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Exercise-Induced Asthma

Recognizing and Managing the Problem

By Jon Heck, MS, ATC, and Kaley Abato, BS

______________________________________________________________________________ Jon Heck is the coordinator of athletic training at Richard Stockton College in Pomona, NJ. He received his bachelor's degree at William Paterson University and master's degree from the University of Florida. Kaley Abato is currently a graduate student in the physical therapy program at Richard Stockton College, where she also serves as a student athletic trainer. She received her bachelor's degree in biology at Stockton. ______________________________________________________________________________

As many as 12 million Americans have asthma. Contributing to 5,000 deaths a year, asthma is the seventh-leading chronic condition in the nation. The number of cases is also on the rise. The American Lung Association reported a 57 percent increase in asthma cases from 1982 to 1992 (28). Of interest to the athletic and female population, exercise-induced asthma (EIA) affects up to 30 percent of athletes (18,20,22,30). Exercise-induced asthma affects approximately 10 percent to 23 percent of the general population (9,29) and 9 percent of non-asthmatics (1,25). Studies report that 40 percent of individuals with allergic rhinitis (hay fever) (9,14,19,25,30) and 80 percent of asthmatics (2,3,11,19,25,29) experience EIA. Exercise-induced asthma has a higher occurrence among children (22), although one in four outgrow it by adulthood (28). Exercise-induced asthma is a reversible condition in which the smooth muscle in the airways constricts in response to physical activity. Due to a various attack triggers, breathing becomes so difficult that athletic performance declines significantly (9). A typical attack occurs five to 15 minutes after physical exertion and peaks within six to eight minutes. Symptoms gradually resolve within 30 to 60 minutes. This interval, known as the refractory period, lasts between one and three hours after an attack. During the refractory period, the athlete's performance may return to about normal (4,7,22). The severity and frequency of attacks will vary. Approximately 30 percent to 40 percent of individuals (24) will experience symptoms four to six hours after exercise during a late phase response (22,29,30). Signs and symptoms of EIA can appear during or after exercise. Each person has an individual response and may not display all the same symptoms (9). Symptoms will also vary among individuals. The signs and symptoms of EIA are listed in Table 1.

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TABLE 1 Signs and Symptoms of Exercise-Induced Asthma Obvious Signs and Symptoms:

Wheezing Difficulty breathing Chest tightness Coughing Problems with prolonged sessions of exercise

Subtle Signs and Symptoms:

Stomach pain/nausea Fatigue Inability to exercise in the cold Chest congestion/discomfort Frequent colds Dry throat Inconsistent performance Headache

Several factors contribute to the occurrence and severity of EIA. Individuals with a family history of asthma are genetically predisposed to having EIA (14). Environmental factors such as cold, dry air; air pollutants; airborne allergens or irritants; and high altitude (11) can trigger an attack (9,14,21,22,30). Exposure to food allergens such as shrimp, celery, egg whites, peanuts, almonds or bananas up to two hours before activity may also provoke an attack (25). The optimal conditions for exercise are warm, humid weather; minimal level of pollutants or allergens; and a moderate altitude. The duration and intensity of exercise also have an effect on EIA. High-intensity and long-duration exercise result in increased risk of an episode, whereas brief, high-intensity exercise bouts (e.g., 10 seconds of work, then 30 seconds of rest) or low-intensity, prolonged exercise appear more tolerable (10). Other contributing factors include respiratory infections, underlying bronchial hyperreactivity, the time period since the last EIA attack and a low fitness level (22). Triggers of EIA vary greatly and athletes must identify those that promote their symptoms. The combination of seasonal conditions and the intensity and duration of exercise results in some activities being more tolerable to individuals with EIA. Swimming is the most tolerable, with long-distance running the least tolerable. Healthcare professionals should encourage recreational athletes to pursue activities that do not involve cold, dry air or endurance exercise (2). Trying to redirect competitive athletes from their sport will not be successful in most cases. Table 2 classifies some common sports in regard to EIA risk.

