Jan 29, 2015Breathing Easy
Asthma is becoming more prevalent among today’s athletes. A specialist in pediatric sports medicine answers athletic trainers’ questions on the subject.
By Dr. Jorge Gomez
Jorge Gomez, MD, MS, is a Team Physician at the University of Texas at San Antonio and a Professor and Pediatric Sports Medicine Physician in the Department of Pediatrics at the University of Texas Health Science Center at San Antonio.
Of the 48 elite swimmers who represented the United States at the 2000 Olympics in Sydney, 15 had asthma. Some of them were encouraged to try the sport when they were young, since asthmatics often tolerate swimming pools better than playing fields.
But athletes with asthma are found in every sport at every level. From Jerome Bettis of the Pittsburgh Steelers to the high school freshman on your track and field team, athletes are not letting asthma get in the way of pursuing their sports.
Both the number of athletes with asthma and the severity of the disease are increasing for reasons that are not quite clear. The good news, however, is that now there are many highly effective treatments for asthma. Nearly all young athletes with asthma should be able to do everything they want to if properly managed. This article will answer common questions regarding the management of asthma and provide essential information for the athletic trainer.
What is asthma?
Asthma probably represents several conditions of the lung that have two components in common. One is a constriction of the smooth muscle lining the airways, which causes airway narrowing. The second is inflammation of the airways that leads to the production of mucus, which further clogs airways.
The typical signs of asthma are shortness of breath, wheezing, and coughing. However, many asthmatics have just a nagging cough that gets worse during or after exercise and is often present at night, especially after a bout of hard exercise.
How is asthma diagnosed?
The definitive way to diagnose asthma is by using spirometry, a technique of measuring lung volumes and airflows in and out of the lung. In asthma, the constriction of the airways and mucus production causes air to be trapped in the lungs, and makes it difficult to exhale. The usefulness of spirometry can be enhanced by giving athletes a medication (methacholine) that constricts the airways, or by giving a bronchodilator (albuterol) with spirometry performed before and after use. Such testing is most often done by pulmonary specialists.
Because most doctors don’t have spirometry equipment in their office, they must rely on other methods to diagnose asthma. A less sophisticated but very useful tool is the peak flow meter. This simple device measures the force of airflow that an athlete is able to generate while breathing out. Normal values for peak flows—termed Peak Expiratory Flow Rate, or PEFR—have been determined by gender, height, and ethnic group (see “PEFR Predicted Values”). A peak flow value less than 80 percent of “normal” is considered indicative of asthma.
Peak flow readings can be done either with or without an exercise challenge. However, since most asthmatics will have some trouble breathing during exercise, it is most helpful to do peak flow measurements before and after a bout of moderate to vigorous exercise.
Asthma is frequently diagnosed simply based on a patient’s experience of wheezing, shortness of breath, or coughing during or after exercise, a late night cough, and a family history of asthma. Occasionally doctors will prescribe an inhaler to see if this makes the patient’s symptoms better. If it does, the doctor make the diagnosis of asthma.
Should athletes be screened for asthma during their pre-participation exams?
The medical history portion of the pre-participation exam (PPE) should provide strong evidence about whether an athlete has asthma. The PPE form currently recommended by the American Academy of Pediatrics and American Medical Society for Sports Medicine asks the following questions about asthma:
- Do you cough, wheeze, or have difficulty breathing during or after exercise?
- Is there anyone in your family who has asthma?
- Have you ever used an inhaler or taken asthma medicine?
Any athlete who answers positively to any of these questions should be evaluated by a physician for the possibility of asthma.
What should athletic trainers know about the signs of asthma?
Often, athletes are not aware of having any of the symptoms described in the PPE form but do have asthma. The athletic trainer should recommend an asthma evaluation in any of the following situations:
- An athlete who is otherwise well conditioned has shortness of breath or cough with or after exercise on more than two occasions.
- An athlete has a single severe episode of shortness of breath that is not consistent with his or her level of conditioning.
However, the athletic trainer should remember that asthma is a chronic disease, and that people with asthma have chronic symptoms. For this reason, one episode of mild shortness or breath does not warrant further work-up.
What is the most up-to-date treatment for asthma?
The most current treatment for asthma is based on proper classification of the severity of an individual’s asthma (see “Managing Asthma”). The severity of asthma is based on the frequency with which an individual has daytime and nighttime symptoms, and/or on the PEFR measurement or forced expiratory volume in one second (FEV1) using spirometry. Once the severity of an athlete’s asthma is properly assigned, the treatments indicated in the table should be instituted.
The use of inhaled steroids to control the inflammatory component of asthma has been the most important advent in asthma treatment in the last 25 years. Inhaled steroids, often combined with a long-acting beta2-agonist, are the cornerstone of asthma therapy today.
Are there disagreements in the medical community about treating asthma?
Differences between how physicians manage patients with asthma most often arise because some physicians simply are not up-to-date in their knowledge of asthma treatment. This often results is under-diagnosing asthma, or underestimating the asthma’s severity, which in turn leads to under treatment. Essentially, some physicians do not recommend adequate pre-exercise treatment for their patients.
One minor area of controversy—that should not actually be controversial—is the use of nebulizers versus inhalers. There is adequate scientific data indicating that delivery of controller and rescue medications by inhaler plus spacer is just as effective as delivery with a nebulizer.
