Back to Table of Contents | December 2010

Clinical and Health Affairs

Athletes and Asthma

By William J. Picconatto, R.P.T., Ph.D., A.T.C., Susan K. Ross, R.N., AE-C, and Angeline M. Carlson, R.Ph., Ph.D.

Abstract
Many Minnesotans with asthma participate in recreational and competitive sports. If asthma is undiagnosed or if it is poorly controlled, its symptoms can compromise health, impair athletic performance, and limit sports participation. It can even lead to death. Asthma-related deaths during sports participation, while not common, have occurred in Minnesota. Having asthma should not limit an athlete’s ability to compete and win at the highest levels of competition. This article briefly reviews asthma and exercise-induced bronchoconstriction, discusses the impact of asthma on sports participation and outlines asthma management strategies for team physicians, coaches, and athletic trainers.

An estimated 434,000 adults (11.1%) and 116,000 children (9.5%) in Minnesota have been diagnosed with asthma at some point in their lives. Approximately 304,000 adults (7.8%) and 85,000 children (7%) currently have asthma, and approximately half of those adults and 41% of those children have had an attack during the past year.¹ Many of these individuals participate in recreational and competitive sports. If their asthma is untreated or poorly controlled, it can compromise their health, impair their athletic performance, limit their participation in sports, or even threaten their lives.

The asthma-related deaths of several athletes have been well-publicized. In August of 2001, Rashidi Wheeler was running sprints during a football practice at Northwestern University when he collapsed and died from an asthma episode. In November of 2002, Leslie Dawley, a freshman at Bowling Green State University, collapsed five minutes into a soccer game and died from cardiac arrhythmia brought on by an asthma attack. In 2006, exercise-induced bronchoconstriction (EIB) contributed to the deaths of two high school football players, one in Virginia and one in California. In 2009, a 12-year-old from Salem, Ohio, died following an apparent asthma episode after football practice. In August of this year, 16-year-old Elbert Jovante Woods, son of former Cincinnati Bengals player Ickey Woods, died from an asthma episode approximately eight hours after a high school football practice. Asthma-related deaths have also occurred among athletes in Minnesota. In 2004, a New Ulm high school football player collapsed and died from an asthma episode following a mile-long run during his physical education class. Last September, a 14-year-old boy died following participation in a youth basketball event in the Twin Cities. As these examples point out, both competitive and recreational athletes are at risk.

Asthma-related deaths during sports activities are preventable, however, as they generally occur among persons whose asthma is undiagnosed or poorly controlled, who have had a recent hospital admission or an emergency room visit for an acute episode, or who have a history of frequent asthma episodes.² This article discusses the impact of asthma on sports participation and explores ways to control and manage asthma in athletes.

Asthma, EIB, and Sports

Asthma is a common chronic disorder characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation. Inflammation of the airway contributes to bronchial hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity. In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth-muscle hypertrophy, and angiogenesis. Acute symptoms of asthma usually arise from bronchospasm and respond to bronchodilator therapy. Acute and chronic inflammation can affect not only the airway caliber and airflow but also underlying bronchial hyperresponsiveness, which enhances susceptibility to bronchospasm.³

Exercise-induced bronchoconstriction, in contrast, is an acute, transient narrowing of the airway that occurs during and after exercise. It is defined as a 10% or greater decline in FEV1 after appropriate exercise challenge (six to eight minutes at a workload that raises the heart rate to at least 80% of maximum and ventilation to approximately 40% to 60% of maximum).^4,5 Exercise- induced bronchoconstriction can affect any athlete, although those competing in endurance sports (ie, track, cross-country running, soccer, ice hockey, swimming, and cross-country skiing) are more likely to experience symptoms.5 Symptoms generally occur immediately or up to 30 minutes after exercise and can range from mild performance impairment with a minor reduction in lung function to severe bronchospasm with a large reduction in FEV1. The most common symptoms include coughing, wheezing, chest tightness, dyspnea, and fatigue.⁶ Athletes, coaches, and athletic trainers may notice EIB occurring in specific environments such as ice rinks or swimming pools; they also may notice subtle signs of EIB including poor performance levels given the athlete’s level of conditioning and reduced participation in or avoidance of a specific training activity.⁵

The prevalence of asthma and EIB is greater among athletes than the general population and is even higher among those who take part in endurance sports, winter sports, and swimming than those who play other sports. Depending on the sport, up to 50% of athletes can experience symptoms such as coughing, wheezing, chest tightness, and shortness of breath, which are often associated with asthma.^5,7,8 The number of athletes experiencing these symptoms may be underrepresented, however, as some may disregard vague symptoms (chest discomfort, breathlessness, and fatigue) as merely an indication that they are out of shape and choose not to report them. They also may be reluctant to admit to health care professionals, coaches, and athletic trainers that they have a problem, as it may affect their ability to participate in their sport.^4,5

