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Focus on Allergies & Asthma

By Thomas J. Kallstrom

Respiratory therapists are trained to help you manage your asthma. For asthmatic athletes, exercise if often a contributing factor or trigger to an asthmatic episode.

In their monthly magazine, AARC Times, respiratory therapists were reminded on how to help their patients be aware how exercise may contribute to an asthmatic event for them, with guidance on how to avoid these problems.

We do love our sports in America. Not only is it fun to watch your favorite sports star score a touchdown or hit a grand slam, but it is even more exciting to be able to do it yourself. And there really should be no reason why people cannot participate. However, for the person with asthma there are some considerations that must be taken into account.

Exercise-induced bronchospasm (EIB) commonly occurs in many asthmatics. Does this mean that they should not participate in sports? Absolutely not. What it means is that they need to take the necessary precautions while at the same time paying close attention to what their body is telling them.

The Expert Panel Report II is very clear in stating that patients should expect to live a symptom-free life and should be able to participate in activities of normal living. This certainly includes physical activity.

Activity-induced triggers
If the patient with asthma is participating in an outdoor sporting activity, one of the primary considerations is the air pollution level. Air pollution can cause significant respiratory difficulties if the levels of pollution exceed acceptable limits. Of particular concern is the level of sulfur dioxide (a by-product of power plants and industrial boilers) in the air. If exposed to higher levels, there is a real possibility that subsequent exacerbation may occur.

The index values in the Air Quality Index ranges on a scale of 0–500. It is when the numbers exceed 150 that patients with asthma may start to experience respiratory distress; and if the numbers are over 200, the Environmental Protection Agency recommends that all outdoor activities should be avoided. Even those without asthma should pay close attention to this as well, especially when the number passes the 300 mark.

Sulfur dioxide levels are not the only outdoor concern. So, too, are higher levels of ozone, particle pollution, and carbon monoxide levels. It would be prudent for the physically active patient to consider these air health indicators before participating in outdoor sporting activities. Reading the newspapers, watching local weather reports, or going to the Web can accomplish this.

Indoor sports also need to be considered. For example, patients with asthma who swim in chlorinated indoor pools may be exposed to a chemical called nitrogen trichloride, an aggravating factor for patients with asthma. Actually, it also is a causative factor in the development of asthma.1

Other sports come with a level of risk as well. Ice skaters have been shown to have a 30 percent overall incidence of EIB as determined by rink-side pulmonary function studies.2 Adult athletes generally have a higher level of EIB (11–50 percent) than the population at large compared to high school athletes who experience EIB about 38 percent if the time.3 The Asthma Guidelines recommend that patients susceptible to EIB pre-medicate with either a short- or even a long-acting bronchodilator before participating in a strenuous physical activity.4

First line of defense: coaches and teachers
It is essential that all coaches recognize the cardinal signs of an asthma attack and have rescue medications readily available for emergencies. Even more important is that athletes with asthma inform their coaches of their condition and share their asthma action plans.

Health promotion in scholastic sports is an area that needs much work. From my past experience, I have found a relative dearth of knowledge of asthma, especially with public school officials. Teachers, coaches, and school administrators must receive proper health promotion information to ensure a safe sports environment. They need to understand that it is not only the known asthmatics who need extra attention, there is danger for the undiagnosed asthmatic who experiences EIB as well. A large number of school-aged children participate in athletics but are not screened for asthma before beginning a program. One study that looked at this found that when 348 students without known asthma were given an exercise challenge test, 29 percent were positive for EIB when given an exercise challenge and then underwent spirometry.5 Therein lies an opportunity for the civic-minded respiratory therapist to start working with local school systems in an effort to educate and screen for asthma.

Unfortunately, the consequences of not being aware of a sports-related exacerbation could lead to death. Every year there are more than 5,000 asthma-related deaths. EIB-caused deaths are part of the equation. Generally, sports-related deaths occur more often with white subjects; and males are more predominant. It is more often seen under the age of 20, with the most prevalent age group being 10–14 years of age.6

Second line of defense: respiratory therapists
The take-home message for us as respiratory specialists is that we need to reach out to our active patients who participate in sports and instruct them on precautions and the need for accurate monitoring of their condition before, during, and after physical exertion. We need to educate them on the fact that they must have rescue medications available during sports events so that they can pre-medicate or, if the need arises, use a rescue medication. By this I mean that the patient who experiences an exacerbation is able to use the rescue medication for quick relief or to prevent exercise-induced bronchospasm.

It is also essential that we teach the people running the local sports programs all about asthma, especially the necessary steps to save a child experiencing an asthma attack. Therein lies a grand opportunity for respiratory therapists that I will cover in a future issue of this column.

Thomas J. Kallstrom is associate executive director and chief operating officer of the AARC. He is also a member of the NAEPP Coordinating Committee and is a certified asthma educator. •

1. Bernard, A., Carbonnelle, S., Michel, O., et al. (2003). Lung hyperpermeability and asthma prevalence in schoolchildren: Unexpected associations with the attendance at indoor chlorinated swimming pools. Occupational and Environmental Medicine, 60(6), 385-394.
2. Provost-Craig, M.A., Arbour, K.S., Sestili, D.C., et al. (1996). The incidence of exercise-induced bronchospasm in competitive figure skating. The Journal of Asthma, 33(1), 67-71.
3. Mannix, E.T., Roberts, M.A., Dukes, H.J., et al. (2004). Airways hyperresponsiveness in high school athletes. The Journal of Asthma, 41(5), 567-574.
4. National Asthma Education & Prevention Program. (1997). Expert panel report II. Guidelines for the diagnosis and management of asthma (NIH Publication No. 97-405). Bethesda, MD: U.S. Department of Health and Human Services.
5. Rupp, N.T., Guill, M.F., & Brudno, D.S. (1992). Unrecognized exercise-induced bronchospasm in adolescent athletes. American Journal of Diseases of Children, 146(8), 941-944.
6. Becker, J.M., Rogers, J., Rossini, G., et al. (2004). Asthma deaths during sports: Report of a 7-year experience. The Journal of Allergy and Clinical Immunology, 113(2), 264-267.

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