Vol. 13 •Issue 8 • Page 18
Allergy & Asthma
Proper Asthma Control Essential for Young Athletes to Reach Top of Their Game
Fifteen-year-old Rob Ames careens down the soccer field, weaving through the opposing team’s cleats. His eyes lock onto the net, and he fires. Goal!
But moments later, the telltale chest tightness hits him. His lungs, dried out by the cool autumn air, begin to crackle, and he starts to wheeze and cough. He heads for the sidelines.
Ames suffers from exercise-induced asthma, a highly preventable condition that continues to remain unrecognized in up to 29 percent of athletes.1 However, because of proper diagnosis and management, Ames has developed into a winning soccer player.
“I used to get taken out of games a lot because my breathing would bother me,” Ames said. “Now I have a system I use if I start to feel bad.”
At the first signs of an attack, Ames will signal to his coach by waving and tapping his chest. Within seconds, the coach will bring him off the field, and Ames will take a puff of his rescue inhaler from the sidelines. Before the half is over, Ames is prepared to run back onto the field.
Ames is wise to have his exercise-induced asthma under control. Researchers at the Sports-Asthma Research Center at Temple University Hospital in Philadelphia have found that children with asthma who participate in organized sports or recreational activity are at increased risk for fatal asthma attacks.2
Physicians, parents and patients should make sure coaches are aware of the asthma sufferers on their teams, able to recognize asthma symptoms, and trained how to administer asthma medications, said Gilbert D’Alonzo, DO, director of the center.
“Without adequate preparedness and control for possible exercise-induced asthma attacks, children will not be able to play to their potential,” Dr. D’Alonzo said. “Furthermore, uncontrolled attacks could affect their desire to engage in play and organized sports at all.”
TARGETING EXERCISE-INDUCED ASTHMA
Diagnosing exercise-induced asthma in young athletes can be subtle and tricky because they often try to hide symptoms due to fears of not being allowed to continue with their sports. In addition, many patients with exercise-induced asthma will have a normal physical exam without evidence of wheezing.
Therefore, physicians must rely on a detailed history obtained from parents, coaches and teammates to circumvent these issues. Look for evidence of shortness of breath, decreased exercise endurance, chest tightness, cough or wheezing immediately following exercise.
“Most of the time when I see children with cough and shortness of breath, they’ve been having symptoms for a long time,” said Jose Birriel Jr., MD, a pediatric pulmonologist with Pediatric Pulmonary Analogy Associates in Boca Raton, Fla.
Ames is a case in point. As a child, his doctor called him a “happy wheezer.” He could wheeze for long periods and continue to be active even though he was in distress. It took him and his family some time to realize how problematic his asthma was.
“It’s important to point out that some patients who have chest discomfort sometimes don’t think it could be exercise-induced asthma because they don’t see the respiratory distress or hear the wheezing,” Dr. Birriel said. “They don’t think of asthma as a possibility.”
The most objective measure of exercise-induced asthma is a pulmonary function test paired with an appropriate exercise challenge. A normal pulmonary function test doesn’t rule out exercise-induced asthma, but airway obstruction determined by the test can be strong evidence for an underlying asthma problem.
One caveat is that patients often don’t exercise as hard and as long in an artificial setting like the pulmonary function lab, and exercise-induced asthma may be missed with spirometry alone.
“The textbook unequivocal diagnosis is if you have greater than a 12 percent drop in FEV1 with exercise,” said Allen Dozor, MD, FCCP, FAAP, associate director of pediatrics at Maria Fereri Children’s Hospital, Valhalla, N.Y. “So, if you do more sophisticated .measurements, you may see changes even if patients don’t perform as well as you’d like.”
For example, a bronchoprovocation test is a more advanced pulmonary function test that may be performed. In this test, the patient uses a treadmill to exercise at different levels, and a measurement is taken at each level to show the patient’s work of breathing. Patients with exercise-induced asthma will show worsening pulmonary function as the exercise intensity increases.
If testing indicates a strong possibility of exercise-induced asthma, trial therapy of using a short-acting bronchodilator may be useful to determine if the patient’s symptoms and performance improve. It’s been noted that good response to pre-exercise treatment with albuterol makes the diagnosis of exercise-induced asthma likely.3
Once a proper diagnosis is made, interventions should be tailored to each child based on the type of activities in which he or she participates.
Patient education is paramount to the management process. Anyone involved in the care of an asthma patient should be educated about the dangers of exercise-induced asthma, its triggers, and how to control it.
“The first thing you need to do is find an expert who can discuss symptoms and modalities of treatment,” Dr. Birriel said. “A well-educated patient and parents translates into better control because everyone knows what to look for and how to treat it.”
