Title: Dyspnea and Wheezing in the Athlete
1Dyspnea and Wheezing in the Athlete
- Joel Shaw MAJ, MD
- Primary Care Sports Medicine
- March, 2007
2Objectives
- Definition
- Epidemiology
- Pathophysiology
- Presentation
- Diagnosis
- Treatment
- Differential Diagnosis
3Mandatory Sports Medicine Cartoon
4Definition
- Asthma- reversible airway obstruction caused by
chronic airway inflammation and
hyper-responsiveness. - Exercise-induced bronchospasm (EIB)- transient
and reversible airway narrowing precipitated by
vigorous exercise.
5Epidemiology
- Chronic asthma
- 1997 NIH expert panel on asthma
- 17 million adults in US
- 5 million children
6EIB epidemiology
- 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/atopic dermratitis
patients have EIA - 10 of normal subjects
7Achievements by athletes
- 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
8Olympic B-Agonist Use
- Sydney 2000 gt18 of athletes from Canada, US,
GB, Australia, New Zealand - Sydney 2000 sports variation triathlon 20,
cycling 17, swimming 14.5, track and field 4.1 - Nagono 1988 14-20 in Norway, Sweden, US and
Australia 33 in Netherlands
9EIB in Cross Country Skiers
- Winter vs. Summer Olympics
- 42 elite cross country skiers Pohjantahti Scand
J Med Sci Sports 2005. - 50 of competitive ski mountaineers Durand Int J
Sports Med 2005
10Pathophysiology of EIBTheory 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
11Pathophysiology 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
12Other theories for EIB
- Dog model- airway remodeling similar to asthma
after exposure to cold, dry air. Davis MSSE 2003 - Sputum samples in EIB show increase in
eosinophils. Kanazawa Chest 2002 - Concentration of NO in sputum higher in EIB,
which correlates with vascular permeability - Combination of vascular permeability, drying,
inflammation, and airway remodeling
13Clinical Effects of Cold Air
- Swedish cross country skiers
- 33 incidence vs. 3 age-matched controls
- Norwegian cross country skiers
- 14 compared to 5 age-matched controls
- US winter sports athletes
- 23 incidence, 50 incidence for cross-country
skiers
14Evidence for chronic changes
- Training gt20 hours/week increased risk of asthma
development. - Elite vs. lower level swimmer 21 vs. 11.2
- Endobronchial biopsies cross country skiers
increased T-lymphocyte, macrophage, eosinophil,
basement membrane tenascin expression (marker for
airway modeling) vs. control
15Presentation Patient Symptom Accuracy
- 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)
- Diagnosis of EIA/EIB based purely on symptoms may
result in either over or underdiagnosis of the
condition leading to the inappropriate use of
medications
16Making 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
17Making 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?
18Clinical Presentation
- Classic symptoms
- Cough
- Chest tightness
- Shortness of breath
- Burning chest pain
- Wheezing is rare
- Unrecognized symptoms
- Excessive fatigue after exercise
- Poor exercise tolerance
- Decreased athletic performance
19EIB symptoms
- Most commonly symptomatic after exercise
- 3 to 5 minutes after cessation of exercise
- Peak 10 to 20 minutes after exercise
- Late inflammatory phase
- 2 to 12 hours after exercise
- May persist for 1 or 2 days (URI?)
- 30 of patients with EIB Lacroix Phys Sportmed
1999
20Making the DiagnosisPeak Expiratory Flow
- PEF rate commonly reduced but cannot substitute
for full PFTs - Effort dependent
- Less reproducible than FEV1
- Portable devices varying between manufacturers
- Ambulatory monitoring can help with the
management of asthma - Look for asthma triggers
- Empowers asthmatics to control their disease
- Early signal for exacerbations
- Monitor effectiveness of therapy
21Making the DiagnosisSpirometry
- Measurement of the FEV1 is the best PFT for
diagnosing asthma and assessing severity - Ensure consistent effort/reproducibility
- Spirometry performed looking for baseline
obstruction (FEV1/FVC lt70) - If obstruction perform bronchodilator response
(BDR) - Look for 12 and 200mL improvement
- Baseline PFTs in mild asthmatics and
- patients with EIB are usually normal
22Making 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
23Making 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
- 1999 ATS Guidelines
- When pretest likelihood of asthma is 30-70.
