Pulmonary Problems in Athletes CHRISTINA NISONGER MURPHY, MD Disclosures •No financial disclosures. Objectives •Review mechanism of exercise induced bronchospasm •Review mechanism of vocal cord dysfunction •Discuss treatment options Case •18yo female collegiate track athlete presents to the clinic with shortness of breath. Since coming to college, she has noted increasing shortness of breath and coughing with and after activity. She reports a sense that she cannot get air in. She feels like she can only get a quarter of her lungs full before she ‘hits a wall’. No shortness of breath with her daily activities. Albuterol has not been as effective as it was previously. Reports diagnosis with exercise induced asthma as a sophomore in high school. Exercise Induced Bronchospasm • Airway obstruction occurring associated with exercise with or without history of asthma ◦ In 80-90% of those with underlying asthma ◦ In 10% of the population without underlying asthma • Symptoms often present after completion of exercise and last up to 30 minutes • Symptoms: cough, wheezing, shortness of breath, chest pain ◦ Wheezing is commonly absent with only symptom being post exercise cough
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Exercise Induced Bronchospasm •Often provoked by 5-8 minutes of strenuous exercise •Peak symptoms 5-10 minutes after completion of exercise and resolve by 30 minutes
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 What is the cause of Exercise Induced Bronchoconstriction?
TWO THEORIES……..
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Temperature induced bronchoconstriction
Warm, moist air Temperature induced bronchoconstriction
Leukotrienes Chemokines
Heat Heat Heat Heat Cold, Dry Air Heat Heat
Heat Heat
Histamine Temperature induced bronchoconstriction
Bronchoconstriction Osmolarity Induced Bronchoconstriction
Solute
Warm, moist air Osmolarity Induced Bronchoconstriction
H2O H2O
H2O
H2O Cold, Dry Air H2O H2O
H2O H2O Osmolarity Induced Bronchoconstriction
H2O H2O
H2O
H2O Cold, Dry Air H2O H2O
H2O H2O Osmolarity Induced Bronchoconstriction
Bronchoconstriction Diagnostic Testing
•Drop in FEV1 by at least 10% after an ‘appropriate’ challenge
•NO ACCEPTED GOLD STANDARD
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Diagnostic Testing •Methacholine Challenge Testing ◦ Variable sensitivity and specificity ◦ Negative testing does not exclude EIB ◦ Should NOT be relied on for diagnosing EIB
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Diagnostic Testing •Exercise Challenge Testing ◦ Six minutes of exercise at 80-85% of predicted maximum heart rate ◦ Breathing dry air while wearing a nasal clip
◦ No short active β2-Agonists within 12 hours, long active β2- Agonists within 24 hours or exercise within 4 hours ◦ Positive Testing:
◦ Decrease in FEV1 by ≥ 10-15% on serial spirometry for 30 minutes following exercise challenge
Parsons et al. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Diagnostic Testing •Eucapnic Voluntary Hyperpnea ◦ HYPERVENTILATION ◦ Increased minute ventilation to 80-95% of predicted for 5-6 minutes ◦ Positive Testing
◦ Decrease in FEV1 by ≥ 10-15% on serial spirometry ◦ Recommended by International Olympic Committee for diagnosing Exercise Induced Bronchospasm
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Nonpharmacologic Management •Warming and humidification of air ◦ Nasal breathing ◦ Scarf ◦ Avoidance of winter sports ◦ Exercise in a climate-controlled environment
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Nonpharmacologic Management •Dietary Modifications (all weak evidence) ◦ Low salt diet (1500mg sodium) ◦ Fish Oil Supplementation ◦ Lycopene supplementation ◦ Vitamin C
Parsons et al. Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. Nonpharmacologic Management •Induction of relative refractory period ◦ 10-15 minute moderately vigorous warm up ◦ Variable high-intensity exercise ◦ Exercise induced bronchoconstriction is reduced for the next 2 hours ◦ “Refractory period”
Parsons et al. Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. Strickland et al. Effect of Warm-Up Exercise on Exercise-Induced Bronchoconstriction. Medicine & Science In Sports & Exercise, March 2012. 44(3): 383-391. Pharmacologic Management
•Short-acting β2-Agonists ◦ Albuterol (Proair, Ventolin, Proventil), levalbuterol (Xopenex) ◦ First line treatment ◦ Administered 15 minutes prior to exercise ◦ Effects last for 2-4 hours after administration
◦ Drop in FEV1 with exercise is decreased by 25% after administration of SABA
Parsons et al. Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. Pharmacologic Management
•Short-acting β2-Agonists ◦ Daily use should be avoided due to risk of desensitization
◦ Down regulation of β2-receptors on mast cells and airway smooth muscle cells ◦ Reduced efficacy of pre-treatment and rescue treatment
◦ Due to this risk, use of long-acting β2- agonists is NOT recommended for exercise induced bronchospasm.
