severe asthma plagued him since infancy. His parents tried all available remedies and traveled worldwide to find him a healthier climate, but it was only when he discovered vigorous exercise that he became a healthy, productive adult. William Tecumseh Sherman (1820–1891) Civil War Union general who unsuccessfully battled asthma all his life. Even as he destroyed his way through Georgia, it was the south’s temperate climate that finally eased his symptoms.

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Martin Van Buren (1782–1862) Eighth president of the United States whose physician diagnosed his coughing spells and labored breathing as “malignant catarrh.” Today experts are not sure whether he had other lung problems or asthma. Daniel Webster (1782–1852) American lawyer and statesman who refused to take the then-popular asthmatic treatment, opium, in favor of rest and herbal teas. William III (1650–1702) Prince of Orange and king of England, Scotland, and Ireland, his chronic asthma worsened by London’s filthy air improved only during the time he experienced a running sore from a cannonball injury. Doctors mistakenly believed that this coincidence heralded a new cure for asthma. Woodrow Wilson (1856–1924) The 28th president of the United States was virtually incapacitated by severe asthma, long days at the Versailles Peace Conference, and arteriosclerosis. Despite all this, his poor health was kept secret from the American public.

SCIENTISTS John Arbuthnot (1667–1735) British physician, writer, and scholar who served as physician extraordinary to England’s Queen Anne. Arbuthnot developed asthma in his early 60s, which he blamed on the unhealthy London air, overheated rooms, rainy weather, and “viscid blood.” Baruj Benacerraf (1920– ) 1980 Nobel Prize winner for his discovery of the genetic basis of autoimmune diseases. His childhood experiences with asthma triggered a fascination with immunology, which he explores today at Boston’s famed Dana-Farber Institute. Maclyn McCarty (1911–2005) American biologist who in 1944 helped make the landmark discovery of deoxyribonucleic acid (DNA). His allergies to lab rabbits and his daughter’s cat triggered asthma early in his career, which dogged him until his death of congestive heart failure in early 2005. Armand Trousseau (1801–1867) French physician who believed, as did other 19th-century scientists, that his asthma was aggravated by emotions and could be relieved by taking tobacco and arsenic.

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WRITERS, THINKERS Henry Ward Beecher (1813–1887) American clergyman, reformer, journalist, and orator who, along with other “fugitives from hay fever,” escaped seasonal asthma by traveling to New Hampshire’s White Mountains. He credited his triumph over the disease to this change of climate. Ambrose Bierce (1842–1914) American journalist, essayist, and author who was afflicted with asthma for 50 years. Bierce used chloroform to help his breathing and lived on the top of a mountain because he thought it helped him breathe more easily. Despite his distress, Bierce produced many volumes of stories and essays. Elizabeth Bishop (1911–1979) This American poet, teacher, and author won almost every important literary prize of her day. She struggled with asthma throughout her life, turning to injections of adrenaline, calcium, antihistamines, transfusions, electroshock, cortisone, and alcohol—none of which helped. Charles Dickens (1812–1870) To ease his “chest troubles,” this British author turned to opium, which was a popular asthma remedy during his lifetime. Dickens created Mr. Omer, an asthmatic character in the autobiographical novel David Copperfield, to mirror Dickens’s suffering. John Hamilton (1511–1571) Scottish archbishop whose nocturnal asthma improved after Europe’s leading physician suggested that he substitute silk for feather stuffing in his pillow, mattress, and blanket. This is one of the earliest examples of the identification of an allergen. Oliver Wendell Holmes (1809–1894) American poet, physician, inventor, teacher, artist, and essayist, whose lifelong asthma restricted his ability to move around. Despite his chronic breathing problem, Oliver Wendell Holmes practiced and taught medicine, sketched, and wrote memorable poems, essays, novels, and medical treatises. He also invented the stereoscope, creating a three-dimensional effect in photographs. Pliny (Gaius Plinius Secundis) the Elder (23–79) This Roman historian, scholar, and writer penned many historical and scientific works, including a comprehensive 37-volume encyclopedia of the natural sciences. Plagued by chronic asthma, he suffocated from the fumes of erupting Mt. Vesuvius.

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Marcel Proust (1871–1922) French novelist who drank caffeine, injected adrenaline, inhaled stramonium, smoked tobacco and marijuana, and used narcotics in fruitless attempts to ease his asthma. Proust spent his last 12 years in bed, writing In Search of Lost Time, his greatest work. Joseph Pulitzer (1847–1911) Publisher and philanthropist who sought help in vain to cure his asthma by consulting physicians around the world. After 43 years of breathing problems, he died on the yacht whose breezes often eased his breathing. Lucius Annaeus Seneca (4 BCE–79 CE) Roman orator, author, and statesman who wrote that nothing was as troublesome to him as his asthma. Yet hampered as he was by breathing problems, he nevertheless became a powerful Roman leader, a wealthy merchant, and prolific author. Barbara Smith (1946– ) American writer, critic, lecturer, publisher, and activist in black feminism and women’s literature who struggled with asthma throughout her 30s. Eventually, she was able to control her asthma with a steroid inhaler daily. As a result, she always carried one or two inhalers on her frequent lecture tours. Dylan Thomas (1914–1953) Welsh poet and playwright whose love of language was encouraged by his mother, who read to him when he was bedridden with asthma, bronchitis, and colds. As an adult, he suffered more from alcoholism than asthma, and he died of alcohol abuse at age 39. Howard Thurman (1900–1981) African-American clergyman, educator, and author who experienced poverty and racism in the South as a child and struggled against asthma as an adult. John Updike (1932– ) American author of novels, poetry, short stories, and essays, who mistook his first asthma flare as a fatal attack in his 20s. He was later diagnosed with bronchial asthma, aggravated by cats. Edith Wharton (1862–1937) American novelist who experienced asthma flares throughout her life yet still wrote short stories, travel books, and many successful novels, including the Pulitzer Prize–winning Age of Innocence in 1921.

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APPENDIX 3 International Health Insurance Companies If you’re going to be traveling abroad and you have asthma, it’s vital that you have some type of medical insurance coverage. Most typical U.S. health insurance policies don’t automatically offer this, so your parents may need to do some checking before you leave. Here’s a list of international health insurance companies that may be able to help. Access America, Inc. P.O. Box 71533 Richmond, VA (800) 729-6021 http://www.accessamerica.com ASA, Inc. International Insurance Consultants P.O. Box 93100 Phoenix, AZ 85070-3100 (888) ASA-8288 http://www.asaincor.com Clements International (800) 872-0067 (202) 872-0060 http://www.clements.com CSA Travel Protection (888) 873-5484 http://www.csatravelprotection.com HTH Travel Insurance One Radnor Corporate Center, Suite 100 100 Matsonford Road

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Radnor, PA 19087 (888) 243-2358 (610) 254-8700 http://highwaytohealth.com International Medical Group (IMG) (800) 628-4664 (317) 655-4500 http://www.imglobal.com MEDEX 8501 LaSalle Road, Suite 200 Towson, MD 21286 (410) 453-6300 http://www.medexassist.com Multinational Underwriters 107 S. Pennsylvania Street, Suite 500 Indianapolis, IN 46204 (800) 605-2282 (317) 262-2132 http://www.mnui.com Travelex P.O. Box 641070 Omaha, NE (800) 228-9792 http://www.travelex-insurance.com/Consumer/Welcome.htmx Travel Guard 145 Clark Street Stevens Point, WI 54481 (800) 826-1300 (715) 345-0505 http://www.noelgroup.com/companies/companies.aspx Travel Insurance Services InterMedical Division 2950 Camino Diablo, Suite 300 Walnut Creek, CA 94597-3991 (800) 937-1387 http://www.travelinsure.com

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Travel Insured International 52-S Oakland Avenue P.O. Box 280568 East Hartford, CT 06128 (800) 243-3174 http://www.travelinsured.com Wallach & Company 107 West Federal Street P.O. Box 480 Middleburg, VA 20118 (800) 237-6615 http://www.wallach.com Worldwide Assistance 1825 K Street NW, Suite 1000 Washington, DC 20006 (800) 777-8710 (202) 331-1609 http://www.worldwideassistance.com/default.asp

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APPENDIX 4 Asthma Camps Most of the camps listed below are part of a network of 99 American Lung Association (ALA) asthma camps spread across the country. Each camp differs in the details of its program, but the goal is the same—allowing children with asthma to enjoy a camping experience while being monitored by medical personnel and learning asthma management skills. At these unique camps, asthma specialists join kids and their families in developing effective asthma management techniques geared toward individuals and their specific situations. Children participate in a variety of settings—day camps, weeklong outdoor camps, and school-based programs—and gain methods for living with asthma that work best for them.

ALABAMA Camp WheezeAway ALA of Alabama 3125 Independence Drive, Suite 325 Birmingham, AL 35209-4177 (800) LUN-GUSA [email protected] http://www.alabamalung.org Camp WheezeAway is a five-day overnight camp for kids ages eight to 12 with moderate to severe asthma, held at Camp ASCCA in Jackson’s Gap. Children sleep in air-conditioned cabins and are supervised 24 hours by trained counselors. A 24-hour medical staff gives children medications as directed by their physicians. Children are monitored while enjoying all the normal camp activities, including ropes courses, canoeing, swimming, arts and crafts, horseback riding, fishing, and tubing; above all they learn to manage their asthma.

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Young Teen Asthma Camp Camp Winnataska 1524 Shades Crest Road Birmingham, AL 35226-3243 (205) 934-6799 [email protected] http://www.winnataska.org The Young Teen Asthma Camp is a residential camp held at Camp Winnataska near Birmingham. The activities for teens ages 12 to 15 include swimming, crafts, hiking, games, canoeing, and horseback riding. At the same time, campers experience asthma education through Power Breathing for Teens presented by nurse practitioners. Findings from the camp show increased responsibility, self-care, and resilience in participants. Camperships are available.

ALASKA Champ Camp ALA of Alaska 500 West International Airport Road, Suite A Anchorage, AK 99518-1175 (907) 644-6417 [email protected] http://www.aklung.org Champ Camp is a weeklong summer recreation and asthma education program at Camp Kushtaka on the shores of Kenai Lake. Campers explore their skills in outdoor activities including canoeing, hiking, swimming, archery, and arts and crafts as they experience a boost in self-confidence and a sense of responsibility. The camp teaches preventive measures to improve asthma management and avoid asthmatic episodes, thereby increasing a campers’ sense of independence.

ARIZONA Camp Not-A-Wheeze ALA of Arizona 102 West McDowell Road Phoenix, AZ 85003-1213 (602) 258-7505 [email protected] http://www.lungusa.org

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A week at Camp Not-A-Wheeze is a positive, powerful experience that can change the way a child deals with asthma. At Camp Not-AWheeze, no one feels different or left out because of disease. The only camp of its kind in Arizona, it is designed especially for kids aged seven to 14 with moderate to severe asthma. In a safe and medically monitored environment, the campers learn how to manage their asthma better. Their self-esteem increases as they participate in activities along with peers who know what it’s like to have an asthma episode. Best of all, a recent study has shown that programs like Camp Not-A-Wheeze can decrease the hospital stays and school absenteeism rates typically associated with childhood asthma.