- Negative predictive power gt90
- Positive predictive power 90-98 (at PC20 1mg/ml)
and 70 (at PC20 4mg/ml).
24Making 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
25Making 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
26EVH compared to Exercise
- Similar level of ventilation and inhaled water
content of the inspired air - Airway response on most occasions is delayed to
after the test - Majority of subjects have maximum airway response
within 10 minutes of cessation - Increasing duration of challenge increases the
response - Respond to same drugs
- Production of refractory period
27Environmental ControlAllergen and Irritant
Avoidance
- Dander and Dust mite control
- Mattress covers
- Frequent cleaning
- Avoid carpets
- Choose pets wisely
- Avoid outside activities during peak exposures
- High pollen counts
- Smog/Ozone alerts
28Environmental 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
29Environmental ControlSport Selection for
Asthmatics
- Avoid highly asthmogenic activities
- High minute ventilation
- Distance running
- Cycling
- Soccer
- Basketball
- Rugby
- Cool dry climate
- Ice hockey/ skating, Cross-country skiing
30Environmental ControlSport Selection for
Asthmatics
- Good Choices
- Swimming/Diving
- Gymnastics
- Sprints/Field Events
- Volleyball
- Baseball
- Tennis
- Golf
- Goal Keeper
31Behavioral 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
- Buteyko Breathing Technique
- Developed in 1960sto avoid hyperventilation and
restore CO2 levels to normal - Involves controlled shallow breathing with
intermittent breath holding - Popular in Australia and New Zealand
- Warm-up/Refractory Period
- 30 second sprints vs. continuous low-intensity
warm-up - Shown to induce 1-2 hour refractory period
- May be due to improved bronchial blood flow and
H2O delivery to surface - Only effective in approximately 50 of asthmatics
- Inhibited by NSAIDs
32Asthma exacerbation treatment
- Baseline Peak Expiratory Flow (PEF)
- Albuterol- 2 puffs now
- Oxygen if available and needed
- Ambulance vs. watch.
33Return to play
- Peak expiratory flow
- Green- gt80
- May compete with observation
- Yellow- 50-80
- Treat and watch
- Red- lt50
- Transfer
34Medical 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
35Medical 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
36Medical Treatment For AsthmaBeta2-Agonists
Problems
- Tolerance develops with prolonged, regular use of
Beta-Agonists - Poor asthma control
- Increased bronchial hyperresponsiveness
- May result in reduction in baseline lung function
if underlying inflammation not controlled in
chronic asthmatic - Not recommended for prevention of EIA in regular
exercisers with frequent symptoms or elite
athletes
37Medical Treatment For AsthmaMast Cell Stabilizers
- Stabilize mast cell basement membrane preventing
degranulation - Effective in early and late phase reaction
- No bronchodilator effect
- Sodium cromoglycate (Intal)
- 2 puffs 30 minutes prior to exercise
- Lasts 2 hours
- Nedocromil sodium (Tilade)
- 2 puffs 30 minutes prior to exercise
- Lasts up to 4 hours
38Medical Treatment For AsthmaAcetylcholine
Receptor Antagonist
- Ipratropium (Atrovent)
- Short-acting bronchodilator with duration of 3-5
hours - 2 puffs 15 minutes prior to exercise
- Individual response varies
- Useful as alternate to or in combination with
albuterol or mast cell stabilizer - Consider for
- Beta-agonist intolerance
- Incomplete relief with beta-agonist or mast cell
