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Asthma has been defined as a chronic inflammatory disorder of the airways that is characterized by variable airway obstruction and bronchial hyperresponsiveness that may lead to ongoing bouts of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.1 Although asthma cannot be cured airflow limitation is often reversible. However, if asthma is left untreated, ongoing asthma symptoms may result in chronic irreversible airway obstruction. For some asthma is a minor nuisance, while others may have problems with daily activities or suffer severe life-threatening asthma attacks. Asthma often changes over time, so it’s important to work with doctors and specialists to track signs and symptoms, and adjust treatment as needed. It isn’t clear why some people get asthma and others don’t, but it’s probably due to a combination of environmental and genetic factors. A number of factors are thought to increase the chances of developing asthma; these include:2

⦁ Having a blood relative (such as a parent or sibling) with asthma
⦁ Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever)
⦁ Being overweight
⦁ Being a smoker
⦁ Exposure to secondhand smoke
⦁ Having a mother who smoked while pregnant
⦁ Exposure to exhaust fumes or other types of pollution
⦁ Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing
⦁ Having some types of bacterial or viral infections
⦁ Exposure to certain germs or parasites

Exposure to various allergens and irritants can trigger signs and symptoms of asthma. Asthma triggers are different from person to person and can include:1-2

⦁ Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust mites
⦁ Respiratory infections, such as the common cold
⦁ Physical activity (exercise-induced asthma)
⦁ Cold air
⦁ Air pollutants and irritants, such as smoke
⦁ Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)
⦁ Strong emotions and stress
⦁ Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine
⦁ Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
⦁ Menstrual cycle in some women

Asthma symptoms range from minor to severe, and vary from person to person. For some people, asthma symptoms flare up in certain situations, such as:1-2

⦁ During exercise (Exercise-induced asthma), which may be worse when the air is cold and dry
⦁ During work (Occupational asthma), triggered by workplace irritants such as chemical fumes, gases or dust
⦁ When exposed to a specific allergen (Allergy-induced asthma), triggered by particular allergens, such as pet dander, cockroaches or pollen

Others suffering from asthma may have symptoms all the time. Proper treatment of asthma makes a big difference in preventing both short-term and long-term complications caused by asthma, which can include:1-2

⦁ Symptoms that interfere with sleep, work or recreational activities
⦁ Sick days from work or school during asthma flare-ups
⦁ Permanent narrowing of the bronchial tubes (airway remodeling) that affects how well you can breathe
⦁ Emergency room visits and hospitalizations for severe asthma attacks
⦁ Side effects from long-term use of some medications used to stabilize severe asthma

Asthma is typically associated with the following signs and symptoms:2

⦁ Shortness of breath
⦁ Chest tightness or pain
⦁ Trouble sleeping caused by shortness of breath, coughing or wheezing
⦁ A whistling or wheezing sound when exhaling
⦁ Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu

If an individual develops only hives (only skin problems), administration of an antihistamine, shall be considered. A plan for close observation of the athlete for additional symptoms over the next 6hrs shall then be developed, including counseling the athlete, parent/guardian, and coaches in instructions for what to do if symptoms progress.

Metered Dose Inhaler (MDI)
An MDI is an aerosol canister filled with medicine that is housed in a plastic holder with a mouthpiece. To ensure proper function and that medication is available when needed, the medical team shall counsel all athletes with a MDI in the proper care and maintenance of their MDIs. Counseling shall include the following steps for cleaning the MDI and monitoring reliever medication dosages:3,4,6,7

⦁ MDIs with removable canisters should be cleaned weekly by removing the canister and rinsing the plastic holder with warm running water to prevent the holes from getting clogged. Shake the MDI well and allow to air dry completely.
⦁ MDIs which do not have removable canisters shall be cleaned by wiping the mouthpiece with a cloth or cleaning with a cotton swab. Refer to the patient instructions that come with each MDI for specific cleaning instructions.
⦁ It is important to monitor how much medication is left in an MDI. Most inhalers have counting devices built in. Remember to watch the counter and replace the inhaler when the counter is on zero.
⦁ There are a few inhalers that do not have a built-in counter. For these, remaining dosage must be tracked by tallying how many puffs have been administered, including priming puffs. The number of puffs contained in an MDI is printed on the side of the canister. If an MDI is used every day for control of symptoms, the life of the MDI can be calculated by dividing the total number of puffs in the inhaler by the total daily puffs prescribed. For example: 2 puffs x 2 times per day = 4 total puffs per day. If there are 120 puffs, the MDI will last 30 days. If an MDI is used only when needed, keep track of how many times the MDI is sprayed, including priming sprays.

