ASTHMA Roger J. Kruse, MD
Medical Director, Sports Care
Head Team Physician, University of Toledo
Head Team Physician, Winter US Olympic Team, 1998 Nagano, Japan
NCAA Committee of Competitive Safeguard and Medical Aspects of Sports
ACKNOWLEDGEMENTS
Jeff Burnell, DO - Sports Medicine Fellow
Megan Boyle, M.S., CCC-SLP – Speech Language Pathologist
DESCRIPTION
Chronic inflammatory disorder of the airways
Inflammation leads to airway hyper-responsiveness
(constriction), air-flow limitation, respiratory symptoms
Chronic inflammation may cause remodeling of the airway
Inflammatory cells, chemical mediators, and chemotactic
factors
Reversible airway obstruction
CLASSIFICATION
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Types:
Adult onset
Cough variant
Exercise induced
EPIDEMIOLOGY
Most common chronic disease of childhood in industrialized
countries
Affects about 6 million children; 24.6 millions persons in U.S.
-> ~ 8.2% prevalence
Boys affected more than girls prior to adolescence
RISK FACTORS
Pre-term birth
Genetic predisposition - African American race
Atopy
Allergic rhinitis
Smoking exposure
Living environment (ie. tobacco smoke, pets, mold)
Working environment – chemicals, farming
Hospitalization due to infection with RSV
Wheezing before age of 3 years
Obesity
EXACERBATING COMORBIDITIES
Allergic Rhinitis
Sinusitis
GERD
Nasal Polyps
Obesity
PATHOLOGY
Atopy – IgE mediated response
Imbalance of T helper cells, 1 and 2
Mast cell proliferation, infiltration of smooth muscle
Inflammatory cell infiltration -> airway hyperresponsiveness
-> airflow limitation -> respiratory symptoms -> change in
airway architecture(chronicity)
Exhalation more commonly affected
Some persistent changes include: fibrosis, increase mucus
production, cell injury, smooth muscle hypertrophy,
angiogenesis
SIGNS AND SYMPTOMS
Coughing
Wheezing
SOB or Rapid Breathing
Chest tightness
Tachycardia
Prolonged expiratory phase
Cyanosis, retraction, decreased air movement, tripoding, diaphoresis, pulsus paradoxus,
Eczema or allergic rhinitis
Frequency, severity, and factors that worsen Sx
Exacerbating factors
PHYSICAL EXAM
Skin – atopic dermatitis, eczema
HEENT – increased nasal secretion/mucus, boggy turbinates,
nasal polyps in some cases
Cardiac – tachycardia, pulsus paradoxus
Pulmonary – wheezing(not always present), may only be in
forced expiration; prolonged phase of forced exhalation
Chest – hyperexpansion of thorax, accessory m. use,
hunched shoulders, chest deformity
DDX OF COUGH AND WHEEZE
Upper Respiratory Tract:
Allergic rhinitis, Hypertrophy of tonsils, Foreign body, Sinusitis
Middle:
Bronchial Stenosis, Epiglottitis, Laryngomalacia, Pertussis, Toxic
inhalation
Lower:
Asthma, Bronchiectasis, Chronic Aspiration, Cystic Fibrosis, GERD,
Tumor, Viral
TRIVIA
What is the disorder involving nasal polyps, asthma, and ASA
sensitivity?
