1. Pharmacological Management In the Athletic Setting
Asthma
Pharmacological
Management
In the
Athletic Setting

2. Exercise Induced Asthma (EIA)
Transient bronchospasm resulting from vigorous physical activity
EIA affects 10-15% of population
70-90% of asthmatics have EIA
40-50% of people with allergies have EIA
16-18% of Olympic Athletes have EIA

3. Clinical Symptoms
EIA occurs after strenuous exercise near 80% maximum capacity for > 6 minutes
Can also occur 4-8 hrs after exercise
Repetitive attacks can cause  severity by strengthening bronchial muscle
Common symptoms
Shortness of breath
Coughing
Chest tightness
Wheezing

4. Pulmonary Function 15-20% fall of forced expiratory volume (FEV1)
> 10% fall of peak expiratory flow rate (PEFR)
Bronchospasm is greatest 3-15 minutes post exercise
Severity: mild, moderate, severe

5. Environmental conditions
Influencing Factors
Type of exercise
Duration of exercise
Intensity of exercise
Environmental conditions
Pulmonary disease
Dietary salt

6. Type of Exercise Activities that cause EIA
Running
Cycling
X-country skiing
Activities less likely to cause EIA
Swimming
Dancing
Gymnastics
Rowing

7. Duration / Intensity of Exercise
Occurs after 5-8 minutes of vigorous exercise
Exercise for longer periods does not increase the chance of bronchospasm
Strenuous defined a >80% maximal heart rate

8. Environmental Conditions
Increased with cold, dry air, pollution, allergens
Decreased with warm / humid air

9. Other Factors
Pre-existing conditions such as asthma, bronchitis, emphysema
Dietary salt
High intake increases symptoms, occurrence
Lower intake decreases symptoms, occurrence

10. Current Theories
Increased ventilation results in water loss from bronchial tree
This results in increased osmolarity of epithelial fluid that causes inflammatory mechanisms (mast cell degranulation)
Inflammatory mediators are released when exposed to allergens
Mouth breathing cools the airways and causes bronchial vascular bed dilation

11. Diagnosis Refer for testing in clinical situation
Must abstain from medications before testing
Beta agonists – 6 hrs.
Leukotriene inhibitors, oral meds.
Have medications to treat bronchospasm after testing

12. Nonpharmacological Rx
Conditioning
Warm up that includes strenuous bouts
Diet (salt intake, 30 mg. lycopene)
Run through
Avoid hyperventilation
Nasal breathing
Cover mouth in cold weather
Avoid strenuous exercise when allergens are high
Choose indoor sports during winter

13. Pharmacological Treatment
Beta agonists
Cromolyn sodium & nedocromil
Leukotriene inhibitors
Theophylline
Steroids
Ipratropium Bromide
Ca++ channel blockers

14. Beta 2 Agonists Taken 15 minutes prior to exercise
Relax smooth bronchial muscle
If more than 1/month is needed – other medications needed for better control
Side effects: tachycardia, tremors, headache
Inhaled forms more popular
Prohibited by IOC without documented tests, Hx. of use

15. Albuterol / Salbutamol / Terbutaline
Commonly prescribed
Short acting
Long duration
Salmeterol
Long acting, helps with latent phase EIA
Commonly used with anti-inflammatories
Metaproterenol
Moderate duration

16. Cromolyn sodium / Nedocromil
Better used as preventative if know exposure to allergens
Inhibits response to cold, dry air
Works in synergy with beta 2 agonists
Safe
Side effects : bad taste or smell

17. Leukotriene Inhibitors
Long control medications
Approved for use after 11 yrs. Old
Convenience of pill vs. inhaler
Zafirlukast (Accolate)
Zileuton (Singulair)

18. Theophylline Dilate bronchial smooth muscle
Increases diaphragm contractility
Anti-inflammatory effects
Long term control
May help with nocturnal symptoms

19. Ipratropium Bromide Anticholergenic Causes bronchodilation
Effective for quick relief of symptoms
Not effective if underlying allergies, asthma
Atrovent

20. Steroids Long term medications
Taken to control persistent asthma, not EIA
Inhaled used 1st - spacer makes delivery more effective
Advair

21. Oral medications are reserved for severe cases of asthma that don’t respond to other therapy
Long term use can suppress cortisol production

