Financial Disclosure. Exercise Induced Bronchospasm BHR. Exercise Induced Asthma

Transcription

1 Financial Disclosure Exercise Induced Bronchospasm Elizabeth Bailey MSN, CRNP Allergy & Asthma Specialists BREATHE II March, 23, 2012 I have no commercial conflicts of interest and no financial relationships with a commercial entity. Exercise Induced Asthma BHR Occurs in % of children. Most common trigger of persistent asthma. Baseline Spirometry is frequently normal. Spirometry can identify children who under recognize their disease. Formal exercise challenge may be necessary. is not related to baseline lung function, bronchodilator response, or freq. of exacerbations. 9% individuals with have no history of asthma or allergy. Screening by physical examination and medical history does not accurately detect asthma. 1

2 Other Causes of Abu-Hasan et al. Studied 117 children exercise-induced dyspnea 9.4% had 41% normal physiologic limitations 22 % deconditioning 11 % VCD Transient narrowing of the airways that follows vigorous exercise. Symptoms : SOB Cough Wheeze Chest tightness Difficulty Breathing Asthma in Elite Athletes Prevalence of asthma, and AHR are increased in elite athletes. Several studies suggest that long-term intense endurance training may promote the dev. of asthma and AHR. David Beckham's big secret was revealed when it emerged that the most high-profile footballer on the planet has suffered from asthma since he was a boy. 2

3 Sports Related Asthma Deaths Jerome was diagnosed with asthma at age 14 after passing out and being rushed to the hospital during his high school football practice in Detroit. Rather than discontinuing his play, his mother encouraged him to keep playing and follow his doctor's orders to keep symptoms under control. He has since gone on to become one of the most talented and respected players in the NFL. Becker et al. Asthma identified as the cause in only 1% of competitive athletes. 80% occurred in children< 21 years of age Half occurred in children years of age 69% male and 66 % white 90% had known history of asthma, only 5 % used maintenance medications Exercise Triggers Godfrey et al: Established rank order From the largest to smallest effect on reduction in PEFR: Running Treadmill Ergometer ( rowing) Walking Swimming One of the greatest rebounders in NBA history. Dennis Rodman also won six NBA championships. 3

4 Training as a cause of asthma Environmental conditions with high ventilation required by the intense effort may contribute to this. Exposure to chlorinated pools, cold air, allergens, or high levels of pollutants may irritate or sensitize the airways. Mechanical stress of extreme breathing on airway epithelial cells may cause release of mediators which then contributes to AHR. The first time a doctor asked me to get on a treadmill to test for asthma, I thought he was crazy. I thought people with asthma were sickly wheezers. I was a world champion swimmer, hardly a weakling. Sure, I was sick a lot and tended to cough during and after working out, but who doesn't breathe hard after an intense match against worthy opponents? But this doctor told me that people with asthma do not always wheeze (I did not), and that approximately ten percent of Olympic athletes from all over the world have asthma. He then gave me a list of the symptoms and I had almost all of them. I agreed to take the test, and was astonished to discover that when I really pushed it, I could be swimming with a 40% decrease in my lung capacity! Nancy Hogshead Competitive Endurance Athletes Athletes who train in the cold weather, indoor ice rinks and swimming pools have a particularly high risk of without persistent asthma % have and AHR Famous Athletes with 1984 Olympics: 11 % of the US team had 67 Olympians with EIA won 41 medals in all and 15 won gold medals. J Ped

5 Jackie Joyner- Kersee Diagnosed with asthma at age 18, she at first hid her condition from coaches, which put her life at great risk and caused her much suffering. When she finally began taking care of herself and following her doctor's health plans, Joyner-Kersee, who is regarded as one of the greatest female athletes in history, continued to shine athletically and has since said, "I wasn't going to let asthma get the best of me." Physiology Amt. of ventilation and temp. of inspired air are factors that determine severity. Inhalation of lg. vol.of dry, cold air during exercise leads to loss of heat and water from the bronchial mucosa and airway cooling and drying. The mucosal drying and increased osmolarity stimulates: mast cell degranulation; Rapid rewarming after exercise, causes vascular congestion, increased permeability and edema leading to obstruction. Symptoms arise within mins. peaks 8-15 mins after the exertion is ended; resolves about 60 mins. later A fall of 10%-15% in FEV1 and a 15% fall in PEFR are standards for diagnosis of EIA. Up to 90% asthmatics; 45% patients with AR 50% of Olympic athletes 12 % of the general population have Diagnosis of Assess for persistent asthma R/O other causes of exertional dyspnea Treat persistent asthma with stepwise approach Inhaled corticosteroids ICS + inhaled long-acting B 2 agonists Pretreatment if needed with inhaled short-acting B 2 agonists Sports Med Jan;25 5

6 Exercise testing of elite athletes in the lab became too diffi Diagnosis Spirometry Pre and Post Exercise Challenges Provocation Tests: Methacholine Challenge Mannitol Challenge Exercise became a challenge in itself in the field 22 Mannitol Testing First reported in Involves inhaling increasing doses of a dry powder form of mannitol. Imposes an osmotic stress on the airways and therefore it may induce bronchoconstriction by the same mechanism as exercise. Equipment Mannitol capsules, inhaler device and instruction leaflet) Spirometer & mouthpiece Nose clip Timer (which can be set to 60 seconds) Calculator Bronchodilator (albuterol) & spacer (if using a metered dose inhaler) Oxygen and other relevant emergency equipment should be readily available as per standard Bronchial Provocation Testing protocols. 6

7 The response of the muscle to prostaglandins, leukotrienes & histamine is being tested at the same time inhalation of mannitol Increases osmolarity of the airway surface liquid Inactivity in the presence of this diagnosis should not be accepted. Inflammatory cells release mediators decrease in (FEV 1 ) in people with active airway inflammation & sensitive smooth muscle Maneuvers to decrease Warm-up exercises such as submaximal sprints. Cooling down slowly after exercise. Breathing primarily thru the nose instead of the mouth. Face masks in cold air. Exercise and Children In children with asthma, an exercise program improves quality of life and fitness and decreases the need for asthma maintenance medications. Education of family and child about triggers and asthma mgmt. is crucial. Bronchodilators should be available during practice/training and games. Asthma education to coaches, teachers etc. 7

8 Inhalation Therapy Aerosol Delivery Metered Dose Inhalers Dry Powder Inhalers Spacers Holding Chambers Inhaled Route Rapid Onset of Action Less Drug Required Better Tolerated Treatment of Choice for Acute Obstruction Spacers Spacer with Mask Initially intended to overcome: Poor hand-breath coordination in adults Treating tidal breathing infants and children Intellectually challenged patients Assist patients requiring intubation and ventilation more efficiently and cost-effectively 8

9 Spacer with Mouthpiece Spacer Autohaler Diskus 9

10 Flexhaler Twisthaler Next up- Demonstrations 10