respiratory pathologies. stats 15 million people in the us have asthma 15-20% of kids, 6-8% of...
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Respiratory Pathologies
Stats• 15 million people in the US have Asthma• 15-20% of kids, 6-8% of adults• Most kids out-grow it• Most asthma deaths occur in July – 11 die
per year• 11% of college athletes have EIA
Anatomy• Airway divided 17 times
• Right Lung - 3 lobes, 10 segments
• Left lung - 2 lobes, 8 segments
Breathing & Wheezing• Inhalation
– Ribs expand creating a (-) pressure– Airways are “pulled open”
• Exhalation– Allowed to collapse– In asthmatics – air is trapped d/t obstructions
• Air forced past obstruction making noise– Wheeze – occurs mainly during expiration– Stridor – occurs with inspiration in upper
airways– Rales, Crackles – occurs with inspiration
Asthma -Pathophysiology• Airway hyper-responsiveness & reactivity
(bronchospasm)• Airway inflammation –mucus thickening &
lining swelling (from release of chemicals)
• Response to a variety of triggers• Muscle contraction decr. Lumen size, this
air can’t exit lungs
Asthma - Pathophysiology• In everybody – during 1st few minutes of
exercise, bronchodilation occurs.
• In asthmatics – after ~ 10 minutes of activity, their bronchioles return to baseline and can progress through bronchoconstriction, peaking ~ 5-10 minutes after stopping activity.
• In asthmatics, problem is with exhalation, thus they can’t get rid of CO2 – become acidic
• The bronchioles usually return to normal over 20-40 minutes after activity, but can take up to a few hours.
Exercise Induced Brochospasm• Two Theories:
– A. Water-lose Theory• With exercise, ↓nasal breathing, thus ↓ moisture, Δ
osmolarity, Δ pH & temp
• Causes mediator release from Mast Cell (histamines, leukotriene, prosteglandin).
• Leads to broncioconstriction
– B. Heat-exchange Theory• AFTER exercise stops, bronchial vascular dilation
and engorgement occurs to re-warm the epithelium
• Thus ↑ blood flow to area causes narrowing of airways
• Can also leak, leading to mediator release, thus bronchoconstriction
Asthma - Diagnosis• S/S:
• Exposure to triggers (Next slide)
• Family Hx – relationship to other diseases
• Pulmonary Function Tests (PFTs)• Peak Flow testing/monitoring• FEVs• Spirometry
• Response to Tx
Asthma – Common Triggers• Cold air/dry air
• Allergens
• Irritants – smog, smoke, drugs
• Stress – emotional/physical
• Laughing
• Infections
• Exercise
Exercise-Induced Bronchospasm• Exercise induced “asthma”
• Symptoms ONLY seen with exercise• Frequently missed (out of shape, youth)• Suspect in patients with:
• SOB• Exercise intolerance• Cough after exercise up to an hour
• Occurs when?– 5-10 minutes after exercise starts– Gradual onset– Gets worse after exercise– s/s resolve 15-60 mins after exercise stops
EIA• A decrease of ≥10% in peak flow
expiratory flow rate after exercise confirms a diagnosis of EIA.
• History:– 1. Atopy – Eczema & food allergies– 2. Underlying lung diseases– 3. Fhx of asthma or atopy, premature
baby– 4. Peak Flow chart: Age, Sex, Height
Peak Flow Meters• Portable – should have in your kit
• Designated “zones” –compared to baseline/charts
• GREEN – 80% - 100%• YELLOW – 50% - 80%• RED – less than 50%
• Blow as hard and fast as possible– Can cheat the system
• Establish baseline and then test often. (80%) of function to participate.
Formal PFTs• Pulmonary Function Tests
• Computerized
• Graph Data
Asthma - Treatment• Prevention:
• Know their triggers• Remove triggers• Inhibit inflammation cells that contribute to
reactivity &swelling• Monitor: Zones – PLAN for each zone, may
have different meds for each zone
• Medication treatments: – Goal: either decrease inflammation or reduced
bronchospasm
Treatments: Inhalers• Meter Dose Inhalers (MDI):
• “puffers” - beta-2-adrenergic agonist• Most commonly albuterol• Use 2 hrs prior to exercise• ALWAYs use with a spacer• 2 puffs – wait 1-2 min between• Breathe in and hold• Proper use is key!
