Asthma Pharmacological Management In the Athletic Setting.

Asthma

Pharmacological

Management

In the

Athletic Setting

Exercise Induced Asthma (EIA)

Transient bronchospasm resulting from vigorous physical activity

EIA affects 10-15% of population 70-90% of asthmatics have EIA 40-50% of people with allergies have EIA 16-18% of Olympic Athletes have EIA

Clinical Symptoms

EIA occurs after strenuous exercise near 80% maximum capacity for > 6 minutes

Can also occur 4-8 hrs after exercise Repetitive attacks can cause severity by

strengthening bronchial muscle Common symptoms

Shortness of breath Coughing Chest tightness Wheezing

Pulmonary Function

15-20% fall of forced expiratory volume (FEV1)

> 10% fall of peak expiratory flow rate (PEFR)

Bronchospasm is greatest 3-15 minutes post exercise

Severity: mild, moderate, severe

Influencing Factors

Type of exercise

Duration of exercise

Intensity of exercise

Environmental conditions

Pulmonary disease

Dietary salt

Type of Exercise

Activities that cause EIA Running Cycling X-country skiing

Activities less likely to cause EIA Swimming Dancing Gymnastics Rowing

Duration / Intensity of Exercise

Occurs after 5-8 minutes of vigorous exercise Exercise for longer periods does not increase

the chance of bronchospasm

Strenuous defined a >80% maximal heart rate

Environmental Conditions

Increased with cold, dry air, pollution, allergens

Decreased with warm / humid air

Other Factors

Pre-existing conditions such as asthma, bronchitis, emphysema

Dietary salt High intake increases symptoms,

occurrence Lower intake decreases symptoms,

occurrence

Current Theories

Increased ventilation results in water loss from bronchial tree

This results in increased osmolarity of epithelial fluid that causes inflammatory mechanisms (mast cell degranulation)

Inflammatory mediators are released when exposed to allergens

Mouth breathing cools the airways and causes bronchial vascular bed dilation

Diagnosis

Refer for testing in clinical situation Must abstain from medications before

testing Beta agonists – 6 hrs. Leukotriene inhibitors, oral meds.

Have medications to treat bronchospasm after testing

Nonpharmacological Rx

Conditioning Warm up that includes strenuous bouts Diet (salt intake, 30 mg. lycopene) Run through Avoid hyperventilation Nasal breathing Cover mouth in cold weather Avoid strenuous exercise when allergens are

high Choose indoor sports during winter

Pharmacological Treatment

Beta agonists

Cromolyn sodium & nedocromil

Leukotriene inhibitors

Theophylline

Steroids

Ipratropium Bromide

Ca++ channel blockers

Beta 2 Agonists

Taken 15 minutes prior to exercise Relax smooth bronchial muscle If more than 1/month is needed – other

medications needed for better control Side effects: tachycardia, tremors, headache Inhaled forms more popular Prohibited by IOC without documented tests,

Hx. of use

Albuterol / Salbutamol / Terbutaline Commonly prescribed Short acting Long duration

Salmeterol Long acting, helps with latent phase EIA Commonly used with anti-inflammatories

Metaproterenol Moderate duration

Cromolyn sodium / Nedocromil

Better used as preventative if know exposure to allergens

Inhibits response to cold, dry airWorks in synergy with beta 2 agonistsSafeSide effects : bad taste or smell

Leukotriene Inhibitors

Long control medications Approved for use after 11 yrs. Old Convenience of pill vs. inhaler Zafirlukast (Accolate) Zileuton (Singulair)

Theophylline

Dilate bronchial smooth muscle Increases diaphragm contractility Anti-inflammatory effects Long term control May help with nocturnal symptoms

Ipratropium Bromide

Anticholergenic Causes bronchodilation Effective for quick relief of symptoms Not effective if underlying allergies,

asthma Atrovent

Steroids

Long term medications Taken to control persistent asthma, not

EIA Inhaled used 1st - spacer makes delivery

more effective Advair

Oral medications are reserved for severe cases of asthma that don’t respond to other therapy

