is an obstructive or restrictive condition which inhibits airflow due to inflammation of the airway. This obstruction occurs via increased edema in the small bronchioles walls as well as greater production of a thick mucus secretion from the bronchial lumen, thus narrowing the space available for oxygen intake to the lungs. During what are often referred to as asthma attacks or sudden onset of exacerbated symptoms of the conditions, people with astma may also experience spasms of the smooth muscle within the pulmonary trunk in addition to the narrowing of the airway. 3 More than 25 million people in the United States are affected by asthma, including 7 million children. 4 The Department of Health repors 8.8% of US population and 7.7% of South Dakotans. This condition typically develops as a child but can affect people at any age with more females than males typically affected. Like most pulmonary conditions, there is no cure for asthma, and sometimes no obvious reason for an attack, it is important to understand how to manage this condition via environmental controls, medication, and self-management to be ready to treat it and manage it regularly if an episode occurs. The most common education components typically include education on proper use of an inhaler, steps to take during an asthma attack, and how to recognize early signs. Both children and adults who are hospitalized more often due to asthma are typically able to recall more education sessions related to management as well. 7 Related to exercise performance abilities it is important to understand the difference in severities both between people, within an individual, and the impact of the condition on the individual both physiologically and psychologically. 2 doh.sd.gov/statistics/2009brfss/asthma.pdf Asthma 1
Symptoms and causes Symptoms include wheezing, tightness of the chest, shortness of breath, coughing, and even anaphylactic reactions that can be fatal. Often diagnosed in childhood, people at any age can have this condition. Asthma is often associated allergies or negative reactions to an exposure to a substance of intolerance. Diagnosis If experiencing any of the related symptoms such as sudden attacks or periods of these symptoms above, one should present to their physician for an assessment. Typically the provider will consider personal and family history, perform a physical exam, and review test results to determine if the cause is asthma. It is important to note specific symptoms, the frequency of their onset, and if certain times or conditions are present at these times such as at time, with activity, or when outside. Wheezing, swollen nasal passage, runny nose, or eczema may all be signs of asthma or allergies but need not necessarily be present at the time of exam to still have asthma. Some testing can help the physician determine if conditions of the airway are in fact asthma, and explore the condition further. Often times if a person has allergies and symptoms improve with medication, it is typically considered asthma without extensive testing. However these tests can be useful to rule out other pulmonary conditions. Using spirometry to test lung function is a common test a physician will use to measure your ability to breathe in and out. This test can help quantify both how much air flow and how fast you can do it to help determine function. Sometimes a physician will recommend or order allergy testing to help identify and reduce other triggers. A bronchoprovocation test can help to measure how sensitive the airways are using spiometry during different conditions such as changes in temperature or during physical activity. Ruling out other conditions with similar symptoms such as sleep apnea, vocal cord dysfunction, or reflux disease can also be helpful. Chest X rays or electrocardiogram tests can also determine if a foreign object in the airways are to blame. Children with Asthma- Under the age of five symptoms of asthma are common symptoms of several other conditions that make it difficult to diagnose. Wheezing for example, maybe be because he child s airways have not fully developed yet and being small, become more narrow during a common cold or respiratory infection and therefore the symptom of wheezing can resolve after resolution of the cold or when getting older. Children are more likely to have asthma if both parents do, if they have allergies including pollens or airborne substances, if they have chronic skin conditions, or chronic wheezing without an infection. Often times a short term trial of asthma medication, such as four to six weeks, can help to determine if symptoms improve related to asthma or if other conditions are the cause. 4 Treatment/Management Management goals related to asthma are to first identify specific triggers that may onset an attack which is characterized by a sudden onset of difficulty breathing, tightness in the chest, or excessive coughing. Often times asthma exacerbations or attacks are associated with allergens. These may include dust mites, pollens 2