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TABLE 2 Classifications of Sports and Exercise-Induced Asthma Risk Tolerable Sports/Activities:

Archery, baseball, circuit weight training, downhill skiing, football, golf, gymnastics, karate, kayaking, riflery, short-distance running, swimming, tennis, volleyball and wrestling

Less Tolerable Sports/Activities

Basketball, cross-country skiing, cycling, ice hockey, ice skating, lacrosse, long-distance running, rowing and soccer

Recognizing the Problem Diagnosing EIA in athletes without chronic asthma can be difficult. This fact is particularly true for athletes with more subtle symptoms. In addition, many athletes will minimize or deny EIA symptoms as a "real problem" for participation. They may have been dealing with the condition for years without treatment. Estimates of athletes with undiagnosed EIA range from 5 percent to 30 percent (9,17). For most athletic programs, a careful history is crucial in identifying EIA (17). This diagnosis often is made on the basis of history alone (26). The preseason physical provides an excellent opportunity to screen athletes. The past medical history portion of the examination must include specific questions concerning asthma. The tendency to cough or wheeze after hard physical activity may be the only symptom reported by many athletes with EIA (16). This specific question should be included in every historical questionnaire. There are several other risk identifiers. Athletes with a history of diagnosed asthma or hay fever are likely to experience EIA. Athletes with EIA will frequently experience upper respiratory tract infections or bronchitis and use antibiotics. Athletes who receive allergy shots or regularly use antihistamines or decongestants are also candidates for EIA (16). The treating physician must make a critical distinction whether the athlete has solitary EIA or chronic asthma with exercise-induced episodes. This distinction is important regarding treatment. The athlete with solely EIA will normally require only pre-exercise treatment. Those athletes with persistent asthma will require daily anti-inflammatory therapy plus pre-exercise treatment (26). This distinction may require pulmonary function tests using a computerized spirometer in a physician's office. In-season observation by the coaching and athletic training staffs is also valuable in identifying athletes at risk. Athletes with EIA will often become easily winded during prolonged exercise; however, they tolerate short bouts well. They may describe not getting into shape as

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fast as their teammates. The well-conditioned individual who becomes "out of shape" at midseason may be experiencing EIA. Athletes, if questioned, also are likely to discuss "conditioning difficulties" while they are involved in rehabilitation for other injuries. Peak Flow Meter A peak flow meter can be a useful tool in recognizing and managing EIA. It is inexpensive, costing about $15 to $20, and is simple to use. A peak flow meter measures peak expiratory flow rate (PEFR), or the fastest speed at which the athlete can blow air out of the lungs after taking a maximal breath. Peak expiratory flow rate is a measure of how well the lungs are moving air. Whether recognizing or managing EIA, a resting score must be obtained. This figure will represent the baseline, or normal score. The highest of three trials should represent the athlete's PEFR score. The normal range for females is 450 milliliters to 490 milliliters (575 milliliters to 610 milliliters for males). Undiagnosed athletes can be given an exercise test to help identify EIA. The exercise challenge should last six to eight minutes at an intensity of 85 percent 90 percent of predicted maximal heart rate (16). The athlete should not take the test within four hours of his or her last EIA attack (16). The PEFR is then taken every three minutes over a 15-minute span, postexercise. A reduction of 10 percent or more indicates EIA (Table 3) (16). The peak flow meter can also be used to manage EIA. After an attack, an athlete should not return to participation until the PEFR is within 10 percent of his or her normal score. TABLE 3 Exercise-Induced Asthma Classification

Exercise-induced asthma severity classification based on percent reduction in peak expiratory flow rate (PEFR) from pretest to post-exercise test (16): 10-25% 25-35% 35-50% >50% Mild Moderate Moderate to severe Severe

Pharmacotherapy Once diagnosed, prescription medication is the treatment of choice in successfully managing EIA. Virtually every athlete can compete in his or her chosen sport with the appropriate drug therapy. Olympic athletes with diagnosed EIA have gone on to medal at a rate similar to their Olympic counterparts without asthma (1,9). First-line defense drugs for EIA usually include a short-acting beta-agonist. Albuteral, metaproterenol sulfate, pirbuterol acetate, and terbutaline sulfate all fit into this category (26). Ninety percent of patients will be successfully managed with beta-agonists (1,6). This medication is administered by a metered dose inhaler 15 to 30 minutes before exercise. The betaagonist inhalers are also used as a rescue treatment for rapid relief of an acute attack (6). Salmeterol, cromolyn sodium or nedocromil can also be used in first-line defense.

