Vol. 14 •Issue 14 • Feature 1 Managing Asthma in Athletes
Managing Asthma in Athletes
Many athletes have poorly controlled asthma, which can be deadly.
By Tisha Nickenig
James Rogers, often would see athletes use their asthma inhalers four, five or six times during a sports match or practice.
“Do you feel OK?” he’d ask, when they’d rush to the sidelines for a puff. Most answered “yes.”
So Rogers, director of special programs for Temple Sports Medicine Centers and co-director of the Temple Sports Asthma Center at Temple University in Philadelphia, would send them back into play.
But in November 1993, he was shocked when one of his athletes died from an asthma attack. In his mind, he had failed the athlete and her coaches because he hadn’t trained them about the severity of asthma.
After taking a month-long sabbatical to study the disorder and its death-related risks, Rogers discovered that many sports medicine specialists didn’t know what those risks were and that most athletes’ asthma was poorly controlled. Athletes have poorly controlled asthma if they have to resort to using medication, besides their prescribed prophylactic dose, more than two or three times a week, according to guidelines from the National Institute of Health on exercise-induced asthma.
Athletes with asthma are divided into two distinct groups, explains Anthony Montanaro, MD, professor of medicine and head of the division of allergy and immunology at Oregon Health Services University in Portland, Ore.
The first group has exercise-induced asthma (EIA), a condition in which exercise triggers underlying chronic asthma. Chronic asthma is often caused from inflamed airways that develop after respiratory tract infections or from allergic triggers, such as pollens or animals, and pollutants, explained Montanaro. If these asthma attacks aren’t well controlled with proper medication, nearly 90 percent of patients develop EIA, adds Gilbert D’Alonzo, DO, professor of medicine in the division of pulmonary and critical care at Temple University.
Although most athletes with asthma have EIA, some are diagnosed with exercise-induced bronchospasm (EIB), which affects people who develop bronchial restrictions only when they exercise. EIB is usually caused by a change of temperature or moisture in a patient’s airways. The most common factors that trigger these bronchial restrictions are cold, dry environments or air pollutants, such as sulfur dioxide, said Montanaro. Sports that require heavy running, such as basketball or soccer, also contribute to the severity of EIB, added Mitch Carr, MS, athletic trainer and director of the Helen M. Galvin Center for Health and Fitness at the Rehabilitation Institute of Chicago in Chicago. While EIB and EIA symptoms are usually the same–wheezing, coughing and chest tightness–sports medicine specialists must understand that the conditions and their treatments are different, if they want to accurately manage athletes’ asthma.
“Many chronic asthma patients are diagnosed with EIB and overuse their inhalers, when they really should be treating their underlying asthma with anti-inflammatory medications,” explained Montanaro. In addition, athletes who abuse their inhalers usually make their asthma worse, because they remodel their airways, which contributes to lung disease later in life, added D’Alonzo.
Although proper medication control is an important way to manage asthma in athletes, athletic trainers and coaches never had a concrete way to monitor it until several years ago when Rogers and D’Alonzo began gathering and analyzing data about EIA and EIB. In one study, they tested athletes with a peak flow meter, a portable instrument that detects decreases in air flow and monitors small changes in breathing capacities. They observed that nearly 10 percent of the athletes had unrecognized EIB and that there was a high incidence of poorly controlled or undertreated chronic asthma among them.
Based on this information, along with multiple studies that produced similar results, Rogers and D’Alonzo developed a method to help trainers measure the severity of asthma attacks.
They had athletes blow three times into a peak flow meter, and then administered a sport-specific exercise challenge to test how well their inhalers worked. If athletes ran, they took them to a track. If they swam, they took them to a pool. “It’s important to go to their activity site, because there could be an allergen there that might trigger their asthma attack,” explained Rogers. The athletes would then run or swim a mile, for example, for nearly eight minutes, so their heart rate would increase.
“I basically wanted…to provoke an attack,” explains Rogers. Five, 10 and 15 minutes after they exercised, the athletes blew into the peak flow meter. If their peak flow decreased 12 percent, from a 550 reading to a 480 reading, for example, their diagnosed condition wasn’t well controlled and they needed more medical treatment.
These peak flow meters give trainers and coaches a chance to help manage EIA and EIB, which can enhance an athlete’s overall treatment program. “Without peak flow meters, trainers and coaches just flip athletes their inhalers and have no way of monitoring how an asthma attack is responding to medication,” said Rogers. “But combined with spirometry, (a method that measures the volume of air that enters and leaves the lungs), and patients’ history, these meters are helping doctors treat EIA and EIB more accurately,” he explained.
While monitoring attacks with peak flow meters is an important way to help manage asthma, other methods can help decrease EIA and EIB symptoms. Warm, humid environments, such as swimming pools, are the best places for athletes to exercise, because cold, dry air often causes bronchial restrictions, said Carr. But if athletes insist on running in cold environments, Carr recommends they wear a mask or scarf around their mouth, so their breath stays moist.
For patients with severe symptoms, Carr recommends sports that have more rest periods, such as baseball or volleyball, because they have time to catch their breath. In addition, a warm-up period is important for any type of exercise so an athlete’s airways have time to adapt to airflow changes, he adds.
Another crucial factor is making sure athletes pre-treat their condition with rescue inhalers 30 minutes to an hour before they exercise, said Montanaro. “Many people wait until they develop asthma symptoms, and then it is too late,” he explains.
If sports medicine specialists follow these recommendations, they can increase everyone’s awareness of EIA, EIB and their treatment options. Roger’s use of peak flow meters, for example, has already raised awareness among many sports medicine specialists. “When trainers and athletes see an NFL player being tested with a peak flow device, they are more willing to accept them,” explained Rogers. “This will eventually improve the standard of care in sports medicine,” he adds.
It has certainly improved Roger’s standard of care. Now, when asthma attacks, he and his athletes are wiser to its ways. That wisdom is life-saving.
Tisha Nickenig is an ADVANCE editorial assistant.