ARKANSAS American Lung Association Asthma Camp ALA of Arkansas 211 Natural Resources Drive Little Rock, AR 72205-1539 (501) 224-5864 [email protected] Asthma Camp is a six-day residence camp for children ages 6 to 16 with moderate to severe asthma. The camp provides 24-hour medical supervision with allergists, pharmacists, and nurses on site and respiratory therapists giving treatments. Asthma Camp provides 50 children from around the state the opportunity to enjoy camping experiences such as canoeing, fishing, hiking, and camping while also providing them the education they need to manage and cope with their asthma better. There is no fee to attend. Med Camps Asthma Camp Med Camps of Arkansas, Inc./Camp Aldersgate 2000 Aldersgate Road Little Rock, AR 72205-7018 (501) 225-1444 [email protected] http://www.campaldersgate.net At Camp Aldersgate, Arkansas kids with asthma can get to know the great outdoors with the latest facilities and as few barriers as possible. Hundreds of campers with asthma come each year from across Arkansas and from surrounding states. The camp includes 120 acres of wooded hills, 22 buildings, a six-acre lake, cabins, two ropes courses, a fully accessible treehouse, an archery pavilion, horseback riding, two pools, and paved trails.

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CALIFORNIA AAFA Asthma Camp Asthma & Allergy Foundation of America 5900 Wilshire Boulevard, Suite 2330 Los Angeles, CA 90036-4216 (323) 937-7859 [email protected] http://www.aafasocal.com AAFA asthma camp provides fun and adventure for children ages eight to 14 with asthma, as they also learn about their asthma and self-management skills. The camp promotes self-confidence and an understanding of ways to manage asthma through education. Doctors, nurses, and respiratory therapists volunteer their time to teach children how to manage their asthma, while they participate in outdoor activities that will not affect their breathing. Boys and girls who have been diagnosed with mild to severe asthma are eligible to attend. Swimming, climbing wall, ropes challenge activity, basketball, arts and crafts, hiking, and asthma education are offered. Camp Sierra 4948 North Arthur Avenue Fresno, CA 93705-0603 (559) 222-4800 [email protected] http://www.amerilungcencal.org Camp Sierra is a residential camp with 24-hour medical supervision for children ages 10 to 13 held at Camp Wawona, located in Yosemite National Park. Activities include crafts, campfires, hiking, fishing, horseback riding, swimming, boating, games, and more. Teen Asthma Camp, also held at Camp Wawona, is available for ages 14–17. Teen Asthma Camp offers activities including canoeing, hiking, rock wall climbing, fishing, swimming, horseback riding, ropes course, crafts, and visiting Yosemite’s valley floor. Asthma education and management is given to the campers every day. Camp SuperStuff American Lung Association of Santa Clara–San Benito 1469 Park Avenue San Jose, CA 95126-2530 (408) 998-5864 [email protected]

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http://www.lungsrus.org Camp Super Stuff is an asthma camp for children and their families that addresses asthma problems by teaching asthma self-management and offering unique opportunities for children to socialize with their peers who have the same chronic illness. Camp Super Stuff was organized with the goal of providing an entertaining and educational summer camp experience. In addition to asthma self-management, campers are provided with opportunities for trying new activities at their own, often reduced level of participation. Camp fellowships and informal social interactions in a variety of settings (sports, picnicking, nature study, hiking, boating, fishing, swimming, crafting, and so on) round out the program. Family Asthma Camp ALA of California 4948 North Arthur Avenue Fresno, CA 93705-0603 (559) 222-4800 [email protected] http://www.amerilungcencal.org If anyone in the family suffers from asthma, the whole family can attend this camp, where family members receive age-appropriate asthma education. SCAMP Camp ALA of Orange County 1570 East 17th Street, Suite F Santa Ana, CA 92705-8511 (714) 835-5864, ext. 105 [email protected] http://www.oclung.org The Southern California Asthma Medical Program (SCAMP) is a weeklong, overnight camp for children between the ages of eight to 14 with asthma. SCAMP Camp has been providing underserved asthmatic children with a unique, educational, and rewarding summer camp experience for more than 30 years. Kids learn how to manage their asthma better and enjoy traditional camp activities such as swimming, mountain biking, and hiking. With thousands of pine trees, rolling hills, nature trails, and a small lake, YMCA Camp Marston is the perfect setting. “Scampers” enjoy swimming, canoeing, wall climbing, archery, soccer, campfire singing, and much more. Scampers also are involved

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in a variety of activities that will teach them to manage their asthma effectively, such as recognizing asthma, identifying triggers, preventing episodes, and communicating about asthma to others. Education is given on a daily basis and coordinated by trained medical volunteers. Physicians specializing in allergy/ pulmonary medicine, registered nurses, respiratory therapists, and other health professionals are available 24 hours a day to provide routine and emergency treatment. Medications are administered on a regular schedule, and arrangements are made for those with dietary restrictions.

COLORADO Champ Camp ALA of Colorado 5600 Greenwood Plaza Boulevard, Suite 100 Greenwood Village, CO 80111-2305 (303) 388-4327 [email protected] http://www.alacolo.org/champcamp.cfm Created by the American Lung Association of Colorado (ALAC) in 1979, Champ Camp is the state’s only residential summer camp for children with asthma. Children ages seven to 14 who can’t go to traditional camps because of their asthma can share their fears and experiences, learn asthma management, and participate in fun activities in a supportive setting. All Champ Camp activities are provided under the supervision of trained medical experts. More than 100 of these volunteers spend an entire week helping Champ Campers learn to manage their asthma while having fun in the great outdoors. Campers have the opportunity to participate in activities such as archery, canoeing, hiking, biking, mountain climbing, fitness challenges, outdoor education, swimming, crafts, and more.

FLORIDA AAFAbulous Camp Asthma and Allergy Foundation of America, Florida 5421 Beaumont Center Boulevard, Suite 620 Tampa, FL 33634-5200 (813) 885-4484 [email protected] http://www.aafaflorida.org

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AAFA’s Florida chapter holds a one-week residential camp for underprivileged children ages eight to 12 with asthma. AAFAbulous Camp is free, and children are medically supervised while enjoying camping activities at Rotary’s Camp Florida in Brandon. Asthma Summer Camp ALA of Florida 5526 Arlington Road Jacksonville, FL 32211-5216 (239) 275-7577 [email protected] http://www.Lungfla.org This weeklong sleepover camping experience at the Boggy Creek Gang Camp offers all of the traditional camp activities along with the medical facilities and support to make it a safe and educational environment for kids with asthma. This unique camping experience is for children between the ages of seven and 16. Soaring Eagle Camp ALAF-Southeast Area 2701 North Australian Avenue West Palm Beach, FL 33407-4526 (561) 659-7644 [email protected] http://www.inhaleexhale.org The only five-day camp for children aged seven to 12 with mild to moderate asthma in the state. The program includes traditional camp activities, arts and crafts, music, team sports, swimming, computer, raising butterflies, and field trips. In addition to trained camp counselors, the camp has a volunteer medical staff including local doctors, respiratory therapists, and nurses, as well as adult activities pals. Soaring Eagle offers more than 60 children with mild to intermittent asthma a unique, medically supervised environment. The camp also provides daily asthma management education to the parents and caregivers of the kids who attend. The camp is located on the grounds of the Benjamin School in North Palm Beach.

GEORGIA Camp Breathe Easy ALA of Georgia 2452 Spring Road SE Smyrna, GA 30080-3828

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(770) 434-5864, ext. 224 [email protected] http://www.alaga.org Camp Breathe Easy is a seven-day, six-night overnight camp at beautiful Camp Twin Lakes in Rutledge, Georgia (about an hour east of Atlanta). The camp is designed for children aged seven to 13 with asthma who need medication and are limited in summer camping opportunities. The campers learn asthma self-management techniques and coping strategies to handle their illness better. Children receive a traditional summer camp experience under the watchful eye of medical professionals who volunteer their time to the program. Campers swim; rappel off trees; fish; canoe in the lake; play soccer, basketball, and miniature golf; and participate in ceramics and arts and crafts. The camp is operated by the American Lung Association of Georgia and is one of the largest asthma camps in the United States, serving up to 200 kids. Champ Camp ALA of Georgia 2050 Walton Way, Suite 208 Augusta, GA 30904-4163 (706) 738-6435 Champ Camp is a five-day summer camp for kids ages six to 12 who have been diagnosed with asthma and require daily medication. The goal of the camp is to promote self-confidence and responsibility in campers while helping them learn to manage their own asthma. Additionally, Champ Camp stresses to campers that despite their asthma, they can function as well as other children. Champ Camp specializes in caring for children suffering from respiratory disease and emphasizes the importance of a normal lifestyle. Campers are encouraged to explore a variety of interests, including swimming, sports, nature, and arts and crafts. The Nancy J. Knight Camp Catch-A-Breath ALA of Georgia 1104b West 3rd Avenue Albany, GA 31707-3641 (229) 435-3626 The camp includes a week full of activities designed to educate children with asthma about their disease, while providing recreation suited to their special needs.

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HAWAII Asthma Sports Day Camp ALA of Hawaii—Kauai 2992 Umi Street Lihue, HI 96766-1344 (808) 245-4142 [email protected] http://www.ala-hawaii.org This camp is open to kids ages five to 12 with mild to severe asthma, who participate in outdoor recreational activities, sports clinics, and crafts in a camplike atmosphere. Children will improve their asthma management skills and their self-image as they make friends in a supportive and medically supervised environment.

Asthma Sports Day Camp ALA of Hawaii—Maui 95 Mahalani Street Wailuku, HI 96793-2521 (808) 244-5110 http://www.ala-hawaii.org This camp is open to kids ages five to 12 with mild to severe asthma, who participate in three days of outdoor recreational activities, sports clinics, and crafts in a camplike atmosphere. Children will improve their asthma management skills and their self-image as they make friends in a supportive and medically supervised environment.

Asthma Sports Day Camp ALA of Hawaii—Oahu 680 Iwilea Road, Suite 575 Honolulu, HI 96817-3921 (808) 537-5966, ext. 307 http://www.ala-hawaii.org/asthmasportsdaycamp.asp This camp is open to kids ages five to 12 with mild to severe asthma, who participate in three days of outdoor recreational activities, sports clinics, and crafts in a camplike atmosphere. Children will improve their asthma management skills and their self-image as they make friends in a supportive and medically supervised environment.

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IDAHO Camp Super Breathers American Lung Association of Idaho 1111 South Orchard, Suite 245 Boise, ID 83705 [email protected] http://www.lungs.org Camp Super Breathers is a five-day camping program north of Fairfield, Idaho, for children with asthma, ages nine to 13, who otherwise might never have a chance to enjoy the camping experience. Kids participate in day hikes, water sports, campfires, games, crafts, skits, and more. Medical supervision and health care is provided to ensure a safe, healthy, and happy camping experience for each child. The mission of Camp Super Breathers is to promote optimal health and wellness for children with asthma in a camp setting and to teach asthma management skills for life.

ILLINOIS Camp Maywood ALA of Metropolitan Chicago 1440 W. Washington Boulevard Chicago, IL 60607-1821 (312) 432-2000 [email protected] Maywood day camp is a five-day camp for six- to 12-year-olds who live or go to school or church in Maywood and have asthma. Located at Maywood Parks & Recreation, the camp is run by a community-based campaign including the American Lung Association, Loyola University Medical Center, and the Village of Maywood. Qualified applicants enjoy field trips and supervised play while receiving education on how to manage their asthma. Camp SuperKids ALA of Illinois–Iowa 3000 Kelly Lane Springfield, IL 62711-6226 (800) LUN-GUSA [email protected] http://www.lungilia.org Camp SuperKids has given children ages eight to 12 who have asthma an opportunity to have the same summer experience as their nonasthmatic peers. The Illinois camp is open to any

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child who has moderate to severe asthma from anywhere in the state, except Cook County, which has its own camp. Children are accepted on a first-come, first-served basis.

