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

5. 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 don’t use inhaled steroids and in 50% who do • 40% of allergic rhinitis patients have EIA

6. 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 Achievements by Asthmatics

7. 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

8. Pathophysiology of EIB:Theory #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

9. Psychological Stress Aeroallergens Respiratory Infection Respiratory Irritants Exercise

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

11. 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 PFT’s based on history consistent with EIA Only 46% had a positive laboratory exercise challenge test (Rice et al. Ann Allergy 1985) Diagnosis of EIA based purely on symptoms may result in either over or underdiagnosis of the condition leading to the inappropriate use of medications Presentation:Patient Symptom Accuracy

12. 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 Making the Diagnosis:The Medical History

13. 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? Making the Diagnosis:The Medical History

14. Making the Diagnosis:History, 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

15. 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

16. 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

17. 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: >10% drop in FEV1 • Requires access to spirometry to be accurate • PEF less reliable • Requires available trained personnel to administer

18. 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

19. Return to play • Peak expiratory flow • Green- >80% • May compete with observation • Yellow- 50-80% • Treat and watch • Red- <50% • Transfer

20. Environmental Control:Sport 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

21. 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 Behavioral Control:Sport Performance for Asthmatics

22. 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

23. Medical Treatment For AsthmaBeta2-Agonists • Short-acting agents—2 puffs 15-30 minutes prior to activity – lasts 2-4 hours • Albuterol (Proventil) • Terbutaline (Brethaire) • Pirbuterol (Maxair) • Bitolterol (Tornalate) • Long-acting agents—2 puffs 30-60 minutes prior to activity – lasts 8-12 hours • Salmeterol (Serevent) • Formoterol—immediate and long acting

24. 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

25. 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)

26. 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?

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

28. Asthma Treatment • Non-Pharmacologic • Environmental • Behavioral • Pharmacotherapy • Medications • Immunotherapy

29. 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 Concerns Unique to the AthleteControlled Medications and Anti-Doping

30. 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

31. 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

32. Questions??