CHAPTER 36 • PULMONARY 217ANTILEUKOTRIENES
- This class offers the advantage of oral administration
and long duration of action. Both montelukast and
zafirlukast have demonstrated an immediate protec-
tive effect against EIB (Leff et al, 1998). Montelukast
is 10 mg daily in adults and 5 mg in 6–14-year old
children. It has a 3–4-h onset of action and duration of
24 h. Zafirlukast is 20 mg bid in adults and 10 mg bid
in children 5–11-year old. It has an onset of action of
30 min and duration of 12 h. Zileuton is 600 mg qid
in adults and children ≥12. It has an onset of 30 min
to 2 h and duration of 5–8 h.
IPRATROPIUM
- This drug has limited usefulness in preventing EIB.
- Nonpharmacologic treatments:The use of masks or
scarves to decrease the amount of heat and water lost
with exercise in cold weather may diminish EIB. - Aerobic conditioning may reduce severity of EIB by
improving rate of ventilation during exercise, but no
proof it prevents EIB (Cochrane and Clark, 1990;
Holzer, Brukner, and Douglass, 2002). - Appropriate cool downs help decrease EIB. Cooling
down helps by allowing gradual rewarming of the air-
ways which decreases vascular dilation and edema. - Refractory period:Defined as the time after sponta-
neous recovery from an episode of EIB where >50% of
athletes will not experience another episode of bron-
choconstriction with exercise. Effect is usually 1 to 2 h
in duration. Can benefit athletes who experience this
effect in that they can induce a refractory period prior to
their actual competition to lessen the severity of EIB
during their event. Various methods exist to induce the
effect, including 20 to 30 min of low-intensity exercise
or seven 30-s sprints separated by short intervals
(Disabella and Sherman, 1998; Holzer, Brukner, and
Douglass, 2002). Recent studies demonstrate that a con-
tinuous low-intensity warm-up is more beneficial than
interval training to decrease risk of EIB (McKenzie,
McLuckie, and Stirling, 1994). Studies also demon-
strate that this effect is inhibited with use of nonsteroidal
anti-inflammatories (O’Byrne and Jones, 1986;
Margolskee, Bigby, and Boushey, 1988; Wilson, Bar-
Or, and O’Byrne, 1994). Athletes should be counseled
to still use their prescribed EIB medications, as effect is
partial for most people (Storms and Joyner, 1997).
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
- Chronic obstructive pulmonary disease is a progressive
disease that primarily refers to emphysema and chronic
bronchitis. It is a condition of slowly deteriorating
pulmonary function whereby expiratory airflow
obstruction leads to dyspnea and deconditioning.
While exercise cannot reverse the process, it can pro-
vide improvements in quality of life and decreased
disability (Mink, 1997).- Approximately 15–25 million Americans are afflicted
with COPD. It is responsible for 200,000 deaths annu-
ally and is a major cause of disability (Shayevutz and
Shayevitz, 1986). - The primary cause is chronic tobacco use, but other
etiologies such as alpha1-antitrypsin deficiency and
environmental exposures do play a role. - The pathophysiology of COPD is multifactorial.
Airway hyperreactivity and/or increased respiratory
secretions lead to chronic obstruction. This results in
air trapping and respiratory muscle dysfunction,
which, over time, causes generalized deconditioning.
Additionally, the emphysematous component causes
destruction of alveolar capillary membranes, which
leads to hypoxemia. Chronic hypoxemia results in
pulmonary hypertension and right ventricular failure
(Smith and MacKnight, 1998).
•Severe limitations in respiratory function and chronic
hypoxemia cause great fear and anxiety in COPD
patients. This can result in fear of exercise and further
deconditioning (Casaburi, 1993). - Our role as sports medicine physicians is to enable
COPD patients to exercise comfortably and safely.
The most dramatic improvements in function are
often the most severely compromised (Mink, 1997). - Evaluation:Prior to providing an exercise prescrip-
tion, patients must have an assessment of their current
status through a physical examination and pulmonary
function testing. One can expect reductions in FEV 1
and increased ventilatory muscle effort.
•A careful assessment of cardiac risk and exercise
capacity including exercise testing is recommended
for all patients (Mink, 1997). Many protocols exist for
both treadmill and stationary cycle testing. Exercise
testing can help to determine safe levels of exercise to
prevent arrhythmias and hypoxemia, the amount of
supplemental oxygen needed during exercise and any
need for bronchodilators. - Management:The care of the COPD patient is aimed
at maintaining, or improving, the functional capacity
through a multidisciplinary approach. - Exercise:Studies demonstrate that exercise improves
dyspnea, provides an aerobic training response,
reduces ventilation, and improves overall exercise tol-
erance (Casaburi et al, 1991; O’Donnel, Webb, and
McGuire, 1993; Reardon et al, 1994). No evidence
exists that exercise lengthens life expectancy in the
COPD patient, but it provides immense physical and
psychologic benefits.