Adolescents and Exercise Induced Asthma

More than 10 million school days a year are missed by students who have asthma (Sapien, Fullerton-Gleason, B. Allen, 2004). This disease is more prevalent in children than it is in adults. It is the only chronic disease, besides AIDS and tuberculosis, with an increasing death rate (Asthma and Allergy Foundation of America, 2005). Whether in the classroom, gymnasium, or on the field, coaches and physical educators need the knowledge and skills to help prevent and handle an asthma attack.

This article defines asthma and focuses on exercise induced asthma (EIA); provides information on the triggers, signs, symptoms, and treatments for these conditions; and presents guidelines on how to handle an asthma attack in the physical education classroom or on the athletic field.

Definition of Asthma and Exercise Induced Asthma

Asthma is a disease that is characterized by narrowing of the airways of the lower respiratory system. Inflammation of the airways, constriction of bronchial airways, and increased mucous production causes airway obstruction, which leads to difficulty breathing - a major symptom of asthma (Merck Manual of Medical Information, 2003). EIA is a reversible airway obstruction that occurs during or after physical activity (Lacroix, 1999). EIA occurs in 90 percent of people with asthma or in healthy individuals who do not have chronic asthma (Lacroix, 1999).

Typically, when a child or adolescent starts physical activity, their airways expand. This allows for extra air exchange to meet the increased oxygen needs while playing a game or performing a drill. However, when someone has EIA the initial airway opening is diminished, and about 6-8 minutes into activity the individual begins to notice the airways closing.

An interesting phenomenon associated with asthma attacks is the "second wave" (American Lung Association, 2005). Sometimes the symptoms of an asthma episode will start to get better and then progressively get worse again. This can trigger an asthmatic episode as the airways become even more sensitive to irritants. This "second wave" can last from a few hours up to several days and may require medical attention.

Triggers, Signs, and Symptoms of Asthma

Triggers of asthma can be divided into two different groups: extrinsic and intrinsic (Starkey R Ryan, 2002). Extrinsic asthma can be caused by various reasons, such as upper-respiratory infections, allergens (e.g., pollen and dust), food or drug allergies, stress, anxiety, and irritants (e.g., tobacco smoke and cold air).

Intrinsic asthma, on the other hand, is caused by factors not related to allergies. Exercise is one type of intrinsic trigger, which in most cases, is the main reason for EIA. However, other factors, such as cold and dry weather, intense activity, or other predisposing conditions (i.e., asthma or infections) can contribute to the onset of EIA.

Signs and symptoms of an asthma attack may vary. Usually an attack begins acutely with wheezing, coughing, and shortness of breath or with slowly increasing signs of respiratory distress; however, itching over the anterior neck or upper chest may be an early symptom. Dry cough, particularly at night and during exercise, maybe the only presenting symptom, especially in children. An asthmatic usually first notices a cough, shortness of breath, and tightness or pressure in the chest and may hear wheezing. The cough during an acute attack sounds “tight” and generally does not produce mucus. EIA symptoms usually begin about 5-20 minutes after starting exercise. The symptoms usually peak about 5-10 minutes after stopping exercise, and then gradually diminish. The symptoms are often gone within an hour, but they may last longer.

Table 1. Signs/Symptoms and Triggers (Merck Manual, 2003)
Condition	Signs and Symptoms	Triggers
Asthma	• Wheezing • Coughing • Tightness or pressure in the chest • Shortness of breath • Fatigue or severe distress • Bluish discoloration of skin or mucous membranes	• Upper resiratory infections • Allergens (e.g. dust) • Emotionally upset (e.g. stress.anxiety) Irritants (e.g. smoke, cold air) • Exercise
Exercise Induced Asthma	• Wheezing • Coughing • Tightness or pressure in the chest • Shortness of breath • Fatigue or severe distress • Bluish discoloration of skin or mucous membranes • Stomach ache • Nausea	• Exercise (especially highly intense activities such as basketball, cycling, long-distance running, and soccer) • Cold aid

 

Physiological Causes of EIA

There are two theories about how exercise-induced asthma is triggered: the Water Loss Theory and the Heat Exchange Theory (Lacroix, 1999). The Water Loss Theory involves the amount of water loss in the tissue of the bronchi. Air is normally inspired through the nose, passes through the sinuses and down the trachea into the lungs. This allows for the air to be warmed and moisture to be added to the air. During intense physical activity, inspiration usually tends to occur through the mouth, instead of the nose. This does not allow the air to be sufficiently moisturized, causing dry air to irritate the lungs.

