EXERCISE-INDUCED BRONCHOSPASM. Corey J. Ellis, M.D. 5/9/2015

Transcription

1 EXERCISE-INDUCED BRONCHOSPASM Corey J. Ellis, M.D. 5/9/2015

2 DEFINITION Exercise-Induced Bronchospasm is a transient and reversible bronchoconstriction that happens during or after strenuous exercise

3 TERMINOLOGY Exercise-Induced Bronchospasm (EIB) vs. Exercise-Induced Asthma (EIA) EIA is exercise related bronchoconstriction in individual with underlying asthma

4 EPIDEMIOLOGY 12-15% of population 40-90% of asthmatic individuals Exercise-induced asthma 35-45% of individuals with allergic rhinitis Up to 20% in elite athletes srxawordonhealth.com

5 RISK FACTORS Family history Atopy to environmental factors Cold weather sports

6 TRIGGERS Cold dry air Irritant exposure Environmental allergens chlorine Intense exercise

7 PHYSIOLOGY Exact mechanism is unknown Airway drying theory Airway rewarming theory Epithelial injury

8 AIRWAY DRYING THEORY Repetitive airway exchange results in drying of airway Loss of water leads to dehydration and increased intracellular osmolarity of epithelial cells Inflammatory mediator release (histamine, cytokines, leukotrienes) Bronchospasm occurs a-girl-after-gods-heart.blogspot.com

9 AIRWAY REWARMING THEORY leadingwithtrust.com Repetitive airway exchange results in cooling Perfusion increases in epithelial cells to heat airway Airway edema/ hyperemia develop leading to mediator release Bronchospasm occurs

10 EPITHELIAL INJURY THEORY Airway epithelial injury from poorly conditioned air High volume of irritant gases or particles deansplumbing.com

11 HISTORY - SYMPTOMS Shortness of breath Cough Chest tightness or pain Wheezing Poor performance Sore throat Upset stomach

12 HISTORY - ENVIRONMENT Cool temperatures Low humidity Poor air quality Chemicals Pollen

13 HISTORY - SPORT Aerobic rather than anaerobic Basketball, soccer, mid-long distance running Delayed presentation after start of exercise (8-10 minutes) More likely with higher intensity

14 HISTORY Symptom based diagnosis Moderate sensitivity, moderate specificity Both undiagnosed and overdiagnosised Multiple studies indicating unreliability of symptoms when compared to objective evidence

15 PRECIPITATING FACTORS Medical Poorly controlled asthma (exercise-induced bronchospasm) Poorly controlled allergic rhinitis Upper respiratory infection Athlete with previous history of asthma has recurrence of EIB with URI

16 PRECIPITATING FACTORS thefarmatgreenvillage.com Environmental Airborne allergens Environmental chemicals Chlorine Fertilizers on fields Insecticides on fields

17 PRECIPITATING FACTORS Medications Beta-blockers Not many young athletes on these loweringbloodpressurenow.com

18 DIFFERENTIAL DIAGNOSIS Vocal Cord Dysfunction Paradoxical closure of vocal cords Laryngoscopy may provide direst visualization Special consideration when EIB not respond to treatment

19 DIFFERENTIAL DIAGNOSIS Gastroesophageal Reflux Disease Atypical symptoms of chronic cough or wheeze Associated with regurgitation, dyspepsia, large meals or alcohol en.wikipedia.org

20 DIFFERENTIAL DIAGNOSIS Swimming-induced Pulmonary Edema Associated evidence of pulmonary edema (SOB and cough) Spirometry with acute restrictive pattern May remain for up to one week

21 DIFFERENTIAL DIAGNOSIS Exercise-induced Arterial Hypoxemia Reported in highly trained athletes Exact mechanism unclear Rapid transit of RBCs through pulmonary capillaries with incomplete oxygen diffusion Pulse oximetry may be helpful in diagnosis

22 DIFFERENTIAL DIAGNOSIS Cardiovascular abnormality DECONDITIONING

23 EXAM Skin: Atopic eczema

24 EXAM HEENT: URI

25 EXAM Pharynx: Tonsillar enlargement Sinus drainage

26 EXAM Nose: congestion

27 EXAM Sinus: tenderness texasentandallergy.wordpress.com

28 EXAM Heart: Irregular Murmurs ucdavisstores.com

29 EXAM Lung: Wheezing Prolonged expiration

30 EXAM Peak flow meter Baseline for all athletes reporting symptoms Three attempts, record highest of three Repeat peak flow following 8-10 minutes into exercise at 80% of max Drop of 15% support diagnosis of EIB

31 EIB DIAGNOSIS ALGORITHM

32 WORK-UP PROCEDURES Pulmonary function test Asthma Chronic disease Measures forced expiratory volume in 1 second (FEV 1 ), forced expiratory flow from 25-75% of forced expiratory volume (FEV ), forced vital capacity (FVC) Normal spirometry common with EIB

33 EIB DIAGNOSIS ALGORITHM

34 CLINICAL TRIAL Short acting beta-agonist trial with resolution of symptoms a positive test High risk of false positives and false negatives High level athletes will require objective testing Reasonable when limited financial and testing resources

35 WORK-UP PROCEDURES World Anti-Doping Agency (WADA) approved diagnostic procedures Eucapnic voluntary hyperpnea Methacholine aerosol challenge Mannitol inhalation Hypertonic saline aerosol challenge Exercise challenge (field or laboratory) Histamine challenge