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Athletes who do not control their asthma with first-line therapy and adaptations may need daily inhaled corticosteroids (26). The team physician should also re-evaluate these athletes for chronic asthma that is exacerbated with exercise. The inhaled corticosteroids are used for daily maintenance, and a first-line drug is still used before exercise (26). Nonpharmacologic Treatment Vitamin C There appears to be an association between dietary vitamin C intake and asthma attacks (13). Vitamin C is the major antioxidant substance present in the lining of the lungs (13,28). It may be in this role that vitamin C battles the damaging effects of oxidant contaminants that can contribute to an asthma attack. Oxidant contaminants include environmental pollutants, dirty air, cigarette smoke and those produced by the body. A diet low in vitamin C is a risk factor for asthma. Recently, Cohen et al. (5) reported that vitamin C supplementation blocked an EIA attack in 45 percent of the 20 patients in their study. Seven out of 11 other studies have found similar effects on asthma with supplements of 1 gram to 2 grams of vitamin C. Cohen et al. gave their patients 2 grams of oral vitamin C one hour before exercise. They could not predict which patients would benefit from the supplementation. Of further interest, a subgroup of patients who benefited from the single dose also blocked attacks for two weeks with 500 milligrams of daily supplements. It seems that vitamin C therapy warrants consideration as an adjunct treatment of athletes with EIA. But there are some concerns. The 2,000 milligrams is a megadose that is 30 times the Recommended Daily Allowance of 60 milligrams. The RDA for vitamin C is often considered too low, however, and 200 milligrams to 300 milligrams may be more appropriate (13,27,28). In addition, another study found the blood is 91 percent saturated with vitamin C at an intake of 400 milligrams and 100 percent saturated at 1,000 milligrams (27). This finding questions the need for doses higher than 400 milligrams. A reasonable approach for athletes may be to attempt a megadose of 1 gram to 2 grams before exercise to see if it blocks their asthma episodes over several trials. If successful, they can try daily supplementation at a level f 200 milligrams to 500 milligrams to determine if they get similar benefits. This level of intake can be achieved through an appropriate diet of foods high in vitamin C (Table 4). Overall, vitamin C is an inexpensive treatment option that is relatively safe with a low side effect profile (8,12). If attempted, it should be combined with pharmacotherapy.

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TABLE 4 Foods Containing Vitamin C Food Vitamin C (mg)

Strawberries (7 medium) Bell peppers (1/2 cup) Orange juice (6 oz.) Chili peppers (1/4 cup) Orange Grapefruit juice (6 oz.) Broccoli (1/2 cup) Cantaloupe (1/4) Brussels sprouts (1/2 cup) Grapefruit (1/2) Watermelon (1 slice) 127 95 93 91 80 70 62 58 48 47 46

Preventive Measures The ideal treatment would involve avoidance of triggers, combined with modifying the athlete's exercise program. These practices are not always feasible when dealing with competitive athletes. Within the athletic setting, the following preventive procedures can help reduce the severity and occurrence of EIA. Athletes must experiment with time frames and exercise intensity to find what works best for them. 1. Thirty to 60 minutes prior to activity, begin with a 10 to 15 minute warm-up (7,9,30) involving stretching and light activity. 2. Begin short bursts of submaximal activity involving jogging or running (4,11,14,22,30). This level should be sustained for five to 10 minutes. The objective is to have the athlete reach the refractory period in which they can continue activity with fewer symptoms (2,4,7,9,11,15,22,23,25). 3. Premedicate 15 to 30 minutes prior to practice/competition (7,11,23). 4. Post-competition, end with a 10 to 15 minute gradual cool-down (9,11), involving walking and stretching. This cool-down helps to avoid provoking an EIA attack secondary to rapid temperature changes in the airways (11). Other management techniques can be incorporated into the athlete's training program. A high fitness level tends to decrease the need for medication and reduce the occurrence of attacks (2,7,9,11,22). Since EIA can be triggered by rapid increases in a training program, slowly progress the duration and intensity during training (15,22,23,25). The use of slow, deep breathing techniques helps to avoid hyperventilation (11,15,30). Specific measures to take during cold, dry weather include covering the mouth with cold-weather masks or scarves (11,15,30). When possible, nasal breathing is also helpful. These techniques filter, warm and humidify the air (2,4,7,911,22,23,25). EIA Management Protocol At Stockon College, we use a protocol that is derived from the Temple Asthma Watch Program. It includes educating the athletes and coaches about their roles in the EIA management process.