If an athlete presents with signs and symptoms of asthma that include wheezing, the medical team will consider treatment with reliever medication using a MDI. If the athlete is familiar with the use of a MDI and is not in any particular distress that would limit the effective administration of medication via proper use of the MDI, the medical team shall counsel the athlete in proper administer reliever medication via the MDI as follows:5

1. Prime the MDI by spraying one or more puffs into the air before use to make sure that the inhaler is ready to use and will deliver the correct dose of medication. Priming may be different for each medication, so it is important to read the patient instructions that come with your inhaler.
2. Remove the cap from the MDI and shake well for 5 seconds.
3. Breathe out all the way.
4. Keep chin up.
5. Place the mouthpiece of the inhaler between teeth and seal lips tightly around it.
6. Breathe in slowly while simultaneously pressing down on the canister one time.
7. Keep breathing in slowly to completely fill lungs. (It should take about 5 to 7 seconds to completely breathe in.)
8. Hold breath for 10 seconds to allow the medication to reach the airways of the lung.
9. Repeat the above steps for each puff ordered by your doctor. Wait about 1 minute between puffs.
10. Replace the cap on the MDI when finished.

Spacing Chambers
Spacing chambers hold the MDI spray medication, making it easier to use the MDI and can help get the medication into the lungs more effectively for athletes who are having trouble using an MDI. To ensure proper function of a spacing chamber the medical team shall counsel the athlete in proper care and maintenance of their valve holding chamber, including:6

⦁ Clean the chamber about once a week. Remove the soft ring at the end of the chamber. Soak both the chamber and soft ring in warm water with a mild detergent. Carefully clean, rinse in clear water, and shake well. Allow to air dry completely.

If an athlete is in mild distress that may affect his or her ability to effectively deliver reliever medication via a MDI, the medical team may consider use of a spacing chamber. A spacing chamber shall also be used if using a corticosteroid MDI. When administering medication via a spacing chamber, the medical team shall counsel the athlete in proper use as follows:

1. Remove the cap from the MDI and chamber.
2. Shake well for 5 seconds.
3. Insert the MDI into the open end of the chamber (opposite the mouthpiece).
4. Breathe out all the way.
5. Keep chin up.
6. Place the mouthpiece of the chamber between teeth and seal lips tightly around it.
7. Press the canister once.
8. Breathe in slowly through mouth to completely fill lungs. If a “horn-like” sound is heard, the athlete is breathing in too quickly and needs to slow down.
9. Hold breath for 10 seconds (count to 10 slowly) to allow the medication to reach the airways of the lung.
10. Repeat steps 2-8 for each puff ordered by doctor. Wait about 1 minute in between puffs.
11. Replace the cap on the MDI when finished.
12. If using a corticosteroid MDI, rinse mouth and gargle using water or mouthwash after each use.

Positive Pressure Nebulizer
Many medications are available as inhaled treatments. Inhaled methods deliver medication directly to the airway, which is helpful in cases when athletes are unable to self-administer reliever medication using an MDI or an MDI with a holding chamber.

A nebulizer delivery system consists of a nebulizer (small plastic bowl with a screw-top lid) and a source for compressed air. The air flow to the nebulizer changes the medication solution to a mist. When inhaled correctly, the medication has a better chance to reach the small airways. This increases the medication’s effectiveness.

When available the medical team may consider administering reliever medications via a nebulizer. This may require having an appropriate team member escort the athlete to the nurse’s office. To initiate a nebulizer treatment, be sure to refer to manufacturer’s specific instructions for use. General assembly and treatment instructions for a nebulizer and air compressor are as follows:4

1. Place the compressor where it can safely reach its power source and where you can reach the ON/OFF switch.
2. Wash hands prior to preparing each treatment.
3. Use a clean nebulizer.
4. Measure the correct dose of medication and other solutions prescribed and add these to the nebulizer.
5. Connect the air tubing from the compressor to the nebulizer base. Make sure all connections are snug.
6. Attach a mask to the nebulizer.
7. Turn the compressor on and check the nebulizer for misting.
8. If the nebulizer is not misting, check all connection.

The medical team administering reliever medication via a nebulizer shall counsel the athlete in proper use of the nebulizer as follows:

1. Hold the mask to the face so both the nose and mouth are covered. The mask may be secured to the head with an elastic band.
2. Turn the compressor on to start the mist. The head should be held upright. This correctly positions the nebulizer and opens the airway.
3. Assure deep breathing throughout the treatment.
4. Occasionally tapping the side of the nebulizer helps the solution to drop to where it can be misted.
5. Continue the treatment until the onset of inconsistent nebulization, i.e. sputtering.

Follow the manufacturer’s instructions for cleaning the nebulizer equipment. The tubing should be replaced every two weeks because it is difficult to clean. Follow the manufacturer’s instructions for care and cleaning the compressor. Some suggested cleaning guidelines include:

1. Take apart the nebulizer. Wash all parts (except tubing and finger valve) in liquid dish soap and water. Rinse with water.
2. After washing the nebulizer shake off any excess water.
3. Reattach the nebulizer pieces and tubing to the air compressor and turn on the compressor to dry the nebulizer quickly. Make sure the nebulizer is completely dry before storing the nebulizer.

