Some Historical Perspective

BREAKING THROUGH ALL THE ACRONYMS CLEARING UP CONFUSING RESPIRATORY ISSUES IN ATHLETES Chris Koutures, MD, FAAP 8 th Annual Pediatric and Adolescent Sports Medicine Update Some Historical Perspective 1

First in Line Chest tightness, Shortness of breath, but no Shortness of Acronyms A Common Scenario Cough after 10-15 minutes of activity or once activity ends Late phase symptoms may occur 4-8 hour after activity Mouth breather Tightness in chest Difficulty getting air in Higher level of exertion With rest, no recurrence of cough 2

Activities and Triggers Ice Hockey and Ice Skating Cold environments Ice Resurfacing Machine Exhaust Carlsen KH, Anderson SD, Bjermer L, et al. Exercise-induced asthma, respiratory and allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: Part I of the report from the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN.Allergy. 2008;63:387-403 Activities and Triggers Competitive Swimmers Chloramine inhalation from pool water Intense level of exercise Carlsen KH, Anderson SD, Bjermer L, et al. Exercise-induced asthma, respiratory and allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: Part I of the report from the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN.Allergy. 2008;63:387-403 3

Activities and Triggers Outdoor Field Sports Chemicals Insecticides Pesticides Fertilizers Local Environmental Allergens Weiler J, Bonini S, Coifman R, et al.american Academy of Allergy, Asthma, and Immunology Work Group Report: Exercise-induced asthma. J Allergy Clin Immunol. 2007;119(6):1349-1358. Likely Suspects 40-90% of known asthmatics will have exercise-associated symptoms 41% of those with allergic rhinitis Personal or family history of atopy to environmental factors Saglimbeni A. Exercise-induced asthma. emedicine.http://emedicine.medscape.com/ Updated December 9, 2005. 4

One Presentation, Two Titles, Management Approaches Exercise Induced Asthma (EIA) Patients have underlying asthma Exercise is a trigger that exacerbates asthma Underlying chronic inflammation Reduce symptoms at all times of days Mainstay: inhaled corticosteroids Two Exercise Induced Bronchospasm (EIB) Patients do not have a history of asthma Exercise is only trigger of bronchospasm Debatable role of antiinflammatory medications Reduce symptoms during exercise Mainstay: pre-exertion shortacting beta-agonists Molis MA and Molis WE. Jul 2010; 2(4): 311 317. doi: 10.1177/1941738110373735 Clearing Diagnostic Confusion for EIB/EIA Diagnose and Treat Based on Symptoms Multiple studies question sensitivity and specificity Physical Exam for Confounders Ocular Injection Eczema Nasal Turbinate Swelling Cobblestone in throat 5

Objective Testing Exercise Challenge Use Exercise Environment Portable Spirometer Peak Flow Meter 8 minute challenge Reach 90% max HR for at least 6 minutes Molis MA and MolisWE. 2010; 2(4): 311 317. doi: 10.1177/1941738110373735 Jul Dietary Adjuncts for Asthma Control Increased Fruits and Vegetables Berries and Cherries for antiinflammatory effect Increased Omega-3 Fatty Acids Fish or fish oil Flaxseed Judicious Caffeine Use More in older adolescent/young adult population Limited Sodium Intake 6

Other Non-Pharmocologic Measures Improved conditioning Increase threshold of symptom occurence Reduce symptom severity Warm/humid air Masks Nasal Breathing Be aware of changing environments Travel Monitor allergen/pollen levels Illness outbreaks Warm-Up and EIB Refractory Period SubmaximalWork Loads and Sprints Extinguish EIB Induce resistance to EIB 10-15 minutes before start of regular activity 8 60-80 yard sprints at 60-80% max speed 7

EIA- Optimize Baseline Asthma Control Consider the Rules of Two Do You: Have asthma symptoms or take your quick-relief inhaler more than Two times a week? Awaken at night with asthma symptoms more than Two times a month? Refill your quick-relief inhaler more than Two times a year? Measure your peak flow at less than thantwo times 10 (20%) with asthma symptoms? Rules of Two is a federally registered service mark of Baylor Health Care System. 2011 Baylor Health Care System. Peak Flow Monitoring Percent of Peak Flow Response Green Zone 80-100% No change in activity or baseline management Yellow Zone 60-80% Reduce exercise, increase medication, notify medical provider Red Zone <60% No exercise Consult medical professional 8

