Exercise Induced Asthma/Bronchospasm
It was around 10:00p.m. when I got the call from the exchange. “My daughter is 16 months old and she has a fever of 101 degrees.
Jon, a 14-year-old patient of mine, is a freshman in high school. I did his sports physical this summer as he was going out for the cross country team. He was in excellent shape, always being active in sports. He came to the office in mid-September for a consult about trouble breathing. It seems when running he starts out fine and feels strong. But after a couple of miles he feels as if he can’t get enough air in. He has a tightness in his chest and is short of breath. This causes a disappointment in his performance and he knows he could do better. Once home he says that he can breathe fine. Mom has never heard him wheeze or cough and he has never been diagnosed with asthma. Jon and his parents even questioned if there may be a psychological component to this and wanted to know if he should see a sports psychologist.
His examination and vital signs were normal He had no signs of being an allergic individual: allergic shiners, enlarged turbinates in the nose, eczema or wheezing. In fact, his heart rate was 60/minute suggesting he was in great cardio-vascular shape. His lungs were clear.
Getting more of a detailed history Jon has always played sports. He played flag football and soccer in 5th and 6th grade, baseball from kindergarten until 8th grade and did a few years of karate. He was an avid swimmer at the beach and participated in Junior Life Guards for five summers. He has never had a problem with his breathing before. Going into high school he was afraid that he wouldn’t be able to make the baseball team and instead decided to go out for cross country with a couple of his friends. It started out fine and he actually did quite well. But the breathing problems started a few weeks into the season.
After hearing the history I told them that I thought Jon had exercise induced bronchospasm or EIB (used to be called exercise induced asthma).
I prescribed an albuterol inhaler (a bronchodilator) and I told him to take 2 puffs of the inhaler 10 minutes beforehe ran. This should work preventatively. I also wanted him to start the next dayin keeping a detailed log or diary about how he felt during the practices and about his times. I wanted to see him back in a week to re-evaluate.
Five days later he came back. I was actually worried that things had not worked out for him. Upon entering the room he had a big smile on his face as did his mom. He said that he couldn’t wait to see me because the change was almost miraculous. Not only did he feel strong throughout the entire practice, his times improved dramatically. Clearly he did have EIB.
EIB is a common phenomena that is seen in athletes. It doesn’t mean that they have asthma, but 90% of people who do have asthma have some form of EIB.
It is very common in elite athletes. Quite often you will see Olympic athletes using their inhalers before they compete. The exact mechanism of EIB is not known but one theory is that as we normally breath through our nose the air in is warmed and humidified as it passes through the nose by the turbinates in the nasal cavity. When we exert ourselves we breath more through our mouths. The air we take in is colder and dryer. This triggers a reaction whereby the bronchioles will spasm and constrict. This then leads to irritation of the airway which causes inflammation and production of mucus. The end result is a narrowing of the airway that can cause coughing or actual wheezing. The symptoms of EIB include coughing, wheezing, fatigue, shortness of breath, chest tightness and simply poor performance. The symptoms usually start shortly after exertion and will last for 10-20 minutes after the exercise is stopped. The symptoms then resolve completely.
Conditions that may exacerbate EIB include cold or dry air, low humidity, air pollution, chlorine in pools and chemicals used with ice rink resurfacing equipment.
Jon’s mom asked an interesting question. “Why did Jon play all of those sports when he was younger with no problems? Why now?” The only logical answer I could think of was that when he was younger playing soccer and flag football he never pushed himself or exerted himself where he crossed that threshold to trigger such a reaction. Certainly a cross country work out where there is sustained running at a fast pace for miles would do this.
The way we treat EIB is to give a bronchodilator (asthma medicine) such as albuterol before the exercise and it will work preventively. It is not effective, however, when used after the symptoms have started. It is reported to work in over 80% of cases of EIB. Other treatment modalities are available should albuterol not be effective. These include a Singulair tablet given 2 hours before exertion or a combination inhaler with a steroid and a long acting bronchodilator, or a mast cell stabilizer such as Cromolyn. If albuterol does not help there are a number of alternatives that can be used pro-actively before exercise. These must be determined on an individual basis.