Asthma and Sports. J. Savoy

Asthma and Sports J. Savoy 01.06.06

EXERCISE INDUCED ASTHMA Definition Condition characterized by symptoms of cough, wheezing, shortness of breath and chest tightness during or after exercise, and associated with airway obstruction after exercise EIB patients with normal pulmonary function EIA exacerbation of a patient s asthma

EIA PREVALENCE General population 6 13 % Asthmatics 90 % Elite athletes (up to) 50 % Allergic rhinitis 40 %

EIA INCIDENCE Cross country skiers 50 % Speed skaters 43% Ice hockey players 35 % Figure skaters 35% Summer olympic athletes 17% School children 12%

EIA SYMPTOMS Typical Cough Wheezing Shortness of breath Chest tightness Atypical Stomach cramps Headache Beeing out of shape Fatigue Dizziness

EIA DIAGNOSIS History Eucapnic Volontary Hyperventilation Cold air Methacholine Mannitol Field

EIA PREDICTIVE VALUE OF SYMPTOMS SS SP PPV NPV Any 67 68 35 88 Cough 67 77 43 90 Wheeze 33 85 38 83 Tightness 56 82 46 88 Excess mucus 22 82 50 82 43 elite women ice hockey players Rundell Med Sci Sports Exerc. 36:405 (2004)

EIA DIAGNOSIS 154 children (age 13 years) Step test against treadmill (gold standard) SS SP PPV NPV 88 95 98 82 Tancredi, ERJ23:569 (2004)

EIA DIAGNOSIS Step test 30 cm step 30 steps/min 3 min Nose clip FEV 1 at 1, 5, 10, 15, 20, 30 min

EIA MECHANISMS 1. Hyperosmolarity theory 2. Airway rewarming theory

EIA Against the thermal hypothesis EIA also occurs in conditions of hot dry air Water loss better pridicts EIA than heat loss (for the same water loss, same response for different heat loss) Preventing rewarming at the end of exercise does not change the response Vasoconstriction does not occur when inhaling hot dry air, yet EIA does occur after hot dray air Rapid response to β 2 agonists does not result from their vasoconstrictive effect, rather from their dilating action

EIA, rewarming air during recovery Anderson, JACI 106:453 (2000)

EIA In favour of the osmotic hypothesis Severity of EIA is proportional to water content in inspired air and to measured water loss Inhaling humid air prevents EIA Calculated water loss is enough to explain osmotic changes Osmotic challenge mimic EIA Osmotic challenge induces mediator release Histamine and leucotriene receptor antagonists improve EIA Anderson JACI 106:453 (2000)

EIA treatment with LABA

EIA TREATMENT Montelukast N = 25 N = 25 12 weeks Placebo Montelukast Leff et al EM 339.147 (1998)

EIA, montelukast on dual phase (Children 7 16 years, 5 out of 22)) Melo JACI 111:301 (2003)

EIA, montelukast with or without ICS (children 7 16 years old, n = 22) Melo JACI 111:301 (2003)

EIA TREATMENT Budesonide during 4 weeks EI % fall in FEV1 Placebo 55 100 μg 26 200 μg 20 400 μg 10

EIA, inflammatory disease JACI 95:29 (1995)

EIA AND HEAVY TRAINING N = 42 elite swimmers I 16 continue to swimm II 26 stop competition baseline follow up HRB% I 44 50 II 31 12* EIA% I 31 44 II 23 4* Helenius, JACI 109:962 (2002)

Stopping elite swimming Helenius JACI 109:962 (2002)

Airway inflammation in elite skiers skiers asthma control N (male) 40(32) 12(6) 12(7) Age 17 40 25 FEV1 (%) 99 96 109 Atopy (%) 15 42 0 β 2 use (%) 6 11 0 Karjalainen et AJRCCM 161:2086 (2000)

Airway inflammation in elite skiers AJRCCM 2000

Airway inflammation in elite skiers Karjalainen AJRCCM 161:2086 (2000)

EIA Montelukast in elite ice hockey players Screened 88 Investigated 16 (EIA) No effect on Spirometry HRB Sputum eosino, neutro Symptoms Helenius Allergy 59:39 (2004)

EIB in elite cold weather athletes High prevalence Reversible after stopping heavy training No response to montelukast No refractory period Other cellularity Another disease

EIA DIAGNOSIS N = 50 elite summer athletes EVH (gold standard) Mannitol challenge Target FEV1 x 30 5,10,20,40, 80,120 mg 6 min FEV1 fall (%) PD 10 SS SP PPV NPP 96 92 92 96 Holzer et al ARCCM 167:534 (2003)

Case No 2 17 years old female, high school athlete referred for EIA. Symptoms Dyspnea during and immediately after activity Sometimes persistant cough No history of allergy, asthma or rhinitis No response to salbutamol, montelukast, inhaled steroids or salmeterol

Case No 2 Pulmonary function baseline post-exercise FVC 4.59 3.78 FEV1 3.42 2.77 % 74 73 FEF50/FIF50 2.29 1.92

EIA INSPIRATORY STRIDOR Prevalence 5 % (> in female) Misdiagnosed as EIA No response to β 2 FEF50/FIF50 > 1.5 Variable flow/volume loop Inspiratory adduction of vocal cords (laryngoscopy)

EIA Swimming program for children N = 73, over 2 years PF no change Self confidence improved 77 % Visits to doctors decreased 46 % Hospitalisations decreased 64 % School absences decreased 74 % Understanding asthma improved 78 % Continue swimming intended to 89 % MAJ 2000;173:647

Physical training for asthma PEFR Cochrane review 2005, issue 1

Physical training for asthma VO 2 max Cochrane review 2005, isssue 1

Physical training for asthma FEV1 Cochrane review 2005, issue 1

Case No 3

Influence of surface liquid on Aw resistance

EIA NON PHARMACOLOGIC TREATMENT EI fall in FEV1 % Fish oil diet 3 Placebo 14 Normal diet 17 Mechanisms: decrease in Leucotrienes E4, B4 Prostaglandines F2 TNFα IL-1β

EIA TREATMENT Fish oil supplementation Polyunsaturated fatty acids Eicosapentaenoic acid Docohexaenoic acid Inhibition of AA metabolism Leucotrienes Prostaglandines Cytokines Mickelborough AJRCCM 168:1181 (2003)