Ames worked closely with his pediatrician. When the doctor wanted him to use a peak flow meter, Ames kept a chart and would call the doctor when he felt a change in his health. As he’s grown older, he also has taken responsibility for administering his own medications.
“We made Rob responsible for his condition, and he probably knows how to monitor his asthma better than we do,” said his mother, Lori Ames. “He can tell the doctor exactly what he does or doesn’t need.”
Most importantly, physicians need to convey to patients and their families that exercise-induced asthma shouldn’t prevent children from performing in their sport of choice. Patients also should never be excluded from participating in sports because of the condition, as long as it’s managed conscientiously.
“We know that with proper therapy the child’s disease can be extremely well-controlled,” Dr. D’Alonzo said. “You don’t want to let the asthma condition control the child’s life.”
KEYS TO MANAGEMENT
One of the most important steps to managing exercise-induced asthma is making sure that young athletes warm up and stretch before they begin more intense activity. Secondly, children should participate in physical conditioning programs during the off-seasons to keep in shape.
“The truth is, exercise-induced asthma is more common in kids who aren’t well-conditioned physically,” Dr. Dozor said. “For instance, every year the mile run in gym class gets us at least 20 or 30 referrals because suddenly kids who lie around playing video games all summer have to run a mile and can’t do it.”
Athletes should wait at least two hours after eating before exercising and warm up for at least 10 minutes before rigorous exercise begins. Following exercise, they need to cool down or lower the intensity of exercise before stopping.
When possible, athletes should exercise in a warm, humidified environment. During cold weather, they can help steer clear of asthma episodes by covering their noses and mouths with masks or scarves.
Being aware of environmental allergens such as pollen, mold and animal dander also can prevent concurrent aggravation of asthma by allergies. Athletes with environmental allergies may find that a leukotriene inhibitor such as montelukast sodium can help keep allergies associated with asthma at bay.
Perhaps the most important key to management is to make sure any underlying asthma is under control before a young athlete begins to exercise. “We know that if children use proper therapy, then their disease can be extremely well-controlled, and they can participate safely,” Dr. D’Alonzo said.
However, a study found 75 percent of children with physician-diagnosed asthma who participated in sports didn’t have rescue medication available.2 The same study reported that appropriate therapy allows up to 90 percent of patients with exercise-induced asthma to control their symptoms and be able to participate in vigorous activity.
Researchers defined appropriate therapy as the inhalation of a beta2-agonist, such as albuterol, 15 to 20 minutes before exercise and having access to a beta2-agonist in case of an asthma attack.4 The child should have a good inhaler technique, and a holding chamber can be considered to achieve maximum results.
Ames and his physician developed a system for treating his asthma before soccer matches. Thirty minutes prior to game time, Ames takes one puff of his albuterol. After 10 minutes, he takes a second puff. “This lets me play an entire game, two 45-minute halves, without coming out of play,” Ames said.
Inhaled corticosteroids also are a common long-term maintenance treatment for exercise-induced asthma. However, Dr. D’Alonzo expressed frustration over concerns of their use in young patients.
“One of my biggest pet peeves is that some parents are highly reluctant to use inhaled corticosteroids to control this disease because they are worried about the risks, which in fact are very small,” Dr. D’Alonzo said. “We found that a lack of steroids was a blaring problem in the cases of kids who died in our study, and we believe the use of inhaled steroids could have curtailed a lot of those deaths.”
As far as advice to other young athletes, Ames suggested, “Just be aware of what’s wrong with your body, and have a good relationship with your doctor and coach. You’ll always be able to figure your asthma out.”
For a list of references, please call Debra Yemenijian at (610) 278-1400, ext. 1153, or visit www.advanceweb.com/respmanager.
Debra Yemenijian is assistant editor of ADVANCE. She can be reached at email@example.com.
AT THE TOP OF THEIR GAME
The American Academy of Allergy, Asthma and Immunology compiled the following list of world-class athletes who have exercise-induced asthma:
• Jerome Bettis, NFL football player
• Tom Dolan, Olympic medalist — swimming
• .Jackie Joyner-Kersee, Olympic medalist — track and field
• Greg Louganis, Olympic medalist — diving
• .Debbie Meyer, Olympic medalist — swimming
• Art Monk, NFL football player
• Hakeem Olajuwon, NBA basketball player
• Dennis Rodman, NBA basketball player
• .Jim Ryun, Olympic medalist — running
• Amy VanDyken, Olympic swimmer
• Dominique Wilkins, NBA basketball player
• Joanna Zeiger, Olympic triathlete