Pulmonary Problems in Athletes Zo J. Foster, MD October 19, 2016 Learning Objectives Generate a differential diagnosis for rhinitis, cough, and wheezing in athletes. Define terms including: EIA, EIB, and VCD. Discuss how the pathogenesis of asthma differs in athletes compared to sedentary individuals.
Consider respiratory conditions in special settings, including athletes with sickle cell trait (SCT) and SCUBA divers. Case 1: M. 49 y.o. woman who wants you to complete her health form for a SCUBA diving class. PMH: asthma PSH: cholecystectomy,
bariatric surgery MEDS: none Do you complete her form? Clearance for SCUBA Diving Could the condition predispose to a diving illness? Could the condition be provoked by diving? Could the condition compromise the diver's safety or performance underwater?
Pulmonary Disorders and SCUBA Diving Absolute contraindications: H/o spontaneous pneumothorax Impaired exercise performance d/t respiratory disease Relative contraindications: Asthma or reactive airway disease EIB Solid/cystic/cavitary lesions Prior PTX d/t surgery, trauma or over inflation Immersion pulmonary edema Interstitial lung disease
Asthma and SCUBA Diving Criteria for clearance prior to SCUBA diving: Asymptomatic adult with past history of childhood asthma. Well controlled asthma with known triggers and normal PFTs with a reduction of < 20% in peak mid-expiratory flow after exercise. No evidence of cold-induced wheezing or exercise-induced bronchospasm. Case 1: M.
Spirometry was normal. Pt. reported no wheezing or medication use in the past 5 yrs. Was cleared to scuba dive. Case 2: L. 11 y.o. girl brought in
by mom for coughing and wheezing during a basketball tournament. Was playing in a game this weekend and they had to pull her out d/t wheezing. She was on the bench coughing for about 2 hours before she was back to normal.
Case 2: L. PMH: eczema as a child PSH: none Meds: occasional MVI ALL: NKDA
SocHx: 6th grade. No smokers at home. Pet cats. Plays basketball 4 hours per week. FamHx: Dad with asthma Vitals: wt 115#, BP 110/60, pulse 68 HEENT: TMs pearly gray, nasal mucosa with clear rhinorrhea, no pharyngeal
erythema, no anterior cervical LAD CV: RRR, no m/r/g Resp: CTA, no wheezing Peak flow: 280, 250, 280 Differential Diagnosis for Wheezing? Deconditioning Bronchitis or other viral URI Exercise-induced bronchospasm (EIB) Exercise-induced asthma (EIA)
Exercise-induced hyperventilation (EIAH) Paradoxical vocal cord dysfunction (VCD) Exercise-induced anaphylaxis GERD Differential Diagnosis for Coughing? Viral/bacterial upper or lower respiratory tract infection Upper airway cough syndrome related to rhinitis, sinusitis, laryngitis or other upper airway conditions Spontaneous pneumothorax Bronchiectasis
Asthma or EIB Laryngeal trauma GERD Environmental exposures Exercise-induced Hyperventilation Also known as pseudo-asthma syndrome. Hyperventilation
during exercise causing respiratory symptoms (wheezing, chest tightness), not directly related to bronchial obstruction. Exercise-Induced Anaphylaxis Wide variety of exercise is implicated.