Long term use can suppress cortisol production

Banned Substances

Check list frequently as it changes with new medications

Generally Beta 2 agonists need documentation of

testing, hx. of use for IOC, not for NCAA Clenbuterol is banned

Asthma

Asthma

EtiologyCaused by viral respiratory tract infection,

emotional upset, changes in barometric pressure or temperature, exercise, inhalation of noxious odor or exposure to specific allergen

Sign and SymptomsSpasm of smooth bronchial musculature, edema,

inflammation of mucus membraneDifficulty breathing, may cause hyperventilation

resulting in dizziness, coughing, wheezing, shortness of breath and fatigue

Asthma - Characteristics

Disease of the respiratory system Due to:

spasm of bronchial smooth muscles, inflammation of bronchial wall, increase mucous secretion

Stimuli - allergies, colds, viral infections, smoking, psych. stress, exercise

Is not a progressive disease

Signs & Symptoms of Asthma Attack

tight chest wheezing coughing rapid, shallow breathing anxiety tachycardia pale color lack of endurance

Exercise Induced Asthma

Onset of S/S w/in 30 min. post exercise

Prevention of symptoms know environmental conditions warm-up gradually & cool down use a bronchodilator

Exercise Induced Asthma

15% decrease in peak expiratory rate is diagnostic

10-20% of general population, 90% with asthma Episode usually occurs after 5-10 minutes May be caused by water and heat loss from

airways from mouth breathing and increased respiration rate

Also consider: Type of exercise Environmental factors Preexisting inflammation Intensity of exercise

Treatment for Asthma Attack

Calm the patient Controlled breathing Drink water Medications

Bronchodilators Corticosteroids Leukotriene Receptor Antagonists

Refractory Period

Occurs after an asthmatic episode Time during which additional exercise doesn’t

cause bronchospasm Lasts 1-4 hours In some individuals a refractory period can be

induced with light exercise and no episode (ex) run 10 submaximal 100 yard sprints 30

minutes before competition

Preventive Measures

Avoid cold, dry polluted air Increase nose breathing Change sports Decrease intensity Regular exercise, appropriate warm-up and cool

down, w/ intensity graduated Exercise in warm, humid environment Exercise during refractory period

Monitoring Asthma

Peak expiratory flow rate can be measured with a hand-held peak flow meter to allow self monitoring

Take before and after bronchiodilator therapy to check effectiveness of Rx

ATC may consider keeping one in kit with disposable mouth pieces

Medications

5-10% of asthma symptoms are worsened by NSAIDS Controller medications

To prevent Sx (ex) Long acting beta agonist – Salmeterol

Reliever medications 2-4 puffs just before exposure or as Sx present (ex) Short acting agonist – Albuterol

Cause dilation of smooth muscles around lung and inhibits release of chemicals that cause inflammation

Usually inhaled, but also oral (ex) Mast cell stabilizers

Prevent release of contents of mast cells –therefore prevent inflammation and brochoconstriction

Medications - Bronchodilators

Stimulate Beta2 receptors - causes dilation of bronchials

Decrease smooth muscle spasm For an acute asthma attack

**Long term / excessive use causes hyper- responsiveness

Bronchodilators - Examples

Administration - Inhalation (Albuterol) Proventil (Piributerol) MaxAir (Salmeterol) Serevent (Epinephrine) Primatene Mist (Theophylline) TheoDur, SlowBid

decrease release of prostaglandins

Side effects - nausea, mental confusion, irritability, restlessness

Medications - Corticosteroids

Use prophylactically before asthma attack to decrease release of prostaglandins, decrease responsiveness of smooth muscles in airways

Has no effect on an acute attack

Corticosteroids - Examples

Administration - Inhalation, Ingestion (Dexamethasone) Decadron (Cromolyn) Intal, NasalCrom Azmacort Tilade Vanceril Flonase – allergy corticosteroid

Medications - Leukotriene Receptor Antagonists

Prevents spasm and swelling within the bronchial smooth muscles Leukotrienes cause constriction of airways

& promote mucous secretions

Examples Singulair Accolate

Role of the ATC

1. Recognize decreased performance caused by EIA

2. Measure peak flows and refer if indicated

3. Monitor efficacy of Rx by tracking Sx and tracking peak flows

4. Educate on proper inhaler use

Proper use of an inhaler

Diabetes

What is diabetes?