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During physicals, all athletes with suspected chronic asthma or EIA have their lung volume measured with a peak flow meter. This measurement represents their "normal" score. Each head coach then receives a list of all asthmatic athletes on his or her team. It is the coach's responsibility to ensure that no athlete will practice or play without his or her asthma inhaler readily available. Athletes who forget their inhaler may not participate until they have it with them. It is worthwhile to note that an asthma inhaler at the practice field does an athlete no good if he or she has an attack while on a distance run through campus. The inhaler should accompany the athlete during such training. An athlete who has an attack at practice will be retested with the peak flow meter by the student athletic trainers. After using the inhaler, the athlete must score within 10 percent of his or her normal score in order to return to practice. Acceptable Treatment Range: The athlete who uses an asthma inhaler to premedicate before competition and only once during competition to manage symptoms is in an acceptable treatment range. Ineffective EIA Management: The athlete who needs an inhaler more than once during practice (excluding premedication) represents ineffective treatment. Participation that day will be terminated for any athlete who has two attacks during that exercise session. This athlete then is referred to our team physician for a re-evaluation for chronic asthma and to explore other prescription options. Asthma Emergency: An athlete who has an attack and the inhaler does not alleviate the situation in five to seven minutes should be transported to the emergency room by an emergency medical service. A clear understanding among the coaching staff, athlete and medical staff is crucial. The goal is to optimize the athlete's performance while effectively managing the condition. Asthmatics will have bad days or nights in which their symptoms may prevent full participation. The athlete cannot fear repercussions of decreased playing time if he or she is unable to practice. The 10 percent rule via the peak flow meter is an objective criteria that takes the responsibility of participation status away from the athlete. Conclusion If untreated, exercise-induced asthma can be a hindrance to achieving top athletic performance. The preseason physical is an excellent opportunity to screen athletes for asthma and EIA. Once the problem is recognized, virtually every individual can complete in his or her chosen sport with the appropriate drug therapy. The use of a peak flow meter and the establishment of an asthma protocol help provide an optimal environment for athletes with EIA to compete safely. REFERENCES 1. Afrasiabi, R. and Spector, S.L. (1991). Exercise-induced asthma. The Physician and Sportsmedicine, 19(5), 49-60.