Symptoms include: generalized pruritus (92%), urticaria (83%), angioedema (78%), respiratory symptoms (59%), syncope (32%). 2:1 female predominance. Can show familial
pattern. Associated with hx of allergic rhinitis or eczema. Subtype associated with ingestion of specific foods. Food-dependent Exercise-Induced Anaphylaxis Symptoms are usually induced by physical exercise
after food ingestion. Causative foods include: shellfish, wheat products, vegetables, fruits, nuts, eggs, mushrooms, corn, garlic, rice, and meat. Aspirin and NSAID ingestion has been documented to induce symptoms or to provoke more severe symptoms. Paradoxical Vocal Cord Dysfunction (PVCD) Upper airway obstruction associated with the paradoxical adduction/closure of the vocal folds occurring primarily on inhalation, and
sometimes during exhalation. Presentation can range from mild dyspnea to acute, severe respiratory distress. Without hypoxemia. Many patients point to or grab their throats when describing respiratory symptoms. Incidence is as high as 27% of young, physically active adults Frequently comorbid with asthma in as many as 40% of pediatric patients and 38% of adults. Ratio of 3:1 females to males
The underpinnings of PVCM are poorly understood and more a matter of conjecture than of science. Generally does not respond to pharmacologic treatment for asthma. Diagnosis of PVCD Laryngoscopy is considered the gold standard for diagnosis. Treatment of PVCD Termination of unnecessary medications
Reassurance (that condition is benign and oxygenation is normal despite dyspnea) Speech therapy as primary treatment To abort acute attacks: Panting, sniffing, pursed lipped breathing on exhalation, nasal inhalation Heliox (works by decreasing work of breathing) Benzodiazepines Exercise-Induced Asthma (EIA) Condition in which exercise induces symptoms of asthma in
patients who have asthma. Possibly because of poor control of the disease. In individuals with intermittent asthma, EIA may be the only expression of asthma. EIA is found in 8-10% of normal child population and in approximately 35% of children with current asthma. Symptoms usually occur shortly after heavy exercise. Wheezing will be expiratory. Exercise-Induced Bronchospasm (EIB) Describes airway obstruction that occurs in association
with exercise. Without regard to the presence of chronic asthma. Defined as 10% reduction in FEV1 after exercise. More common in endurance sport athletes or in sports that require high minute ventilation. Prevalence ranges from 11 to 50% Approaches 90% in athletes with asthma. 5-10% of athletes with EIB have no concomitant respiratory or allergic disease. Symptoms of EIB
Coughing, wheezing, chest tightness and unusual SOB Occurring during strenuous exercise and peaking about 5-10 minutes after exercise. Children and adolescents may have more nonspecific symptoms: Poor performance or feeling out of shape, Parents may note inability to keep up with peers Abdominal pain, headaches, muscle cramps,
fatigue, dizziness or chest pain. Pathophysiology of EIA/EIB. Considered a chronic inflammatory condition. EIA usually an eosinophilic inflammation. EIB usually a neutrophilic or mixed inflammation. Inflammation causes increase in airway hyperresponsiveness. Diagnosis of EIB or EIA Based on a detailed history suggestive of EIB or EIA.
For EIA, consider spirometry. Preferred method of measuring airflow limitation and reversibility. A normal FEV1 does not preclude EIA. For EIB, consider a pulmonary function test coupled with an appropriate exercise challenge. Lack of a gold standard test for the diagnosis of EIB in the literature. Pearls Symptoms occurring during the first 5
minutes of exercise are usually not indicative of EIB. More likely related to other changes in pulmonary function, poorly controlled underlying asthma, poor conditioning, or chest wall injury. Case 2: L. - Diagnosis Baseline spirometry with mild obstructive pattern. At 15 minutes post-exercise, significant decrease in small airway flow indicating EIB (FEV1 2.61L).
Full recovery with albuterol (FEV1 2.90L; 11% change from post-exercise reading). Diagnosis: exercise-induced asthma EIA/EIB Treatment 1 Line st Short-acting inhaled -agonists Albuterol, pirbuterol (Maxair), terbutaline For prophylaxis For management of acute bronchospasm
Albuterol Most commonly used pre-exercise medication. 2 puffs administered 15 minutes prior to exercise. Side effects include tremor, palpitations, increased heart rate. Issues with -Agonists Inhaled -agonists are permitted by the NCAA. Daily treatment with -agonists can enhance the severity of EIB. Recovery from EIB after a standard dose of -agonists
is slower and additional doses are often required when either LABAs or SABAs are used daily. Long-acting -agonists produce sustained improvement in pulmonary function persisting, on average, for more than 12 hours. Are not recommended for use as monotherapy. EIA/EIB Treatment: 2 Line nd
Inhaled corticosteroids: Fluticasone (Flovent), triamcinolone (Azmacort), budesonide (Pulmicort), flunisolide (AeroBid), beclomethasone (QVAR) Have been demonstrated to be useful in tx of EIB Require four weeks to achieve maximal effect Side effects: oral candidiasis, hoarseness Consider adding long-acting -agonist (LABA) if symptoms not well controlled on corticosteroids alone. EIA/EIB treatment: 2nd line
Leukotriene receptor antagonists Montelukast (Singulair), zafirlukast (Accolate) A single dose can protect against EIB for up to 12 hours after administration. Benefit is not reduced over time when used on a regular basis as monotherapy. Can be tried alone in those who do not meet WADA or IOC criteria for inhaled corticosteroid use.