stabilizer
39Medical Treatment For AsthmaLeukotriene Receptor
Inhibitors
- Daily treatment is effective in preventing
EIA/EIB - Studies show an immediate decreased inflammatory
and bronchoconstrictor response when given prior
to exercise Rundell Br J Sports Med 2005 - Long term they are more effective than salmeterol
- No tolerance is observed
- Leukotrienes are potent inflammatory mediators
- Bronchoconstrictors
- Increase mucus production
- Increase vascular permeability leading to airway
edema - LTIs block action of leukotrienes at the CysLT1
receptor - Montelukast (Singulair) 10mg once daily
- Zafirlukast (Accolate) 20mg twice daily
40Medical 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
41Medical Treatment For AsthmaInhaled Steroids
- Inhaled Corticosteroids
- Triamcinolone (Azmacort)
- Flunisolide (AeroBid)
- Fluticasone (Flovent)
- Advair
- First line therapy for chronic asthma
- Also consider in elite athletes who train nearly
daily and require consistent prophylaxis - Alleviate post-exercise cough
- Frequent late phase symptoms
42New research
- 2 grams Vitamin C 1 hour before exercise- 9/20
patients responded Cohen in Arch Ped Adol Med - Once daily treatment with Singulair at bedtime
blocked 47 fall in FEV1 NEJM July 98 - Omega 3 Polyunsaturated fatty acids (fish oil
supplementation) blocked 80 of fall in FEV1
Mickleborough Am J Resp Crit Care Med 2003 - Inhaled heparin blocked 78 of drop when used 1
hour before exercise
43Medical Treatment For AsthmaStepwise Approach
- Mild Intermittent
- Beta2 agonist or mast cell stabilizer as needed
- Mild Persistent
- Inhaled low-potency corticosteroid
- Short-acting Beta-agonist as needed
- /- long acting Beta agonist or leukotriene
inhibitor
- Moderate Persistent
- Inhaled medium-potency corticosteroid
- Long-acting beta agonist
- Leukotriene inhibitor
- Short-acting Beta-agonist as needed
- Severe Persistent
- As above but increase to high-potency steroid
Consider immunotherapy if atopic
44EIB Treatment Algorithm
Continue treatment Reassess regularly
Pre-Exercise Treatment
Assess Response
Adequate
Control
Inadequate Control
Adequate Control
Add daily medications step-wise
Inadequate Control
Maximize medications Evaluate for other
conditions Bronchoprovocation testing
45Concerns Unique to the Athlete
- Most studies indicate increase in muscle strength
and endurance in non-asthmatics who use
Beta-Agonists - Salbutamol increased strength in 16 of 16 and
endurance in 10 of 16 non-asthmatic men tested
Van Baak MSSE 2000 - Athletes believe it is ergogenic
- IOC ban suggests experts believe the same
46Concerns 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
47Concerns 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 1
week prior to competition including - Detailed report of symptoms
- Hospital/Clinic medical records
- Evidence of 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 - Questionable cases will be retested prior to Games
48EIB Testing in the 2002 Winter Olympics
- 135 of 147 EIB challenge tests were approved
- FEV1 response to bronchodilators averaged 16.2
- ECT led to 15.9 average drop in FEV1
49Controlled Medications and Anti-Doping
- Medication information and documentation
requirements - World Anti-Doping Agency (WADA)
- www.wada-ama.org
- United States Anti Doping Agency (USADA)
- www.usantidoping.org
50Differential Diagnosis
- All that wheezes is not asthma.
- Asthma doesnt always wheeze.
