Virginia Tech Departmental Policy 27 Sports Medicine Key Function:

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1 Virginia Tech Departmental Policy 27 Sports Medicine Key Function: Review: Yearly Director of Athletic Training Title: Management of Asthma in Athletes Section: Treatment S-A Safety POLICY STATEMENT: This policy was developed to provide standard guidelines for the acute care of an asthma attack. PURPOSE: Asthma action plan for managing and urgently referring all patients who may experience significant or lifethreatening attacks. ENTITIES TO WHOM THIS POLICY APPLIES: All events covered by Virginia Tech Sports Medicine. PROCEDURE: 1. All athletes must receive preparticipation screening evaluations and peak flow assessment sufficient to identify the possible presence of asthma. 2. Athletic trainers should be aware of the major signs and symptoms suggesting asthma, as well as the following associated conditions: a. chest tightness b. coughing (especially at night) c. prolonged shortness of breath (dyspnea) d. difficulty sleeping e. wheezing (especially after exercise) f. inability to catch one s breathe g. physical activities affected by breathing difficulty h. use of accessory muscles to breathe i. breathing difficulty upon awakening in the morning j. breathing difficulty when exposed to certain allergens or irritants k. exercise-induced symptoms, such as coughing or wheezing l. an athlete who is well conditioned but does not seem to be able to perform at a level comparable with other athletes who do not have asthma m. family history of asthma n. personal history of atopy, including atopic dermatitis/eczema or hay fever (allergic rhinitis) 3. The following types of screening questions can be asked to seek evidence of asthma a. Does the patient have breathing attacks consisting of coughing, wheezing, chest tightness, or shortness of breath? b. Does the patient have coughing, wheezing, chest tightness, or shortness of breath at night? c. Does the patient have coughing, wheezing, chest tightness, or shortness of breath after exercise? d. Does the patient have coughing, wheezing, chest tightness, or shortness of breath after exposure to allergens or pollutants? e. Which pharmacologic treatments for asthma or allergic rhinitis, if any, were given in the past, and were they successful? 4. Athletic trainers should incorporate into the existing emergency action plan an asthma action plan for managing and urgently referring all patients who may experience significant or life threatening attacks of breathing difficulties. In addition, athletic trainers should have pulmonary function

2 measuring devices (such as peak expiratory flow meters) at all venues for athletes and should be familiar with how to use these devices. 5. All patients with asthma should have a rescue inhaler available during games and practices, and the certified athletic trainer should have an extra rescue inhaler for administration during emergencies. 6. Athletic trainers and coaches should consider providing alternative practice sites for athletes with asthma triggered by airborne allergens when practical. Pollen count information can be accessed from the National Allergy Bureau at 7. Patients with asthma should have follow-up examinations at regular intervals. (6-12 months) 8. Athletic trainers should understand the various types of pharmacologic strategies used for short and long acting B2 agonists. 9. Patients with past allergic reactions or intolerance to aspirin or NSAIDs should be identified. 10. Patients who are experiencing any degree of respiratory distress (including a significant increase in wheezing or chest tightness, a respiratory rate greater that 25 breaths per minute, inability to speak in full sentences, uncontrolled cough, significantly prolong expiration phase of breathing, nasal flaring, or paradoxic abdominal movement) should be referred rapidly to an emergency department or to their personal physicians for further evaluation and treatment. Referral to an emergency room or equivalent facility should be sought urgently if the patient is exhibiting signs of impending respiratory failure. 11. The athletic trainer should be aware of the various Web sites that provide general information and frequently asked questions on asthma and EIA. American Academy of Allergy, Asthma and Immunology (www.aaaai.org) American Thoracic Society (www.thoracic.org) Asthma and Allergy Foundation of America (www.aafa.org) American College of Allergy, Asthma, and Immunology (www.acaai.org) HOW TO USE A PEAK FLOW METER PEFR monitoring should be performed on a regular basis, even when asthma symptoms are not present. PEFR should also be checked if symptoms of coughing, wheezing, or shortness of breath develops. Patients should demonstrate PEFR measurement with their healthcare provider to verify that their technique is accurate. Different brands of peak flow meters have unique features; however, these general instructions can be adapted to an individual's peak flow meter. Getting the best readings Several steps are important to make sure the peak flow meter records an accurate value: The peak flow meter should read zero or its lowest reading when not in use Use the peak flow meter while standing up straight Take in as deep a breath as possible Place the peak flow meter in the mouth, with the tongue under the mouthpiece Close the lips tightly around the mouthpiece Blow out as hard and fast as possible Breathe a few normal breaths and then repeat the process two more times. Write down the highest number obtained. Do not average the numbers. Note: The test should be repeated if the tongue partially blocks the mouthpiece or if the patient coughs or spits during the test. Most peak flow meters need to be cleaned periodically; cleaning instructions should be available when the unit is purchased.