A disease which involves the production or function of insulin

Normal blood sugar level = 80-90mg/100 ml blood

Diabetes - Types

Type II, Non-Insulin Dependent, Adult Onset 90% of all cases Predisposing factor – obesity, heredity Pancreas still produces insulin Symptoms usually controlled by diet & exercise Oral Antidiabetic Drugs - stimulates pancreas to

produce insulin Amaryl Glimepiride Glucophage Avandia

Diabetes - Types

Type I, Insulin Dependent, Juvenile Onset Onset before age 30 Pancreas does not produce insulin

Must take insulin - type & dosage determined by severity & Dr.

Administration Injection Implant pumps

Effects of exercise on diabetes

Decreases need for insulin

Associated Conditions

Diabetic Coma blood sugar elevated develops over days S/S - thirst, difficulty breathing, nausea,

vomiting, mental confusion, loss of consciousness

Ketoacidosis Rx. - call 911, insulin

Associated Conditions

Insulin Shock (Hypoglycemia) blood sugar level too low develops rapidly S/S - physical weakness, moist pale skin,

headache, tachycardia, fatigue, hunger, anxiety

Rx. - eat sugar, candy, fruit juice, crackers, Prevention - eat before practice

Diabetes Mellitus

1997 report by The Expert Committee on Diagnostic and Classification of Diabetes Mellitus Defined diabetes, “a group of metabolic

disorders characterized by hyperglycemia resulting from insulin secretion, insulin action or both and is associated with damage and failure of various organs, especially the eyes, kidney, nerves, heart, and blood vessels.”

Glucagon vs Insulin

Criteria for Diabetes

2 fasting blood glucose levels > 126mg/dL or

2 random draws > 200mg/dL

Normal blood glucose level varies between 80-120mg/dL

Type I Diabetes

“juvenile onset” or “insulin dependent” Results from destruction of pancreatic beta cells

which make insulin; thus, insulin is not produced < 30 yo Sudden onset Frequent urination, constant thirst, weight loss,

constant hunger, tiredness, weakness, itchy dry skin and blurred vision

Insulin injections required to control If not controlled ketoacidosis occurs

Treatment for Type I Diabetes

Complications are reduced by 76% if managed

Recommendations for Treatment1. Self monitoring of blood glucose 4x/day2. Use insulin pump or shots 3x/day3. Adjust insulin dose based on glucose level4. Anticipate and plan dietary intake and

exercise

Type II Diabetes

“Adult-onset” or “Non-insulin dependent” Caused by insulin resistance Also may see a decrease in insulin production >40 yo Controlled with diet, exercise, weight loss,

and/ or oral medication Not associated with ketoacidosis

Diabetic Coma Etiology

Loss of sodium, potassium and ketone bodies through excessive urination (ketoacidosis)

Extreme hyperglycemia Sign and Symptoms

Labored breathing, fruity smelling breath (due to acetone), nausea, vomiting, thirst, dry mucous membranes, flushed skin, mental confusion or unconsciousness followed by coma.

Management Early detection is critical as this is a life-threatening

condition Insulin injections may help to prevent coma

Insulin Shock Etiology

Occurs when the body has too much insulin and too little blood sugar

Hypoglycemia Sign and Symptoms

Tingling in mouth, hands, or other parts of the body, physical weakness, headaches, abdominal pain

Normal or shallow respiration, rapid heart rate, tremors along with irritability and drowsiness

ManagementAdhere to a carefully planned diet including

snacks before exercise

Guidelines for Pre-exercise Caloric Intake Based on Blood Glucose Levels

1. Eat when < 80mg/dL2. Eat a high complex CHO snack before

exercise before exercise if < 100mg/dL3. Exercise if 100 – 250mg/dL4. Exercise > 1 hour, then eat 15g of CHO and

drink 250 mL every 15-20 min5. >250mg/mL check urine for ketones

• If ketones present or if >300mg/dL, then cancel exercise and adjust insulin

**Sports Drinks?