Exercise – Induced Asthma

History and Clinical Examination

Mr T.T is a 17 year old male patient presented with dry cough, shortness of breath and wheezes which occur once-a-week especially at night and after playing soccer.

He was diagnosed with asthma in 2003 and put on Asthavent Inhaler prn. No previous hospital admission for asthma but was treated in emergency room in 2009 for an asthmatic attack.

He also gives history of atopy for flowers but he is not on allergy treatment.

Clinical Examination : A healthy looking patient with no respiratory distress. Lungs were clear. Chest Radiograph was also normal. Lung Function: FEV1 – 98% pre-bronchodilator, 115% post-bronchodilator with 17% reversibility.

Further Management: Asthavent Inhaler prn continued with an anti- inflammatory steroid inhaler added. On follow-up visit in three

weeks he reported no more nocturnal post-exercise symptoms.

Summary: A 17 year old male asthmatic patient not optimally controlled on bronchodilator alone which disturbs him

from participating fully in sports. He did much better with anti-inflammatory added to his treatment.

Discussion

Exercise-Induced Asthma is a condition of respiratory difficulty triggered by aerobic exercise and lasts several minutes. Symptoms of EIA may resemble those of allergic asthma, or they may be much more vague and go unrecognized, resulting in probable underreporting of the disease. EIA can be life-threatening.

Epidemiology: Asthma is more prevalent in developed countries . New Zealand has the highest prevalence at 15%

followed by Australia at 12%, while the prevalence in the United Kingdom and United States is 9% & 7% respectively. Asthma is more common in children than adults, with over half the cases developing in childhood and another third before the age of 40. Genetic factors are thought to play a role.

Clinical features: Patients usually present complaining of exercise- related respiratory symptoms. This complaint is

much more common among children and younger athletes but can be seen at any age. Symptoms occurring during or following exercise are as follow: -chest tightness or pain, -cough and wheezes, -shortness of breath, - under- or poor performance on the field of play and fatigue,

Clinical features continued

Symptoms denial may be seen due to the following: -peer pressure, -embarrassment, -fear of losing position in the team, -misinterpretation as post-exercise fatigue.

Contributing factors : -cool temperatures, house dust mite, smoke, pollen and exercise which cause bronchial hyperactivity. -other factors are low humidity, poor air quality, coincident respiratory infection & poor physical conditioning.

Aerobic factors: -aerobic exercise appears to much more problematic than anaerobic, -duration of aerobic activity greater than 8 to 10 minutes provokes EIA, -high intensity aerobic exercise also provokes EIA.

Physical Examination: -this is often unremarkable in the clinical setting; a higher yield is obtained on the field or after an exercise

challenge which for the purpose of the physical examination may be informal. For example, the clinician may have the athlete come to the office wearing athletic clothing and run on a treadmill or around the park for 10 minutes, which is then followed by another pulmonary examination.

Physical Examination continued

*skin (atopy) *head, ears, eyes, nose and pharynx (acute/chronic illness) *sinuses ( presence of tenderness) *lungs(presence of rales, rhonchi, wheezes and prolonged expiratory phase) *heart (murmurs).

Causes of EIA -Medical: *poorly controlled asthma results in increased patient symptoms with exercise, *maximizing control of the patient’s baseline asthma when present is critical in the treatment of EIA, *poorly controlled rhinitis also results in increased patient’s symptoms with exercise, *secretions resulting from hay fever can aggravate both allergic asthma & EIA, *viral, bacterial, and other forms of upper respiratory infection also aggravate the symptoms of EIA.

-Environmental: *excess pollens or other allergens in the air can exacerbate both the allergic asthma and EIA in the

following ways:

Environmental causes of EIA continued

*pollutants in the air are irritants to the airways and can lower the threshold for symptomatic bronchospasm,

*chemicals used in certain sports for environmental maintenance can predispose individuals to wheezing &worsen EIA symptoms:

^chlorination in pools, ^insecticides & pesticides used to maintain playing fields, ^ fertilizers & herbicides used to maintain playing fields, ^paints & other decorative substances to enhance the appearance of playing fields.

-Drugs: Beta-Blockers, Aspirin, NSAIDs and Diuretics.

Differential Diagnoses can be seasonal asthma or upper airway obstruction.

Work-up: *Laboratory studies: ^in general, EIA is diagnosed clinically and may not require any further laboratory studies, imaging

or other tests & procedures. Laboratory studies are reserved for equivocal cases, for treatment failures, and to narrow the differential diagnoses when it seems reasonable.

^ESR & FBC for inflammatory &infectious causes. IgE to rule out allergic causes. ^Chest Radiograph for signs of chronic lung disease, CCF and/or valvular heart disease &foreign

body ingested. ECHO for the heart.

Treatment

Non-pharmacological: *Sports selection – it can be helpful to guide an athlete towards the performance of sports in environments

that are less likely to cause bronchospasm. If the athlete has a choice, he or she can choose a time or place to exercise where the air is warmer with higher humidity.

Likewise, a more flexible athlete can change sports to be more active in these sorts of environments e.g.. changing from running to swimming automatically increases the humidity of the environment. Focusing on sports with less prolonged aerobic demands such as sprinting, weightlifting, baseball or football is better tolerated by affected athletes.

*Breathing and Warm-up techniques- altering breathing techniques by changing from predominant mouth breathing to nasal breathing can result in less bronchospasm with the performance of an activity because the inhaled air inhaled in this manner is both warm & humidified.

*Coordination and timing of competition with medication can also maximize exercise performance with regard to bronchospasm. This is most likely to occur by initiating a15 to 30 minute warm-up followed by a 15 minute rest period at which time the medication is administered. This entire period should be limited to result in commencement of the competition 15 to 30 minutes after medication administration.

Pharmacological treatment is aimed at preventing symptoms. Therapeutic Use Exemption.

Follow-up: - return to play: a player who is removed from play for an asthmatic attack should be kept out of play

Return to play continued

Until his or her respiration has normalized. This should occur within 5 to 10 minutes of medication administration. The athlete should be monitored closely for signs of relapse over the next several hours. If the symptoms do not completely resolve with sideline medication, the athlete should be referred for further treatment, preferably transported via an ambulance.

Complications of EIA: *if not treated properly EIA can lead to status asthmaticus, respiratory failure or even death.

Prognosis is excellent with proper interventions.

Education to the athletes about the importance of taking their treatment properly and to the coaches who sometimes turn to downplay the athlete symptoms e.g.. Thinking that shortness of breath is due to poor conditioning.

References  National Heart, Lung,and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 3:Guidelines for

the Diagnosis and Management of Asthma: Full Report 2007. Bethesda, Md: NHLBI; August 2007. Publication no. 07-4051. [Full Text].

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