INDIANA Camp Superkids—Indiana American Lung Association of Indiana 3454-A Stellhorn Road Fort Wayne, IN 46815-4630 (260) 486-2001 [email protected] http://www.lungin.org Camp Superkids at Camp Crosley, YMCA, near North Webster in Kosciusko County, is open to Indiana residents seven to 14 years old with moderate to severe asthma. No child will be denied acceptance because of financial need. Scholarships are provided through contributions to the ALA of Indiana camp fund.

IOWA Camp SuperKids ALA of Iowa 5601 Douglas Avenue Des Moines, IA 50310-1800 (800) LUN-GUSA [email protected] http://www.lungilia.org At this YWCA Camp in Boone, Indiana, kids learn about their asthma, the proper techniques for taking medicine, and training on how to manage their asthma better in a summer camp setting. Children must be eight to 13 years old and on daily medication for asthma. Junior Leaders ALA of Iowa 5601 Douglas Avenue Des Moines, IA 50310-1800 (800) LUN-GUSA [email protected] http://www.lungilia.org Teens ages 14 to 16 with asthma can participate at this camp, located at YWCA at Boone, Indiana. Space is limited to 16 Junior

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Leaders (eight boys and eight girls). Junior Leaders will have a chance to participate in two overnight experiences and will learn leadership development by shadowing a camp counselor and joining a cabin with younger campers.

KENTUCKY Camp Incredikids ALA of Kentucky 4100 Churchman Avenue Louisville, KY 40215-1154 (502) 563-2652 [email protected] http://www.kylung.org The four-day camp teaches 30 youngsters how to manage asthma. Much of the asthma education taking place at the annual camp is in the form of games or crafts. The campers are carefully monitored by a staff of 20, many of whom are registered nurses, respiratory therapists, student nurses, and even teen “candy stripers” from the hospital’s volunteer roster. Camp Superkids ALA of Kentucky 4100 Churchman Avenue Louisville, KY 40215-1154 (502) 563-2652 [email protected] http://www.kylung.org Camp Superkids is an overnight camp for children ages seven to 13 who have moderate to severe asthma. It is staffed around the clock by nurses, pharmacists, physicians, and respiratory therapists; an infirmary is located on site, and additional health care facilities are within easy driving distance of Camp Piomingo, 20 miles south of Louisville. A variety of supervised activities allows campers to enjoy all the fun and challenges of a regular camp, such as swimming, arts and crafts, a challenge course with wall climbing, a ropes course, archery, hiking, and kayaking at Doe Valley Lake. Camp We No Wheeze ALA of Kentucky 4100 Churchman Avenue Louisville, KY 40215-1154

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(502) 563-2652 [email protected] http://www.kylung.org This camp offers kids aged six to 12 a chance to have fun and make new friends while gaining self-confidence and learning how to take control of their asthma. Camp Wheeze Be Gone ALA of Kentucky 4100 Churchman Avenue Louisville, KY 40215-1154 (502) 563-2652 [email protected] http://www.kylung.org This camp offers kids aged six to 12 a chance to have fun and make new friends while gaining self-confidence and learning how to take control of their asthma. Camp Wonderkids ALA of Kentucky 4100 Churchman Avenue Louisville, KY 40215-1154 (502) 563-2652 [email protected] http://www.kylung.org Camp Wonderkids is a weeklong day camp at Madisonville City Park for children with asthma. There are a variety of activities, including swimming, tennis, soccer, hiking, and arts and crafts, as well as asthma education.

LOUISIANA Camp Pelican Louisiana Pulmonary Disease Camp/La Lions Camp P.O. Box 333 Kenner, LA 70063-0333 (504) 466-7124 [email protected] http://www.camppelican.org Camp Pelican at the Louisiana Lions Camp is an overnight residential camp for children with moderate to severe asthma or other pulmonary problems. Founded in 1977, Camp Pelican is jointly sponsored by the Louisiana Pulmonary Disease Camp, Inc., and the

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Louisiana Lions Camp. More than 100 kids attend annually and participate in education, sports, arts and crafts, swimming, and other camping activities. Medical staff including physicians, nurses, respiratory therapists, and social workers participate in the camp.

MAINE AH! Asthma Camp MaineHealth 465 Congress Street, Suite 600 Portland, ME 04101-3528 (207) 541-7515 [email protected] AH! Asthma camp is a one-week overnight camp at the state YMCA camp in Winthrop Maine. Children participate in canoeing, swimming, arts and crafts, and other activities alongside other campers. Asthma Camp is a great way for kids to have fun while learning more about their asthma and how to keep it under control. Doctors, nurses, and respiratory therapists provide medical care around the clock to AH! Campers. Space is limited to 32 children between the ages of eight and 13.

MARYLAND Camp Superkids ALA of Maryland 11350 McCormick Road, Executive Plaza 1, Suite 600 Hunt Valley, MD 21031 (410) 560-2120, ext. 224 [email protected] http://www.marylandlung.org This overnight asthma camp is located at Camp Friendship, for children seven-and-a-half to 12 years of age. During the week of camp, kids participate in arts and crafts, nature hikes, karate, swimming, sport activities, and much more. Along with these activities there are two sessions a day of asthma education.

MASSACHUSETTS Camp Chest Nut American Lung Association of Massachusetts, Inc. 5 Mountain Road Burlington, MA 01803-4712

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(781) 272-2866 [email protected] http://www.lungma.org This overnight camp for children aged eight to 13 with asthma is held at the Bement Camp and Conference Center in Charlton Depot, Massachusetts.

MICHIGAN Camp Michi-MAC Asthma and Allergy Foundation of America 39136 Canterbury Drive Harrison Township, MI 48045-6017 (586) 465-0163 [email protected] http://www.aafamich.org Camp Michi-MAC is a unique camp that mainstreams children with asthma into regular camp activities with nonasthmatic campers. Kids from third through eighth grade may attend. There is a 24hour volunteer medical staff consisting of doctors, allergists and pulmonologists, nurses, respiratory therapists, and pharmacists at the camp.

MINNESOTA Camp Superkids ALA of Minnesota 490 Concordia Avenue Saint Paul, MN 55103-2412 (651) 227-8014 [email protected] http://www.alamn.org Camp Superkids at the YMCA Camp Ihduhapi in Loretto, Minnesota, celebrates 40 years of offering children a way learn about their asthma, the proper techniques for taking medicine, and training on how to better manage their asthma in a summer camp setting. Children must be eight to 13 years old and on daily medication for asthma. Junior Leaders is a program for teens 14 to 16 years old who must have attended Camp Superkids previously. Camp We-No-Wheeze North ALA of Minnesota 424 West Superior Street, Suite 203 Duluth, MN 55802-1542

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(218) 726-4721 [email protected] This three-day overnight camping experience is set at beautiful Wolf Ridge Environmental Learning Center. Campers and parents start out at the University of Minnesota (Duluth campus), and campers are bused to the location. Asthma education is integrated throughout the program. A medical team is on site 24 hours a day. Camp We-No-Wheeze South Community Memorial Hospital P.O. Box 5600 855 Mankato Avenue Winona, MN 55987-0600 (507) 457-4423 [email protected] This three-day, two-night camp incorporates fun with learning. Eagle Bluff offers classes and experience about Minnesota history (pioneer village) and nature (pond life), plus a ropes course and rock wall climbing for kids with asthma. We No Wheeze Central 1511 Northway Drive, Suite 101 Saint Cloud, MN 56303-1262 (320) 654-8266 [email protected] This camp is set at Camp Courage in Maple Lake, where children learn about their asthma, the proper techniques for taking medications, and how to manage their asthma better, all within a summer camp setting.

MISSISSIPPI Camp Breath Ezzzze North Mississippi Medical Center Respiratory Care 830 South Gloster Street Tupelo, MS 38801-4934 (662) 377-2542 [email protected] http://www.asthmacamp.net The first camp in Mississippi for kids aged six to 12 with asthma, Camp Breathe Ezzzze features fun activities, as well as educational sessions on asthma and its treatment. The camp is designed

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to boost self-esteem and nurture friendships among children with asthma. Camp Breathe Ezzzze is sponsored by the North Mississippi Medical Center with assistance from the American Lung Association of Mississippi and Project Hope. Aroundthe-clock care is provided by registered nurses and respiratory therapists. Camp Wheez-Away ALA of Mississippi P.O. Box 2178 Ridgeland, MS 39158-2178 (601) 206-5810 [email protected] Camp Wheez-Away is a summer camp for Mississippi children ages eight to 12 with asthma located at Camp Wesley Pines in Gallman, Mississippi. At Camp Wheez-Away, campers learn to manage their asthma better; enjoy great food, fun, and prizes; and participate in games and activities supervised by qualified medical volunteers.

MISSOURI Camp Super Breathers Cass Medical Center 1800 East Mechanic Street Harrisonville, MO 64701-2017 (816) 380-5888, ext. 416 [email protected] This day camp at the Harrisonville Christian Church is for kids seven to 13 with asthma. The camp offers activities related to asthma education, including swimming, hiking, asthma olympics, an overnight shut-in, and family involvement. Camp SuperKids ALA of Missouri 1118 Hampton Avenue Saint Louis, MO 63139-3147 (314) 645-5505, ext. 1003 [email protected] The American Lung Association of Missouri in partnership with Herbert Hoover Boys & Girls Club provides kids ages six to 16 the opportunity to learn about asthma and how it affects both them and their families. Campers receive daily asthma education

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classes and carefully monitoring by health professionals while they participate in a variety of exciting activities.

MONTANA Camp Huff N Puff ALA of the Northern Rockies 825 Helena Avenue Helena, MT 59601 (406) 442-6556 [email protected] The ALA of the Northern Rockies sponsors a weeklong camp for children with asthma ages seven to 13 at Luccock Park Methodist Church camp in Livingston. The camp is attended around the clock by a physician and nurses. All camp staff are volunteers with the exception of camp counselors. Campers requiring medication receive careful attention to their medical routines, and their prescribed medicines are dispensed by nurses.

NEBRASKA Camp Superkids ALA of Nebraska 7101 Newport Avenue, Suite 303 Omaha, NE 68152-2167 (402) 572-3030 [email protected] Camp Superkids was created for children with moderate to severe asthma. Camp Superkids gives children who have asthma a chance to experience a camping setting in a medically supervised and safe environment. A week of Camp Superkids helps children learn more about themselves, others, and their condition.

NEVADA Camp Breathe Easy ALA of Nevada 6275 Neil Road, Suite 300 Reno, NV 89511-1136 (775) 829-5874 [email protected] http://www.lungs.org

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Camp Breathe Easy at Camp Concord, Lake Tahoe, includes all the fun of regular camp, swimming, hiking, canoeing, arts and crafts, and more, along with asthma education. Medical staff is available 24 hours a day. Campers may receive medications, respiratory therapy if needed, and nonallergenic diets as needed. Carson Asthma Day Camp ALA of Nevada 6275 Neil Road, Suite 300 Reno, NV 89511-1136 (775) 829-5864 http://www.lungs.org Asthma day camp provides youth ages five to 12 the opportunity to learn how to manage their asthma while having fun in a camp setting. Activities include arts, crafts, games, and more. Medical staff is available during the course of the day. Reno Asthma Day Camp ALA of Nevada 6275 Neil Road, Suite 300 Reno, NV 89511-1136 (775) 829-5864 [email protected] Asthma day camp provides youths ages five to 12 the opportunity to learn how to manage their asthma while having fun in a camp setting. Activities include arts, crafts, games, and more. Medical staff are available throughout the day. Campers can receive medication, other respiratory therapy, and nonallergenic diets. Activities include arts, crafts, games, sports and more.