A. Beck’s Triad
B. Cushing’s Triad
C. Salus’s Triad
D. Samter’s Triad
SPIROMETRY
Spirometry showing obstructive pattern and evidence of reversibility
Performed before and after inhalation of short-acting beta-agonist (SABA)
Significant reversibility defined as increase ≥ 10% of predicted FEV1 or combination of increase in FEV1 > 200 mL and ≥ 12% from baseline after SAB
Methacholine challenge test can be considered to diagnose airway hyperresponsiveness in patients with FEV1 ≥ 65% predicted (negative test may help to rule out asthma)
VOLUME FLOW LOOP
Black line represents FEV1
before SABA
Red line shows
improvement in FEV1 with
SABA
Classic for diagnosing
asthma
If FEV1 does not improve,
likely other obstruction
(ie. COPD)
TREATMENT
Guidelines set by the National Heart, Lung, and Blood
Institute's (NHLBI)
Stepwise approach
Mainstay of treatment is education
Short acting Beta-agonist as rescue inhaler
Step up and step down therapy per patients compliance and
extent of symptoms
INTERMITTENT ASTHMA
NHLBI Step Treatment of Choice Alternatives
Step 1 •SABA as needed
•For exacerbations due
to viral respiratory
infections SABA every 4-
6 hours for 24 hours
(longer with physician
consult)
•Consider 3-10 days of
oral systemic
corticosteroids if
moderate-to-severe
exacerbation or history
of severe exacerbation
PERSISTENT ASTHMA
NHLBI Step Treatment of Choice Alternatives
Step 2
•Add daily low-dose ICS
(NHLBI Evidence A)
•Consider subcutaneous
allergen immunotherapy if
patient has allergic
asthma
•cromolyn or nedocromil
(NHLBI Evid A)
•LTRA (montelukast or
zafirlukast) therapy
(NHLBI Evid A)
•sustained-release
theophylline (NHLBI Evid
B)
PERSISTENT ASTHMA
NHLBI Step Treatment of Choice Alternatives
Step 3
•Medium dose ICS, or
low-dose ICS plus LABA
(NHLBI Evidence A)
•Consider subcutaneous
allergen immunotherapy if
patient has allergic
asthma
•low-dose ICS and one of
following
• LTRA (NHLBI
Evid A)
• sustained-release
theophylline
• (NHLBI Evid B)
• Zileuton
• (NHLBI Evid D)
PERSISTENT ASTHMA
NHLBI Step Treatment of Choice Alternatives
Step 4
•Medium-dose ICS plus
LABA (NHLBI Evidence
B)
•Consider subcutaneous
allergen immunotherapy if
patient has allergic
asthma
•Medium-dose ICS and
one of following
• LTRA (NHLBI
Evid B)
• sustained-release
theophylline
(NHLBI Evid B)
• Zileuton (NHLBI
Evid D)
PERSISTENT ASTHMA
NHLBI Step Treatment of Choice Alternatives
Step 5
•High-dose ICS plus
LABA (NHLBI Evidence
B)
•Consider omalizumab
for patients who have
allergies
No alternative treatment
PERSISTENT ASTHMA
NHLBI Step Treatment of Choice Alternatives
Step 6
•High-dose ICS plus
LABA plus oral
corticosteroid
•Consider omalizumab
for patients who have
allergies
Before oral
corticosteroids are
introduced, a trial of high-
dose ICS and LABA and
either LTRA, theophylline,
or zileuton may be
considered
COMPLICATION/PROGNOSIS
Status asthmaticus:
Acute exacerbation of asthma that does not respond to therapy
May require hospitalization
Some wheezing subsides with age
Risk factors for asthma will persist:
allergy, gender, parental asthma, environment
ASTHMA CONTROL TEST
http://www.docstoc.com/docs/document-
preview.aspx?doc_id=19427681
EXERCISE INDUCED ASTHMA
During or after exercise with h/o asthma
If no hx of asthma -> exercise induced bronchospasm
Typically within 5-15 of exercise; recovery 30-90 min.
Risk factors: cold weather sports, endurance,
environmental(smoke, chemicals, allergens)
70-80% of asthmatics, 40% w/ allergic rhinitis, 35-50% cold
weather athletes
Dx: decreased FEV1 by 10-15%, sport specif exercise testing, 80-
90% of VO2 max for 6-8 min.