22. Banned Substances
Check list frequently as it changes with new medications
Generally
Beta 2 agonists need documentation of testing, hx. of use for IOC, not for NCAA
Clenbuterol is banned

23. Asthma

24. Asthma Etiology Sign and Symptoms
Caused by viral respiratory tract infection, emotional upset, changes in barometric pressure or temperature, exercise, inhalation of noxious odor or exposure to specific allergen
Sign and Symptoms
Spasm of smooth bronchial musculature, edema, inflammation of mucus membrane
Difficulty breathing, may cause hyperventilation resulting in dizziness, coughing, wheezing, shortness of breath and fatigue

25. Asthma - Characteristics
Disease of the respiratory system
Due to:
spasm of bronchial smooth muscles, inflammation of bronchial wall, increase mucous secretion
Stimuli - allergies, colds, viral infections, smoking, psych. stress, exercise
Is not a progressive disease

26. Signs & Symptoms of Asthma Attack
tight chest
wheezing
coughing
rapid, shallow breathing
anxiety
tachycardia
pale color
lack of endurance

27. Exercise Induced Asthma
Onset of S/S w/in 30 min. post exercise
Prevention of symptoms
know environmental conditions
warm-up gradually & cool down
use a bronchodilator

28. Exercise Induced Asthma
15% decrease in peak expiratory rate is diagnostic
10-20% of general population, 90% with asthma
Episode usually occurs after 5-10 minutes
May be caused by water and heat loss from airways from mouth breathing and increased respiration rate
Also consider:
Type of exercise
Environmental factors
Preexisting inflammation
Intensity of exercise

29. Treatment for Asthma Attack
Calm the patient
Controlled breathing
Drink water
Medications
Bronchodilators
Corticosteroids
Leukotriene Receptor Antagonists

30. Refractory Period Occurs after an asthmatic episode
Time during which additional exercise doesn’t cause bronchospasm
Lasts 1-4 hours
In some individuals a refractory period can be induced with light exercise and no episode
(ex) run 10 submaximal 100 yard sprints 30 minutes before competition

31. Preventive Measures Avoid cold, dry polluted air
Increase nose breathing
Change sports
Decrease intensity
Regular exercise, appropriate warm-up and cool down, w/ intensity graduated
Exercise in warm, humid environment
Exercise during refractory period

32. Monitoring Asthma
Peak expiratory flow rate can be measured with a hand-held peak flow meter to allow self monitoring
Take before and after bronchiodilator therapy to check effectiveness of Rx
ATC may consider keeping one in kit with disposable mouth pieces

33. Medications 5-10% of asthma symptoms are worsened by NSAIDS
Controller medications
To prevent Sx
(ex) Long acting beta agonist – Salmeterol
Reliever medications
2-4 puffs just before exposure or as Sx present
(ex) Short acting agonist – Albuterol
Cause dilation of smooth muscles around lung and inhibits release of chemicals that cause inflammation
Usually inhaled, but also oral
(ex) Mast cell stabilizers
Prevent release of contents of mast cells –therefore prevent inflammation and brochoconstriction

34. Medications - Bronchodilators
Stimulate Beta2 receptors - causes dilation of bronchials
Decrease smooth muscle spasm
For an acute asthma attack
**Long term / excessive use causes hyper- responsiveness

35. Bronchodilators - Examples
Administration - Inhalation
(Albuterol) Proventil
(Piributerol) MaxAir
(Salmeterol) Serevent
(Epinephrine) Primatene Mist
(Theophylline) TheoDur, SlowBid
decrease release of prostaglandins
Side effects - nausea, mental confusion, irritability, restlessness

36. Medications - Corticosteroids
Use prophylactically before asthma attack to decrease release of prostaglandins, decrease responsiveness of smooth muscles in airways
Has no effect on an acute attack

37. Corticosteroids - Examples
Administration - Inhalation, Ingestion
(Dexamethasone) Decadron
(Cromolyn) Intal, NasalCrom
Azmacort
Tilade
Vanceril
Flonase – allergy corticosteroid

38. Medications - Leukotriene Receptor Antagonists
Prevents spasm and swelling within the bronchial smooth muscles
Leukotrienes cause constriction of airways & promote mucous secretions
Examples
Singulair
Accolate