Exercise-induced bronchoconstriction occurs in up to 90% of patients with asthma, but it also can occur in up to 10% of persons who are not known to be atopic or have persistent asthma.⁵ In high school and college athletes with no history of asthma, prevalence rates of EIB up to 15% have been reported.⁹ The EIB that occurs in athletes who do not have a history of asthma and who have otherwise normal lung function may be distinct from the bronchospasm that occurs in those with a history of asthma. Although inflammation is a critical component of asthma and EIB, the role of inflammation in EIB in the absence of persistent asthma is not completely clear.⁵ Some research suggests that inflammation is present in both but that the type of inflammatory cell infiltration is different.⁵ Studies have demonstrated that the underlying physiological mechanism that results in EIB symptoms is loss of heat and/or evaporative water in the lung during exercise. Deep, exhaustive breathing brings cold, dry air into the lungs,³ overcoming the upper airway’s ability to warm and humidify the air before it reaches the smaller airways.⁶ This deep breathing may further expose the athlete to cold air, airborne allergens, or environmental irritants in sports venues. It is accompanied by the release of inflammatory mediators and contraction of smooth muscle in the airway.^10-13 The inflammation is at least partially reversible when activity ends.

The Role of the Environment

The environment also plays a role in the development of bronchial hyperresponsiveness.¹⁴ Exposure to cold air for extended periods of time by skaters, cross-country skiers, and other winter sports participants is a primary factor leading to the higher prevalence rate of EIB in players of those sports. In addition, research has demonstrated a relationship between the number of hours spent in indoor swimming pools, where swimmers are exposed to organic chlorine products, and the risk for pre-school and school-aged children to develop asthma.^15,16 Inhaling cold air contaminated by indoor air pollutants such as exhaust from ice resurfacing machines also has been implicated in the development of asthma and in triggering epsiodes,^17,18 although alternate theories hint at a connection with chemical fumes originating from the actual surface of the ice.

Sports-related deaths associated with asthma have generally occurred during late summer through fall. This may be because of the increased mold and pollen in the air. Potent allergens such as alternaria mold and ragweed can exacerbate asthma symptoms in sensitive individuals. In addition, extreme heat and humidity may play a role. Although the underlying physiologic pathway is not completely understood, early theories suggest sudden, severe apoxia, reduced chemosensitivity to hypoxia, and blunted perception of dyspnea by the athlete.^2,4

Team physicians, coaches, athletic trainers, and athletes should be aware of the role that poor air quality plays in triggering acute asthma episodes. The Minnesota Pollution Control Agency reports air quality levels for select areas in Minnesota using an air quality index (AQI) (http://aqi.pca.state.mn.us/). When the AQI exceeds 50, athletes may experience problems breathing, increasing their risk for an asthma episode. Athletes and their coaches and athletic trainers should monitor AQI levels and develop a plan for alternate practice sites and a change in activity level when AQI levels are high.

Asthma Management during Sports Activity

By nature, sports are competitive, and with competition comes the expectation that athletes will exert themselves to the most of their abilities. Having asthma should not limit an athlete’s ability to compete and win. However, athletes who have asthma must be smart about how they play, take special precautions to avoid an asthma episode, be ready to manage their asthma symptoms, and have knowledgeable coaches, athletic trainers, and response personnel ready to assist them if necessary.

The National Heart Lung and Blood Institute’s guidelines for the diagnosis and management of asthma (EPR-3) recommend that clinicians and patients jointly develop treatment goals that keep in mind preferences for treatment.³ Athletes who have asthma or who experience EIB may require a more focused set of instructions to ensure they comprehend the impact their condition may have on their ability to compete. They should be able to clearly articulate their asthma-related needs to their coach and/or athletic trainer and be able to use preventive and rescue medications appropriately. Athletes with asthma should be re-evaluated every six to 12 months, depending on the extent to which their asthma is under control.^3,4 Those who experience symptoms while participating in a sports activity should be assessed by their health care provider more frequently.

Underestimating the severity of asthma may contribute to a lack of appropriate monitoring and not having an intervention plan in place in the event of an episode.² An athlete’s asthma should be well-controlled. The occurrence of any symptoms during the days prior to a sporting event (coughing at night, nighttime awakening, or wheezing during the day or night) or multiple uses of a reliever medication during a sporting event are signs that it is not. Athletes should always have a reliever medication available.⁴ Although using it prior to a sports activity or once during an activity is acceptable, additional uses should be an indication that an athlete should stop the activity and be assessed for respiratory function.^2,4 Athletes experiencing any degree of respiratory distress (a significant increase in wheezing or chest tightness, a labored respiratory rate greater than 25 breaths per minute, inability to speak in full sentences, an uncontrolled cough, significantly prolonged expiration phase of breathing, nasal flaring, or paradoxical abdominal movement) should be further evaluated and possibly taken to an emergency department.⁴ Emergency transport should be sought immediately if the athlete is exhibiting signs of impending respiratory failure (weak respiratory efforts, weak breath sounds, unconsciousness, or hypoxic seizures).⁴

■ The Asthma Action Plan
In addition to health care providers, coaches, athletic trainers, and other personnel who supervise athletes should be aware of the signs and symptoms of asthma and EIB and know what steps to take during an episode. An asthma action plan is an important management tool. (The Minnesota Department of Health’s Asthma Action Plan can be found at www.health.state.mn.us/asthma/documents/09.childaap.pdf.)