36 WORK-UP PROCEDURES Indirect challenges Higher sensitivity for EIB Preferred method of diagnosis Eucapnic voluntary hyperpnea Hypertonic saline aerosol challenge Exercise challenge (field or laboratory)

37 EXERCISE CHALLENGE PFT Exercise PFT Baseline PFT Exercise to protocol intensity >90% peak HR before 2 minutes and continue for 6 minutes >85% max voluntary ventilation Spirometry immediate after exercise then at minutes

38 EXERCISE CHALLENGE PFT Drop greater than 10-15% on FEV 1 consistent with EIB Mild 15-20% decline Moderate 20-40% decline Severe >40% decline Field testing ideal when resources allow Field testing has higher sensitivity

39 EUCAPNIC VOLUNTARY HYPERVENTILATION Eucapnic voluntary hyperventilation Inhale dry gas consisting of oxygen, carbon dioxide (5%) and nitrogen achieving maximum voluntary ventilation 60-85% Spirometry at baseline and 3 minutes after challenge Drop of >10% in FEV 1 positive test High sensitivity, high specificity Recommended by IOC Not routinely done in all regions of country

40 HYPERTONIC SALINE CHALLENGE PFT Hypertonic saline challenge Inhalation of 4.5% hypertonic saline for 30 seconds Doubles to 1 minute, 2 minutes, 4 minutes and 8 minutes if not positive Drop of >15% is considered positive test

41 METACHOLINE CHALLENGE PFT Metacholine challenge Inhalation of nebulized metacholine Traditionally used to diagnosis asthma Drop of >20% at cumulative dose of 400mcg or noncumulative of 200mcg is considered positive test

42 WORK-UP PROCEDURES PFT with chemical challenge Histamine Mannitol Low sensitivity, high specificity

43 EIB DIAGNOSIS ALGORITHM

44 LAB WORK-UP CBC for infectious cause Skin testing for allergies entcarepc.com

45 IMAGING WORK-UP radiopaedia.org Chest x-ray Chronic lung disease Congestive heart failure Foreign body EKG Echocardiogram

46 WORK-UP PROCEDURES Laryngoscopy Foreign body Post-exercise laryngoscopy VCD wiki.uiowa.edu

47 TREATMENT - ACUTE Immediate removal from event Peak flow If 10% below baseline, 2 puffs of albuterol (rapid onset B-agonist) After 5 minutes, if peak flow return to baseline, ok for return to play 2 puffs of albuterol After 5 minutes, if peak flow return to baseline, ok for return to play No further participation, continue to follow

48 TREATMENT - RECOVERY Initial refractory period after recovery Bronchoconstriction may relapse after onset, usually 4-8 hours Consider albuterol every 4 hours Cooling down may decrease symptoms

49 TREATMENT - PREVENTION Refractory period Short vigorous exercise to induce response 15 minute rest during recovery Start of competition after recovery when EIB now less severe Ten 30 second sprints every minute may be used as stimulus minutes prior to competition

50 TREATMENT - PREVENTION Nasal breathing Warms and humidifies the air Mask or scarf for cold weather Warms and humidifies the air

51 TREATMENT - PREVENTION Supplements High dose omega-3 fish oil for 3 weeks reduced use of bronchodilators Dietary changes Reduced sodium intake for 2 weeks may reduce amount of bronchoconstriction

52 TREATMENT - MEDICATIONS Beta-agonists Albuterol HFA (4-6 hrs) 2 puffs minutes preexercise Salmeterol (12 hrs) 2 puffs at least 1 hour preexercise NOT to be used as monotherapy pixshark.com

53 TREATMENT - MEDICATIONS Mast cell stabilizers Cromolyn sodium (Intal) No bronchodilatory effect (do not use as emergent dilator) Nebulizer product only

54 TREATMENT - MEDICATIONS Leukotriene receptor antagonists Montelukast (Singulair), Zafirlukast (Accolate) Only as adjunct May be more effective in patient with asthma or allergic rhinitis Singulair 10 mg at least 2 hours pre-exercise (24 hrs)

55 TREATMENT MEDICATIONS Inhaled steroids Flunisolide (nasalide), triamcinolone (azmacort) More helpful for athletes with diagnosis of asthma Third line agent Doses vary

56 TREATMENT - MEDICATIONS Theophylline Multiple interactions and can be toxic Anti-histamines May be useful if allergic component Experimental Inhaled diuretics, heparin, prostaglandin E 2

57 TREATMENT MEDICATIONS NCAA All medications permitted with physician note Beta-agonist as aerosol only. International Olympic Committee Declaration of use for aerosol albuterol Therapeutic use exemption (TUE) validated by appropriate physician for all medications except albuterol and salmeterol. Objective evidence of airway narrowing required to use inhaled beta-agonists

58 MONITOR Peek flow meter Obtain baseline levels on all asthmatics

59 MONITOR - EXERCISE INDUCED ASTHMA Daily peak flows If peak flow less than 80% of baseline, no participation that day If peak flow 80-90%, ok to try albuterol to get above 85% of baseline for participation If no temporary trigger, consider adjusting preventive meds

60 RESOURCES Elward K, Pollart S. Medial Therapy for Asthma: Updates from NAEPP Guidelines. American Family Physcian. 2010;82(10): Krafczyk M, Asplund C. Exercise-Induced Bronchoconstriction: Diagnosis and Management. American Family Physcian. 2011;84(4): Molis M, Molis W. Exercise-Induced Broncospasm. Sports Health. 2010;2(4): Sinha T, David A. Recognition and Management of Exercise-Induced Bronchospam. American Family Physcian. 2003;67(4):769-74