Sports Medicine: Just the Facts

CHAPTER 36 • PULMONARY 215

Montelukast and zafirlukast are approved in children,

have a favorable safety profile, and are taken orally qd

or bid. Zileuton is not approved in children <12-year

old, requires qid dosing and monitoring of hepatic

function (Nathan and Spector, 1999).

MEDICATIONS

BRONCHODILATORS

• Short-Acting B2-agonists: Inhaled albuterol is the
  main rescue medication for acute bronchoconstric-
  tion. Inhaled forms have a good safety profile with
  primarily mild central nervous system (CNS) side
  effects. Medication has an immediate effect, and is,
  therefore, subject to overuse. Overuse can also lead to
  decreases in efficacy and increased bronchial hyperre-
  activity (Bhagat, Kalra, and Swystun, 1995). Oral
  forms are not approved for use by the Olympics or
  National Collegiate Athletic Association (NCAA).


• Long-Acting B2-agonists:Salmeterol (Serevent) has
  a duration of action of 12 h and is useful in assisting
  with long-term control. Not intended to be used as a
  rescue medication.


• Anticholinergics:Ipratropium bromide (Atrovent) is
  a bronchodilator used more often in patients with
  chronic obstructive pulmonary disease(COPD). It
  can be an adjunct for patients who have an inadequate
  response to β2-agonists. The duration of action is 3 to
  4 h with an onset of 30 to 90 min.


• Use caution when prescribing medications to collegiate,
  professional, and elite athletes. Always check with the
  sport’s governing body in regards to banned substances.
  U. S. Olympic Committee has an up-to-date list avail-
  able through their website @www.usantidoping.org or
  call their drug control hotline 1-800-233-0393.


• Once asthma is well controlled, exercise should be
  encouraged. Studies have demonstrated decreased num-
  bers of exacerbations, less medication use, and fewer
  missed days of work/school in asthmatics who exercised
  (Cochrane and Clark, 1990; Szentagothai et al, 1987).


• Normal ranges of ventilation, work capacity, blood
  pressure, and maximal heart rate are exhibited in asth-
  matics that are well conditioned and have their disease
  under control (Bundgaard, 1985).


• The exercise presciption should include a preexercise
  assessment to document control. FEV 1 should be
  ≥80% of expected levels (Disabella and Sherman,
  1998). The exercise goal should be consistent with the
  American College of Sports Medicine’s recommenda-
  tion to exercise on most days of the week for 20 to
  30 min(American College of Sports Medicine, 1998).
  The type of exercise can be anything that the patient
  enjoys, but should provide aerobic benefit as well as
  strength and flexibility conditioning.
  
  
  • Advise caution on risky activities such as exercising
    outside on a cold day, when wheezing or when peak
    flows suggest a decline in lung function, as exercise
    can trigger symptoms of bronchoconstriction. (See
    exercise-induced bronchospasm section below.)
  
  
  
  

EXERCISE-INDUCED BRONCHOSPASM

• Exercise-induced bronchospasm(EIB) is defined as
  the transitory increase in airway resistance that typi-
  cally occurs following vigorous exercise. EIB will
  usually resolve spontaneously.


• EIB is found in 12–15% of the general population
  (Randolph, Randolph, and Fraser, 1991; Rupp, Guill,
  and Brudno, 1992). Ninety percent of patients with
  chronic asthma and 40% of patients with allergic rhinitis
  or atopic dermatitis will have EIB (Feinstein et al, 1996).


• The prevalence of EIB in athletes varies by sport with
  ranges between 12 and 55% (Langdeau and Boulet,
  2001) and occurs in amateur to elite level athletes.
  Higher risk sports include those with high minute ven-
  tilation such as basketball, track, and soccer as well as
  those in cool, dry air such as cross-country skiing, ice
  skating, and hockey.


• The pathophysiology of EIB remains debatable. Two
  main theories exist:


• The water loss theoryattributes EIB to the loss of
  water through the bronchial mucosa as the body tries
  to warm rapidly inhaled air during exercise. This dries
  the mucosa and causes local changes in pH, osmolar-
  ity, and the temperature of the airway, which may trig-
  ger bronchoconstriction (Storms, 1999).


• The thermal expenditure theoryholds that EIB is the
  result of respiratory heat loss that occurs during exer-
  cise. The increased ventilation of exercise causes a
  cooling of the airways. Once exercise ceases, the
  blood vessels dilate and engorge to rewarm the epithe-
  lium, which may lead to rebound hyperemia and bron-
  choconstriction (Storms, 1999).

PRESENTATION

• Clinical symptoms may include coughing, wheezing,
  chest tightness, or shortness of breath during or after
  intense exercise. Atypical symptoms can include
  stomach cramps, chest pain, nausea, headache, or
  feeling out of shape. Examination during an attack
  may demonstrate increased respiratory rate, pro-
  longed expiration, decreased breath sounds, and
  wheezing. Some athletes may describe a late-response
  6 to 8 h after the onset of exercise. This occurs in
  ~30% of patients with EIB, and is more frequently
  seen in children (Lacroix, 1999).