NEW JERSEY Camp Superkids ALA of New Jersey 1600 Route 22 East Union, NJ 07083-3415 (908) 687-9340, ext. 21 [email protected] Now in its 24th year, Camp Superkids at the Fairview Lake YMCA Camp and Conference Center provides an exciting, one-week, educational, overnight camping experience for New Jersey children eight to 12 years of age. Activities include boating, swimming,

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nature trails, archery, land sports, climbing tower, arts and crafts, and asthma education classes.

NEW YORK Camp Superkids ALA of New York Syracuse, NY 13202-1918 [email protected] (212) 889-3370 Camp Superkids is a residential summer camp for children ages eight to 12 with moderate to severe asthma. Camp Superkids provides a one-week camping experience that includes swimming, hiking, canoeing, arts and crafts, boating, and special events. Sprinkled throughout the day, educational classes teach the children asthma self-management techniques. Children learn breathing exercises, learn how to use their medication properly, and master the steps they need to control their disease instead of letting it control them. Respiratory therapists and nurses provide asthma education, and camp staff provide traditional camping activities. Medical staff are available on site to provide medical attention if needed. The children stay in year-round Adirondack-style lodges surrounded by 1,100 acres of rolling fields and forests with a 46-acre lake. Camp Superkids ALA of New York 225 Wireless Boulevard Hauppauge, NY 11788-3914 (631) 325-5585, ext. 20 [email protected] Camp Superkids of Metro New York services 100 children with moderate persistent to severe asthma, providing a one-week sleep-away camping experience that includes swimming, hiking, canoeing, arts and crafts, boating, and special events. Educational classes teach the children asthma self-management techniques. The camp, which serves children from New York City, Brooklyn, Queens, Nassau, and Suffolk counties (Long Island), is in Copake, New York, 100 miles north of New York City. Camper scholarships are given to most campers. ALA-sponsored educational groups are a daily part of the program.

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NORTH CAROLINA Camp Air Care ALA of North Carolina 5315 Greenbrook Drive Charlotte, NC 28205-6521 (704) 716-4300 http://www.lungnc.org Camp Air Care provides recreational day camp programs run during the summer months for children with asthma. Asthma education is integrated into fun camp activities, and campers leave the experience with improved self-esteem and a sense of empowerment for handling their disease. Camp Challenge Oak Hill Fellowship, Inc. 3824 Barrett Drive, Suite 107 Raleigh, NC 27609 (919) 782-2888 http://www.campoakhill.org For one session each summer, Camp Oak Hill operates Camp Challenge, a special week for children suffering from asthma at a camp dedicated to Christian values and leadership development. During Camp Challenge, professional medical volunteers enable asthma suffers not only to participate in this life-changing experience but also to learn asthma management skills. Camp Challenge helps campers experience new freedoms in a Christian environment. Mission Kids Camp (formerly Camp Mountain Air) 509 Biltmore Avenue Asheville, NC 28801 (828) 778-9094 http://missionhospitals.org/camp-mountainair.htm This one-week sleep-away camp is designed for boys and girls ages eight to 13 with asthma (a teen camp is also offered for teens aged 14 through 16). Located near Hendersonville, North Carolina, in the scenic Blue Ridge Mountains, the camp offers campers with asthma a variety of fun outdoor activities. In the process, they also learn more about managing their asthma—everything from identifying what triggers an asthma episode to taking their daily medications. The Mission Kids Camp provides an action-packed

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week of outdoor activities, including hiking, a climbing tower, swimming, field games, music, zip-line, boating, a ropes course, campfires, and arts and crafts. These activities help improve selfconfidence, respect for others, and respect for the environment.The camp’s medical staff includes physicians, nurses, and respiratory therapists. Victory Junction Gang Camp 4500 Adam’s Way Randleman, NC 27317 (336) 495-2017 http://www.lungnc.org/programs/asthma/asthmacamps_details. php#residential This one-week sleep-away camp for ages seven through 15 is offered under the auspices of the American Lung Association and the Victory Junction Gang.

OHIO Camp Superkids—Camp Kern ALA of Ohio 11113 Kenwood Road Cincinnati, OH 45242-1817 (513) 985-3990, ext. 17 [email protected] http://www.ohiolung.org At this camp, children with asthma are given a chance to take part in an overnight camping program. An excellent asthma education program is provided in addition to the regular camping experiences that many remember as an important part of childhood. COBA Asthma Camp Central Ohio Breathing Association 1520 Old Henderson Road Columbus, OH 43220-3639 (614) 457-4570, ext. 11 [email protected] http://www.breathingassociation.org This two-day camp at Recreation Unlimited at 7700 Piper Road, Ashley, Ohio, is open to children between the ages of seven and 14 who are currently under a physician’s care for moderate to severe

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asthma. The camp offers fun activities, good food, and creative asthma education in a beautiful camp setting. Caregivers are also welcome to attend. Children must live in Franklin, Delaware, Madison, Licking, Union, Pickway, or Fairfield counties.

OREGON Camp Christmas Seal American Lung Association of Oregon 7420 Southwest Bridgeport Road, Suite 200 Tigard, OR 97224 (800) 586-4872 [email protected] http://www.lungoregon.org Children with asthma will swim, hike, boat, sing campfire songs, and enjoy camp life at Camp Christmas Seal at Camp Namanu. They also receive daily asthma education sessions to improve their asthma awareness and promote asthma control.

PENNSYLVANIA Camp AsthmaCadabra ALA of Pennsylvania Marywood University, Center For Healthy Families 2300 Adams Avenue Scranton, PA 18509 (570) 346-1784 [email protected] http://www.alapa.org An overnight camp for children who have asthma, cosponsored by the American Lung Association and the Max & Lorraine Foundation. The camp, at the YMCA’s Camp Kresge in White Haven, is for boys and girls ages seven to 12 who might otherwise be denied a summer camping experience because of their asthma. Camp AsthmaCadabra’s main goal is for children with asthma to have fun and enjoy a weekend camping adventure. The emphasis at Camp AsthmaCadabra is to help children better understand their asthma. This increases their self-confidence and enhances their ability to cope with asthma. In addition to traditional summer activities like swimming, boating, and arts and crafts, campers will participate in educational sessions on asthma and how it affects them.

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Camp Breathe EZ American Respiratory Alliance Western PA Cranberry Professional Park 201 Smith Drive, Suite E Cranberry Township, PA 16066 (800) 220-1990 [email protected] http://www.healthylungs.org These day camps are for children ages six to 12 with asthma in the Pittsburgh area. Campers participate in a number of educational sessions covering a variety of asthma self-management topics. Teens with asthma, ages 13 to 18, may participate as junior counselors.

Camp Green Zone York Hospital/Wellspan Health 1001 South George Street York, PA 17403-3676 (717) 851-4339 [email protected] Camp Green Zone provides a day camp experience for children between the ages of seven and 12 at Penn State–York. Education is provided for campers and parents alike. Activities that enhance the camp experience include physical fitness, swimming, arts and crafts, and presentations by special guest vistors. Activities are designed to promote self-care, self-image, and independence for children with asthma.

Camp Huff ’n Puff American Respiratory Alliance of Western PA Cranberry Professional Park 201 Smith Drive, Suite E Cranberry Township, PA 16066 (800) 220-990 [email protected] http://www.healthylungs.org Camp Huff ’n Puff, now in its 22nd year, provides a four-day camping adventure for children with asthma ages eight to 13. In addition to asthma education sessions, activities include swimming, hiking, a ropes challenge course, arts and crafts, team sports, and plenty of time to make new friends.

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RHODE ISLAND Asthma Camp 2005 Community Asthma Programs/Hasbro Children’s Hospital 593 Eddy Street, P.O. Box 438 Providence, RI 02903 (401) 444-6268 [email protected] http://www.lifespan.org/Services/Allergy/HCH Children attending Asthma Camp at Canonicus Camp and Conference Center are nine to 13 years old and have been diagnosed with moderate or severe persistent asthma. Campers are provided a traditional camp experience that includes swimming, kayaking, fishing, hiking, arts and crafts, field games, and activities that enhance leadership skills. The camp provides the added security of a 24-hour volunteer medical staff. One hour of daily asthma education games is also incorporated into camp activities, making it fun for the campers to learn good asthma management skills.

SOUTH CAROLINA Camp Air Waves, Camp Puff ’n Stuff, and Camp Sea Breeze ALA—Southeast Region 1941 Savage Road, Suite 200a Charleston, SC 29407-4789 (843) 556-8451 [email protected] The Camp Air Waves and Camp Sea Breeze programs are designed to help kids better understand their asthma, to reduce the frequency and severity of their asthma symptoms, to reduce their exposure to allergens, and to develop an asthma management plan. Camp Puff ’n Stuff gives kids with asthma who are unable to attend other camps the opportunity to enjoy a summer camping experience while under medical supervision. The kids learn how to better manage their asthma, how to take their medications correctly, why they need to take their medications as prescribed, and how to reduce the frequency and severity of their asthma symptoms.

TENNESSEE Camp Wezbegon Allergy & Asthma Affiliates P.O. Box 18125 Knoxville, TN 37928-2125

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(865) 977-8242 [email protected] Camp Wezbegon aims to provide a unique five-day summer camp at Wesley Woods Camp in Townsend, Tennessee, for children ages eight to 12 with asthma, whose health has made it difficult for them to attend a regular summer camp. On-site 24-hour medical supervision by teams of volunteer physicians, nurses, and respiratory therapists is provided. A camp activity staff, expertly oriented to meet the specialized needs of the asthmatic, coordinates a program that includes arts and crafts, hiking, games, campfires, swimming, songfests, and more.

TEXAS Camp Broncho–Dallas and Ft. Worth ALA of Texas 8150 Brookriver Drive, Suite 102 Dallas, TX 75247-4068 (214) 631-5864, ext. 202 [email protected] http://www.texaslung.org Camp Broncho at Camp John Marc in Meridian, aims to provide kids affected by asthma, who may not otherwise attend summer camps, challenging opportunities in a medically safe and educationally supportive environment. Campers are selected based on the severity of their asthma as indicated by their physician. This camp is for kids ages seven to 14.

Camp Broncho–Alamo Region ALA of Texas 8207 Callaghan Road, Suite 140 San Antonio, TX 78230 (210) 308-8978 [email protected] http://www.texaslung.org Camp Broncho-Alamo is a medically supervised asthma camp at John Newcombe Tennis Ranch in New Braunfels, designed for moderate to severe asthmatic children ages eight to 12. The program has worked with children and families since 1989.

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Camp Easy Breathers Coastal Bend Asthma Initiative 3533 South Alameda Street Corpus Christi, TX 78411-1721 (361) 694-4580 [email protected] http://www.driscollchildrens.org/campeasybreathers Camp Easy Breathers is a specialty camp located at Del Mar College– East Campus for children seven to 12 years of age with asthma. At camp, children learn about their airways and the changes that happen in the airways when asthma flares up. Children practice asthma management skills in swimming, arts and crafts, and other activities. Camp teaches children the importance of asthma and preventing attacks. Camp Wenoweez Children’s Respiratory Summer Camp Foundation 6621 Fannin Houston, TX 77030 (832) 822-3392 [email protected] Camp Wenoweez is a special camp for youths ages seven to 12 with asthma. It takes place at Camp for All in Burton, Texas. Huff ’n Puff ALA of Texas 2830 Calder Street Beaumont, TX 77702-1809 (409) 899-7065 [email protected] Children from six to 12 who have asthma can attend Christus Hospital’s annual Camp Huff ’n Puff, a day camp for children with asthma. Shannon Sneeze & Wheeze Asthma Camp Shannon Health & Wellness, Children’s Miracle Net 424 South Chadbourne Street San Angelo, TX 76903-6926 (325) 481-6170 [email protected] Shannon Sneeze and Wheeze Asthma Camp is a four-day, medically supervised day camp at Barnhart Lake Ranch, Lake Nasworthy, for children who are entering fourth through seventh grade and

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who have been diagnosed with asthma. While at camp, children are encouraged to participate in all camp activities, such as swimming, field sports, arts and crafts, team challenges, fitness activities, and asthma education activities. The asthma education is provided by health care professionals. Texas Asthma Camp for Kids ALA of Texas 11937 U.S. Highway 271 Tyler, TX 75708-3154 [email protected] Campers ages seven to 14 learn together to take an active role in the management of their asthma during work and play. The campers receive excellent medical support in a 24-hour clinic staffed by onsite physicians and nurses.

