Respiratory Considerations and Exercise PDF

Respiratory Considerations and Exercise KIN 471 What is going on with Hannah? ff Di erential Diagnosis Case Hannah started to struggle with her training sessions and felt like she could not nish them. Hannah, who is studying sports, biology and chemistry at College, said: 'I felt out-of-breath and d...

Respiratory Considerations and Exercise KIN 471 What is going on with Hannah? ff Di erential Diagnosis Case Hannah started to struggle with her training sessions and felt like she could not nish them. Hannah, who is studying sports, biology and chemistry at College, said: 'I felt out-of-breath and dizzy, breathless and a bit panicky. I just could not understand what was happening.' fi Case Doctors diagnosed Hannah with sportsinduced asthma as they realised the condition was only brought on when she was exercising and prescribed her with inhalers. However, Hannah found these did not help much. Then about a year ago, Hannah su ered an attack which felt very di erent and much more severe. ff ff Case She said: 'I was doing an 800m race at the end of a heptathlon and before that race, I was coming rst. 'But as I did the 800m, I had to drop out into the inside of the track because I felt like I was being strangled.' Back on track: Hannah's oxygen levels dropped by 15 per cent within the space of a minute before she was treated fi Now what is going on with Hannah? Overview EIB and Asthma Exercise Induced Laryngeal Obstruction Pulmonary Embolus Bronchodilators and Performance fi ff ff Objectives Di erentiate between asthma and exercise- induced bronchospasm De ne an approach to the treatment of EIB and discuss the doping related considerations Di erentiate between EIB and other key conditions causing dyspnoea during exercise De nitions fl fl Asthma - is a common chronic in ammatory disease of the airways characterized by variable and recurring symptoms, reversible air ow obstruction, and bronchospasm. fi Exercise-Induced Bronchoconstriction De nition: fi “an intermittent narrowing of the airways, accompanied by a decrease in some measure of air ow that the individual experiences as wheezing, chest tightness, coughing, and dyspnoea that is triggered by exercise.” Occurs in 50-90% of Asthmatics fl What is stridor? What is a wheeze? Exercise-induced Bronchochonstriction fl Pathophysiology Transient airway narrowing High ventilatory rates, lead to evaporative water loss Cooling and osmolar changes in the airway In ammatory cascade Smooth muscle contraction, airway oedema Exercise-induced Bronchoconstriction Signs and Symptoms: Wheeze, cough, dyspnoea, chest tightness Less common: Headache, fatigue, cramps poor performance for a given level of conditioning performance changes that are season- and climate-related. Symptoms may last 30 to 90 minutes following exercise a refractory period of 1 to 3 hours can occur (during which continued exercise does not produce bronchoconstriction) Exercise-induced Bronchoconstriction Can be aggravated by: Cold dry air (Nordic skiing) Chlorine (pool sports) Internal Combustion Exhaust (Ice resurfacing machines) EIB-Diagnosis 1) Exercise Challenge and Spirometry Field Test - Gold Standard Impractical Lab Treadmill test can be insensitive 2) Chemical Challenge Tests i.e. Methacholine challenge Good for chronic asthma, not speci c for EIB 3) Eucapnic Voluntary Hyperpnea Test (next slide) fi Eucapnic Voluntary Hyperpnoea (EVH) EVH Testing 6 min at high ventilation (see video) Target is FEV1.0 × 30 each minute FEV1.0 = forced expired volume in one second Mimics exercise hyperpnoea (and thus airway cooling) Eucapnic Voluntary Hyperpnoea EIB: Treatment Treatment- Nonpharmacologic Activities Ideally activities without high ventilatory rates Warm, humid environment Examples: baseball, football, golf, gymnastics, martial arts, sprinting, swimming, tennis, weightlifting, and water polo (chlorine) extended low-to-moderate intensity warm-up Use the refractory period! Intensity increased in steps WarmIdeal Up: Ideal Protocol Strategy 20-30 minutes 5-7 x 30s high intensity bouts 2-5 minute mod-high intensity bouts 80-90% of maximal intensity 80-90% of maximal intensity 1.5-2.5 minute rest periods equivalent rest periods 4-6 repetitions Will minimize the impact of EIB during subsequent exercise Will minimize the impact of EIB during subsequent exercise Warm-up for EIB Postgrad Med J 2008;84:512-517 