Respiratory Pathologies

Stats• 15 million people in the US have Asthma• 15-20% of kids, 6-8% of adults• Most kids out-grow it• Most asthma deaths occur in July – 11 die

per year• 11% of college athletes have EIA

Anatomy• Airway divided 17 times

• Right Lung - 3 lobes, 10 segments

• Left lung - 2 lobes, 8 segments

Breathing & Wheezing• Inhalation

– Ribs expand creating a (-) pressure– Airways are “pulled open”

• Exhalation– Allowed to collapse– In asthmatics – air is trapped d/t obstructions

• Air forced past obstruction making noise– Wheeze – occurs mainly during expiration– Stridor – occurs with inspiration in upper

airways– Rales, Crackles – occurs with inspiration

Asthma -Pathophysiology• Airway hyper-responsiveness & reactivity

(bronchospasm)• Airway inflammation –mucus thickening &

lining swelling (from release of chemicals)

• Response to a variety of triggers• Muscle contraction decr. Lumen size, this

air can’t exit lungs

Asthma - Pathophysiology• In everybody – during 1st few minutes of

exercise, bronchodilation occurs.

• In asthmatics – after ~ 10 minutes of activity, their bronchioles return to baseline and can progress through bronchoconstriction, peaking ~ 5-10 minutes after stopping activity.

• In asthmatics, problem is with exhalation, thus they can’t get rid of CO2 – become acidic

• The bronchioles usually return to normal over 20-40 minutes after activity, but can take up to a few hours.

Exercise Induced Brochospasm• Two Theories:

– A. Water-lose Theory• With exercise, ↓nasal breathing, thus ↓ moisture, Δ

osmolarity, Δ pH & temp

• Causes mediator release from Mast Cell (histamines, leukotriene, prosteglandin).

• Leads to broncioconstriction

– B. Heat-exchange Theory• AFTER exercise stops, bronchial vascular dilation

and engorgement occurs to re-warm the epithelium

• Thus ↑ blood flow to area causes narrowing of airways

• Can also leak, leading to mediator release, thus bronchoconstriction

Asthma - Diagnosis• S/S:

• Exposure to triggers (Next slide)

• Family Hx – relationship to other diseases

• Pulmonary Function Tests (PFTs)• Peak Flow testing/monitoring• FEVs• Spirometry

• Response to Tx

Asthma – Common Triggers• Cold air/dry air

• Allergens

• Irritants – smog, smoke, drugs

• Stress – emotional/physical

• Laughing

• Infections

• Exercise

Exercise-Induced Bronchospasm• Exercise induced “asthma”

• Symptoms ONLY seen with exercise• Frequently missed (out of shape, youth)• Suspect in patients with:

• SOB• Exercise intolerance• Cough after exercise up to an hour

• Occurs when?– 5-10 minutes after exercise starts– Gradual onset– Gets worse after exercise– s/s resolve 15-60 mins after exercise stops

EIA• A decrease of ≥10% in peak flow

expiratory flow rate after exercise confirms a diagnosis of EIA.

• History:– 1. Atopy – Eczema & food allergies– 2. Underlying lung diseases– 3. Fhx of asthma or atopy, premature

baby– 4. Peak Flow chart: Age, Sex, Height

Peak Flow Meters• Portable – should have in your kit

• Designated “zones” –compared to baseline/charts

• GREEN – 80% - 100%• YELLOW – 50% - 80%• RED – less than 50%

• Blow as hard and fast as possible– Can cheat the system

• Establish baseline and then test often. (80%) of function to participate.

Formal PFTs• Pulmonary Function Tests

• Computerized

• Graph Data

Asthma - Treatment• Prevention:

• Know their triggers• Remove triggers• Inhibit inflammation cells that contribute to

reactivity &swelling• Monitor: Zones – PLAN for each zone, may

have different meds for each zone

• Medication treatments: – Goal: either decrease inflammation or reduced

bronchospasm

Treatments: Inhalers• Meter Dose Inhalers (MDI):

• “puffers” - beta-2-adrenergic agonist• Most commonly albuterol• Use 2 hrs prior to exercise• ALWAYs use with a spacer• 2 puffs – wait 1-2 min between• Breathe in and hold• Proper use is key!