The second theory is called Heat Exchange Theory (Lacroix, 1999). It states that when the body starts inspiring air faster, the tissue of the lower airways cools down. The body then tries to warm up the airways with warm blood. The increased flow of blood through the blood vessels causes a decrease in space within the airways for air to flow. This may eventually lead to difficulty in breathing for an individual performing physical activity.

Sport and EIA

In regard to EIA, sports have been grouped into two categories. Category one consists of activities that are higher likely to cause EIA. Category two contains activities that are occasionally going to cause EIA. The highly asthmogenic (asthma causing) activities include basketball, cycling, long distance running, and soccer. Cross country skiing, ice hockey and speed skating are also highly asthmogenic activities, due to the fact that these activities usually occur in environments with cool, dry air. The mildly asthmogenic activities include baseball, football, golf, martial arts, sprinting, swimming, tennis, volleyball, weight lifting, and wrestling (Lacroix, 1999).

Most children and adolescents who are diagnosed with EIA are under the care of a physician who has prescribed needed medication. It is important to understand which activities are more prone to bring on an asthma attack. However, with regular exercise and proper treatment, EIA can be controlled very effectively. In fact, 20-30 minutes of exercise at 60-85 percent of the patient's maximum heart rate is advised. Regular activity can also help improve fitness which, may also lead to decreased medication use and reduced airway reactivity (Disabella & Sherrman, 1998). Regular and vigorous exercise in children may reduce absences from school, decrease the amount of days spent in the hospital, and reduce the incidence of asthma attacks overall (Kendrick, 2000). Many elite athletes actually continue to compete regardless of their asthma. A survey by the American Academy of Allergy, Asthma and Immunology (2003) showed that nearly one out of six U.S. Olympians at the 1996 Olympics had asthma, and nearly 30 percent of the athletes who reported having asthma won an individual or team medal.

Preventing and Minimizing EIA

For children and adolescents diagnosed with EIA who participate in sport and exercise during school, certain safety precautions should be taken. Environmental conditions must be considered when deciding on appropriate precautionary measures. The parents and students should know the day's activities beforehand, so that medication can be taken at appropriate times.

As stated earlier, EIA is induced by inhalation of dry cold air, so warming and humidifying inhaled air should decrease the symptoms of EIA. This can be accomplished by wearing a muffler or taking part in exercises that are performed in a warm and humid environment, such as an indoor swimming pool. A proper warm-up prior to exercise has been shown in some cases to decrease the symptoms of EIA and reduce the need for repeated medications (Spector, 1993). The National Asthma Education and Prevention Program (NAEPP) recommends 6-10 minutes of slow warm-up activities at a low level of activity before exercise and to avoid high intensity exercises for the first 10-15 minutes of exercise. It is further suggested that persons prone to EIA should cool down following exercise for 10-30 minutes by walking, stretching, or performing light calisthenics (Kumar 8 Busse, 1996).

Table 2. Sports Activities and EIA (Lacrois, 1999)
Type of Activity	Example of activity
Highly Asthmogenic Activities	Basketball Cycling Long-distance running Soccer
Activities involving cold, dry air	Corss-country skiing Ice hockey Speed Skating
Mildly Asthmogenic Activities	Baseball Football Golf Swimming Volleyball Weightlifting Wrestling

 

Guidelines for Handling an EIA Episode

If an EIA episode does occur, teachers and coaches should follow the student's asthma action or management plan (National lnstitutes of Health, 1995). This is a written plan that tells people with asthma, or those who care for them, how to treat symptoms. It includes what to do daily to prevent symptoms and also what to do if symptoms are present. This action plan should be devised by appropriate school officials for the possible occurrence of EIA during participation in sports or exercise, and the plan should be discussed with the parents, student, teacher, coach, nurse, and family physician. When used properly, the plan can help control asthma.

If a student or athlete is going to participate in physical activity, teachers and coaches need to know if the student's treatment plan requires pre-medication (National institutes of Health, 1995). They also need to be familiar with the warning signs and symptoms for asthma, but also encourage students with EIA to participate actively in sports, recognizing and respecting their limits. Teachers and coaches should permit less strenuous activities if a recent illness or an EIA episode precludes full participation, and refer questions about a student's ability to fully participate in physical activities to the parents or the school nurse.