3 Establishing a baseline measurement Unlike a blood pressure reading or a cholesterol test, there is no PEFR that is normal for everyone. For this reason, it is important to determine what PEFR value is normal for each individual. To determine an individual patient's normal PEFR, they should measure their PEFR when they have no asthma symptoms. Three PEFR measurements should be done with the same peak flow meter two to four times daily for two to three weeks. For long term management, most clinicians will recommend testing once per day, usually in the morning. The patient should note the highest PEFR measure achieved; this is the "personal best" PEFR. This number is used to determine if future PEFR readings are normal or low, and is also used to create a normal PEFR range (between 80 and 100 percent of the personal best PEFR). Readings below the normal range are a sign of airway narrowing in the lungs. A low PEFR can occur before asthma symptoms such as wheezing or shortness of breath develop. A personal best PEFR value should be remeasured each year to account for growth (in children) or changes in the disease (in both children and adults). In addition, home PEFR measurements should be verified with readings taken with equipment in a healthcare provider's office since this equipment is more sensitive. The action plan Once the normal range can been established, the healthcare provider will provide tailored guidelines (also called an action plan) to follow when the PEFR begins to decrease (Asthma action plan Patient Card). Peak expiratory flow rates are divided into three zones, which are assigned colors similar to those of a traffic light. These zones can be used to make decisions about the need for treatment: GREEN (80 to 100 percent of personal best) signals that the lungs are functioning well. When readings are within this range and symptoms are not present, patients should continue their regular medicines and activities. YELLOW (50 to 80 percent of personal best) is a sign that the airways in the lungs are somewhat narrowed, making it difficult to move air in and out. A short-term change or increase in medication is generally required. Patients should change or increase their medication to reverse airway narrowing according to the treatment recommendations previously discussed with their provider. RED (below 50 percent of personal best) is a sign that the airways are significantly narrowed and requires immediate treatment. The "rescue" inhaler should be used according to the treatment recommendation previously discussed with the provider. PEFR should be rechecked 10 to 15 minutes after the rescue medication is used. If the PEFR improves, the patient should monitor their PEFR throughout the day. The healthcare provider should be contacted after the patient improves; daily medication may be changed or increased.

4 2007 UpToDate Asthma action plan (example) 2007 UpToDate

5 Asthma action plan/patient Card This plan is provided as an example to clinicians. Adapted from Cecilia Vincuna-Keady, RN. Note: It is the athlete s responsibility to have their inhaler at all athletic activities. It is the athlete s responsibility to provide a separate inhaler with the supervising athletic trainer at the event (must have on file a signed Prescription Release form) to carry in the emergency medical kit. The athlete must notify the sports medicine staff if they are suffering increased symptoms associated with their asthma. The athlete must notify the sports medicine staff of all asthma attacks. If an athlete suffers an asthma attack strong enough to warrant use of their rescue inhaler, the athlete is not permitted to return to practice or competition on that day until they can perform a peak flow measurement that is at least 80% of their established baseline reading. Official Statement-Management of Asthma in Athletes, NATA web page:

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