Upload
sybill-velasquez
View
35
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Use of the Refractory Period in the Treatment of Exercise- Induced Bronchoconstictions in a Collegiate Football Player: A Case Study. Brian G Pietrosimone, M.Ed, ATC John MacKnight, MD Ethan Saliba, PhD, PT,ATC,SCS Jay Hertel, PhD, ATC. Asthma. - PowerPoint PPT Presentation
Citation preview
Use of the Refractory Period in the Treatment of Exercise- Induced Bronchoconstictions in a
Collegiate Football Player: A Case Study
Brian G Pietrosimone, M.Ed, ATCJohn MacKnight, MD
Ethan Saliba, PhD, PT,ATC,SCSJay Hertel, PhD, ATC
Asthma• Exercise triggers asthma in 50 -90% of known
Asthmatics (Parsons et al., Freed et al.)
• 10 % of non – asthmatics report symptoms of asthma during exercise (Parsons et al.)
• Wheezing• Coughing • Tightness in chest• Inability to catch one’s breath• Increased mucus production
Pathogenesis of EIB• The pathogenesis behind exercise
induced bronchospasm is not fully understood (Tan et al. & Chang- Yeung)
• Different Theories – Dehydration of mucosal lining – Bronchial mucosal hyperemia
Dehydration of Mucosal Lining• Cold, dry air causes dehydration of the
mucus membrane• Water loss causes an increase in osmotic
pressure• Mast Cell degranulation leads to
inflammatory mediator release (Parsons & Mastronarde, Tan, Maler)
Hyperemia• Re- warming in the lungs causes distal
airways to increase blood flow• Increased hydrostatic pressure in
bronchial vasculature• Increased airway edema (Parsons & Mastronarde, Tan, Maler)
History• Setting
• ACC, NCAA Division 1 Football Program• Climate Zone 3
• Athlete Demographics– 18 year old – Male– Single– Caucasian– Height: 6’ 2’’– Weight: 258 pounds– Position: Defensive Line– Hometown in Climate Zone 3
Past Asthma History• Health history form – Indicated past history of
asthma• Exercise was a stimulus• No other health problems, or family problems
• Prescribed prior to enrolling at the University– Albuterol MDI prn- short-acting bronchodilator– Salmeterol (Serevent) MDI - long-acting
bronchodilator– Fluticasone propionate (Flovent) MDI- inhaled
corticosteroid
Encounter Physical Examination Treatment
September2001
wheezing, coughing, mucus production, difficulty breathing, and tightness in chest
Transition to Fluticasone-Salmeterol (Advair diskus) bid Albuterol prn
December Same symptoms continue, * subject not compliant with previous treatment
Continue previous prescribed treatmentReturn if symptoms worsen
January No change in intensity, duration or frequency of EIA bouts
ADDED Montelukast (Singulair) 10 mg
February No relief with Montelukast
Advair was increased ADDED Cromolyn Sodium (mast cell stabilizer) was taken qid
September 2002
The athlete would not be able to finish the first quarter
Team Physician orders echocardiogram & spirometry post exercise treadmill test
Differential Diagnosis• Exercise Induced Bronchospasm • Extrinsic Asthma• Chronic Bronchitis• Cardiomyopathy
FEV1
• Spirometry measurements reported a decrease of 19% in FEV1 - confirming the diagnosis of EIB (Tan and Spector)
• FEV1 = (Pretest FEV1 - Post test FEV1) x100
Pretest FEV1
• No significant findings on Echocardiogram
Pattern• Team Physician noticed pattern
1st2nd
3rd4th
Unable to participate
Able to participate
6- 10 m 20-25 m2 h
3h4 h
Refractory Period
Real Time
Game Time
Refractory Period• The refractory period is the time in which
the athlete remained asymptomatic after the first bout of symptoms
• Refractory period occurs in 40% to 50% of asthmatics (Milgrom & Taussig )
Refractory Period• Theory suggests that a depletion in
inflammatory mediators occurs with an initial bronchospasm
(Freed & Chang- Yeung et al.)
• Subsequent exercise results in no additional mediator release
• The refractory period last for 2 to 4 hours after the first bout of EIA (Ben- Dov et al. & Wilson et al.)
Treatment• 75 minutes prior to game time under the
supervision of the Team Physician – 4 x 50 yard sprints at a moderate intensity – Series of 5, 10 and 20 yard shuttle runs
• 30 second rest was taken between each shuttle run in order to determine if the athlete had provoked sufficient bronchospasm to allow for a refractory period.