90% sensitivity if 10% decrease, 100% with 15% decrease in FEV1
Inhaled mannitol also with high sensitivity
TREATMENT
Good warm up with moderate activity for 15 min., 15-30 min before
activity
Avoid triggers
Mask to warm air in cold weather
Nose breathing
Good underlying control of asthma prior to clearance for activity
SABA 2 puffs 15-30 min prior to activity; repeat if necessary
2nd line: LABA/ICS combo before exercise; cromolyn 4-10 puffs 20 min
prior; montelukast 10mg PO 2 hrs prior(good for allergic rhinitis)
PREVENTION
#1 Education Peak flow monitoring
Written Action plan
Adherence
PEAK FLOW
Peak expiratory flow rate (PEFR) more useful for
monitoring than diagnosis; long-term daily peak flow
monitoring suggested if moderate or severe persistent
asthma or history of severe exacerbations
Detect early changes that require treatment
assess responses to changes in therapy
quantify degree of impairment
WHEN TO REFER
Life-threatening asthma exacerbation
Hospitalization or more than 2 tx of steroids in a year
Not controlled after 3-6 months of active therapy and
appropriate monitoring
Unresponsive to treatment
Older than 5 requires step 4 care or greater, younger than 5
at step 3 or higher
VOCAL CORD
DYSFUNCTION
Roger J. Kruse, MD
Medical Director, Sports Care
Head Team Physician, University of Toledo
Head Team Physician, Winter US Olympic Team, 1998 Nagano, Japan
VOCAL CORD DYSFUNCTION
First, you need to think about it and then you
need to recognize it.
“You may not have seen it, but it’s seen you.
I guarantee it.”
- Roger J. Kruse
DEFINITION
Abnormal adduction of the vocal cords during the
respiratory cycle (particularly the inspiratory
phase) that produces an airflow obstruction at the
level of the larynx.
Resulting in dyspnea and throat/upper chest
tightness; stridor may or may not be present
Also described as laryngospasm, irritable larynx
WHAT TO LOOK FOR
Typical characteristics of patients:
Female 10-30 years old
Females 2-20 x more likely
History most important
Ask if they have “trouble getting air in or out”
Have inspiratory stridor
”Air Hunger”
throat tightness, difficulty getting air in
Characteristics continued:
Cannot phonate
A lot of stress
high achiever, Type A
Athletes
Helicopter parents
Associated with depression, anxiety, somatic complaints
SYMPTOMS
SOB/Dyspnea
Does not have to be exercise related- can present as chronic cough, sometimes primary voice complaint, ultimately leading into episode
More difficulty inhaling than exhaling
Sudden onset with fairly rapid resolution
Other complaints:
Dysphonia, throat clearing/coughing, globus sensation, PND/increased mucus, GERD, chronic sinus/allergy symptoms
ONSET AND TRIGGERS
Abrupt onset and resolution
Feel like they are choking and have hoarseness
Triggers or underlying disorders
Stress/anxiety
Upon first presentation, many patients state, “I am afraid I am going to die from this”
Physical exertion/exercise
Many patients are self-described as “type A”
Symptoms may present/be most severe in more “game-time” situations
Inhaled irritants/strong smells; weather changes/humidity
Reflux
Upper respiratory infections (often seen in non-athlete patients)
Coughing/laughing/talking
DIAGNOSIS
Laryngoscopy/Videostoboscopy
Pulmonary function test (PFT):
Normal spirometry loop but a truncated inspiratory
loop
Negative results/response to pulmonary/allergy treatments
Minimal relief with inhaler use
Dyspnea Index, Cough Severity Index- helps pinpoint
symptoms as well as impact on quality of life
PULMONARY FUNCTION TESTING
VCD AT REST (55 SEC)
VIDEOS
http://youtu.be/gmNwpJf1zUQ
https://www.youtube.com/watch?v=gmNwpJf1zUQ&feature=youtu.be
TREATMENT
Acute - have athlete/patient pant like a dog
Treat underlying/exacerbating disorders
Treat GERD if present with PPI
Treat underlying anxiety with CBT or medication(SSRI,
TCA, Buspar, etc.)
Speech Pathology Referral
BREATHING EXERCISES appear to be the MOST
IMPORTANT treatment
TREATMENT CONT…
Initial evaluation:
Identify/educate: understanding basic anatomy
Everyday breathing pattern- 1.) how to open the glottis 2.) how
to maintain the opening
Develop better muscle memory/motor learning
Nearly all patients demonstrate some type of maladaptive
breathing behaviors
Ratio breathing for better diaphragmatic muscle memory
development and encourage better thoracic/abdominal
engagement and control
Respiratory retraining- how to prevent/control episode
TREATMENT CONT… Follow up therapy:
Unique to each patient but can include:
Vocal hygiene and acid reflux management
Transitioning from rest breathing into mild ranging to high intensity exercise
Modify per specific sport
Emphasize “warm up” breathing as well as recovery breaths following
exertion
Adjusting mouth/jaw posture (golf ball)
Overall body awareness and relaxation: stretching (shoulder, back, neck
handouts provided), posture
Use of Therabands for ratio breathing exercise, Kinesio tape for awareness
Education re: potential influence of phonation on symptoms
How do they breath before speaking and/or rate/support during running
speech production
Where is sound focused?
