When an athlete can’t catch his breath
A patient who’s fine during practice but runs out of breath before the game’s over may have exercise-induced bronchoconstriction. This practical guide can help.
Cromolyn, antileukotrienes are options, too
Mast cell stabilizers (cromolyn) can be used with β2 agonists as prophylactic therapy. When these agents are used together, they have an additive effect.13 The athlete may take them 10 minutes to an hour before exercise. Make sure your patient knows that mast cell stabilizers cannot be used as a rescue inhaler or bronchodilator.
Inhaled corticosteroids (flunisolide, fluticasone, others) may be needed for athletes with poorly controlled chronic asthma; they can also be used as adjunct preventive treatment for athletes who have EIB with no underlying chronic asthma.14-16 Often, inhaled corticosteroids are used as combination therapy with a LABA or an antileukotriene agent (montelukast, zafirlukast; see below). Recent research shows that montelukast in combination with inhaled corticosteroids is more efficacious than LABA with inhaled corticosteroids.14,17
Antileukotriene agents can be especially helpful for EIB in patients with mild, stable asthma.18 Patients who do respond to antileukotriene agents usually respond very favorably. Antileukotrienes offer a reasonable alternative to inhaled corticosteroids and LABAs. They have a low side-effect profile and should be considered as daily prophylaxis.19,20 The effects of montelukast are evident as early as 2 hours after administration, and bronchoprotective effects can last as long as 24 hours.21,22 For that reason, montelukast is especially useful in children whose exercise patterns are not always predictable.
Be prepared for acute exacerbations. Prophylactic medication does not always prevent acute exacerbations. When that happens, your EIB patient will need to use a β2 agonist as rescue therapy. Make sure your patient knows that none of the other medications are effective bronchodilators in acute exacerbations.
Remember, too, that EIB cannot be effectively treated if the athlete has poorly controlled chronic asthma. Underlying causes of asthma exacerbations like allergies or respiratory infections must be addressed and stabilized first, following guidelines of the National Asthma Education and Prevention Program (NAEPP).9 You can access the guidelines at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
These tips can help the athlete
Encourage athletes with EIB to keep up their exercise routines, because cardiovascular fitness has a beneficial effect on this condition. Fit individuals breathe more slowly, which reduces the likelihood of exacerbations. Of note, though: Certain sports are easier on patients with EIB. Patients may want to keep this in mind when deciding which team they want to go out for. Specifically, indoor sports, where air temperature, humidity, and exposure to allergens are controlled, and sports like baseball, sprinting, or football, which require less prolonged aerobic endurance, are good options.
Tell athletes whose sports require cold, dry conditions—ice skating, or skiing, for instance—to try breathing through a scarf or mask to keep inspired air warm and less irritating.
And tell all athletes with EIB to warm up properly before they start to compete.23 That means a 15-minute warm-up at moderate exertion, followed by a 15- to 30-minute rest period. The rest period is the time to take their medication.
When therapy fails
When an EIB patient fails to respond despite multiple drug therapy, it’s time to reconsider other diagnoses, such as vocal cord dysfunction and severe GERD, which may mimic symptoms of EIB.
On the horizon. Other therapies for possible treatment of EIB are being studied. These include omega-3 fatty acid dietary supplementation and inhaled enoxaparin.24,25 Data are currently insufficient to recommend use of these agents in clinical practice.
As for Luke, indirect testing via exercise challenge was positive for EIB. Adjunctive therapy with montelukast was added to his albuterol inhaler, and the combination has worked well for him. He’s still playing basketball, and enjoying it.
Acknowledgments
The authors thank Ken Rundell, PhD, for reviewing this article. Dr. Rundell is director of the Human Physiology Laboratory at the Keith J. O’Neill Center of Marywood University, Scranton, Pa.
CORRESPONDENCE
Michael A. Krafczyk, MD, FAAFP, St. Luke’s Sports Medicine, 153 Brodhead Rd, Bethlehem, PA 18017; krafczm@slhn.org
