Asthma Pharmacological Management In the Athletic Setting
Mar 27, 2015
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?