UTAH Camp Wyatt ALA of Utah 1930 South 1100 East Salt Lake City, UT 84106-2317 (801) 484-4456 [email protected] Camp Wyatt provides kids a chance to be away from their parents for a week; doctors and nurses are on staff 24 hours a day. Camp Wyatt offers an old-fashioned camping experience in the foothills of Tooele and is the only camp in the Intermountain area for children ages eight to 14 with asthma.

VIRGINIA Camp ASTHMAtopia–Middleburg ALA of Virginia 9221 Forest Hill Avenue Richmond, VA 23235-6876 (804) 267-1900 http://www.lungusa.org/virginia At asthma camp, children can have fun, receive support from one another, and manage their asthma at the same time. This camp emphasizes in educating the campers about their disease and how to manage the physical and psychosocial aspects of it.

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Camp Incredible ALA of Virginia 9221 Forest Hill Avenue Richmond, VA 23235-6876 (804) 267-1900 http://www.lungusa.org/virginia Camp Incredible is a day camping adventure for children with asthma ages six to 12. The American Lung Association of Virginia and the Central Virginia Asthma Coalition sponsor this one-day camping experience at the Science Museum of Virginia in Richmond. Camp Superkids–Abingdon ALA of Virginia 370 East Main Street P.O. Box 1249 Abingdon, VA 24210-2906 (276) 628-1277 [email protected] http://www.lungusa.org/virginia This three-day day camp at the Harry Coomes Recreation Center, Abingdon, offers activities, education, and meals. All camp volunteers complete a screening process. Camp Superkids–Roanoke ALA of Virginia 3512 Brambleton Avenue, Suite 3 Roanoke, VA 24018-6525 (540) 774-5864 [email protected] This three-day camp at Roanoke College in Roanoke, Virginia, offers activities and education; meals and snacks are provided. The camp is medically supervised, and all camp volunteers complete a screening process.

WASHINGTON Camp Sealth–Western Washington American Lung Association of Washington Camp Fire USA 8511 15th Avenue, NE Seattle, WA 98115 (206) 461-8550, ext. 247 [email protected]

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http://www.campfire-usa.org Co-ed resident camp for kids grades one through 12. Eight camp sessions are open to kids with asthma; specialized medical staff is on hand to provide education and support.

WEST VIRGINIA Camp Catch Your Breath ALA of West Virginia P.O. Box 3980 Charleston, WV 25339-3980 (304) 342-6600 [email protected] http://www.alawv.org This weeklong camp for kids with asthma is held at Jackson’s Mill in Weston, West Virginia, and provides a fun and educational experience for children who might not otherwise get to go to camp. During the session, kids will learn by sharing their experiences, making decisions about their conditions, and expressing their feelings about living with asthma. In addition to the educational component, children will participate in games, sports, swimming, and crafts.

WISCONSIN Camp WIKIDAS American Lung Association of Wisconsin 13100 W. Lisbon Road, Suite 700 Brookfield, WI 53005-2508 (262) 703-4200 [email protected] http://www.lungwi.org Camp WIKIDAS is a camp for boys and girls ages eight to 13 with asthma at Camp Wawbeek in Wisconsin Dells. Children must be on daily asthma medication to attend. These kids differ from other kids only in their strength and commitment to managing their asthma. Camp builds confidence, heightens awareness of asthma, and helps campers cope with their condition—all in the context of a fun and safe summer camp experience.

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GLOSSARY Accolate (zafirlukast) A leukotriene receptor antagonist used for chronic treatment of asthma in adults and children five years of age and older. Accolate is not a bronchodilator and should not be used as a rescue medication. acute Sudden. adrenaline (epinephrine) A hormone produced in response to stress by the adrenal glands, located on the surface of the kidneys. Adrenaline has widespread effects on the circulation, making the heart beat faster, narrowing blood vessels, and dilating the airways. Epinephrine given as an injection is used in the emergency room to treat anaphylaxsis, a potentially life-threatening allergic reaction. It is occasionally used to treat a severe asthma flare, because it can relax the airways. albuterol (Proventil, Ventolin) A medication used as a rescue inhaler to treat wheezing, shortness of breath, and troubled breathing caused by asthma and to prevent breathing problems during exercise. Albuterol belongs to a class of medications called beta 2agonists, which work by relaxing and opening air passages in the lungs, making it easier to breathe. allergen A foreign substance such as pollen that the body interprets as a foreign invader and that can trigger an allergic reaction. allergist A doctor who diagnoses and manages asthma and allergyrelated conditions. Allergists have specialty training in caring for patients with asthma. Alupent See METAPROTERENOL. alveoli Microscopic thin-walled air sacs where oxygen and carbon dioxide are exchanged, located at the end of the smallest airways in the lungs. anaphylaxis An abnormal and potentially life-threatening reaction to a particular allergen. It occurs when histamine and other potent chemicals are released from tissues and cause either local or widespread symptoms. The reaction may occur after an insect sting or as a reaction to a drug or a particular food. It can progress to anaphylactic shock, an extreme bodywide allergic reaction causing

159

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widespread swelling, constriction of the bronchioles, heart failure, circulatory collapse, and sometimes death. antibody A protein produced by a type of white blood cell called a lymphocyte that interacts with an antigen, or foreign protein. Bacteria, viruses and other microorganisms, pollens, dust mites, molds, and foods commonly contain many antigens. Normally, many types of antibodies are produced to protect the body. However, when the body forms large numbers of a particular type of antibody called IgE (Immunoglobulin E), allergic symptoms may develop when the patient is again exposed to the substance that caused the production of IgE antibodies. anticholinergics A group of medicines that relax the muscles surrounding the airways. These drugs block acetylcholine, a chemical produced by the brain that causes airway muscles to constrict. These drugs are used by people with asthma as rescue medications, not as a daily maintenance treatment for persistent asthma. Anticholinergics include Atrovent (ipratropium bromide) and Spiriva (tiotropium bromide); Atrovent is available in metereddose inhalers and in a liquid form for use in compressor-driven nebulizers. Spiriva is only available in handheld dry powder inhalers. When used as additional medication to treat asthma, these drugs work best when used with a short-acting beta 2-agonist inhaler. antigen A substance that can trigger an immune response, producing an antibody as part of the body’s defense against infection and disease. Many antigens are foreign proteins not found naturally in the body. An allergen is a special type of antigen, such as mold or pollen, that causes an allergic reaction. antihistamine Medicine that blocks the action of histamine, a chemical that is released by the body during an allergic reaction and that causes symptoms such as itching and swelling. anti-inflammatory drug Medication that reduces inflammation, such as the swelling in the airway. aspirin-sensitive asthma A type of asthma triggered by aspirin or NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen. This kind of asthma usually occurs in adults and is often accompanied by benign growths in the nose called nasal polyps or a chronically runny or stuffy nose. Aspirin-sensitive asthma may respond to leukotriene-modifying drugs. asthma action plan A list of specific instructions for a person with asthma, including what asthma medicines to take and what to do if peak-flow readings or asthma symptoms get worse. Asthma action plans are usually divided into zones, depending on seriousness

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of symptoms, from normal (green) to caution (yellow) to serious (red). Atrovent See IPRATROPIUM BROMIDE. autohaler A metered-dose inhaler (MDI) activated by the breath that does not require the breath-hand coordination of an aerosol MDI. Azmacort See TRIAMCINOLONE. beclomethasone An anti-inflammatory corticosteroid used in a metered-dose inhaler by patients with asthma. It helps prevent inflammation of the lungs and hypersensitivity in the airways, but it is not effective in relieving inflammation during an asthma flare the way oral corticosteroids can. Side effects may include dry or irritated throat, hoarseness, coughing, bad taste in the mouth, headache, nausea, diarrhea, thirst, and fatigue. These symptoms may improve as the body adjusts to the medication. Trade names include Beclovent, Vanceril, and Qvar for asthmatic use; Beconase and Vancenase are prescribed for nasal inhalation. Beclovent See BECLOMETHASONE. beta-adrenergic agonist (-adrenergic agonist) See BETA 2-AGONIST. beta-agonist (-agonist) See BETA 2-AGONIST. beta 2-agonist ( 2-agonist) A bronchodilator medicine that opens the airways of the lungs by relaxing muscles that have tightened around the airways. These medicines are available in both shortand long-acting forms and in both inhaled and oral forms. Side effects of beta 2-agonists include shaky feelings, overexcitement, and increased heart rate. Rarely, they may cause an upset stomach or sleeping problems. Oral forms of beta 2-agonists (Volmax) can have more side effects, because they are available in higher doses and are absorbed throughout the bloodstream to get to the lungs. Inhaled forms are deposited directly in the lungs and therefore have fewer side effects. beta 2-agonist, long-acting The long-acting forms of beta 2-agonists are used to provide control, not quick relief. They take longer to begin to work than short-acting beta 2-agonists, but their benefits last longer (up to 12 hours). Serevent and Foradil are the only inhaled, long-acting beta 2-agonists available and are used twice a day to maintain open airways for long-term control. They have also been shown to be helpful in treating exercise-induced asthma. Serevent and Foradil are available in dry powder inhaler (DPI) form. Serevent is also available in an MDI. beta 2-agonist, short-acting Short-acting beta 2-agonists administered by inhalation are used to relieve asthma symptoms within five minutes, increasing airflow and facilitating breathing for up to six hours. Short-acting beta 2-agonists include albuterol (Ventolin,

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Proventil, Accuneb), Alupent (metaproterinol), Combivent (combines a beta 2-agonist and an anticholinergic), Duoneb (combines a beta 2-agonist and an anticholinergic), Maxair, and Xopenex. They are available in inhaled, pill, liquid, and injectable forms; the inhaled form is available in metered-dose inhalers (MDIs), dry powder inhalers, and a liquid form. Nonprescription short-acting beta 2-agonist (epinephrine) is available as Primatene and Bronkaid. Long-acting forms include Serevent and Foradil; Advair combines Serevent and Flovent. breath-actuated inhaler Inhaler that is similar to a metered-dose inhaler except that the beginning of inhalation triggers the release of the medication. Maxair (pirbuterol) is available in breathactuated inhaler form. breathing rate The number of breaths a person takes each minute. breath sounds Lung sounds that can be heard through a stethoscope. bronchial tubes A system of tubes within the lungs that connects the lung to the trachea (windpipe). bronchioles The smallest branches of the airways in the lungs that connect to the air sacs (alveoli). If inhaled air cannot make it through the bronchiole to the air sacs because of asthma, the blood’s oxygen saturation level will drop. bronchodilator A medication that opens the airways by relaxing the muscles constricting the airways during an asthma attack, improving airflow and breathing. Bronchodilators also help remove mucus from the lungs so that it can be coughed out. Common bronchodilators include Ventolin or Proventil (albuterol) and nonprescription Primatene (epinephrine). There are three main types of bronchodilator medications: beta 2-agonists (short- and long-acting forms), anticholinergics, and theophylline. Short-acting forms ease or stop asthma symptoms and are very helpful during an asthma attack. Long-acting forms help control asthma symptoms and prevent asthma attacks. bronchospasm The tightening of the muscle bands that surround the airways, causing the airways to narrow. budesonide (Pulmicort) A corticosteroid delivered by a turbuhaler and the first dry powder inhaled steroid approved by the U.S. Food and Drug Administration. The turbuhaler dispenses a measured dose of dry powder with each inhaled breath; no special timing is required. challenge test A test done to determine whether a person’s bronchial tubes are hypersensitive. During the test, the subject breathes in air containing carefully controlled amounts of an