– Timing– Shake canister– Tilt head back

Alburterol/Pirbuterol• Bronchodilator – typical RESCUE MEDS

– Works on spasm (B2 – antagionist)– Steroids work on mucus production

• Side Effects:

• Onset of Action: Minutes, peaks @ 20min• Duration of Action: 2-6 hours• Should mainly be used as rescue

medication• Have with them at ALL times• Allowable by USOC (c note) and NCAA• Albuterol will NOT work if on a beta-

blocker

Dry Powder Inhalers - DPI• Chronic/Daily therapy

• Inhalation of powder med

• May work just as well as MDI

• Advantages:• No spacer needed• Know when they get it – sweet taste• Only need 1 dose

• Disadvantages:• Some technique required

Salmeterol• Long-acting bronchodilator

• Side-effects: Same

• Onset of action: 20 min, peak @ 3 hours

• Duration of action: 12 hours, BID

• NEVER for an acute attack

Cromolyn• Baseline/preventative medication• Mast cell Stabilizer – prevents the

release of histamine

• Onset of Action: 15 mins

• Duration of Action: 3-5 hours• Role in Exercise: Use with Albuterol

before

• Will not help once an attack has occurred

• No restrictions on use

Leukotriene Modifiers• Leukotrienes: New class of meds

» Turn on slow» Pt needs to take them for 3 weeks to notice

the full affect

• Taken orally/daily, @ night

• Medications prevent chemical formation or binding of receptors

• Works in approx. 50% of patients

• Very safe, can be used during pregnancy. Now OTC

Inhaled Corticosteroids• Baseline meds

• Daily

• Not used in isolated EIB

• Reduced incidence/severity of steroid side effects because it is inhaled

• Oral form is systemic, used in more severe, hard to treat cases, banned by USOC (Avoided as tx)

• Trush – yeast infection

Multimodal Therapy• Patients are on many forms of

medications

• Commonly on a daily preventative plus have rescue inhalers PRN

• New single dose combinations

• Most work better in combination, than individually

Keys to EIB Therapy• Treatment:

• Medication before exercise – know the onset and peaks of the medications

• Daily meds needed if underlying asthma is an issue

• Utilization of “refractory period”

• Self-selection of sports• “Rule of 2s”

ALL That Coughs is not AsthmaDifferential Diagnosis

Other options• Paradoxical Vocal Cord Dysfunction

• Hyperventilation

• Whooping cough

• Anxiety Attack

• Reflux (GERD)

• Upper respiratory infection

• Exercise-induced anaphylaxis

• Lung diseases: • Pneumonia• Lymphoma• Heart failure• Cystic Fibrosis

Vocal Cord Dysfunction (VCD)• Vocal cords close during inspiration

• Triggered by post-nasal drip & reflux

• Can’t get “air in” - Stridor• Will NOT respond to traditional treatments;

meds or refractory period• Part of the issue is psychological –

stress/anxiety• > in women• s/s: stridor, difficulty speaking during

exercise, sudden onset & resolution• Tx: breathing & relaxation techniques

• Counselling, Speech pathology

GERD• Gastroesophageal reflux

• Can make asthma & VCD worse

• s/s:

• Tx:

• Avoid foods prior to exercise & sleep

Upper Respiratory Infection• The common cold – head/sinuses

• s/s:

• Tx:

• Modify activity based on energy level.

• Refer for HIGH fever (101+) and wet, productive cough

Exercised-induced anaphylaxis• Rare – literally allergic to exercise!

• Triggered by exercise

• s/s: hives, upper respiratory obstruction, CV collapse, swelling in hands & face

• Tx: - Epi & 911

Pneumonia• Viral or bacteria

• “Can hear it before you can see it”

• Diagnosis – WBC, auscultations, chest x-ray

• Presents with:– 1. deep wet cough or barking cough– 2. fever– 3. Wheezing/crackles

• S/S:

• Tx:

Pulmonary auscultations

Use of stethoscope to identify NORMAL BREATH SOUNDS*Stethoscope placement – 4 quadrants*Abnormal sounds: wheezing, rales, stridor*Pathological breathing patterns: apnea, tachypnea, bradypnea, dyspnea,

hyperventilation & obstructed airway

Summary• Asthma is a diagnosable & treatable

disease• Asthmatics should “know” their disease• Exercise may trigger asthma in

asthmatics, or it may be isolated EIB• The best treatment is prevention• Medicinal treatments MUST be

customized • Other diseases that are life-threatening

may present with a cough• Know what is banned by various athletic

organizations