51Differential Diagnosis
- Vocal cord dysfunction
- Gastroesophageal reflux disease
- Chronic inflammatory asthma-like condition
- Laryngopharungeal reflux
52Vocal Cord Dysfunction- Prevalence
- 10-15 of unresponsive asthma
- Correlation with psychiatric disorder
- Femalemale gt 21
- Age 20-40 yoa
53Vocal Cord Dysfunction- Pathogenesis
- Vocal cord closing
- Normal- during inspiration
- VCD- during expiration
- Triggers
- URI
- Exposure (smoke, chemicals, pollution)
- Stress
- GERD
- Cold air
- Exercise
54Vocal Cord Dysfunction- Symptoms
- Dyspnea
- Wheeze
- Cough
- Chest tightness
55Vocal Cord Dysfunction- Physical Exam
- Normal at rest
- Stridor
- During or after exercise
- Often early in exercise
- During stressful situations
56Vocal Cord Dysfunction- Diagnosis
- PFTs
- Flattening of inspiratory loop
- Only positive if performed while symptomatic
- Direct Laryngoscopy
- Gold standard
- Performed when patient is symptomatic
57Vocal Cord Dysfunction- Treatment
- Classic asthma medications
- Usually no change unless combined disorder
- Breathing exercises
- Abdominal breathing?relax upper respiratory
musculature - Stress management
- Medications
- Heliox (20-40 helium in O2)
- Botulinum toxin injection
58GERD
- Common in asthmatic patients
- 199 asthmatic patients 82 reflux symptoms, 72
esophageal pH testing Harding Chest 1999 - Adults with asthma 77 heartburn, 55
regurgitation, 24 dysphagia Field Chest 1996 - Children with asthma similar GERD rate to adults
based on 24 hour esophageal pH testing Harding Am
J Med 2003
59GERD as trigger for asthma
- Not proven
- Proposed meachnisms
- Aspiration/microaspiration in tracheobronchial
tree - Acid-induced esophago-bronchial vagal reflexes
mediated by receptors in esophageal wall
60GERD and Asthma
- 1- Stimulation of vagal afferents
- Microaspiration
- Acid refluxed directly onto esophageal epithelium
- 2- Airway vagal efferent response
- 3- Pulmonary neuroinflammatory changes
- Airway edema
- Mucus production
- Inflammation
- Bronchial smooth muscle constriction
61Treatment of GERD for Respiratory Symptoms
- Non-pharmacologic
- Diet
- Food type
- Meal timing
- Raise head of bed
- Weight control
- Stress management
- Avoid tobacco products
- Medications
- H2-blockers
- Proton pump inhibitors
62GERD treatment
- Is GERD treatment beneficial for asthma
- May improve subjective symptoms
- May reduce medication requirements
- No evidence of improved lung function by
spirometry
63GERD response to Albuterol
- Effects of Albuterol
- Reduction of LES tone
- Reduction of esophageal contraction amplitude
64Chronic Inflammatory Asthma-like Condition
- Cold weather athletes
- High ventilation rates under specific conditions
- Cold, dry air
- Exposure to volatized fluorocarbons (ski wax
rooms) - Exposure to exhaust from ice resurfacing machines
65Chronic Inflammatory Asthma-like Condition
- Airway remodeling pathologically different from
asthma - Similar symptoms to EIB
- May not respond to Albuterol
- EIB short-track speedskaters did not improve
airway function with Albuterol Wilber Chest 2001 - Inflammation not addressed (inhaled steroids)
- Consider in-rink testing
66Laryngopharyngeal reflux
- Prevalence
- Unknown
- Pathogenesis
- Reflux reaches the UES causing irritation of the
larynx and pharynx - Small amounts of acid exposure can cause
significant irritation
67Laryngopharyngeal Reflux- Symptoms
- Hoarseness
- Excess mucus
- Throat clearing
- Globus
- Cough
- Dysphagia
- Heartburn is RARE
68Laryngopharyngeal Reflux- Diagnosis
- Physical exam
- Typically normal
- Diagnostic tests
- 24 hour pharyngo-esophageal pH monitoring
- Nasopharyngolaryngoscopy
- Erythema
- Edema
- Ulceration
69Laryngopharyngeal Reflux- Treatment
- Classic, non-pharmacologic GERD treatments
- H2-blockers
- Proton Pump Inhibitors
70Summary
- Control of airway inflammation in chronic asthma
is critical for prevention/treatment of EIB - Maximize EIB control with attention to
environment, behavior, and medications - Remember other causes of wheezing
- Sports participation and exercise are both
beneficial to all patients with asthma - Asthmatics compete and win at the highest levels
in sports
71Questions??