Short-acting Beta Agonists Mainstay of control for EIB Use 10-15 minutes before activity Hold mouthpiece 1-2 inches from lips with mouth open Breathe in and squeeze down on the medicine canister Breathe in slowly for 3-5 seconds Hold breath up to 10 seconds Wait 30 seconds before taking another puff Spacer use can improve medication delivery Brushing teeth or mouthwash after inhaled steroid use reduces risk of oral candidiasis PlautTF, One Minute Asthma (5th edition), Pedipress Inc, 2001 Other Medication Choices for EIB Long-acting Beta-Agonists Shown effective in EIB Potential adverse effects reduce montherapy role May be used in conjunction with inhaled corticosteroids in difficult cases Leukotriene Modifiers Proven efficacy Weiler J, Bonini S, Coifman R, et al. AAAI Work Group Report: Exercise-induced asthma. J Allergy Clin Immunol. 2007;119(6):1349-1358. Weinberger M. Long-acting beta-agonists and exercise. J Allergy Clin Immunol. 2008;122(2):251-253. 9

EIA Medications Mainstay: Reduce Inflammation Inhaled Corticosteroids Leukotriene Modifiers Cromolyn Sodium Used at same time as shortacting beta-agonist MDI NCAA/WADA/USADA World Anti-Doping Agency/United States Anti-Doping Agency NCAA: Prescription or note needed Inhaled Albuterol only WADA/USADA Inhaled Albuterol/Salmuterol must have declaration of use Other B2-agonists banned unless Therapeutic Use Exemption (TUE) Inhaled corticosteroids need declaration of use No issues with leukotriene modifiers, antihistamines, or cromolyn sodium globaldro.com 10

Molis MA and MolisWE Jul 2010; 2(4): 311 317. doi: 10.1177/1941738110373735 POTENTIAL LIFE CHANGER A VERY CONFUSING DISORDER 11

A CHORAL STUDENT LAMENTS. I VE BEEN DIAGNOSED WITH ASTHMA ON SEVERAL MEDICATIONS AND THEY AREN T HELPING I FEEL LIKE I M CHOKING WHEN I SING MY THROAT GETS TIGHT WITH THIS FUNNY SOUND I HAVE TROUBLE GETTING AIR IN MY LUNGS IT IS WORSE DURING PERFORMANCES OR STRESS SUCH AS FINALS WEEK VCD Vocal Cord Dysfunction Very Confusing Disorder 12

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Teasing Out VCD Overly anxious or perfectionists May even vomit Failing usual asthma treatment Higher intensity performances Asthma Chest Tightness Difficult getting air Out Audible wheeze Has Refractory Period Predominant Cough VCD Throat Tightness Difficult getting air In Audible stridor or choke No Refractory Period PredominantVoice Change Addressing Co-Morbidities Rhinitis Vocal Abuse Gastroesophageal Reflux Asthma Focus on proper MDI technique Improper particulate flow irritates vocal cords May be able to slowly wean asthma medications 14

Speech Therapy to Overcome VCD Posture Breathing Techniques Calming Behaviors Biofeedback Voice Regulation Vocal Cord Relaxation Can be life-altering 15

VCD Exercises Sincere Gratitude to Nicole Paine, MS, SLP, Pediatric Speech Language Pathologist, Rehabilitation Department at CHOC Children's Hospital (Orange, CA) Breathing Rhythms (Even, Extended, 4x4) Even Breathing: breathe in for as long as you breathe out. Extended breathing: common in many meditation techniques, helps control hyperventilation and decrease blood pressure. breathe out longer than you breathe in (i.e. breathe in for 4, out for 8) 4x4x4x4 breathing: only used to help gain control of diaphragm muscle; not used as a regular breathing pattern breathe in to a count of 4, then hold your breath to a count of 4, then exhale to a count of 4, then hold breath for a count of 4. Pursed Lips name of a breathing exercises that helps learn how to master extended exhalation breathe in through your nose with mouth closed, then breathe out through pursed lips like you were going to whistle Video to help educate patient regarding function and movement of the diaphragm (You Tube: mechanics of respiration) http://www.youtube.com/watch?v=hpgcvw8pry&safety_mode=true&persist_safety_mode=1&safe=active VCD Exercises Sincere Gratitude to Nicole Paine, MS, SLP, Pediatric Speech Language Pathologist, Rehabilitation Department at CHOC Children's Hospital (Orange, CA) Breathing Styles: Abdominal: breathing movements starting around the stomach Thoracic: breathing movements then spreading to the chest Clavicular: breathing movements finishing with a slight rise of the shoulders & collar bone at the top of an inhalation. Diaphragmatic Breathing: using abdomen AND appropriate chest when you initiate an inhalation, let the abdomen move out first, with no life to the shoulder as you feel the lungs fill, feel the chest slowly rise finally, at the top of the inhalation, let the chest open and feel the shoulders rise just a little Training Diaphragmatic Breathing: Lying down: Patient should place one hand on stomach and one hand on chest Explain to patient to focus on moving hand on stomach up, rather than hand on chest Tell patient to gradually increase time of inhale and exhale (i.e. inhale for 3 seconds and exhale for 3 seconds, then increase to 4 seconds) Sitting down in front of mirror (to help patient visualize breathing with stomach) -Standing in front of mirror Free IPhone Apps for download to help practice diaphragmatic breathing & slower breath rate: -My Calm Beat -Belly Bio Interactive Breathing 16