found in outdoor environments; irritants such as environmental tobacco smoke either directly or via secondhand smoke and also animal dander, plants, wood dust, or bark. Molds, typically found in areas around humidly such as bathrooms or kitchens, pests and cockroaches, the ozone and outdoor pollution from vehicles and manufacturing plants may all be specific irritants to an individual with asthma. Enzymes, flour, rubber latex, and reactive chemicals may also cause allergic reactions including an asthma attack. Even certain kinds of detergent enzymes may exacerbate an asthma attack if an individual is intolerant to the agent. Individuals who have been able to identify specific triggers should first try to limit exposure to these irritants to reduce potential for frequency of attacks. Sports training management: As an athletic trainer or within the realm of health and fitness you are more likely to see pulmonary conditions such as asthma, which may have been developed during childhood and have various onsets of attack. In fact, within the last two decades the likelihood of an elite athlete to have asthma has greatly increased; more specifically in cyclists and mountain bikers and less likely in weight lifters. 3 Factors that may have affected this trend may include the change in exposure to pollutants within the environment, change in diet, training, supplement use, training intensities, and overuse of antiboiotics which may affect the immune systems reactions. 3 When working with these individuals a primary goal would be to reduce potential allergens that may exacerbate an asthma attack and have a medication management plan in place. For example, working in an indoor facility if an athlete has outdoor allergies to pollens may help to focus on training during optimal conditions. However, it would be important to consider conditions during race or game time activities compared to training as well to be prepared. Exercise-Induced Asthma(or exercise-induced bronchoconstriction) is not completely understood in its etiology. One thought of the reason for reaction of the narrowed airways is due to changes in temperature and humidity in the atmosphere. 3 Others think certain individuals are more susceptible to this condition who are otherwise healthy and without asthma in daily living. 8 An estimated 10-50% of athletic individuals may experience this condition from recent studies. 8 It is recommended to gradually adjust to increased intensities when experiencing exercise-induced asthma. Typically symptoms peak at about six-to-eight minutes into exercise and improve as you continue, but occur at equal or greater intensities during recovery. 3 Although symptoms and treatment often is similar compared to those who have asthma in daily living, it is important to consider anti-doping regulations when evaluating a management/treatment plan involving medications that may apply. 8 Medications: Asthma In addition to trying to identify allergens that may cause flare-ups, it is important to have a medication management plan as well. There are both long-acting medications that help to keep the airway open and attacks, and quick-relief medications that help to relax the airways allowing more airflow faster in situations such as an attack or sometimes just prior to exercise. It is common to take allergy medications, and short and long acting asthma medications for optimal management. 3
Allergy medications that can help control symptoms that may lead to an attack and affect asthma include antihistamines, montelukast, nasal sprays, eye drops, emergency medications during anaphylaxis, topical ointments or creams, immunomodulators, and oral corticosteroids. Long-term asthma control medications to be taken daily with the goal to prevent the onset of asthma symptoms. These include inhaled corticosteroids, long-acting beta-agonists (LABAs), Cromolyn and Teophylline, Leukotriene modifiers, or immunomodulators. Inhaled corticosteroids are the most effective long-term control medication for asthma and there are several different types available either by itself or in combination with a bronchodilator. The doses and frequency to take vary on the type of drug prescribed, age of the person with asthma, and severity of symptoms. The physician should designate the strength and frequency. Long-acting beta-agonists should always be used in conjunction with inhaled steroids in asthma according to the FDA. These often help relieve bronchospasm occurrences and prevent exercise-induced asthma symptoms. Cromolyn and Theophylline should be alternative controller medications and not primary choice medications. Theophylline is associated with prevention of asthma symptoms that especially occur at night. Leukotriene Modifiers are oral medications that help to treat and prevent symptoms. Immunomodulator medications act directly on the immune system to change the biological response. These are typically taken subcutaneously via injection and used in people with moderate to severe allergic asthma related to air allergens year-round and can be diagnosed via a skin or blood test. Short-term asthma control medications help to relax airway muscles and provide quicker relief via improved airflow. Short-acting Beta-Agonists (SABAs) are common to help relieve the quick onset of asthma symptoms. There are various types and the dose and frequency varies depending on type of drug, age, and severity of symptoms. They are used as inhalers in an aerosol or powder form that is inhaled for quick relief. These are meant to help control an asthma attack rather than taken daily as a preventative method therefore are often used in conjunction with long-acting medications as well. 9 Please see the American Academy of Allergy Asthma & Immunology (AAAAI) website for additional available charts and links to current recommended medication management within each category of FDA approved medications and typically recommended doses related to age. Long-term control medications: These are taken daily to help prevent symptom onset. http://www.aaaai.org/conditions-and-treatments/treatments/drug-guide/inhaledcorticosteroids.aspx Inhaled Corticosteroids: 4