Treatment - Pharmacologic Stabilise Chronic Asthma Bronchodilators, corticosteroids, etc. Short-acting inhaled β–agonist (IBA) - eg. Salbutamol ~15 minutes prior to exercise Can also be used as a ‘rescue’ medication Is it Fair to take IBA in sport? IBA Use and Medal Wins 16 Prevalence Medal Percentage 12 8 4 0 FITCH ET AL J ALLERGY CLIN IMMUNOL VOLUME 122, NUMBER 2 1984 1996 1998 2000 2002 2006 Is it Fair to take IBA in sport? b2-Agonists and Physical Performance Study or subgroup, year Is there an effect? Metaanalysis Pluim et al. Sports Med 2011 MD 51 SE Control β2-agonist Weight total total (%) Salbutamol 10 Booth et al., 1988 0.6 2.27 −0.1 1.82 Carlsen et al., 1997-I 18 −3 Decorte et al., 2008-I 4.01 10 −0.6 4.05 10 Decorte et al., 2008-II −1.2 1.91 Fleck et al., 1993 21 Gong et al., 1988 17 1.2 2.08 −0.1 1.1 Heir and Stemshaug, 1995 17 −0.9 1.73 Meeuwisse et al., 1992 7 −0.5 2.36 Norris et al., 1996 15 Sandsund et al., 1998 2.4 2.5 8 0.3 3.27 10 Stewart et al., 2002-II Subtotal (95% CI) 143 Heterogeneity: Chi2 = 2.61, df = 10 (p = 0.99); I2 = 0% Test for overall effect: Z = 0.15 (p = 0.88) MD IV, fixed [95% CI] 10 18 10 10 21 17 17 7 15 8 10 143 4.4 6.8 1.4 1.4 6.2 5.2 18.6 7.5 4.0 3.6 2.1 61.1 0.60 [−3.85, 5.05] −0.10 [−3.67, 3.47] −3.00 [−10.86, 4.86] −0.60 [−8.54, 7.34] −1.20 [−4.94, 2.54] 1.20 [−2.88, 5.28] −0.10 [−2.26, 2.06] −0.90 [−4.29, 2.49] −0.50 [−5.13, 4.13] 2.40 [−2.50, 7.30] 0.30 [−6.11, 6.71] −0.09 [−1.28, 1.10] 24 20 10 23 77 10.8 3.3 1.9 2.3 18.4 0.00 [−2.82, 2.82] 1.50 [−3.62, 6.62] −1.00 [−7.70, 5.70] −0.40 [−6.48, 5.68] 0.11 [−2.05, 2.28] 18 17 35 6.5 4.9 11.4 0.10 [−3.55, 3.75] −1.16 [−5.37, 3.05] −0.44 [−3.20, 2.32] 20 10 30 5.8 3.3 9.1 −0.80 [−4.66, 3.06] −0.40 [−5.54, 4.74] −0.66 [−3.74, 2.43] 285 100.0 Total (95% CI) 285 Heterogeneity: Chi2 = 3.46, df = 18 (p = 1.00); I2 = 0% Test for overall effect: Z = 0.30 (p = 0.76) Test for subgroup differences: Chi2 = 0.21, df = 3 (p = 0.98); I2 = 0% −0.14 [−1.07, 0.78] Formoterol Carlsen et al., 2001 Riiser et al., 2006 Stewart et al., 2002-I Tjorhom et al., 2007 Subtotal (95% CI) 0 1.5 −1 −0.4 1.44 2.61 3.42 3.1 24 20 10 23 77 MD IV, fixed, 95% CI Heterogeneity: Chi2 = 0.42, df = 3 (p = 0.94); I2 = 0% Test for overall effect: Z = 0.10 (p = 0.92) Salmeterol Carlsen et al., 1997-II 18 0.1 1.86 −1.16 2.15 17 Morton et al., 1992 Subtotal (95% CI) 35 Heterogeneity: Chi2 = 0.20, df = 1 (p = 0.66); I2 = 0% Test for overall effect: Z = 0.31 (p = 0.75) Terbutaline −0.8 1.97 Larsson et al., 1997 20 −0.4 2.62 Unnithan et al., 1994 10 Subtotal (95% CI) 30 Heterogeneity: Chi2 = 0.01, df = 1 (p = 0.90); I2 = 0% Test for overall effect: Z = 0.42 (p = 0.68) −10 −5 Favours placebo 0 5 10 Favours β2-agonist ! ! Fig. 2. Forest plot comparison of inhaled b2-agonists vs placebo; outcome maximal oxygen consumption in mL kg-1 min-1. Study weights are calculated by taking the inverse of the variance of the estimate of the study-specific mean differences (MD). The size of each square is proportional to the size of the weight that the study contributes to the overall weighted summary MD.[38,39,41,42,44,46,48,49,50,52,55,56,57,60-63] Chi2 = Chi-square test; df = degrees of freedom; I2 = I-squared statistic; IV = inverse variance; SE = standard error; Z = Z-test.. the outcome was VO2max, 20-km time trial dura. tion, time to exhaustion at 105–110% VO2max or Wingate testing. The type of b2-agonist used made no difference. salbutamol was found to have a statistically significant effect on peak power, but not on total work, during a 30-second Wingate test. However, the number of participants and training levels Old WADA Guidelines All Beta-2 agonists… including their D- and L- isomers are prohibited. Their use requires a Therapeutic Use Exemption (TUE). As an exception, formoterol, salbutamol, salmeterol and terbutaline, when administered by inhalation to prevent and/or treat asthma and exercise-induced asthma /bronchoconstriction require an Abbreviated Therapeutic Use Exemption. Despite the granting of a TUE, when the Laboratory has reported a concentration of salbutamol (free plus glucuronide) greater than 1000 ng/ml, this will be considered as an Adverse Analytical Finding unless the athlete proves that the abnormal result was the consequence of the therapeutic use of inhaled salbutamol. Martin Johnsrud Sundby Salbutamol is the medication which led to a suspension of Norwegian skier Martin Johnsrud