VCD Exercises Sincere Gratitude to Nicole Paine, MS, SLP, Pediatric Speech Language Pathologist, Rehabilitation Department at CHOC Children's Hospital (Orange, CA) Negative Practice (incorrect breathing): practicing breathing wrong to help patient feel what is correct patient should breathe with lots of tension and using chest only for negative practice. Have patient do 2 cycles of diaphragmatic breathing and 1 chest only breathing. Explain to patient that these cycles will help them to feel the difference between correct and incorrect breathing. Using Weights: using weights (bicep circle) will help the patient control their breath rate and slow down their breathing stand in front of mirror start with weights up (elbows bent, weights up by shoulder) as the patient straightens their elbows and brings weights near waist, they should take a breath in as patient bends elbows, they should take a breath out make sure patient attempts to stay as relaxed as possible throughout the shoulders, neck, and chest explain to patient that these cycles will help them control their breath rate Crashing in more ways than one. A Collapsing Blow to the Chest Wall 17

Mountain Bike Crash in 15 y/o Direct Blow to Right Chest Wall Sudden Onset Right Shoulder and Chest Wall Pain Dyspnea Decreased Breath Sounds Retractions Hyperresonance to Percussion Pneumothorax Air or Gas in Pleural Space of Chest Tension Collapse of one or both lungs due to trauma Diminished Cardiac Output May be life-threatening Urgent Aspiration often Indicated Patterson B. In Pediatric Sports Medicine: Essentials for Office Evaluation, Koutures CG and Wong VYM eds. SLACK Publications, Thorofare NJ, 2013, ppxxx 18

Pneumothorax Air or Gas in Pleural Space of Chest Spontaneous Tall, thin male teenagers and young adults with strenuous physical activities More than half have lung blebs and bullae without history of pulmonary disease Association with Connective Tissue Disorders, Marijuana Inhalation Patterson B. In Pediatric Sports Medicine: Essentials for Office Evaluation, Koutures CG and Wong VYM eds. SLACK Publications, Thorofare NJ, 2013, ppxxx Management of Pneumothorax Chest X-ray to determine extent Inspriatory/Expiratory Films Small-moderate pneumothorax with minimal respiratory symptoms can spontaneously resolve without specific treatment in 1-2 weeks 19

Management of Pneumothorax For a pneumothorax with respiratory distress or altered cardiac function: supplemental oxygen needle aspiration thoracostomy with chest tube use of a sclerosing agent open thoracotomy The goal is to re-expand the collapsed lung. Option of a sclerosing agent may cause issues with long-term pulmonary function in an athlete. Return to Activity after Pneumothorax After resolution, always a chance of recurrence, usually within the first year Process to return to sports is not well described. Recommended that the athlete not participate in any vigorous activity for 2-3 weeks after chest tube removal Monitor the athlete for chest pain or dyspnea, Especially the first year after the initial episode due to the chance of recurrence. 20

Pneumomediastinum SHOULD I PLAY OR SHOULD I GO? ANOTHER COMMON SCENARIO 21

Twas the Night Before The Big Game Nasal Congestion Rhinorhea Cough Sore Throat Acute Upper Respiratory Infection Putting the Cold Shoulder on Play? Neck Rule All symptoms ABOVE neck OK to play Any symptoms BELOW neck Not OK to play AAP Policy Qualified Yes Upper respiratory obstruction may affect pulmonary function. Athlete needs individual assessment for all except mild disease Rice SG. Medical Conditions Affecting Sports Participation Pediatrics 2008;121;841 22

Does Fever Make a Difference? AAP No Participation Elevated core temperature may be indicative of a pathologic medical condition (myocarditis) Fever can result in greater heat storage, decreased heat tolerance, increased risk of heat illness, increased cardiopulmonary effort, reduced maximal exercise capacity, and increased risk of hypotension Rice SG. Medical Conditions Affecting Sports Participation. Pediatrics 2008;121;841 A model of the relationship between upper respiratory tract infection (URTI) risk and intensity of exercise. Moreira A et al. Br Med Bull 2009;90:111-131 The Author 2009. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org 23