The plan should list a patient’s control and rescue medications along with specific steps to help maintain control and respond to emerging symptoms. Action plans divide symptoms into zones of increasing severity. The zones are described as green (breathing is good, no cough or wheeze, can work/play easily, sleeping all night), yellow (hard to breathe, coughing, wheezing, tightness in the chest, cannot work/play easily, wake at night coughing), and red (very hard to breathe, nostrils open wide, ribs are showing, medicine is not helping, trouble walking or talking, lips or fingernails grey or bluish). These zones correlate with peak expiratory flow rates in the event that a sideline assessment becomes necessary—green (79% to 100%), yellow (50% to 80%), and red (below 50%).

A well-written asthma action plan empowers athletes, coaches, and athletic trainers to effectively manage asthma symptoms. Using these instructions, coaches, athletic trainers, and other team personnel can respond to the needs of the athlete quickly and efficiently. National Athletic Training Association position papers emphasize the importance of having an asthma action plan for athletes with asthma,⁴ but the National Collegiate Athletic Association and the Minnesota High School League have not weighed in on this recommendation. Access to an asthma action plan is especially important for young amateur sports participants, junior high school athletes, and high school athletes, as they do not always have access to an athletic trainer who is familiar with their needs during practices and competitions.

■ Controlling Asthma and EIB
Controlling their underlying asthma is the first priority for athletes. The EPR-3 guidelines identify inhaled corticosteroids as the first line of therapy for long-term control.^3,5 Emphasizing to athletes their importance as the primary management strategy is essential. Inhalers that combine a corticosteroid and a long-acting beta2-agonist are being used increasingly for asthma management, but they cannot be used as rescue medications. The EPR-3 guidelines also offer leukotriene modifiers such as montelukast as alternate therapies for management of persistent asthma.³

The most common therapeutic recommendation for minimizing or preventing EIB symptoms is the prophylactic use of a short-acting inhaled beta2-receptor agonist (SABA) such as albuterol. Treatment with two puffs 15 to 30 minutes before exercise is effective, provides peak bronchodilation in 15 to 60 minutes, and offers protective effects from EIB for at least three hours in most persons.^5,6 However, the overuse of SABAs has been shown to result in tachyphylaxis and can worsen symptoms of EIB and asthma because of desensitization of medication receptors in the airways.^4,5

Other drugs also have been studied for their ability to prevent EIB symptoms for persons with asthma. The long-acting bronchodilator formoterol has been shown to be effective approximately 15 minutes after dosing, with the period of efficacy lasting up to 12 hours. Salmeterol needs to be administered well before the event in order to be useful. Neither formoterol nor salmeterol can be used as a rescue medication in an exercise or sport situation.^4-6

Although guidelines exist for the management of individuals with asthma and EIB, there are no guidelines currently available to guide pharmacotherapy in athletes without asthma who experience EIB.5 Because EIB can be experienced by any athlete, inhaled beta2-agonists for athletes with asthma-like symptoms are frequently prescribed on the basis of the symptoms alone. Clinical findings related to the impact that inhaled beta2-agonists may have on athletes without asthma are not consistent. Increased lung function has been found in athletes without asthma who use inhaled beta2-agonists, and some studies have reported a shorter period of breathlessness after exercise, although the effect of these changes on performance has not been studied in depth.6 Nonetheless, inhaled beta2-agonists are listed as banned substances by the World Anti-Doping Agency, the regulatory body for drug use in sports, unless an established medical need is documented. Likewise, there has not been adequate study of the effectiveness of inhaled corticosteroids in persons who do not have asthma but who experience EIB.⁵

Athletes also can use nonpharmacologic strategies to help reduce the frequency and severity of their EIB symptoms. A warm-up period before exercise and a cool-down period afterward may reduce the degree of EIB.⁵ Wearing a facemask during activity to warm and humidify inspired air has been found to work well for elite and recreational athletes who exercise in winter. Breathing through the nose rather than the mouth also helps ameliorate EIB by warming, filtering, and humidifying the air. In addition, athletes with knowledge of their asthma triggers should attempt to avoid them if possible.⁵

Conclusion

Having asthma should not limit an athlete’s ability to compete and win. An athlete must be aware of his or her condition and what can trigger an episode and be ready to manage symptoms if they occur. In addition, coaches, athletic trainers, and response personnel must be knowledgeable about asthma management and be ready to assist players if they need help. MM

William Picconatto is director of the athletic training educational program at St. Cloud State University, a certified athletic trainer, and a licensed physical therapist with NovaCare in Monticello, Minnesota. Susan Ross is the senior clinical advisor for the Minnesota Department of Health Asthma Program, a registered nurse, and a certified asthma educator. Angeline Carlson is adjunct clinical faculty with the College of Pharmacy at the University of Minnesota, director of research with Data Intelligence Consultants, LLC, and a registered pharmacist.
 

References
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