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2. Blumenthal, M.N. (1990). Sports aggravated allergies: How to treat and prevent the symptoms. The Physician and Sportmedicine, 18(12), 52-66. 3. Blumenthal, M.N. and Sherman, C. (1997). Managing allergies in active people. The Physician and Sportsmedicine, 25(8), 129-34. 4. Brown, R. (1996). Exercise-induced asthma. Allergy and Asthma Magazine, 5(1), http://www.healthline.com/articles/ac960102.htm. 5. Cohen, H.A., Neuman, I. and Nahum, H. (1997). Blocking effect of vitamin C in exercise-induced asthma. Archives of Pediatric & Adolescent Medicine, 151, 367-70. 6. Disabella, V. and Sherman, C. (1998). Exercise for asthma patients. The Physician and Sportsmedicine, 26(6), 75-84. 7. Disabella, V. and Sherman C. and DiNubile, N.A. (1998). Your guide to exercising with asthma. The Physician and Sportsmedicine, 26(6), 85. 8. Ferdman, R.M. (1997). [Review of Blocking effect of vitamin C in exercise-induced asthma]. Archives of Pediatric & Adolescent Medicine, 151, 367-70. 9. Fuentes, R.J. and Dimeo, M. (1999). Exercise-induced asthma and the athlete. In R.J. Fuentes and J.M. Rosenberg (Eds.), The Athletic Drug Reference (pp.225-56). Durham, NC: Clean Data Inc. 10. Fitch, K.D. and Godfrey, S. (1976). Asthma and athletic performance. Journal of the American Medical Association. 236(2), 152-57. 11. Gong, H. (1992). Breathing easy: Exercise despite asthma. The Physician and Sportsmedicine, 20(3), 159-67. 12. Haller, D.L. (1997). Vitamin C may help in EIA. The Physician and Sportsmedicine, 25(7), 441. 13. Hatch, G.E. (1995). Asthma, inhaled oxidants, and dietary antioxidants. American Journal of Clinical Nutrition, 61(suppl), 625S-30S. 14. Katz, R. (1994). Exercise-induced asthma. Allergy and Asthma Magazine, 3(1), http://www.healthline.com/articles/ap940003.htm. 15. Katz, R.M. (1986). Prevention with and without the use of medications for exerciseinduced asthma. Medicine and Science in Sports and Exercise, 18(3), 331-3. 16. Kyle, J.M., Walker, R.B., Hanshaw, S.L., Leaman, J.R. and Frobase, J.K. (1992). Exercise-induced bronchospasm in the young athlete: Guidelines for routine screening and initial management. Medicine and Science in Sports and Exercise, 24(8), 856-9. 17. Mahler, D.A. (1993). Exercise-induced asthma. Medicine and Science in Sports and Exercise, 24(5), 554-61. 18. Meza, C.E., Martin, A.A., Jensen, S. and Teuber, S.S. (1999). (Abstract) Prevalence of exercise-induced asthma in a Division I athletic program. [Abstract]. Journal of Allergy and Clinical Immunology, 103:s10, Abstract #38. 19. Nagwua, S. (1995). Exercise-induced asthma. Allergy and Asthma Magazine, http://www.healthline.com/articles/ac950008.htm. 20. Provost-Craig, M.A., Arbour, K.S., Sestili, D.C., Chabalko, J.J. and Ekinci, E. (1996). The incidence of exercise-induced bronchospasm in competitive figure skaters. Journal of Asthma, 33(1), 67-71. 21. Rund, D.A. (1990). Asthma. The Physician and Sportsmedicine, 18(1), 143-6. 22. Rupp, N.T. (1996). Diagnosis and management of exercise-induced asthma. The Physician and Sportsmedicine, 24(1), 77-87.

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23. Slater, J.B. and Slater, E.G. (1996). Exercise induced asthma. Sports Medicine Update, 11(3), 26-9. 24. Sly, R.M. (1986). History of exercise-induced asthma. Medicine and Science in Sports and Exercise, 18(3), 314-7. 25. Spector, S.L. (1993). Update on exercise-induced asthma. Annals of Allergy, 71, 5717. 26. Storms, W.W. and Joyner, D.M. (1997). Update in exercise-induced asthma: A report of the Olympic exercise asthma summit conference. The Physician and Sportsmedicine, 25(3), 45-55. 27. Vitamin C: Foods yes, pills no. (1998). Health, 10(11), 1-4. 28. Vitamin C for warding off asthma? (1996). Tufts University Diet & Nutrition Letter, 13(12), 3. 29. Voy, R.O. (1986). The U. S. Olympic Committee experience with exercise-induced bronchospasm, 1984. Medicine and Science in Sports and Exercise, 18(3), 328-30. 30. Wilkerson, L.A. (1998). Exercise-induced asthma. Journal of the American Osteopathic Association, 98(4), 211-5. Address correspondence to: Jon Heck, MS, ATC Athletic Training Services Richard Stockton College Jim Leeds Road Pomona, NJ 08240

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