Parsons et al. Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. World Anti-Doping Agency •BETA-2 AGONISTS ◦ All selective and non-selective beta-2 agonists, including all optical isomers, are prohibited; ◦ Including, but not limited to: Fenoterol, Formoterol, Higenamine, Indacaterol, Olodaterol, Procaterol, Reproterol, Salbutamol [albuterol], Salmeterol, Terbutaline, Tretoquinol (trimetoquinol), Tulobuterol, Vilanterol World Anti-Doping Agency • BETA-2 AGONISTS • Except: ◦ Inhaled salbutamol: maximum 1600 micrograms over 24 hours; in divided doses not to exceed 800 micrograms over 12 hours starting from any dose; Albuterol 90mcg 2 puffs = 180mcg, every 4 hours = 180mcg x 6 = 1080mcg • Inhaled formoterol: maximum delivered dose of 54 micrograms over 24 hours; Symbicort Formoterol 4.5mcg 2 puffs = 9mcg, twice daily 9mcg x 2 = 18mcg Dulera Formoterol 5mcg 2 puffs = 10mcg, twice daily 9mcg x 2 = 20mcg • Inhaled salmeterol: maximum 200 micrograms over 24 hours. Advair Salmeterol 50mcg 2 puffs = 100mcg, twice daily 200mcg x 2 = 200mcg Pharmacologic Management •Inhaled corticosteroids ◦ Fluticasone (Flovent), mometasone (Asmanex), budesonide (Pulmicort), beclomethasone (QVAR) ◦ Should be added to SABA if daily use is required ◦ Not effective if not used continuously
◦ Does not prevent tolerance to β2-agonists ◦ Goal is to reduce SABA requirement
◦ Drop in FEV1 with exercise is decreased by ~10%
Parsons et al. Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. Pharmacologic Management •Leukotriene Receptor Antagonists ◦ Montelukast (Singulair) ◦ Recommended to be taken at least 2 hours prior to exercise. Effective for 24 hours. ◦ No risk for tolerance
◦ Drop in FEV1 with exercise is decreased by ~10%
Parsons et al. Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction. Am J Resp Crit Care Med. May 2013; 187(9): 1016-1027. Vocal Cord Dysfunction The Great Masquerader Vocal Cord Dysfunction •Inappropriate vocal cord adduction during inspiration Vocal Cord Exercise Induced Dysfunction Bronchospasm
INSPIRATORY stridor EXPIRATORY, lower and upper airway wheezing airway wheezing
Patients indicate throat Patients indicate tightness, inability to get chest tightness air into lungs Shortness of breath with activity Symptoms can persist Symptoms resolve within 5 for up to 30 minutes minutes of stopping exercise after stopping exercise
No response to β-Agonists Improves with β-Agonists Etiology • Gastroesophageal Reflux ◦ Evidence of GERD on laryngoscopy in 95% of adolescents with VCD ◦ Most patients with laryngoscopic evidence of GERD are without typical reflux symptoms • Laryngeal Irritants: ◦ Chemical/environmental inhalants ◦ Vocal cords adduct to protect the lower respiratory tract • Allergic Rhinitis ◦ Associated postnasal drip irritates larynx
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Wilson, JJ; Wilson EM. Practical Management: Vocal Cord Dysfunction in Athletes. Clinical Journal of Sports Medicine, July 2006. 16(4): 357-360. Etiology •Psychological stressors ◦ Classic patient is young, female, overachieving with perceived psychosocial stressors ◦ 73% of patients have an Axis I diagnosis ◦ 37% with Axis II ◦ History of abuse is more common in those with VCD than in asthmatics ◦ Some feel this is over emphasized
Wilson, JJ; Wilson EM. Practical Management: Vocal Cord Dysfunction in Athletes. Clinical Journal of Sports Medicine, July 2006. 16(4): 357-360. Diagnosis •Spirometry: Flattened inspiratory curve ◦ Difficult to reproduce symptoms
Normal Flow-Volume Loop Vocal Cord Dysfunction Expiratory Obstruction
Expiration Flow
Inspiration Flattened Inspiratory Curve Laryngoscopy •Gold standard for diagnosis •Low sensitivity when patient is asymptomatic •May demonstrate evidence of laryngeal irritation (GERD, postnasal drip) •May reproduce symptoms with exercise challenge followed by laryngoscopy
Weder, M; Truwit, J. Pulmonary Disorders in Athletes. Clin Sports Med 30 (2011) 525–536 Oversimplified Vocal Cords
Abducted for Inspiration and Expiration Oversimplified Vocal Cords Vocal Cords Vocal VocalCords
Adducted for Speech Oversimplified Vocal Cords Vocal Cords Vocal VocalCords
‘Chinking’ with Vocal Cord Dysfunction Management •Breathing techniques ◦ Rapid shallow breathing (panting) ◦ Diaphragmatic or abdominal breathing ◦ Nasal breathing ◦ Breathing through a straw ◦ Pursed lipped