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aeorosolized substance known to cause bronchoconstriction, such as methacholine, histamine, or a known allergen. The bronchi of people with asthma respond to much smaller amounts of the substance; this test is often used to confirm a diagnosis of asthma if there is uncertainty. chronic disease A disease that can be treated and controlled but that cannot be cured. Asthma is a chronic disease. chronic obstructive pulmonary disease (COPD) A term for any long-standing condition that interferes with airflow in and out of the lungs; it is used most often to describe chronic bronchitis and emphysema. When persistent asthma develops into a chronic obstructive pulmonary disease, it typically indicates that the lungs have become irreversibly damaged and scarred from repeated, untreated asthma flares. cilia Hairlike structures that line the airways in the lungs, helping clear out the airways. Combivent A metered-dose inhaler that combines both albuterol (Ventolin or Proventil) and ipratropium bromide (Atrovent). Albuterol acts immediately but has a shorter lifespan than ipratropium bromide. Combivent is more commonly prescribed for adults with chronic obstructive pulmonary disease. corticosteroids A steroid hormone produced by the adrenal glands that can reduce swelling and inflammation. Synthetic corticosteroids enhance the body’s own production of these hormones, easing the swelling, inflammation, and mucus production that occur when lungs are irritated as a result of asthma. Oral corticosteroids are used for immediate short-term relief; they can be used to help treat stubborn, serious flares for about a week. Rarely, for patients with severe persistent asthma, oral corticosteorids may be used daily or on alternate days. Inhaled corticosteroids are used daily in persistent asthma to prevent asthma flares, but they will not stop a flare in progress. cromolyn sodium (Intal) A medication that prevents bronchospasm and inflammation. It is usually only effective for asthma that is triggered by allergens or exercise and is available both as a metered-dose inhaler and as a nebulizer solution. dander Bits of cells shed from animal skin or hair that float through the air and settle on household surfaces. Pet dander is a major part of household dust and often causes allergic reactions and triggers allergic asthma. decongestant Medication that shrinks swollen nasal passages to relieve swelling, congestion, and mucus secretion. It is available in both an oral form and a nonprescription nasal spray.

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diaphragm The major muscle of breathing, which contracts with each indrawn breath and relaxes with each exhale. It is attached to the lower ribs at each side and to the breastbone and the backbone at the front and back. diskhaler (Flovent Rotadisk) A type of dry powder inhaler with a round disk containing four doses of medication. To use, the patient punctures the pouch and inhales the drug through the mouthpiece. diurnal variation The difference between the width of the airways in the lungs of asthma patients when measured 12 hours apart. Airways normally narrow and open naturally over a day in healthy individuals, but people with asthma experience a much greater variation. Typically, the larger the diurnal variation, the more unstable the person’s asthma. People with asthma can measure diurnal variation by taking morning and evening peak-flow readings. dry-powder inhaler (DPI) A small breath-activated handheld device for inhaling very fine dry powdered respiratory medicines into the lungs; it does not require an aerosol spray device. DPIs do not contain any of the propellants (CFCs) that are used in standard metered-dose inhalers (MDIs), which can be harmful to the environment. DPIs can be easier to use than MDIs, because the patient does not have to activate the inhaler and breathe in at the same time. DPIs also do not have as bad a taste and as unpleasant a texture as MDIs. Both quick-relief and long-term control asthma medicines can be given by DPI, including Advair Diskus, Asmanex Twisthaler, Ventolin Rotacap, Foradil Aerolizer, Flovent Diskhaler, Flovent Diskus, Flovent Rotadisk, Pulmicort Turbuhaler, and the Serevent Diskus. dust mites Microscopic creatures that live in the dust in the home, especially when the air is humid. Dust mites can be found both in visible dust that might be found under the bed or behind the couch and in soft, hidden places such as pillows, mattresses, blankets, and stuffed animals. Many people with asthma are allergic to dust mites. dyspnea Shortness of breath. edema Swelling caused by the collection of fluid within cells or tissues. ELISA test An acronym for enzyme-linked immuno-sorbent assay, an allergy test to detect allergens in the blood. eosinophil A type of white blood cell associated with the inflammation underlying asthma. People with asthma tend to have more eosinophils in their blood and an unusual number of eosinophils in the lungs.

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epinephrine See ADRENALINE. exercise-induced asthma Asthma that is triggered by exercise. Exercise is a very common trigger of symptoms, affecting between 70 and 80 percent of people with asthma. Flonase See FLUTICASONE. Flovent See FLUTICASONE. flunisolide (AeroBid) An anti-inflammatory corticosteroid used in a metered-dose inhaler that helps prevent inflammation in the airways. It delivers a more potent drug with each puff than does beclomethasone, which is why in the past it was often prescribed for more severe cases of asthma. fluticasone (Flonase, Flovent) Inhaled corticosteroid also available in a nasal preparation for sinusitis and rhinitis. It is prescribed to ease allergic rhinitis symptoms that often trigger asthma flares. gastroesophageal reflux The medical term for acid reflux, a disease that causes painful heartburn when acid from the stomach flows up into the throat. Acid reflux can trigger asthma and make it harder to treat. It happens mostly in people who are older and overweight, but it can happen in all kinds of people. People who have asthma get acid reflux more often than people without asthma, probably because of the pressure changes in the chest during asthmatics’ breathing. This high pressure can force liquid to travel the wrong way. hay fever An allergy caused by pollens that affect the eyes and nose. high-efficiency particulate (HEPA) filter A type of filter on air cleaners that removes particles in the air by forcing them through screens containing microscopic pores. HEPA filters effectively remove 99.97 percent of all particulates (such as pollen and dust) that pass through the filter, returning purified air to the room. histamine A naturally occurring substance in the body that causes allergic reactions such as redness, itching, and swelling of the nose and eyes. This reaction also can occur in the skin, causing hives and swelling. hormones Chemicals released by endocrine glands and carried through the bloodstream to specific tissues, where they can produce either rapid or long-term effects. hypoxia Lack of oxygen in the blood and tissues. In people with asthma who have normal blood flow and blood pressure, a lowered oxygen saturation point can cause this condition. The brain is most critically affected by hypoxia. IgE (immunoglobulin E) The antibody produced in large amounts by people with allergic asthma and other allergic conditions. IgE can

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be measured in a blood sample to help diagnose whether a person is allergic, because people with allergies usually have high levels of IgE. immunoglobulins Proteins that are found in blood and in tissue fluids, also known as antibodies. Immunoglobulins are produced by cells of the immune system called B-lymphocytes; they bind to foreign antigens in the body. A particular type of immunoglobulin, IgE, plays a central role in allergies by binding to antigens (allergens) on the cell’s surfaces, thereby triggering an inflammatory reaction. inflammation Swelling and irritation that in people with asthma affects the airways of the lungs. Inflammation is the body’s response to some kind of injury, a way of protecting itself and helping the injury heal. The purpose of the inflammation is to dilute and destroy whatever is causing the inflammation. In asthma, the linings of the airways become overreactive, inflamed, and so hypersensitive and twitchy that the slightest provocation triggers symptoms. Airway inflammation may always be present in a person with asthma, even if there are no symptoms. Many experts believe that if left untreated, this chronic inflammation can damage the airways and cause long-term loss of lung function. inhalers Small, handheld canisters for delivering asthma medication into the airways, available in four types: CFC metered dose (MDIs), HFA MDIs, breath actuated, and dry powder. Intal See CROMOLYN SODIUM. ipratropium bromide (Atrovent) An inhaled bronchodilator available in both nebulizer solution and metered-dose inhaler form. Atrovent acts more slowly and is not typically used in back-to-back treatments the way albuterol can be. In critical situations, it may be combined with an albuterol dose administered by nebulizer; albuterol offers immediate relief, while Atrovent gives longerlasting effects. Combivent combines the same two drugs in a metered-dose inhaler. Side effects with ipratropium bromide use may include dizziness, headache, nausea, dry mouth, cough, hoarseness, or blurred vision, although these symptoms may fade as the body adjusts to the drug. irritants Substances that bother the nose, throat, or airways when they are inhaled; irritants are not allergens. Examples of irritants in asthma include strong chemicals, cigarette smoke, and perfume. leukotriene Chemical found naturally in the body. Increased amounts of these substances contribute to the swelling and the narrowing of air passages. leukotriene modifier An oral class of nonsteroidal asthma drugs that block chemicals called leukotrienes in the airways, preventing or

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reducing inflammation of the airways. Antileukotrienes fall into one of two categories: inhibitors or antagonists (blockers). Leukotriene inhibitors known as zileuton (Zyflo) prevent leukotriene production; antagonists called montelukast (Singulair) or zafirlukast (Accolate) block the leukotriene receptors responsible for producing mucus and bronchoconstriction. By either preventing or halting the inflammatory reaction, antileukotrienes can potentially lower or eliminate the need for inhaled corticosteroids. long-term control medicine A medicine that must be taken every day to control asthma symptoms. It is not used for emergency relief during an asthma flare. metaproterenol (Alupent) An older bronchodilator available only as a metered-dose inhaler, tablet, or syrup. metered-dose inhaler (MDI) A small aerosol device that, when pressed down from the top, releases a mist of medicine, which is then inhaled. Many asthma medicines are taken with an MDI. Less than 20 percent of the dose arrives in the lungs, and more than 80 percent, the larger particles that are too heavy to be inhaled, is left in the patient’s mouth. These particles are swallowed and absorbed by tissue and then travel throughout the rest of the body. Using a spacer device with an MDI lessens this effect, since the larger particles remain in the chamber instead of the mouth. montelukast (Singulair) An antileukotriene that works by suppressing the effects of leukotrienes on their receptors in airway tissue. By preventing or halting the inflammatory reaction, antileukotrienes can lessen or eliminate the need for corticosteroids. mucus A material produced by glands in the airways, nose, and sinuses that is secreted as a protective lubricant. nebulizer A machine that creates fine droplets of medicine as an aerosol or mist that is then inhaled through a mouthpiece or mask. Nebulizers can be used to deliver bronchodilator medicines to open the airways, such as albuterol, as well as anti-inflammatory medicines. A nebulizer can be used instead of a metered-dose inhaler; because it transforms medicine into extremely fine particles, it increases the absorption rate by the lungs. Nebulizers are one of the most effective delivery techniques available for home use. nedocromil sodium (Tilade) A medication very similar to but longeracting than cromolyn sodium, usually taken once or twice per day. nonsteroidal An anti-inflammatory medicine that is not a steroid. oximetry meter A lightweight finger clamp device that monitors and reports the oxygen saturation of the blood. It is also known as an oximeter or pulse oximeter. Saturation levels should be in the high 90s.