Figure 1
Actions to take in the event of an asthma attack are as follows (National Institutes of Health, 1995)
Stop the student's current activity Follow the student's asthma action/management plan help the student use his or her inhaled medication Observe for effects Seek emergency medical attention if the student fails to improve Syptoms listed on the student's asthma plan as emergency indicators are present (may include): Student is hunched over, with shoulders lifted, and straining to breath Student has difficulty completing a sentence without pausing for a breathe Student's lips or fingernails turn blue Report to appropriate individulas (as stated in emergency action plan)

 

Conclusion

Asthma and exercise-induced asthma are serious conditions. Although EIA affects an individual's ability to perform physically demanding activity; with proper diagnosis, treatment and a management plan, sport and exercise can be rewarding and fun. The young athlete and their caregivers need to work together to control EIA. When an EIA episode does occur, proper steps need to be followed to minimize the episode and ensure the individual's health. EIA no longer has to limit children and adolescents from the enjoyment of sport and exercise.

For additional information regarding EIA, visit:

CDC: Centers for Disease Control and Prevention http://www.cdc.gov/asthma/NACP.htm#children

American Academy for Allergy, Asthma and Immunology http://www.aaaai.org/patients/gallery/childhoodasthma.asp

Schoolasthmaallergy.com http://www.schoolasthmaallergy.com/

References

American Academy of Allergy, Asthma and lmmunology (2003). Tips to Remember: Exercise-induced asthma. Retrieved November 1, 2005 from http://www.aaaai.org/patients/publicedmat/tips/exerciseinducedasthma.stm.

American Lung Association. (2005, July). Asthma Attacks. Retrieved November 1, 2005, from http://www.lungusa.org/site/pp.asp?c=dvLUK900EBb=22583.

Asthma and Allergy Foundation of America. (2005). Asthma Facts and figures. Retrieved November 1, 2005 from http://www.aafa.org.

Disabella, V. 8, Sherman , C. (1998). Exercise for asthma patients; little risk, big rewards. The Physician and Sportsmedicine, 26(6), 85.

Kendrick, Z. (2000). Decreasing activity limits for asthma patients. The Physician and Sportsmedicine, 28(10), 75.

Kumar, A. &, Busse, W. (1996). Patient education: Explaining exercise-induced asthma. Journal of Respiratory Disease, 17, 158-160.

Lacroix, V.J. (1999). Exercise induced asthma. The Physician and Sports Medicine, 27, 75-8 7.

Merck Manual of Medical Information (2 nd home ed). (2003). Whitehouse Station, NJ: Merck Research Laboratories.

National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). Practical guide for the diagnosis and management of asthma. Bethesda (MD): US Dept of Health and Human Services, Public Health Service, National Institutes of Health; 1997.

National Institutes of Health, (1995). Asthma and physical activity in the school: Making a difference. Retrieved November 1, 2005 from http://www.schoolasthmaalergy.com.

Sapien, R. E., Fullerton-Gleason, L., 8, Allen, N. (2004). Teaching school teachers to recognize respiratory distress in asthmatic children. Journal ofAsthma, 41 (7), 739-734.

Spector, S. (1993). Update on exercise-induced asthma. Annals of Allergy, 71, 5 71 -5 85.

Starkey, C. & , Ryan, J. (2002). Evaluation of orthopedic and athletic injuries. Philadelphia : F.A. Davis Co.

Text box sources

1. CDC: Centers for Disease Control and Prevention http://www.cdc.gov/asthma/NACP.htm#children

2. American Academy for Allergy, Asthma and immunology http://www.aaaai.org/patients/gallery/childhoodasthma.asp

3. Schoolasthmaallergy.com http://www.schoolasthmaallergy.com/

Pamela Hansen is an associate professor in the Department of Health, Nutrition and Exercise at North Dakota State University. Former graduate students Shanna Bicknase, Kyle VanSickle, and Mike Bogenreif helped co-author this article.

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Title	Adolescents and Exercise Induced Asthma
Source	Strategies (Reston, Va.)
Authors	Hansen, Pamela; Bicknase, Shanna; VanSickle, Kyle; Bogenreif, Mike
Vol (iss)	21(5)
Date	May/June 2008
Pages	9-12
SIRC ID #	S-1078545

 

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