Inhaled Cordicosteroids: Are considered the most effective long term usage medication for control and management of asthma. Generic Name Brand Name Use Usual Dosage Beclomethasone Propionate HFA QVAR Inhalation Aerosol 40mcg/puff QVAR Inhalation Aerosol 80 mcg/puff prevent ashma. Age 5 and older Children 5-11: 40-80mcg twice daily Adult: 40-320 mcg whice daily Budesonide Pulmicort Flexhaler 90mcg Pulmicort Flexhaler 180 mcg Pulmicort Respules 0.25 mg/2ml susp 0.5 mg/2ml susp 1mg/2mL susp prevent asthma. Age 6 and older prevent asthma. Age 12 months to 8 years. Children 6-17 180 mcg twice dialy. Maximum is 360 mcg twice daily. Age 18 and older: 360 mcg twice daily. Maximum is 720 mcg twice daily. 12months to 8 years: 0.5 mg to 1mg, once daily or in divided doses Budesonide with Formoterol (bronchodilator) Symbicort 80/4.5 Symbicort 160/4.5 Maintenance of asthma. Age 12 and older Symbicort 80/4.5: 2 puffs twice daily Symbicort 160/4.5: 2 puffs twice daily Prescriber should designate the exact strength recommended. Ciclesonide Alvesco Inhalation Aerosol 80 or 160 mcg Maintenance of Asthma. Age 12 and older 80 to 320 mcg daily 5
Flunidolide Aerobid Aerosol 250 msg/ puff Aerobid-M Aerosol 250msg/ puff Age 6 and older: 2 inhalations twice daily Adult: 2-4 inhalations twice daily Fluticasone Propionate Flovent HFA 44, 110, or 220 mcg Inhalation Aerosol Flovent Diskus 50, 100, and 250 mcg Age 4 and above. Dosing varies and is to be adjusted per physician. Diskus dose: 1-2 inhalations twice daily Advair Diskus: Fluticasone with Salmeterol (bronchodilator) Advair Diskus 100/50, 250/50, or 500/50 Advair HFA 45/21, 115, 21, or 230/21 100/50 ages 4-11. And all appropriate for age 12 and older One inhalation twice daily. HFA: age 12 and older for all strengths, 2 inhalations twice daily. Momestasone Asmanex Twishaler 220 mcg age 12 and older Age 12+: 220-880 mcg Asmanex Twishaler 110 mcg age 4-11 Children 4-11: 110mcg in the evening 6
Mometasone with Formoterol (bronciodialator) Dulera 100/5 and 200/5 Age 12+: 2 puffs twice daily. Triamcinolone Acetonide Azmacort Inhalation Aerosol 75mcg/spray Age 6-12: 2-8 puffs daily in divided doses Adults: 4-16 puffs daily in divided doses. *Chart based on similar Medicationguide directly from AAAI website 6 Interesting factoid:methalzanthine, a chemical found naturally in caffeine, is similar to some antiinflammatory medications in pediatric asthma management treatments. So during a flare-up, a child may be able to drink very strong coffee to help reduce symptoms. This was done by former U.S. president Teddy Roosevelt when he was a young child growing up with severe asthma symptoms. 4 Of course, now we would recommend having proper medications on hand in case of this occurrence. 10 Asthma: Exercise Programming Recommendations: (From Durstine s ACSM s Exercise Management for Person s with Chronic Diseases and Disabilities-2003) 2 Mode Goal Intensity/ Frequency/ Duration Time to Goal Aerobic Increase VO2 peak, lactate threshold, & Ventilatory threshold Improved breathing patterns (less dyspnea) RPE 11-13/ 20 1-2 sessions, 3-7 days/wk 30 min/ session Focus on duration over intensity 2-3 months 7
ADL improvement Strength Increase max reps, isokinetic torque/work, and lean body mass Low resistance, high reps 2-3 days/wk 2-3 months Flexibility Increase ROM 3 sessions/ wk Neuromuscular & Balance Improve gait, balance, and breathing efficiency Daily 1. Farrell, P; Joyner, M.; Caiozzo V. Chapter 8: The Respiratory System. American College of Sports Medicine s Advanced Exercise Physiology. 2011, 2 nd Edition. 2. Durstine, L; Moore G. Chapters 15 & 17: COPD & Asthma. American College of Sports Medicine's Exericse Management for Persons with Chronic Diseases and Disabilities. 2003; 2nd Edition. 92-110. 3. Brooks, G; Fahey T; Baldwin, K. Exercise Physiology: Human Bioenergetics and Its Applications, Fourth Edition. Chapters 11-12. The Why and How of PulmonaryVentilation. 2005; 241-282; Chapter 26: Pulmonary Disorders: COPD: 659-663. 4. U.S. Department of Health & Human Services. National Heart, Lung, nd Blood Institute. www.nhlbi.nih.gov 5. American Lung Association. www.lung.org 6. American Academy of llergy Asthma & Immunology. December 2011. AAAI Allergy & Asthma Medication Guide. www.aaaai.org/conditions-and-treatments/treatments/drug-guide/inhaledcorticosteroids.aspx 8
7. Zahran, Hatice. Predictors of Asthma Self-Management Eduction among Children and Adults-2006-2007 Behavioral Risk Factor Surveillance System Asthma Call-back Survey. Journal of Asthma. Feb 2012. 49:(1) 98-106 8. Schumacher, Y; Pottgiesser, T; Dickhuth, H. Exerfcise-Induced Bronchoconstriction: Asthma in Athletes. International Sports Medicine Journal. 2011: 12: (3): 145-149. 9. American Academy of Allergy Astma & Immunology. Dec 2011. AAAAI ALllergy & Asthma Medicaton Guide. www.aaaai.org/conditions-and-treatments/drug-guide.aspx 10. WebMD: COPD HethCnt. :/www.webm./lung/copd/metyxantine-fr-cbobstrcivepl-disease-copd 9