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168 Glossary

oxygen saturation The level of oxygen in the bloodstream, which is expressed as a percentage; the high 90s is considered to be an excellent reading. peak expiratory flow rate (PEF) How fast a person can breathe out. It is one of several tests that can determine how well your lungs are functioning. peak-flow meter A small handheld device that measures how fast air comes out of the lungs when a person exhales forcefully (the peak expiratory flow [PEF]). Measured in liters per minute (lpm), a person’s PEF might drop hours or even days before asthma symptoms appear. Readings from the meter can help a person with asthma recognize early changes that could indicate that the condition is worsening. A peak-flow meter also can help the patient figure out what substances or situations trigger symptoms and understand when symptoms require emergency care. Peakflow readings also help a doctor decide when to add or reduce medicines. personal best peak expiratory flow (PEF) The highest peak-flow number a patient with asthma can achieve when symptoms are under good control. The personal best PEF is the number to which all other peak-flow readings should be compared. If the patient is still growing, the PEF rate is based on height; as the patient grows, the doctor will refigure the PEF about every six months or right after a growth spurt. pneumonia An infection of the lung caused by different types of germs, including bacteria, viruses, fungi, and parasites, in which the air sacs fill up with pus so that air is excluded and the lung becomes solid. Symptoms include fever, chills, cough, rapid breathing, grunting or wheezing breath sounds, labored breathing, vomiting, chest pain, abdominal pain, lethargy, loss of appetite, and bluish or gray color of the lips and fingernails. The extent of symptoms depends on how large an area of the lung is involved and how virulent the germs are. pollen An allergen that is released by grasses, weeds, and trees as a fine, powdery substance. Pollen is a common asthma trigger. pollen and mold counts A measure of the amount of allergens in the air usually reported for mold spores and grass, tree, and weed pollens. The count is reported as grains per cubic meter of air and is translated into absent, low, medium, or high. prednisone/prednisolone An oral systemic corticosteroid that helps prevent inflammation by suppressing the immune response to triggers and stimuli. This powerful drug is typically prescribed only for a short time because it can cause severe side effects if

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used for long periods. Short-term treatments for 10 days or less are considered to be safe as long as they are not prescribed too often. These drugs include prednisone (Cortan, Deltasone, Prednicen-M, or Sterepred), prednisolone (Prelone, Pediapred, Delta-cortef), or methylprednisolone (Medrol and SoluMedrol). Primatene Mist A nonprescription bronchodilator that can be dangerous if abused, because it includes epinephrine. productive cough A “wet” cough that often involves coughing up mucus. Proventil See ALBUTEROL. Pulmicort See BUDESONIDE. pulmonary function tests A test or series of tests that measure many aspects of lung function and capacity. They also may be called lung function tests. pulse oximetry A test in which a device that clips on the finger measures the oxygen level in the blood. quick-relief medicine A rescue medicine that opens the airways right away to relieve symptoms of asthma. These medications are usually used only when symptoms have appeared. RAST test An acronym for radioallergosorbent test, which identifies allergens in blood samples that can cause an allergic reaction. reflux See GASTROESOPHAGEAL REFLUX. rescue medications Short-term bronchodilators that provide immediate relief to the airways during an asthma flare. However, these drugs do not address the underlying inflammation causing the asthma attack. rhinitis Inflammation of the mucous membrane of the nose that may be caused by a viral infection or an allergic reaction. It is characterized by nasal congestion, runny nose, itching, and sneezing. Rhinitis often triggers flares in susceptible asthmatics. rotahaler A dry powder inhaler used with Rotacaps. salbutamol (Ventolin) The World Health Organization’s preferred name for albuterol, a bronchodilator. salmeterol inhaled (Serevent) A long-acting bronchodilator that may be prescribed as a maintenance drug in combination with an inhaled corticosteroid, especially for people with asthma who need long-lasting effects. It may be used by students whose school systems restrict or prohibit the use of short-acting bronchodilator inhalers without a visit to the school nurse. Salmeterol does not stop an attack once it has started. Side effects include dry mouth and irritated throat, dizziness or lightheadedness, headache, heartburn, appetite loss, altered taste sensations, restlessness, anxiety, nervousness, trembling, and sweating.

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Serevent See SALMETEROL INHALED. Singulair See MONTELUKAST. sinusitis An inflammation or infection in one or more sinuses (the hollow air spaces around the nose and eyes). Solumedrol See PREDNISONE. spacer A chamber used with a metered-dose inhaler to help make the inhaler easier to use and to help deliver the medicine into the airways. spirometry A basic lung function test that measures how fast and how much air can be inhaled and exhaled. The total volume of air a patient exhales is called the forced vital capacity (FVC). The spirometer also measures the volume of air you exhale in the first second (forced expiratory volume in one second, or FEV1). sputum Saliva mixed with mucus or phlegm, coughed up from the respiratory tract. Coughs that produce sputum are considered productive. status asthmaticus An extremely serious, life-threatening condition in which an asthma flare is not responding to treatment. This condition, which can be fatal, often requires hospitalization. steroids (corticosteroids) A common term often used with corticosteroids to describe medicine that reduces swelling and inflammation and is available in pill, syrup, injectable, and inhaled forms. It is also available as creams, ointments, and lotions for topical care of certain skin problems. theophylline (Uniphyl, Theo-Dur, Slo-Bid, Theo-24) A type of bronchodilator used as a long-term medicine to open airways, easing or preventing bronchospasm. This caffeine derivative is much less popular today than inhaled corticosteroids in the treatment of asthma. Available as a pill, liquid, or intravenous drug, it is used to treat difficult-to-control or severe asthma and must be taken daily. Side effects include nausea and/or vomiting, diarrhea, stomachache, headache, rapid or irregular heartbeat, muscle cramps, jittery or nervous feeling, and hyperactivity. Some medications, such as antibiotics containing erythromycin, seizure medicine, or ulcer medicine, can interfere with the way theophylline works. Some diseases and illnesses also can change how your body responds to theophylline. Theophylline’s potential side effects and its very thin margin between therapeutic dose and toxicity make it a less desirable choice for most patients. Tilade See NEDOCROMIL SODIUM. trachea The main airway (windpipe) supplying both lungs. triamcinolone (Azmacort) A metered-dose inhaled corticosteroid.

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triggers Things that cause allergy and/or asthma symptoms to start or become worse. turbuhaler/turbohaler A dry powder inhalation device used to deliver budesonide (Pulmicort). As the inhaler is rotated, the dry powder medication is released into a holding chamber from which the medicine is inhaled. Vanceril See BECLOMETHASONE. ventilator A machine that breathes for a patient when the person’s lungs can no longer inhale or exhale. A ventilator is typically the last resort when a patient is in severe status asthmaticus. Ventolin See ALBUTEROL. zafirlukast See ACCOLATE.

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READ MORE ABOUT IT Adams, Francis V. The Asthma Sourcebook. New York: McGraw-Hill, 1998. Berger, William E. Asthma for Dummies. New York: Wiley, 2004. Berkowitz, Jonathan M. Asthma: Relax, You’re Not Going to Die. Laguna Beach, Calif.: Basic Health Publications, 2003. Fanta, Christopher H., Lynda Cristiano, and Kenan Haver. The Harvard Medical School Guide to Taking Control of Asthma. New York: Free Press, 2003. Gold, Milton. The Complete Kid’s Allergy and Asthma Guide: Allergy and Asthma Information for Children of All Ages. Dallas: Robert Rose, 2003. Kaufman, Miriam. Easy for You to Say: Q and As for Teens Living with Chronic Illness or Disabilities. Ontario, Canada: Firefly Books, 2005. Paquette, Penny Hutchins. Asthma: The Ultimate Teen Guide. Lanham, Md.: Scarecrow Press, 2006. Plottel, Claudia. 100 Questions and Answers about Asthma. Boston: Jones and Bartlett Publishers, 2005.

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INDEX A AAAAI. See American Academy of Allergy, Asthma and Immunology (AAAAI) AAFA. See Asthma and Allergy Foundation of America (AAFA) abroad, traveling 85–87 acid reflux, home remedies 41 actors with asthma 115–117 additives, triggers of asthma 20–21 Aeroallergen Network 89 African Americans persons at risk for asthma 6 airborne allergens, cutting down 62 airplanes 89, 90 air pollutants, triggers of asthma 19, 66 air quality, associations and resources 105–106 albuterol 32 allergens 5 airborne allergens, cutting down 62 at risk persons for asthma 6 allergic asthma 5. See also allergy and triggers 17 allergy associations and resources 106–107 versus asthma 4–6 and exercise-induced asthma (EIA) 71 triggers of asthma 17 Allergy and Asthma Network Mothers of Asthmatics 81 allergy shots 38 traveling 93

American Academy of Allergy, Asthma and Immunology (AAAAI) 86 National Allergy Bureau (NAB) 88–89 American Lung Association 43, 94 Americans with Disabilities Act of 1990 Title II 59 anabolic steroids 33 Anti-IgE 35, 36 anti-inflammatory agents 35 Aspergillus repens 29 associations and resources 105–113 air quality 105–106 allergy 106–107 asthma 107–109 government organizations 110–111 health services 111–112 respiratory disease 112 school-based asthma concerns 112–113 asthma allergy versus 4–6 associations and resources 107–109 attacks. See asthma flare control of 7 diagnosis. See diagnosis facts 7 fatalities 94 and responsibility 43–44 at risk persons 6–7 school, coping with. See school, coping with asthma

175

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Index

asthma (continued) and social life. See social life, asthma and and sports. See sports, asthma and symptoms. See symptoms and traveling. See traveling, coping with asthma triggers. See triggers of asthma uncontrolled 41 asthma action plan 12–13 following 46 helping others cope with asthma 95 of school 54–55 Asthma and Allergy Foundation of America (AAFA) 81–82 asthma attacks. See asthma flare asthma camps 129–158 Asthma Control Test 43 asthma flare 30–44 allergy shots 38 Asthma Control Test 43 described 2–3 emergency room visits 41–43 emergency treatment at school 52, 55 emotional issues 78–79 exercise-induced asthma (EIA) 66–67, 71–72 facts to know 44 fears of 78–79 heading off attack. See heading off attack home remedies for symptoms 40–41 impending severe flare, recognition of 48 medication 31–38. See also medication peak-flow meter. see peak-flow meter remembering to take medication 39–40

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and responsibility 43–44 severe, warning signs 48 and social life 78–79 and triggers 16 uncontrolled asthma 41 asthma gene 6 athletes with asthma 65, 117–118 at-risk persons 6–7 Atrovent 32

B beta blockers, triggers of asthma 21–22 bitolterol 32 bronchodilators long-acting 34, 36, 69 short-acting 69 Bureau of Primary Health Care 100

C camping 91 Canadian medications 103 cars 90 categories of asthma 10–11 cats, triggers of asthma 17–18 managing 26–27 challenge test 10 chest X-rays 10 cigarette smoke, triggers of asthma 19 managing 24 cockroaches, triggers of asthma 17 managing 24–25 colds, triggers of asthma 19–20 college airborne allergens, cutting down 62 before leaving for 60–61 campus health center 62 dormitories 61–62 exercise 63 inhaler, carrying 62 molds, monitoring 62 personal prevention 62 prescriptions, filling 61 returning home 63

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Index composers with asthma 118–120 contact information while traveling 85 control of asthma 7 corticosteroids 32–33, 35–36 inhaled 34, 70 oral 32–33, 35–36 cough 3 home remedies 40–41

177

dogs, triggers of asthma 17–18 managing 26–27 dormitories, college 61–62 drugs medication for asthma. See medication triggers of asthma 21–22 dust, trigger of asthma 17, 26 dust mites, triggers of asthma 17 managing 28–29

