Asthma and the Athlete

1
Asthma and the Athlete

• William Scott Deitche DO
• Primary Care Sports Medicine Fellow
• Uniformed Services University of the Health
  Sciences
• As adapted from lecture by David Brown, MD

2
Objectives

• Definition
• Epidemiology
• Pathophysiology
• Presentation
• Diagnosis
• Treatment Options
• Concerns Unique to the Athlete

3
Definitions

• Exercise-Induced Asthma (EIA) Transient airway
  narrowing with heightened airway reactivity
  induced by exercise.

4
Asthma Epidemiology

• 7 of U.S. population (14 million)
• 4.8 million children
• Prevalence increasing
• 4 in 10,000 asthmatics die annually

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Asthma in Athletes

• EIA affects 12-15 of college athletes
• 80-90 of asthmatics report exercise as a trigger
• EIA occurs in 80 of asthmatics who dont use
  inhaled steroids and in 50 who do
• 40 of allergic rhinitis patients have EIA

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Achievements by Asthmatics

• 1984 Los Angeles Summer Olympics
• 67 of 597 US athletes had EIA (11.2)
• 41 of these athletes won medals
• 1994 Nagano Winter Olympics
• 17 of US Team had EIA
• 1996 Atlanta Summer Olympics
• 117 out of 699 US athletes had history of asthma
  and/or took medications (16.7)
• 35 of these athletes won medals

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Pathophysiology of EIB Theory 1

• Thermal Hypothesis (cold air)
• Airways are forced to warm large volumes of air
  during exercise
• High ventilation rates and compensatory mouth
  breathing lead to airway cooling
• Rapid airway rewarming post-exercise causes
  reactive hyperemia of the bronchial
  micro-vasculature and edema of the airway wall

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Pathophysiology of EIBTheory 2

• Osmotic Hypothesis (water loss)
• Airways are forced to humidify large volumes of
  dry air during exercise
• High ventilation rates and compensatory mouth
  breathing lead to evaporative water loss
• Airway dehydration causes increased surface
  osmolarity? mast cell degranulation
• ?Chemical mediator release
• ?Bronchial smooth muscle contraction
• ?Increased bronchial blood flow/airway edema

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Psychological Stress
Aeroallergens
Respiratory Infection
Respiratory Irritants
Exercise
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Clinical Presentation

• Classic symptoms
• Cough
• Chest tightness
• Shortness of breath
• Wheezing
• Unrecognized symptoms
• Excessive fatigue after exercise
• Poor exercise tolerance
• Decreased athletic performance

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Presentation Patient Symptom Accuracy

• Diagnosis of EIA based purely on symptoms may
  result in either over or underdiagnosis of the
  condition leading to the inappropriate use of
  medications

• Poor correlation between self-reported symptoms
  and both lab and field challenge tests
• 61 of athletes who were positive on a field test
  reported symptoms
• 45 with a negative challenge reported symptoms
• (Tikkanen et al. Med Sci Sports Exerc 1999)
• Study of college athletes referred for PFTs
  based on history consistent with EIA
• Only 46 had a positive laboratory exercise
  challenge test
• (Rice et al. Ann Allergy 1985)

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Making the DiagnosisThe Medical History

• History of asthma or respiratory symptoms
• Timing of the onset of symptoms
• Duration and severity of symptoms
• Triggers
• ER visits/Hospitalizations/Intubations
• History of allergic rhinitis or atopy
• History of medication use or immunotherapy
• Smoking history
• Family history of asthma or atopy

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Making the DiagnosisThe Medical History

• Useful screening questions
• Have you ever missed school or work due to chest
  tightness, coughing, wheezing, or prolonged
  shortness of breath?
• Do you ever have chest tightness?
• When you exercise, do you often have wheezing?

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Making the DiagnosisHistory, Physical and
Spirometry

• Accurate diagnosis is difficult.
• Physical exam and spirometry usually normal.
• Other conditions have similar symptoms.
• Deconditioning
• GERD
• Vocal Cord Dysfunction (15) (Morris, et al.
  Chest 1999)
• Exertional Hyperventilation
• COPD or other pulmonary disease
• Ischemic or valvular heart disease

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Making the DiagnosisBronchial Provocation Testing

• After baseline PFT
• Bronchial provocation testing (BPT) is essential
  to demonstrate objective evidence of airway
  hyperresponsiveness.
• Methacholine Challenge
• Exercise Challenge
• Eucapnic Voluntary Hyperventilation

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Making the DiagnosisMethacholine Challenge Test

• More sensitive than exercise challenge
• Low specificity at higher doses.
• Other conditions can have a positive MC.
• Allergic Rhinitis (30)
• Vocal Cord Dysfunction
• Chronic Bronchitis (20)
• Smoking

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Making the DiagnosisExercise Challenge

