More than 4.8 million American children under 18 have been diagnosed with asthma—and as many as 20 percent more have it, but don't know it yet. That makes asthma the most prevalent chronic condition among children.

In 1993, asthmatics under 15 made 159,000 trips to the emergency room and missed 10 million days of school. Between 1980 and 1994, the prevalence of asthma increased by 75 percent overall.

Asthma is more than an inconvenience: More than 5,000
people die of asthma each year, according to the Centers for Disease Control—and deaths are on the increase.

Spotting a Trend
It was the well-publicized deaths from asthma of two high school athletes in the Philadelphia area eight years ago that got James W. Rogers, ATC, an athletic trainer at Temple University, to thinking. Rogers had noticed increasing numbers of high school athletes bringing inhalers to games. But he wondered if some of the other young athletes he worked with might have undiagnosed asthma.

Rogers felt that while young athletes were being routinely screened for rather rare conditions, asthma and allergies were becoming rampant. (More than 70 percent of people with asthma also suffer from allergies.) "We were checking for hernias and high blood pressure, which almost no kids have," recalls Rogers, "but we weren't checking for asthma."

When he started asking kids about allergies and breathlessness, he found out that many of them had symptoms of asthma. "They thought everyone felt that bad," Rogers says. "They had no frame of reference."

Exercise-induced asthma, or a slightly different condition called exercise bronchospasm, results from obstruction within the airways. The airways in asthma sufferers' lungs are chronically inflamed—this inflammation can be made worse by exercise, or by exposure to allergens, chemicals, viruses or cold air. This is when someone diagnosed with asthma feels the need to take a "rescue" puff of his or her inhaler.

If asthma is being properly treated with appropriate dosages of long-acting medications such as steroids, the need for "rescue bronchodilation" is much reduced.

But if a youngster does not have an inhaler or does not know he or she has asthma, the sudden, acute inflammation of the airways can be so severe that it necessitates a trip to the emergency room.

Rogers' Study
Rogers and colleagues from the Temple School of Medicine decided to take a closer look at the question of undiagnosed asthma among student athletes. The results of their study were published in Chest, the periodical of the American College of Chest Physicians, in 1998.

In the study, they pointed out that exercise-induced bronchospasm affects over a third of athletes and 90 percent of asthmatics. A simple running test, they postulated, could be used to screen athletes for asthma.

Rogers and his colleagues tested 238 male high school varsity football players. The players answered a questionnaire about family and asthma history and then undertook a 1-mile outdoor run, out there amidst the fumes and pollen, instead of in an air-conditioned pulmunologist's office. After the run, peak expiratory flow (a measure of the amount of air an individual can expel in a single forceful breath, as recorded by an air flow meter) was measured at several intervals. If an athlete's PEF went down 15 percent at any of the intervals after the run, exercise-induced bronchospasm (not enough air getting through) was diagnosed.

Using these approaches, Rogers picked up previously undiagnosed asthma in 8 percent of the young athletes. He continues to test today, finding 8 percent to 24 percent of athletes coming on to the teams he works with have asthma or are at risk. Surprisingly, Rogers gets the same kind of results when he tests NFL teams, even with all the medical care the pros get.

The Case for Outdoor Testing
In another test of 28 football players done at Temple, 10 were found by Rogers to be at risk. Of those 10, six failed to complete the 1-mile run. He sent four of those to his colleague, Dr. Gilbert D'Alonzo, professor of pulmonary and critical care at Temple.

D'Alonzo says he was amazed when Rogers first approached him. The two of them started finding 15 percent incidences of unrecognized asthma, he recalls. They were also turning up undertreated cases—kids who were being treated for asthma, but had to use "rescue" medications frequently.

Rogers and Alonzo believe the key is testing kids outdoors, where the triggers of acute asthma episodes are more likely to be found than inside an office. Again and again, D'Alonzo says, he would see the same thing: "On the field, drop in airflow. In the doctor's office, normal."

Rogers also tests kids in the gym and at poolside. The place to test, he thinks, is where the risk is highest—and where the athlete will spend the most time, inhaler at hand or not.