MULTI-DISCIPLINARY APPROACH
Family Medicine/Sports Medicine
Pulmonology
Allergy/asthma
GI
ENT
Psychiatry/Psychology (Sports Psych)
CASE STUDY: JW
History
Collegiate basketball player with onset during previous track season
Initial description of symptoms:
Daily dyspneic episodes, particularly during exertion, as if “breathing through a little hole”, stridor often present
Harder to inhale than exhale, sudden onset, more throat restriction than chest
Symptoms calm down but not resolved by “yawn breath”, pursed lip breathing, or stopping the exercise; worsened by humidity, sprinting, planks
Less intense but similar symptoms with light exertion or at rest
No improvement with inhalers with PFTs suggesting possible VCD
Some occasional coinciding coughing episodes
CASE STUDY: JW
Clinician’s observation: sharp, stridorous inhalations with shoulder elevation,
mild laryngeal focus of voice/slightly decreased intensity
Videostroboscopy:
At rest, mild abnormal adduction after elicited abduction; TVF irritation,
mild dysfunctional voice use with posterior glottal chink, positive imitation
of symptoms
During/after dyspnea: stidor present, moderate abnormal adduction and
mild arytenoid prolapse
DI score: 27 (highly probable upper airway involvement)
CASE STUDY: JW Laryngeal control evaluation and 4 therapy sessions conducted over 11-12 weeks:
Eval: initial introduction and recommendations for rest breathing/awareness/motor learning
Session 1: reeducate, emphasis necessity of c/o basic recs and patience before seeing results at high intensity level. Moderate intensity with adjustments to oral positioning. Recs for warm up, drill c/o at practice
Session 2: Reinforce importance of daily practice; understanding evident but execution (particularly of diaphragmatic engagement) reduced therefore theraband used at tactile cue; Constant cueing required for awareness of breathing pattern/body posture not only during exertion, but prior to and afterwards; specific modifications for practice to try to implement to prevent very severe episodes from escalating/occurring
Session 3: Better carryover and management during exertion reported- realized how much conscious thought/awareness it takes; Kinesio tape used as a cue; improved ratio breathing; decreased cues required during exertion
CASE STUDY: JW
Session 4: No recent severe episodes; did not have to come out of
practice/game; realizes need to continued practice/carry over. Voice
strategies introduced for additional awareness (glottal fry)- particularly
since some dyspnea reported outside of exertion. Wrap up of recs for daily
routine/specific instances for real-life implementation provided.
Discharged with recs for f/u as needed.
THANK YOU!
Questions?
REFERENCES
Franca, Maria Claudia. Differential diagnosis in paradoxical vocal fold movement (PVFM): An interdisciplinary task. International Journal of Pediatric Otorhinolaryngology. 2014. 78: 2169-2173
Guglani, L. et. al. A systemic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction. Frontiers in Pediatrics. 2014. (2): 1-9.
Weinberger, Miles. Exercise-induced dyspnea: more than vocal cord dysfunction or laryngomalacia. Correspondence/Ann Allergy Asthma Immunol. 2014. (112): 270-271.
Asthma and vocal cord dysfunction related symptoms in the general population- a pilot study. Letters/Ann Allergy Asthma Immunol. 2014. (113): 576-577.
Nelson Essentials of Pediatrics, Marcdante, Karen, J, et al 6th edition, 2011.
DynaMed: Asthma in Adults and Adolescents.
UpToDate: An Overview of Asthma Management. http://www.uptodate.com/contents/an-overview-of-asthma-management?source=search_result&search=asthma&selectedTitle=1~150
