Chris Koutures, MD, FAAP
8
th
Annual Pediatric and Adolescent Sports Medicine Update
BREAKING THROUGH ALL THE ACRONYMS
CLEARING UP CONFUSING RESPIRATORY ISSUES IN ATHLETES
Chest tightness, Shortness of breath, but
no Shortness of Acronyms
First in Line
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
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
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
One Presentation, Two Titles, Two
Management Approaches
Exercise Induced Asthma (EIA)
Exercise Induced Bronchospasm (EIB)
Patients have underlying
asthma
Exercise is a trigger that
exacerbates asthma
Underlying chronic
inflammation
Reduce symptoms at all times
of days
Mainstay: inhaled
corticosteroids
Patients do not have a history
of asthma
Exercise is only trigger of
bronchospasm
Debatable role of
anti-inflammatory medications
Reduce symptoms during
exercise
Mainstay: pre-exertion
short-acting 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
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. Jul
2010; 2(4): 311–317.
doi:
10.1177/1941738110373735
Dietary Adjuncts for Asthma Control
Increased Fruits and
Vegetables
Berries and Cherries for
anti-inflammatory effect
Increased Omega-3 Fatty
Acids
Fish or fish oil
Flaxseed
Judicious Caffeine Use
More in older
adolescent/young adult
population
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 80 yard sprints at
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
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.
EIA Medications
Mainstay: Reduce
Inflammation
Inhaled Corticosteroids
Leukotriene Modifiers
Cromolyn Sodium
Used at same time as
short-acting 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,
Molis MA and MolisWE
Jul 2010; 2(4): 311–317.
doi:
10.1177/1941738110373735
POTENTIAL LIFE CHANGER
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
Teasing Out VCD
Overly anxious or
perfectionists
May even vomit
Failing usual asthma
treatment
Higher intensity
performances
Asthma
VCD
Chest Tightness
Throat Tightness
Difficult getting air “Out”
Difficult getting air “In”
Audible wheeze
Audible stridor or choke
Has Refractory Period
No Refractory Period
Predominant Cough
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
Speech Therapy to Overcome VCD
Posture
Breathing Techniques
Calming Behaviors
Biofeedback
Voice Regulation
Vocal Cord Relaxation
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=hp-gCvW8PRY&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:
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….
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
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
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.
Pneumomediastinum
SHOULD I PLAY OR SHOULD I GO?
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
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.