Barriers to Field-Testing Kids
It won't be easy to institute widespread field-testing to screen children for asthma.

For one thing, says Christopher Randolph, MD, a practicing allergist and associate clinical professor at Yale University, Rogers is talking about athletes. "Most kids can't run a mile," he points out.

Peak flow testing, he adds, is not the most reliable screening measure. (Sometimes asthmatics experience no drop in peak flow.) A more reliable technique, spirometry, however, uses a very expensive machine and is not practical for mass screening.

One approach, Randolph says, might be to screen youngsters using a questionnaire and a "step test" (patients step off and on a little step platform) rather than a run. Those who showed possible signs of asthma could be tested with a spirometer.

This technique, tested in Birmingham, Alabama, on a large sample of 6,000 children, ferreted out asthma in 30 percent. "Kids who can't run can step on the stool," Randolph says.

Even this more modest level of physical testing may not become the standard anytime soon.

Trying to Ask the Right Questions
A recent effort to pilot more comprehensive asthma screening in four communities revealed some of the barriers to action.

Allen Leahigh is associate executive director of the American College of Allergy, Asthma & Immunology (ACAAI). The ACAAI recently put out a call for communities to describe how they would use $100,000 each to screen for asthma using questionnaires alone. Of the 67 communities that responded, four were chosen—Chicago, Cleveland, Dallas, and Rochester, Minnesota.

The Rochester results were discouraging. Barbara Yawn, MD, MSc, FAAP, director of research at the Olmsted Medical Center in Rochester and a clinical professor at the University of Minnesota, tested 8,000 kids from K-12, using a questionnaire for the kids and a separate one for the parents.

All the kids returned theirs (they were done in class), and 84 percent of parents responded. The researchers asked whether the child was known to have asthma, was coughing, was waking up coughing, had colds that lasted more than three weeks, had visited the ER for breathing problems, had taken over the counter medicines and so on.

According to the parents, 20 percent of the children tested had been diagnosed with asthma or reactive airway disease. Of that number, 13 percent reported that their kids had been coughing, wheezing, or having breathing problems four or more days in the previous two weeks, indicating poorly controlled disease.

However, the real problem came, Yawn says, when researchers sent home notices to the parents of children considered at risk of undiagnosed or under-treated asthma because of their questionnaire results, recommending the children see a doctor.

Fewer than half of the parents notified followed up by taking their kids to the doctor, and most of those were parents whose children already had been diagnosed with asthma. Only 12 percent of those who had never been told before that their children could have asthma consulted a physician. Because of this, the number of new cases definitively diagnosed and treated as a result of the questionnaire was negligible.

Although she is now doing a study comparing questionnaire results with the results of physical tests, Yawn is skeptical of the prospects for universal asthma testing. "The questionnaires were better in getting help for children who were being poorly or under-treated," she remarks, than in ferreting out undiagnosed cases. "Maybe this would be a better place to spend our money."

National Testing Unlikely?
Nevertheless, the ACAAI hopes to combine the approaches of the four pilot sites and create an effective questionnaire that teachers—not allergists or athletic trainers—can administer. A national program of mandatory testing, such as is done for vision problems, however, is pie in the sky, Leahigh thinks.

Yawn and Rogers both are concerned that asthma may carry a stigma—may not be "sporty" or "macho" enough for parents to admit their children may have it. Rogers counters this by pointing out that a number of Olympic gold medallists have asthma.

Yawn also says some parents are afraid of steroids, which are very effective in controlling asthma. "Kids who take inhaled steroids and have their asthma in good control," she says, "take in more oxygen, feel better, and thus eat and grow better. They also can exercise."

Of course, nothing can stop individual school systems from recruiting an allergist and taking athletes out on the track, measuring peak flow, and blowing the whistle for a 1-mile run.

"This should be our standard of care," Rogers maintains.

Resources

• American Lung Association Open Airways for Schools program. [1]
• About.com asthma [2]
• More on the American College of Allergy, Asthma & Immunology's pilot program [3]

---

Star Lawrence is a medical journalist based in the Phoenix area. Her work also appears weekly on WebMD.