Sundby. Sundby nebulized 15 milligrams — or 15,000 micrograms — of the medication in a ve-hour period in Davos, Switzerland, in 2014 and Toblach, Italy, in 2015. As a result, Sundby’s urine samples from the two races in question both had over 1,300 ng/mL of salbutamol, well over the WADA limit of 1,000 ng/mL,which WADA considers “not to be an intended therapeutic use of the substance” fi Chris Froome 4-time winner of the Tour de France, 2018 Giro d’Italia Winner 2017 blood salbutamol level was 2000ng/mL (permitted limit is 1000ng/mL) Blamed illness, and dehydration case dropped Other anti-asthmatics Mast-cell stabilisers, leukotriene antagonists, theophylline PERMITTED Inhaled corticosteroids are PERMITTED Case They discovered that Hannah's oxygen levels dropped by 15 per cent within the space of a minute when exercising and that her vocal cords would shut down meaning she was breathing through a little gap instead of a wide open throat. Hannah was diagnosed with Exercise Induced Laryngeal Obstruction and she began having treatment at the airways asthma clinic at Lancashire Teaching Hospitals. ff Doctors diagnosed Hannah with sports-induced asthma as they realised the condition was only brought on when she was exercising and prescribed her with inhalers. However, Hannah found these did not help much. Then about a year ago, Hannah su ered an attack which felt very di erent and much more severe. ff Alternative Diagnoses Consider when EIB treatment fails: Exercise Induced Laryngeal Obstruction Vocal Cord Dysfunction Paradoxical vocal cord motion Laryngeal dyskinesis Vocal cord adduction Münchausen’s stridor Pulmonary Embolism Exercise Induced Laryngeal Obstruction Pathophysiology Paradoxical vocal cord adduction Inspiratory air ow obstruction Females more common (2:1) Younger patients more common ?more common in high performance athletes fl Exercise Induced Laryngeal Obstruction Fauquier ENT https://www.youtube.com/watch?v=gmNwpJf1zUQ EILO Symptoms and Signs Throat tightness Stridor Chest tightness Air hunger Coughing, hoarseness Variable pattern, not easily repeatable Often at very high intensity exercise Diagnosis Usually a clinical diagnosis Often initially diagnosed as EIB Does not respond to EIB Therapy May have ndings on spirometry when symptomatic Laryngoscopy when symptomatic is gold standard fi EILO Treatment ux disease fl Education Treatment of aggravating factors GERD - Gastro-esophageal re Post-nasal drip Vocal Cord Resynchronisation Cough, pant abdominal breathing Postural Techniques Jut out jaw Shoulders back Stress management EILO - the evidence...? fi fi fi Exercise associated PVCM may respond to the above described psychological counseling and speech therapy with relaxation exercises. In addition, pretreatment with an anticholinergic medication prior to exercise may be bene cial. As an example, in an uncontrolled case series, exercise induced PVCM was prevented in six of seven patients who used ipratropium prior to exercise. Successful use of inspiratory resistive training with a pressure-loaded respiratory muscle trainer has been described in case reports. As an example, an 18-year old soccer player (n=1) experienced resolution of PVCM symptoms after ve weeks of a ve day per week regimen ( ve sets of 12 breaths) of inspiratory muscle training. The inspiratory resistance was set at 75 percent of maximum inspiratory capacity. fi Pulmonary Embolism Rare cause of exertional dyspnoea Not to be missed Paget von Schrötter Syndrome Axillary Vein Thrombosis More common in athletes (esp. throwers) Can lead to PE Thromboembolism in athletes - risk factors Use of illicit substances Ritual dehydration Boxers, lightweight rowers etc. E ort-induced thrombosis ff Diuretics, EPO, anabolic steroids... Trauma to the vessel wall? PE in athletes Symptoms Pain, swelling, numbness in distal limb Chest pain, dyspnoea Poor exercise performance Profound arterial desaturation during exercise Koehle et al. 2003 Summary EIB: Stabilise chronic asthma Warm-up, Activity modi cation β-agonist 15’ prior to exercise Exercise Induced Laryngeal Obstruction Consider if stridor, or failure of EIB Therapy PE Rare, but not to be missed fi What’s going to happen to Hannah? Read more: http:// www.dailymail.co.uk/health/ article-1361411/Asthma-treatmentOlympic-athlete-hopeful-HannahLupton-improves-vocaltraining.html#ixzz1GLK3NTwH What is a wheeze? What is stridor? Post-Test!