Vol. 11 •Issue 5 • Page 50
Full-Court Press Against Exercise-Induced Asthma
The death of a Northwestern University football star last year reminds us of the often unpredictable nature and potential seriousness of asthma when it’s not controlled. Rashidi Wheeler was a 22-year-old senior who played safety. While participating in a preseason conditioning drill in August, he died from an asthma attack.
Asthma flare-ups were common for this young athlete. His coaches, athletic trainers and teammates had observed Wheeler suffer through many of them. Why then was this particular episode beyond control, and what could have been done to prevent this tragedy?
Exercise-induced asthma, also known as exercise-induced bronchospasm (EIB), is a transient narrowing of the airways in response to strenuous exercise. An EIB episode produces a narrowing of the airways due to smooth muscle contraction and doesn’t include the inflammatory response seen in chronic or allergy-related asthma.
It’s rare to find an individual whose asthma is triggered solely by exercise, and sensitivity to EIB is often enhanced by pre-existing inflammation. Because airway inflammation may not be associated with symptoms, this interaction makes the response to exercise somewhat “unpredictable” in intensity.
EIB normally reaches its maximum intensity five to 10 minutes post-exercise and resolves on its own within 30 to 60 minutes. A small percentage of individuals with asthma, however, experience a delayed bronchoconstrictive response four to 10 hours post-exercise. In any case, once an attack occurs, the individual may be protected from another attack for as long as four to six hours. This is known as the refractory period.
Although the mechanism of EIB is unknown, airway cooling and/or dehydration are thought to be the main culprits. Patients who are systemically dehydrated may be at increased risk of airway narrowing due to the potential for airway dehydration. Although the extent of constriction after exercise is similar between normal and dehydrated states, baseline pulmonary function test values are significantly lower during dehydration.1 This suggests that individuals with asthma may experience a better quality of life during normal activities if they remain well hydrated.
The National Heart, Lung, and Blood Institute (NHLBI) recommends several steps in proper asthma treatment. First and foremost, patients need to receive proper medical supervision. Studies indicate that as few as 4 percent of patients with asthma are under the care of a pulmonologist or allergist for their asthma.2 Patients under care are more likely to comply with their asthma treatment and be confident with regulating their asthma when symptoms occur. There is no reason to believe that athletes are any different from the general population in this regard.
But even if patients with persistent asthma are seeing a physician, they still may not be receiving proper treatment. Many times physicians medicate solely with bronchodilators3 to control the symptoms of asthma – wheezing, coughing, shortness of breath – without medications to control the underlying inflammatory disease. In one report, as few as 21 .percent of children with persistent asthma were taking anti-inflammatory or corticosteroid medications for their asthma.4 Long-term use of short-acting beta2-agonists may decrease the drugs’ effectiveness, so it’s important that they’re reserved for easing symptoms of acute exacerbations.
Once appropriate medications are prescribed, the physician must ensure the patient is given thorough training on the administration of those medications, something not often done. The use of a holding chamber or spacer is recommended, especially for young children, to provide optimal dosage of the medication.
The NHLBI also recommends the use of peak flow meters and maintaining written action plans and symptom diaries to help control asthma. Peak flow meters help determine early decreases in lung function, which allows the patient to self-medicate before symptoms become exaggerated. Written action plans remind the patient of the steps necessary to better control flare-ups and prevent them from becoming life-threatening.
Diaries may help, particularly in the case of athletes, to understand the interrelationships between EIB and allergy-related asthma. Symptom diaries will assist the physician in determining proper medication regimens for specific athletes.
UNDERREPORTING AND NONCOMPLIANCE
A cause of improper medication control, however, may be the significant underreporting of symptoms that occurs. Too often athletes neglect to report that they use their emergency inhalers several times a week, or that their breathing difficulties cause them to withdraw from athletic activities or wake in the middle of the night.
Athletes often feel their symptoms are “something they must deal with” and don’t realize these symptoms may be indicators that they’re not yet properly medically controlled. The physician may need to take an active role in drawing out this information.
Another frustration for the physician is patient noncompliance with prescribed treatments. One study found that 48 percent of children with asthma didn’t use a holding chamber for their inhalers, 66 percent didn’t use their peak flow meters to monitor lung function, 71 percent had no written action plan they followed, and 89 percent didn’t maintain a symptom diary.2
In addition, about one-third of adults and one-quarter of pediatric patient caregivers report skipping doses of prescribed medications to avoid unwanted side effects. Asthma medications such as the beta2-agonists can cause jitteriness, hyperactivity or inability to sleep. Patients often hear that steroid medications can cause long-term side effects so they self-terminate the prescribed steroids, leaving themselves vulnerable to more inflammation and more frequent asthma episodes.
Patients need to report undesirable side effects so their medications can be adjusted if warranted. Initial treatments should call for minimal doses of medications and should be accompanied by education on the balance between adverse effects of the medication and the benefits.
TIPS FOR ATHLETES
Most athletic trainers can give accounts of athletes who have self-terminated their asthma medications. The usual reason given by the athlete is that they “haven’t had any problems in a while and don’t really like taking the medications anyway.” These are often the same athletes for whom the athletic trainers must provide immediate care during an athletic contest due to sudden and intense flare-ups of their symptoms.
For athletes, additional techniques can be undertaken to prevent asthma episodes. Early morning or later evening activities may provide more comfort to the athlete due to lower pollution levels at those times of day. Exercising at this time, particularly in hot climates, also reduces the chance for the exacerbating problem of dehydration.
Athletes should consider pretreating with their prescribed inhaler rather than relying solely on their rescue inhaler after an attack occurs. EIB can be controlled best with pre-exercise treatments of beta2-agonists or mast cell stabilizers, as well as by monitoring the environment in which the exercise takes place. Warm, moist environments elicit the least EIB, whereas dry, cold, moldy or dusty environments trigger the greatest EIB response.
Athletes also may benefit from a warm-up period of 15 minutes prior to intense exercise. Encouraging athletes to complete a continuous warm-up activity at approximately 60 percent of maximum effort significantly lowers the chance that the athlete will experience an asthma attack during subsequent intense activity.3
Another helpful prevention tool is an asthma education program, which aims to enable patients to control their asthma through a better understanding of their condition and its symptoms, proper use of asthma medications, and better tracking of symptoms and interventions when the symptoms occur.
Educational intervention programs that are structured and emphasize self-management significantly improve patient outcomes more than limited intervention or conventional treatment without education.5 Intervention programs that simply instruct patients on inhaler use and give a one-time written action plan to follow are far less likely to ensure compliance with asthma treatment. These patients also are far more likely to need emergency intervention in the future.5
Unfortunately, formal educational programs targeting athletes aren’t common, possibly due to the individualized monitoring of athletes by team physicians and athletic trainers.
Proper control of athletes’ asthma must be a team effort. Physicians must take an active role in determining symptoms, adjusting medications as needed and providing adequate education for their patients. Athletes must accurately report symptoms to their physicians and adhere to their prescribed treatment plan. By following this game plan, most athletes with asthma can enjoy a full, active lifestyle.
Dr. Maxwell is a clinical associate professor and the athletic training program director in the department of physical therapy, exercise and nutrition sciences at the University at Buffalo, N.Y. Dr. Cerny is an associate professor and chair of the department of physical therapy, exercise and nutrition sciences at the same facility.
For a list of references, call John Crawford at (610) 278-1400, ext. 1499, or visit www.Respiratory-care-sleep-medicine.advanceweb.com/mrreflist.html.