Treatment• Desired response was a bout of EIB large
enough to provoke a subsequent refractory period
– Athlete response» Wheezing » Coughing » Tightness in chest» Sputum production
Treatment• After team physician and athlete agreed
that desired response had been reached:• Consciously slowed breathing rate• Albuterol (2 puffs)• 15-20 minute cool down time prior to team warm
up
Treatment Effect
1st 2nd
3rd
4thPre- game
Onset of EIB
6-10 m75 min 1.5 h 2.5 h 3.25- 3.5 h
4.5 h
Able to play asthma free
EIB
Critical area: Ability for bronchospasms to return
Effectiveness of Treatment• Effectiveness was greatly reliant on the
ability of physician and athlete to adequately induce the initial bronchospasm
• During the Senior year• 72% of the games asthma free (8/11)• 2/3 bouts of EIB occurred in the second half• Rare additional Albuterol use with good effect
Uniqueness• The refractory period is a well documented
phenomenon
• It has not been documented as a treatment in the athletic population
• This treatment worked consistently well and minimized the use of medication
Limitations with this Treatment• Time frame does not allow for treatment
prior to practices
• Many trials are needed to accurately predict refractoriness
Implications for Future Research• Can the refractory period be used routinely
to effectively treat athletes?
• Mechanisms behind the refractory period
• Does the refractory period decrease EIB in athletes more effectively than medications?
What do I do with this Information?• Possible treatment strategy
– Diagnosed athlete with breakthrough EIB– Rescue therapy in place
• Provides comfort in return to play decisions for ATC and sports medicine team
Conclusion• The timing of the refractory period can be
manipulated to coincide with the competition, preventing an exercise- induced bronchospasm during play.
Questions
References• 1. Parsons J, Mastronarde J. Exercise - induced bronchoconstriction in athletes. Chest. 2005;128:33966-33974.• 2. Freed A. Models and mechanisms of exerise-induced asthma. Eur Respir J. 1995;8:1770-1785.• 3. Tan R, Spector S. Exercise - Induced Asthma. Sports Med. 1998;25(1):1-6.• 4. Arif A, Delclos G, Lee E, Tortolero S, Whitehead L. Prevalence ad risk factors of asthma and wheezing among US adults:
an analysis of the NHANES III data. Eur Respir J. 2003;21:827-833.• 5. Goodman D, Lozano P, Stukel T, Chang C, Hecht J. Has asthma medication use in children become more frequent, more
appropriate, or both? Pediatrics. 1999;104:187-194.• 6. Ben-Dov I, Bar- Yishay E, Godfrey S. Refractory period after exercise induced asthma unexplained by respiratory heat
loss. Am Rev Respir Dis. 1982;125:530- 534.• 7. Milgrom H, Taussig L. Keeping children with exercise- induced asthma active. Pediatrics. 1999;104:38-43.• 8. Chang- Yeung M, Vyas M, Grzybowski S. Exersice induced asthma. Am Rev Respir Dis. 1971(104):915 - 924.• 9. Mahler D. Exercised- induced asthma. Medicine and Science in Sports and Exercise. 1993;25:554-561.• 10. Haverkamp H, Dempsey J, Miller J. Repeat exercise normalizes the gas- exchange impairment induced by a previous
exercise bout in asthmatic subjects. J Appl Physiol. 2005;99:1843- 1852.• 11. Anderson S, Daviskas E. The mechanism of exercise- induced asthma is. Allergy Clin Immunol. 2000;106:453-459.• 12. McFadden E, Nelson J, Skowronski M, Lenner K. Thermally induced asthma and airway drying. Am J Respir Crit Care
Med. 1999;160:221-226.• 13. Wilson B, Bar-Or O, Seed L. Effects of humid air breathing during arm or treadmill exercise on exercise - induced
bronchoconstriction and refractoriness. Am Rev Respir Dis. 1990(142):349- 352.• 14. Edmunds A, Tooley M, Godfrey S. Refractory period after exercise induced asthma: Its duration and relation to the
severity of exercise. Am Rev Respir Dis. 1978;177:247- 255.• 15. Rosenthal R, Laube B, Hood D, Norman P. Analysis of refractory period after exercise and eucapnic voluntary
hyperventilation challenge. Am Rev Respir Dis. 1990;141:368- 372.• 16. Matsumoto L, Araki H, Tsuda K, et al. Effects of swimming training on aerobic capacity and exercise induced
brochoconstriction in children with bronchial asthma. Thorax. 1999;54:196-201.