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Title: Dyspnea and Wheezing in the Athlete


1
Dyspnea and Wheezing in the Athlete
  • Joel Shaw MAJ, MD
  • Primary Care Sports Medicine
  • March, 2007

2
Objectives
  • Definition
  • Epidemiology
  • Pathophysiology
  • Presentation
  • Diagnosis
  • Treatment
  • Differential Diagnosis

3
Mandatory Sports Medicine Cartoon
4
Definition
  • 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.

5
Epidemiology
  • Chronic asthma
  • 1997 NIH expert panel on asthma
  • 17 million adults in US
  • 5 million children

6
EIB 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

7
Achievements 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

8
Olympic 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

9
EIB 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

10
Pathophysiology 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

11
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

12
Other 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

13
Clinical 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

14
Evidence 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

15
Presentation 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

16
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

17
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?

18
Clinical 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

19
EIB 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

20
Making 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

21
Making 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

22
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

23
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
  • 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).

24
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

25
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

26
EVH 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

27
Environmental 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

28
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

29
Environmental 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

30
Environmental ControlSport Selection for
Asthmatics
  • Good Choices
  • Swimming/Diving
  • Gymnastics
  • Sprints/Field Events
  • Volleyball
  • Baseball
  • Tennis
  • Golf
  • Goal Keeper

31
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
  • 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

32
Asthma exacerbation treatment
  • Baseline Peak Expiratory Flow (PEF)
  • Albuterol- 2 puffs now
  • Oxygen if available and needed
  • Ambulance vs. watch.

33
Return to play
  • Peak expiratory flow
  • Green- gt80
  • May compete with observation
  • Yellow- 50-80
  • Treat and watch
  • Red- lt50
  • Transfer

34
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

35
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

36
Medical 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

37
Medical 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

38
Medical 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

39
Medical 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

40
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

41
Medical 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

42
New 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

43
Medical 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
44
EIB 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
45
Concerns 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

46
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

47
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 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

48
EIB 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

49
Controlled 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

50
Differential Diagnosis
  • All that wheezes is not asthma.
  • Asthma doesnt always wheeze.

51
Differential Diagnosis
  • Vocal cord dysfunction
  • Gastroesophageal reflux disease
  • Chronic inflammatory asthma-like condition
  • Laryngopharungeal reflux

52
Vocal Cord Dysfunction- Prevalence
  • 10-15 of unresponsive asthma
  • Correlation with psychiatric disorder
  • Femalemale gt 21
  • Age 20-40 yoa

53
Vocal Cord Dysfunction- Pathogenesis
  • Vocal cord closing
  • Normal- during inspiration
  • VCD- during expiration
  • Triggers
  • URI
  • Exposure (smoke, chemicals, pollution)
  • Stress
  • GERD
  • Cold air
  • Exercise

54
Vocal Cord Dysfunction- Symptoms
  • Dyspnea
  • Wheeze
  • Cough
  • Chest tightness

55
Vocal Cord Dysfunction- Physical Exam
  • Normal at rest
  • Stridor
  • During or after exercise
  • Often early in exercise
  • During stressful situations

56
Vocal Cord Dysfunction- Diagnosis
  • PFTs
  • Flattening of inspiratory loop
  • Only positive if performed while symptomatic
  • Direct Laryngoscopy
  • Gold standard
  • Performed when patient is symptomatic

57
Vocal 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

58
GERD
  • 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

59
GERD 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

60
GERD 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

61
Treatment 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

62
GERD treatment
  • Is GERD treatment beneficial for asthma
  • May improve subjective symptoms
  • May reduce medication requirements
  • No evidence of improved lung function by
    spirometry

63
GERD response to Albuterol
  • Effects of Albuterol
  • Reduction of LES tone
  • Reduction of esophageal contraction amplitude

64
Chronic 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

65
Chronic 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

66
Laryngopharyngeal reflux
  • Prevalence
  • Unknown
  • Pathogenesis
  • Reflux reaches the UES causing irritation of the
    larynx and pharynx
  • Small amounts of acid exposure can cause
    significant irritation

67
Laryngopharyngeal Reflux- Symptoms
  • Hoarseness
  • Excess mucus
  • Throat clearing
  • Globus
  • Cough
  • Dysphagia
  • Heartburn is RARE

68
Laryngopharyngeal Reflux- Diagnosis
  • Physical exam
  • Typically normal
  • Diagnostic tests
  • 24 hour pharyngo-esophageal pH monitoring
  • Nasopharyngolaryngoscopy
  • Erythema
  • Edema
  • Ulceration

69
Laryngopharyngeal Reflux- Treatment
  • Classic, non-pharmacologic GERD treatments
  • H2-blockers
  • Proton Pump Inhibitors

70
Summary
  • 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

71
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