D daily program 13 dancers with asthma 118–120 dancing 80 dating 76–77 definition of asthma 1–2 depression 79 diagnosis 8–14 action plan 12–13 categories of asthma 10–11 challenge test 10 chest X-rays 10 exercise-induced asthma (EIA) 67–68 exercise tests 10 facts 13–14 first appointment 9–10 importance of 2 medical history 9 mild intermittent asthma 10–11 mild persistent asthma 11 moderate persistent asthma 11 peak-flow meter, use of 11–12 pulmonary function tests 9–10 severe persistent asthma 11 skin tests 10 diet and steroids 49 watching 48 directors with asthma 115–117 doctors college, appoint before leaving for 61 regular visits to 47

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E early warning signs, checking for 47 EIA. See exercise-induced asthma (EIA) emergencies. See also emergency room visits ambulance, when to call 96–97 helping others cope with asthma 96–98 at school 52, 55 symptoms 4, 41–43 what to do first 96 emergency room visits 41–43 insurance card 98 paying for 100 what to take to ER 97–98 emotional issues 77–79 depression 79 flares, fear of 78–79 medication, burden of 78 pets, loss of 78 triggers of asthma 23 Environmental Protection Agency 57 Epi-Pen 33 exercise-induced asthma (EIA) 20. See also sports, asthma and and allergy treatment 71 asthma flares 66–67, 71–72 best exercises 72 cause of 66 at college 63 cool-down period 70 dancing 80

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178 Index exercise-induced asthma (continued) diagnosis 67–68 facts to know 74 and general health 70 and humidity 70 and liquids 70 managing 24 monitoring 73–74 Olympic athletes 65 pretreatment 69 at school 54, 74 and swimming 72 symptoms of 66–67 treatment 68–71 warm-up period 70 what to expect 73 when not to exercise 71 worst exercise 72–73 exercise tests 10

F facts to know asthma 7 asthma flare 44 diagnosis 13–14 exercise-induced asthma (EIA) 74 heading off attack 50 helping others cope with asthma 98 paying for care 104 pets, triggers of asthma 27 school, coping with asthma 63 social life, asthma and 82 traveling, coping with asthma 93 triggers of asthma 27, 29 famous people with asthma 115–124 actors and directors 115–117 athletes 65, 117–118 musicians, singers, composers, dancers 118–120 politicians 120–122 scientists 122 writers, thinkers 123–124

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fast breathing 4 fatalities 94 fatigue 4 FDA. See U.S. Food and Drug Administration (FDA) food triggers 18 friends, issues with 76–77 fur, trigger of asthma 17–18 managing 26–27

G genetics and susceptibility to asthma 6 government organizations associations and resources 110–111 grass pollen, triggers of asthma 18–19 managing 18

H heading off attack 45–50 asthma action plan, following 46 diet, watching 48 doctors, regular visits to 47 early warning signs, checking for 47 facts to know 50 impending severe flare, recognition of 48 lifestyle changes 49–50 managing asthma 46–50 medications, taking 47 peak-flow meter, use of 46–47 steroids and diet 49 stress, avoiding 50 triggers, avoiding 47 warning signs of severe flare 48 health care clinics, low-cost 100 health insurance international health insurance companies 125–127

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Index Health Resources and Services Administration (HRSA) Bureau of Primary Health Care 100 health services associations and resources 111–112 heartburn 41 helping others cope with asthma 94–98 emergencies, what to do 96–98 facts to know 98 with medications 95 heredity, at-risk persons for asthma 6 holidays, traveling 91 hotel reservations 87 Hotline for American Travelers 86

I IAQ. See Indoor Air Quality (IAQ) Tools for Schools Action Kit immune system and allergens 5 impending severe flare, recognition of 48 Individuals with Disabilities Education Improvement Act (IDEIA) 59 Indoor Air Quality (IAQ) Tools for Schools Action Kit 57, 58 indoor dust, trigger of asthma 17 managing 26 infections, triggers of asthma 19–20 managing 23–24 inhaled anti-inflammatory agents 34 inhaled corticosteroids 34, 70 inhaled medication 37–38 inhalers 37, 69 insurance emergency room visits, insurance card 98 international health insurance companies 125–127 medical insurance, travel 85

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179

International Association for Medical Assistance to Travelers 86 international health insurance companies 125–127 ipratropium bromide 32 irritants, triggers of asthma 19

K Key Officers of Foreign Service Posts 86

L levalbuterol 32 lifestyle changes 49–50

M managing asthma 46–50 mast-cell stabilizers 69 Medicaid 99, 100 MedicAlert 84, 85 medical history 9 medical insurance, travel 85 medications 31–38 albuterol 32 anabolic steroids 33 Anti-IgE 35, 36 anti-inflammatory agents 35 bitolterol 32 bronchodilators, long-acting 34, 36, 69 bronchodilators, short-acting 69 Canadian medications 103 corticosteroids 32–33, 35–36 costs 101–103 emotional issues 78 Epi-Pen 33 helping others cope with asthma 95 inhaled anti-inflammatory agents 34 inhaled corticosteroids 34 inhaled medication 37–37 ipratropium bromide 32 levalbuterol 32

10/24/07 8:21:31 AM

180 Index medications (continued) long-term control medications 33–37 mast-cell stabilizers 69 metaproterenol 32 methylprednisolone 33 oral corticosteroids 32–33, 35–36 oral leukotriene modifiers 34, 36, 70 patient assistance program Web sites 101–103 pirbuterol 32 prednisolone 33 prednisone 33 quick-relief medications 31–33 remembering to take 39–40 rescue medications, cautions against relying on 81 running out, prevention 37 at school 53, 54 side effects 33 and social life 78 spacers 37–38 steroids 33 taking 47 terbutaline 32 traveling 84–85 types of 31 Xolair 37 metaproterenol 32 methylprednisolone 33 mild intermittent asthma 10–11 mild persistent asthma 11 moderate persistent asthma 11 molds, triggers of asthma 17 college, monitoring 62 managing 25–26 musicians with asthma 118–120

N National Allergy Bureau (NAB) 88–89 National Heart, Lung, and Blood Institute (NHLBI) 56 National Institutes of Health 31

ilwa$$all.indd 180

nonallergic asthma 6 NSAIDs, triggers of asthma 22

O Olympic athletes 65, 69 oral corticosteroids 32–33, 35–36 oral leukotriene modifiers 34, 36, 70 others, helping cope. See helping others cope with asthma outdoor allergic inhalants, triggers of asthma 18 ozone, triggers of asthma 19

P pallor 4 parents, issues with 75–76 patient assistance program Web sites 101–103 paying for care 99–104 Canadian medications 103 emergency room coverage 100 facts to know 104 health care clinics, low-cost 100 Medicaid 99, 100 medications 101–104 patient assistance program Web sites 101–103 peak-flow meter use of 11–12, 16, 38–39, 46–47, 82 zones 12 pets, triggers of asthma 17–18 loss of, emotional issues 78 managing 26–27 school, pets in 58 traveling 87–88 pirbuterol 32 politicians with asthma 120–122 pollen, triggers of asthma 18–19 college, monitoring 62 managing 27–28 traveling 88–89 prednisolone 33 prednisone 33

10/24/07 8:21:32 AM

Index preventing attack. See heading off attack private homes, visiting 87–88 pulmonary function tests 9–10

R race, at-risk persons for asthma 6 ragweed, trigger of asthma 18 Rehabilitation Act of 1973 Section 504 59 rental properties, traveling 87 rescue medications, cautions against relying on 81 respiratory disease associations and resources 112 restless sleep 4 rights of asthma patients at school 58–59 roaches. See cockroaches, triggers of asthma

S school, coping with asthma 51–63. See also college action plan of school 54–55 asthma flare, emergencies 52, 55 asthma-friendly nature of school 55–58 classroom, checking for triggers 53 college, before leaving for 60–61 and exercise-induced asthma (EIA) 54, 74 facts to know 63 going to school versus staying home 59–60 Indoor Air Quality (IAQ) Tools for Schools Action Kit 57, 58 informing school 51–54 medications 53, 54 pets in school 58 rights of asthma patients 58–59 staff training 55

ilwa$$all.indd 181

181

stress 53–54 student asthma action cards 54–55 symptoms, recognition by school 54 teachers, telling 53 school-based asthma concerns associations and resources 112–113 scientists with asthma 122 secondhand smoke, trigger of asthma 19 managing 24 Section 504 of the Rehabilitation Act of 1973 59 severe persistent asthma 11 ships 89 shortness of breath 4 singers with asthma 118–120 skin tests 10 smoke, trigger of asthma 19 managing 24 smoking 80 social life, asthma and 75–82 Asthma and Allergy Foundation of America (AAFA) 81–82 and dancing 80 dating 76–77 emotional issues 77–79 facts to know 82 friends, issues with 76–77 parents, issues with 75–76 rescue medications, cautions against relying on 81 and smoking 80 support groups 80–81 tips for teens 80 spacers 37–38 sports, asthma and 64–74. See also exercise-induced asthma (EIA) traveling 92 status asthmaticus 42 steroids 33 and diet 49

10/24/07 8:21:33 AM

182

Index

stress avoiding 50 school 53–54 student asthma action cards 54–55 sulfites, triggers of asthma 20–21 managing 26 support groups 80–81 sweating 4 swimming 72 symptoms 3–4 cough 3 and diagnosis 9 emergencies 4, 41–43 exercise-induced asthma (EIA) 66–67 fast breathing 4 fatigue 4 home remedies 40–41 pallor 4 restless sleep 4 school, recognition by 54 shortness of breath 4 sweating 4 tightness in chest 4 wheezing 3

T terbutaline 32 thinkers with asthma 123–124 tightness in chest 4, 41 time zones, crossing 92 Title II of the American Disabilities Act of 1990 59 traveling, coping with asthma 83–93 abroad, traveling 85–87 airplanes 89, 90 allergy shots 93 on arrival 91 camping 91 cars 90 contact information 85 facts to know 93 holidays 91 hotel reservations 87

ilwa$$all.indd 182

before leaving 84–90 MedicAlert 84, 85 medical insurance, travel 85 medications 84–85 pollen counts, checking 88–89 pretrip checkup 84 private homes 87–88 rental properties 87 ships 89 solo, traveling 90 sports, vacation 92 time zones, crossing 92 water, drinking while flying 90–91 while traveling 90 treatments. See specific topics trees, triggers of asthma 18 triggers of asthma 2, 15–29 additives 20–21 air pollutants 19, 66 allergies 17 avoiding 47 beta blockers 21–22 cats 17–18, 26–27 cigarette smoke 19, 24 cockroaches 17, 24–25 colds 19–20 dogs 17–18, 26–27 drugs 21–22 dust mites 17, 28–29 emotions 23 exercise-induced asthma (EIA). See exercise-induced asthma (EIA) facts to know 27, 29 figuring out 16–17 food triggers 18 fur 17–18, 26–27 grass pollen 18–19, 27–28 infections 19–20, 23–24 irritants 19 managing 23–29 molds 17, 25–26, 62 NSAIDs 22 outdoor allergic inhalants 18

10/24/07 8:21:34 AM

Index ozone 19 pets 17–18, 26–27, 58, 78, 87 pollen 18–19, 62, 88–89 ragweed 18 at school 53 secondhand smoke 19, 24 smoke 19, 24 stress 50, 53–54 sulfites 20–21, 26 trees 18 tuna fish 21 types of 17–23 weather 22–23, 28 weed pollens 18, 27–28 tuna fish, trigger of asthma 21

183

U.S. Food and Drug Administration (FDA) 21 U.S. State Department Hotline for American Travelers 86

W warning signs of severe flare 48 water, drinking while flying 90–91 weather, trigger of asthma 22–23 managing 28 weed pollens, triggers of asthma 18 managing 18 wheezing 3 writers with asthma 123–124

U uncontrolled asthma 41 U.S. Department of Education 59

ilwa$$all.indd 183

X Xolair 37

10/24/07 8:21:34 AM

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