Wilson, JJ; Wilson EM. Practical Management: Vocal Cord Dysfunction in Athletes. Clinical Journal of Sports Medicine, July 2006. 16(4): 357-360. Management •Empiric treatment of triggers
◦ GERD: PPI or H2 Blocker ◦ Rhinosinusitis: Intranasal corticosteroids ◦ Managing psychosocial stressors ◦ Avoidance of laryngeal irritants
Wilson, JJ; Wilson EM. Practical Management: Vocal Cord Dysfunction in Athletes. Clinical Journal of Sports Medicine, July 2006. 16(4): 357-360. Management •Speech Therapy ◦ Goal: Teach patients to recognize and abort or control impending VCD events ◦ Tools ◦ Tightening/Relaxation Exercises ◦ Diaphragmatic Breathing ◦ “Sniff” Breathing ◦ Inhaling quickly through the nose causing reflex vocal cord abduction at the first sign of an impending VCD event ◦ Followed by slow, controlled exhalation through pursed lips
Wilson, JJ; Wilson EM. Practical Management: Vocal Cord Dysfunction in Athletes. Clinical Journal of Sports Medicine, July 2006. 16(4): 357-360. Case •18yo female collegiate track athlete presents to the clinic with shortness of breath. Since coming to college, she has noted increasing shortness of breath and coughing with and after activity. She reports a sense that she cannot get air in. She feels like she can only get a quarter of her lungs full before she ‘hits a wall’. No shortness of breath with her daily activities. Albuterol has not been as effective as it was previously. Reports diagnosis with exercise induced asthma as a sophomore in high school. Case •18yo female collegiate track athlete presents to the clinic with shortness of breath. Since coming to college, she has noted increasing shortness of breath and coughing with and after activity. She reports a sense that she cannot get air in. She feels like she can only get a quarter of her lungs full before she ‘hits a wall’. No shortness of breath with her daily activities. Albuterol has not been as effective as it was previously. Reports diagnosis with exercise induced asthma as a sophomore in high school. Case •18yo female collegiate track athlete presents to the clinic with shortness of breath. Since coming to college, she has noted increasing shortness of breath and coughing with and after activity. She reports a sense that she cannot get air in. She feels like she can only get a quarter of her lungs full before she ‘hits a wall’. No shortness of breath with her daily activities. Albuterol has not been as effective as it was previously. Reports diagnosis with exercise induced asthma as a sophomore in high school. Case •18yo female collegiate track athlete presents to the clinic with shortness of breath. Since coming to college, she has noted increasing shortness of breath and coughing with and after activity. She reports a sense that she cannot get air in. She feels like she can only get a quarter of her lungs full before she ‘hits a wall’. No shortness of breath with her daily activities. Albuterol has not been as effective as it was previously. Reports diagnosis with exercise induced asthma as a sophomore in high school. Case •18yo female collegiate track athlete presents to the clinic with shortness of breath. Since coming to college, she has noted increasing shortness of breath and coughing with and after activity. She reports a sense that she cannot get air in. She feels like she can only get a quarter of her lungs full before she ‘hits a wall’. No shortness of breath with her daily activities. Albuterol has not been as effective as it was previously. Reports diagnosis with exercise induced asthma as a sophomore in high school. Case •More questions ◦ How long do her symptoms last after exercise? ◦ Problems with heartburn? ◦ Allergies? Nasal congestion? Postnasal drip? Case •Potential next steps ◦ Spirometry with albuterol to assess for baseline asthma ◦ Consideration of PPI or nasal steroid trial ◦ Consideration of referral to ENT for laryngoscopy if no improvement after 1 month trial of above ◦ Possible referral to speech therapy Summary • Exercise induced bronchospasm and vocal cord dysfunction can present similarly as shortness of breath. • Mechanism of symptoms is very different • Treatment is very different ◦ Exercise induced bronchospasm is treated with β-agonists and inhaled corticosteroids ◦ Vocal cord dysfunction is treated by decreasing laryngeal irritation and speech therapy strategies to improve vocal cord function Questions?