Another small debate concerns the use of the newer racemic beta-agonist (Xopenex). Many physicians prescribe this more expensive rescue beta-agonist over tried-and-true albuterol because of the possibility of fewer side effects. In comparisons of their effectiveness, there are no differences between these two medications. In comparisons of their side effects, one study has shown that Xopenex did cause less of a rise in heart rate than albuterol, but the difference was small, and for most patients, not enough to justify the extra expense.
What are the side effects of asthma medications?
The asthma medications most likely to cause side effects are the short-acting beta-agonists used as rescue medications. These medications often cause an increase in heartbeat, nervousness, or the “jitters.”
Several studies have examined the long-term effects of inhaled steroids, particularly on children. There is some evidence that long-term use of inhaled steroids may be associated with a slowing of growth in some children, but at this time it is not known whether the slowed growth in these children was due to the medication or to the fact that they had severe asthma.
A lot of athletes seem to struggle with “getting their meds right.” How can athletic trainers help?
Athletic trainers can help, first of all, by making sure the athlete sees a doctor on a regular basis for their asthma. The importance of regular, consistent care with a health professional (preferably the same doctor) cannot be overstressed.
Second, each athlete should have a written “asthma action plan” on file with the athletic trainer. The action plan should state clearly what medications should be taken and when. It is important that athletes know which medicines they need to prevent attacks (controller meds), and which medications they should use when they are having a flare-up (rescue meds). (See “Asthma Medications” closer look at different kinds of asthma drugs.)
The peak flow meter can also help in following the progress of a known asthmatic. It consists of four pieces, which are small enough to be conveniently carried in a student-athlete’s book bag or athletic training kit. Generally, a peak flow reading that is within 80 percent of that predicted for their gender, height, and ethnic group is considered normal or “okay.” A peak flow reading between 50 and 80 percent means the athlete is having mild to moderate difficulty breathing. A peak flow reading less than 50 percent of that predicted means the athlete is having a severe flare-up and needs to take rescue medication immediately and see a physician.
What should an athletic trainer do if an athlete has an asthma attack but does not have his or her inhaler?
First, the athletic trainer should assess the athlete to make sure he or she is really having an asthma attack. The symptoms of an attack are shortness of breath and chest tightness. Physical signs include labored breathing, prolonged expiratory phase of breathing, and wheezing.
If the athlete is truly having an attack and does not have his or her own inhaler, the athletic trainer should give the athlete two to four puffs of someone else’s albuterol inhaler using a spacer device. This way, the athlete does not touch the other person’s inhaler. It would be helpful for the athletic trainer to have a spacer device in their on-the-field bag for such emergencies. After the puffs, the trainer should re-assess. If the athlete is still in distress, the athletic trainer should call for emergency medical assistance. While waiting for EMS, the athletic trainer may give two to four more puffs at 20-minute intervals until the ambulance arrives. The athletic trainer should subsequently notify the athlete (and parent of the athlete at the high school level) whose inhaler was used.
How can an athletic trainer tell if an athlete can start working out again after a bout of asthma?
If an athlete has had a severe flare-up of asthma requiring hospitalization or a visit with a physician, the treating physician should provide a written statement indicating when the athlete may return to full activity. For less severe flare-ups, the athlete should provide objective evidence that their breathing is normal, preferably by performing a peak flow reading and comparing it to standard predicted values.
Should athletes with asthma participate in sports when the air-quality index is bad?
This is a difficult question to answer. When air-quality alerts are broadcast, they make broad recommendations that anyone with lung disease should not be outside. If we were to heed these warnings strictly, many asthmatics would miss a lot of practice and game time.
It is important to remember that not every asthmatic is as sensitive to air quality as the next, and that different pollutants may affect different people to different degrees. For example, some asthmatics may be more sensitive to ozone, and others may be more sensitive to dust or other matter in the air. It is best to ask each asthmatic athlete whether he or she has noticed having more trouble on air-quality alert days, and then to restrict their activity depending on the severity of their symptoms.
What is the connection between allergies and asthma?
Allergies and asthma have at least three things in common. Both are considered “atopic” diseases, which means they are associated with production of increased quantities of immunoglobulin E (IgE) in response to certain stimuli, which in turn causes inflammation, swelling of blood vessels, and mucus production. In the nasal passages, this process causes the person with allergies, also known as allergic rhinitis, to have an itchy, running nose, and congestion. The other major atopic disease is eczema. It is common for people with one type of atopic disease to have the other diseases.
Another common thread is that individuals with asthma often achieve better control of their asthma when their allergies are also under control. This is especially important in the athlete with hard-to-control asthma who also has allergies. Finally, individuals with a chronic, persistent cough may have either allergies or asthma as a cause.
What research or treatments are on the horizon for athletes with asthma?
A lot of research is being directed at other biochemical mediators of inflammation in the lungs, such as drugs to counter the effects of interleukins and cytokines. Such medications are being developed and may be available in a few years. There is also recent evidence that a low-salt diet can improve asthma control.
What is the bottom line in preventing athletes from having asthma attacks?
Most importantly, athletic trainers should know who their asthmatic athletes are and be familiar with the signs and symptoms of an asthma attack. They should also be aware of the daily air-quality index in their locale, and keep a close eye on individuals with asthma to make sure they are not developing signs of an attack. Finally, athletic trainers should make sure that each athlete with asthma has a written treatment plan, a rescue medication, and a spacer to help deliver the medication.
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