Non-Pharmacologic Treatment Measures Increase physical conditioning. High intensity warm up for at least 10 minutes prior to beginning exercise. Cover mouth and nose with scarf/mask in cold weather. Avoid aeroallergens and pollutants. Diet changes. Case 2: L. - Treatment Albuterol MDI, 2 puffs po prior to exercise
Intermittently helps with sx control Loratadine (Claritin) 10mg QD Not taking consistently Montelukast (Singulair) 10mg QD Not taking regularly Fluticasone (Flovent) 110mcg, 2 puffs po BID Didnt like being on steroids Ranitidine (Zantac) 150mg QD No change in symptoms Case 3: C.
41 y.o. recreational marathon runner Notes recurrent URI symptoms including rhinitis and cough. Why is she getting sick so often? Studies show that strenuous or chronic exercise is associated with increased incidence of URIs in athletes. Lifestyle variables high stress levels, sleep
deprivation, dietary unawareness are important cofactors in the immune response. Differential Diagnosis of Rhinitis Allergic rhinitis Non-allergic rhinitis Exercise-induced rhinitis Exercise-Induced Rhinitis Affects more than 1/3 of athletes. Triggers include: Exposure to airborne allergens during training
Cold air Various pollutants Which cause airway inflammation and epithelial damage. Exercise-Induced Rhinitis Treatment: Allergen avoidance Reduction of irritant exposure Medications: Nasal corticosteroids
Nasal anticholingerics Leukotriene receptor antagonists Antihistamines Immunotherapy Consider testing to rule out asthma Case 4: B. 21 y.o. 238# African-American collegiate lineman who fell to his hands and knees on the field during the first day of practice. Was running back-to-back 100 yard sprints.
Complains to the ATC of leg and back cramps. Case 4: B. Observation: sweating, panting overweight athlete; anxious appearing Vitals: T 99.9, tachycardic, tachypnic CV: tachy but regular Resp: CTA B, no w/r/r Musc: no palpable muscle spasms, muscles seem weak against resistance
Case 4: B. - Differential Diagnosis Deconditioning Heat exhaustion or heat stroke Asthma attack Spontaneous pneumothorax Cardiac issue Muscle cramps Anxiety attack Exertional sickling collapse Spontaneous Pneumothorax
2000 cases in the US annually 10% associated with athletic activity. Most often seen in males in their late teens to early 30s; generally in those with a taller slender build Presentation can be varied: Most commonly dyspnea and pleuritic chest pain Chronic cough 10% may have no complaint at all Exertional Sickling Collapse: Symptoms Player who typically slumps to the ground, may
complain of pain (typically low back and legs), muscle weakness, feel like they cant go on. Communicative. Muscles are not locked up. Muscle weakness exceeds muscle pain. Tachypnea (d/t lactic acidosis). Exertional Sickling Collapse: Triggers In athlete with sickle cell trait Maximal exertion sustained for at least a few minutes Abrupt increase in intensity of training
Training at unfamiliar altitude Suboptimal physical conditioning Exertional Sickling Collapse: Treatment Monitor vital signs
Supplemental oxygen by face mask Cool athlete if needed Start IV line and be ready for CPR Transport to hospital if not immediately improving IS A MEDICAL EMERGENCY! Sickle Cell Trait Condition resulting from inheritance of one gene for sickle hemoglobin (HgbS) and one gene for normal hemoglobin.
Incidence in the general population: 8% of African Americans 0.5% of Hispanics 0.2% of whites Sickle Tell Trait Testing now mandated for all Division I student athletes.
Thank you!