The nebulizer should be sterilized every other treatment day. Boiling the nebulizer components is the preferred method if your nebulizer can be boiled.

1. Boiling Water
2. Wash your hands.
3. Take the nebulizer apart.
4. Put all the parts of the PARI LC JET+ TM except the mask, tubing and interrupter in boiling water for 10 minutes.
5. After boiling the nebulizer shake off any excess water
6. Reattach the nebulizer pieces and tubing to the air compressor and turn on the compressor to dry the nebulizer quickly.
7. Make sure the nebulizer is completely dry before storing the nebulizer.

If boiling nebulizer components is not suggested use a vinegar and water solution to soak all parts as follows:

1. Wash your hands.
2. Soak all parts of the nebulizer (except mask, tubing and interrupter) for 1 hour in a solution of 1 part distilled white vinegar and 3 parts hot water. The solution should be fresh. Remove the parts from the vinegar solution and rinse them in water. Discard the solution.
3. Shake off any excess water.
4. Reattach the nebulizer pieces and tubing to the air compressor and turn on the compressor to dry the nebulizer quickly. Make sure the nebulizer is completely dry before storing the nebulizer.

Pre-Hospital Care Management Of An Acute Asthma Attack
When the medical team has provided for the administration of any reliever medications, including antihistamines, due to the onset of signs and symptoms of asthma, the following steps shall be taken as deemed appropriate:

  1. Issue and review anaphylaxis/asthma warning sheet with athlete and parent/guardian;
  2. Observe closely for additional symptoms over the next 6 hours. Counsel athlete and parent/guardians in signs and symptoms of an asthma emergency, including:
    a. Rapid worsening of shortness of breath or wheezing
    b. No improvement even after using a quick-relief inhaler, such as albuterol
    c. Shortness of breath with minimal physical activity
  3. If the individual develops signs and symptoms of severe reaction (anaphylaxis) or respiratory distress, immediately:
    a. Inject Epinephrine IM: Dose □ 0.15mg (Infant/child Epi-pen Jr.) □ 0.30mg (Adult);
    b. Give additional dose of Diphenhydramine (Benadryl) _____mg by mouth;
    c. Have athlete lie down, feet elevated, monitor vital signs;
    d. Maintain a patent airway;
    e. Be prepared to suction any secretions;
    f. Administer oxygen therapy with non-rebreather device;
    g. Be prepared to assist ventilation with positive pressure ventilation with bag-valve-mask;
    h. Activate EMS for immediate transport to appropriate receiving facility.
    i. Document time, suspected allergen if known, and response steps taken to activate EMS;
    j. Be prepared to administer a second dose Epinephrine IM after 15 minutes if symptoms degrade or recur.
  4. Report administration to appropriate EAP personnel.

Prevention Guidelines
During a pre-participation screen the medical team shall obtain a thorough medical history that includes signs and symptoms indicating the presence of asthma. The medical team shall counsel athletes who suffer frequent coughing or wheezing that last more than a few days, or who demonstrate any other signs and symptoms of asthma to seek advice from their physician. These signs and symptoms include:

⦁ Chest tightness;
⦁ Coughing;
⦁ Shortness of breath;
⦁ Wheezing;
⦁ Unable to catch their breath;
⦁ Exercise-induced symptoms;
⦁ Labored breathing;
⦁ Exacerbation of symptoms when exposed to allergens;
⦁ Family history;
⦁ Hay fever.

Those athletes with known asthma shall be advised to monitor their asthma to keep it under control in order to feel better and prevent a life-threatening asthma attack. Athletes with known asthma shall be further advised to:

1. Contact their physician immediately if asthma symptoms worsen, if medication doesn’t seem to ease symptoms, if there is a more frequent need for quick-relief inhaler use;
2. Not try to solve increased asthma symptoms by taking more medication without consulting your doctor as overusing asthma medication can cause side effects and may make your asthma worse;
3. To review asthma treatment.

Asthma often changes over time. Meet with doctor on a regular basis to discuss symptoms and make any needed treatment adjustments, and to their specialist if signs and symptoms of worsening asthma are observed, including:

a. Asthma signs and symptoms that are more frequent and bothersome;
b. Increasing difficulty breathing;
c. The need to use a quick-relief inhaler more often.

Readiness Supplies
Basic Life Support Supplies
⦁ BLS airway adjuncts
⦁ Heart rate monitor
⦁ Blood pressure monitor
⦁ Pulse Oximeter

Protocol Specific Supplies
⦁ Spacing Chamber
⦁ Nebulizer
⦁ Antihistamine
⦁ 1st and 2nd dose epinephrine auto-injector
⦁ Oxygen
⦁ Non-rebreather mask