39. Role of the ATC Recognize decreased performance caused by EIA
Measure peak flows and refer if indicated
Monitor efficacy of Rx by tracking Sx and tracking peak flows
Educate on proper inhaler use

40. Proper use of an inhaler

41. Diabetes

42. What is diabetes?
A disease which involves the production or function of insulin
Normal blood sugar level = mg/100 ml blood

43. Diabetes - Types Type II, Non-Insulin Dependent, Adult Onset
90% of all cases
Predisposing factor – obesity, heredity
Pancreas still produces insulin
Symptoms usually controlled by diet & exercise
Oral Antidiabetic Drugs - stimulates pancreas to produce insulin
Amaryl Glimepiride
Glucophage
Avandia

44. Diabetes - Types Type I, Insulin Dependent, Juvenile Onset
Onset before age 30
Pancreas does not produce insulin
Must take insulin - type & dosage determined by severity & Dr.
Administration
Injection
Implant pumps

45. Effects of exercise on diabetes
Decreases need for insulin

46. Associated Conditions
Diabetic Coma
blood sugar elevated
develops over days
S/S - thirst, difficulty breathing, nausea, vomiting, mental confusion, loss of consciousness
Ketoacidosis
Rx. - call 911, insulin

47. Associated Conditions
Insulin Shock (Hypoglycemia)
blood sugar level too low
develops rapidly
S/S - physical weakness, moist pale skin, headache, tachycardia, fatigue, hunger, anxiety
Rx. - eat sugar, candy, fruit juice, crackers,
Prevention - eat before practice

48. Diabetes Mellitus
1997 report by The Expert Committee on Diagnostic and Classification of Diabetes Mellitus
Defined diabetes, “a group of metabolic disorders characterized by hyperglycemia resulting from insulin secretion, insulin action or both and is associated with damage and failure of various organs, especially the eyes, kidney, nerves, heart, and blood vessels.”

49. Glucagon vs Insulin

50. Criteria for Diabetes 2 fasting blood glucose levels > 126mg/dL or
2 random draws > 200mg/dL
Normal blood glucose level varies between mg/dL

51. Type I Diabetes “juvenile onset” or “insulin dependent”
Results from destruction of pancreatic beta cells which make insulin; thus, insulin is not produced
< 30 yo
Sudden onset
Frequent urination, constant thirst, weight loss, constant hunger, tiredness, weakness, itchy dry skin and blurred vision
Insulin injections required to control
If not controlled ketoacidosis occurs

52. Treatment for Type I Diabetes
Complications are reduced by 76% if managed
Recommendations for Treatment
Self monitoring of blood glucose 4x/day
Use insulin pump or shots 3x/day
Adjust insulin dose based on glucose level
Anticipate and plan dietary intake and exercise

53. Type II Diabetes “Adult-onset” or “Non-insulin dependent”
Caused by insulin resistance
Also may see a decrease in insulin production
>40 yo
Controlled with diet, exercise, weight loss, and/ or oral medication
Not associated with ketoacidosis

54. Diabetic Coma Etiology Sign and Symptoms Management
Loss of sodium, potassium and ketone bodies through excessive urination (ketoacidosis)
Extreme hyperglycemia
Sign and Symptoms
Labored breathing, fruity smelling breath (due to acetone), nausea, vomiting, thirst, dry mucous membranes, flushed skin, mental confusion or unconsciousness followed by coma.
Management
Early detection is critical as this is a life-threatening condition
Insulin injections may help to prevent coma

55. Insulin Shock Etiology Sign and Symptoms Management
Occurs when the body has too much insulin and too little blood sugar
Hypoglycemia
Sign and Symptoms
Tingling in mouth, hands, or other parts of the body, physical weakness, headaches, abdominal pain
Normal or shallow respiration, rapid heart rate, tremors along with irritability and drowsiness
Management
Adhere to a carefully planned diet including snacks before exercise

56. Guidelines for Pre-exercise Caloric Intake Based on Blood Glucose Levels
Eat when < 80mg/dL
Eat a high complex CHO snack before exercise before exercise if < 100mg/dL
Exercise if 100 – 250mg/dL
Exercise > 1 hour, then eat 15g of CHO and drink 250 mL every min
>250mg/mL check urine for ketones
If ketones present or if >300mg/dL, then cancel exercise and adjust insulin
**Sports Drinks?