• 8-10 minutes minimum of hard exercise without
  warm-up, following by serial spirometry post
  exercise
• Reproduces environment more accurately
• More sensitive than indoor treadmill tests
• Lack of standardization in methods and
  interpretation of results
• Positive test gt10 drop in FEV1
• Requires access to spirometry to be accurate
• PEF less reliable
• Requires available trained personnel to
  administer

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Making the DiagnosisEucapnic Voluntary
Hyperventilation

• Voluntary hyperventilation of dry air containing
  5 carbon dioxide
• Steady state protocol 85 max ventilation for 6
  minutes
• Similar airway response to exercise at the same
  ventilation
• High specificity for asthma
• 100 with 20 drop of FEV1
• Major problem is access to centers performing the
  test

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Return to play

• Peak expiratory flow
• Green- gt80
• May compete with observation
• Yellow- 50-80
• Treat and watch
• Red- lt50
• Transfer

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Environmental ControlSport Selection for
Asthmatics

• Choose warm, humid environment over cold and dry
• Choose short burst activities over prolonged
  steady exercise
• Avoid asthma triggers especially for outside
  activities

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Behavioral ControlSport Performance for
Asthmatics

• Use of a mask
• Capture heat and water on expiration
• Found successful in reducing severity of EIA
• Would you wear one??
• Nose breathing
• Promotes inhalation of humidified air
• Achieves similar effect as mask
• Natural switch to mouth breathing at 35 L/min

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Medical Treatment For AsthmaBeta2-Agonists

• The most effective drugs for acute symptom relief
• Mechanism
• Relax bronchial smooth muscle?bronchodilation
• Prevent mediator release from mast cells
• Modify contractile effect of mediators on smooth
  muscle
• Short-acting agents used as first line agents for
  pre-treatment prior to exercise in recreational
  athletes and those performing intermittent
  exercise

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Medical Treatment For AsthmaBeta2-Agonists

• Short-acting agents2 puffs 15-30 minutes prior
  to activity lasts 2-4 hours
• Albuterol (Proventil)
• Terbutaline (Brethaire)
• Pirbuterol (Maxair)
• Bitolterol (Tornalate)
• Long-acting agents2 puffs 30-60 minutes prior to
  activity lasts 8-12 hours
• Salmeterol (Serevent)
• Formoterolimmediate and long acting

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Medical Treatment For AsthmaOther Agents

• Non-sedating anti-histamines
• Consider in patients with allergic rhinitis or
  allergic triggers
• Immunotherapy
• For atopic patients not otherwise controlled or
  intolerant of meds
• Base on skin test results
• Caffeine
• Bronchodilator and reduces respiratory muscle
  fatigue

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Medical Treatment For AsthmaInhaled Steroids

• First line therapy for chronic asthma
• Also consider in elite athletes who train nearly
  daily and require consistent prophylaxis
• Inhaled Corticosteroids
• Triamcinolone (Azmacort)
• Beclomethasone (Vanceril, Beclovent)
• Flunisolide (AeroBid)
• Fluticasone (Flovent)

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Case

• 20yo female basketball player.
• Stops running and sits down
• Difficulty catching breath. Complains of chest
  tightness and coughing at this time.
• Rapid respiratory rate (30) and expiratory wheeze
  with poor air movement.
• What do you do?

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Asthma exacerbation treatment

• Baseline Peak Expiratory Flow (PEF)
• Albuterol- 2 puffs now
• Oxygen if available and needed
• Ambulance vs. watch.

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Asthma Treatment

• Non-Pharmacologic
• Environmental
• Behavioral
• Pharmacotherapy
• Medications
• Immunotherapy

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Concerns Unique to the AthleteControlled
Medications and Anti-Doping

• USOC Permitted
• Theophylline
• Cromolyn
• Ipratropium
• USOC Prohibited
• Bitolterol
• Metaproterenol
• Orciprenaline
• Oral, rectal, IM or IV corticosteroids
• Oral or injected Beta-agonists

• USOC notification required and by inhalation only
• Albuterol/Ipratropium
• Albuterol
• Salmeterol
• Formoterol
• Terbutaline
• Beclomethasone
• Budesonide
• Dexamethasone
• Flunisolide
• Fluticasone
• Triamcinolone

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Concerns Unique to the AthleteControlled
Medications and Anti-Doping

• September 2001 IOC Anti-Doping Code Update
• Written notification by a respiratory or team
  physician to the relevant medical authority prior
  to competition including
• Detailed report of symptoms
• Hospital/Clinic medical records
• Evidence f positive bronchodilator test, positive
  exercise challenge test or a positive
  methacholine challenge test
• At the Olympics, athletes who request use of
  inhaled Beta-Agonists will be accessed by an
  independent medical panel

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Summary

• Control of airway inflammation in chronic asthma
  is critical for prevention/treatment of EIA
• Maximize EIA control with attention to
  environment, behavior, and medications
• Sports participation and exercise are both
  beneficial to all patients with asthma
• Asthmatics compete and win at the highest levels
  in sports

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Questions??