– Timing– Shake canister– Tilt head back
Alburterol/Pirbuterol• Bronchodilator – typical RESCUE MEDS
– Works on spasm (B2 – antagionist)– Steroids work on mucus production
• Side Effects:
• Onset of Action: Minutes, peaks @ 20min• Duration of Action: 2-6 hours• Should mainly be used as rescue
medication• Have with them at ALL times• Allowable by USOC (c note) and NCAA• Albuterol will NOT work if on a beta-
blocker
Dry Powder Inhalers - DPI• Chronic/Daily therapy
• Inhalation of powder med
• May work just as well as MDI
• Advantages:• No spacer needed• Know when they get it – sweet taste• Only need 1 dose
• Disadvantages:• Some technique required
Salmeterol• Long-acting bronchodilator
• Side-effects: Same
• Onset of action: 20 min, peak @ 3 hours
• Duration of action: 12 hours, BID
• NEVER for an acute attack
Cromolyn• Baseline/preventative medication• Mast cell Stabilizer – prevents the
release of histamine
• Onset of Action: 15 mins
• Duration of Action: 3-5 hours• Role in Exercise: Use with Albuterol
before
• Will not help once an attack has occurred
• No restrictions on use
Leukotriene Modifiers• Leukotrienes: New class of meds
» Turn on slow» Pt needs to take them for 3 weeks to notice
the full affect
• Taken orally/daily, @ night
• Medications prevent chemical formation or binding of receptors
• Works in approx. 50% of patients
• Very safe, can be used during pregnancy. Now OTC
Inhaled Corticosteroids• Baseline meds
• Daily
• Not used in isolated EIB
• Reduced incidence/severity of steroid side effects because it is inhaled
• Oral form is systemic, used in more severe, hard to treat cases, banned by USOC (Avoided as tx)
• Trush – yeast infection
Multimodal Therapy• Patients are on many forms of
medications
• Commonly on a daily preventative plus have rescue inhalers PRN
• New single dose combinations
• Most work better in combination, than individually
Keys to EIB Therapy• Treatment:
• Medication before exercise – know the onset and peaks of the medications
• Daily meds needed if underlying asthma is an issue
• Utilization of “refractory period”
• Self-selection of sports• “Rule of 2s”
ALL That Coughs is not AsthmaDifferential Diagnosis
Other options• Paradoxical Vocal Cord Dysfunction
• Hyperventilation
• Whooping cough
• Anxiety Attack
• Reflux (GERD)
• Upper respiratory infection
• Exercise-induced anaphylaxis
• Lung diseases: • Pneumonia• Lymphoma• Heart failure• Cystic Fibrosis
Vocal Cord Dysfunction (VCD)• Vocal cords close during inspiration
• Triggered by post-nasal drip & reflux
• Can’t get “air in” - Stridor• Will NOT respond to traditional treatments;
meds or refractory period• Part of the issue is psychological –
stress/anxiety• > in women• s/s: stridor, difficulty speaking during
exercise, sudden onset & resolution• Tx: breathing & relaxation techniques
• Counselling, Speech pathology
GERD• Gastroesophageal reflux
• Can make asthma & VCD worse
• s/s:
• Tx:
• Avoid foods prior to exercise & sleep
Upper Respiratory Infection• The common cold – head/sinuses
• s/s:
• Tx:
• Modify activity based on energy level.
• Refer for HIGH fever (101+) and wet, productive cough
Exercised-induced anaphylaxis• Rare – literally allergic to exercise!
• Triggered by exercise
• s/s: hives, upper respiratory obstruction, CV collapse, swelling in hands & face
• Tx: - Epi & 911
Pneumonia• Viral or bacteria
• “Can hear it before you can see it”
• Diagnosis – WBC, auscultations, chest x-ray
• Presents with:– 1. deep wet cough or barking cough– 2. fever– 3. Wheezing/crackles
• S/S:
• Tx:
Pulmonary auscultations
Use of stethoscope to identify NORMAL BREATH SOUNDS*Stethoscope placement – 4 quadrants*Abnormal sounds: wheezing, rales, stridor*Pathological breathing patterns: apnea, tachypnea, bradypnea, dyspnea,
hyperventilation & obstructed airway
Summary• Asthma is a diagnosable & treatable
disease• Asthmatics should “know” their disease• Exercise may trigger asthma in
asthmatics, or it may be isolated EIB• The best treatment is prevention• Medicinal treatments MUST be
customized • Other diseases that are life-threatening
may present with a cough• Know what is banned by various athletic
organizations