Benefits of Swimming Umair Falak patient 16 year
Benefits of Swimming Umair Falak
patient • 16 year old • National swimming championship • Viral infection/cold in nov 2018 cough • Breathless only while training , rarely felt wheezy , dry cough • At times after running • Strong chlorine in the pool • SABA pre exercise some effect not always
• Fe. NO 18 PPB • Eosinophil not raised ( 0. 17) • Started on Clenil modulite 100 mcg 1 puff inh bd • Exercise challenge test • ECHO • Physiotherapist review
Things in the differential • Exercise induced Asthma /Bronchoconstriction (EIA/EIB) • Inducible Laryngeal Obstruction –Can get an idea during exercise challenge • Dysfunctional breathing Pattern Disorder • Cardiac condition- cardiac monitoring during exercise challenge • Obesity • Lack of fitness –deconditioning
Exercise challenge test • 95% recovery in FEV 1 by 30 -90 minutes after exercise • FEV 1 is measured serially at intervals after exercise • Usually at 5 , 10 , 15 & 30 minutes after exercise (ATS guidelines) • 10% or more fall in FEV 1 is used as cutoff (ATS) • Two occasions if trying to exclude EIA on it’s basis
Pathogenesis-Two theories Hyperventilation during exercise Cooling of airways vasodilation Airway edema Dryness of airways Osmotic changes Inflammatory cascade
Eucapnic Hyperventilation test • Being labelled as the TEST OF Choice • Mimics exercise • Endorsed by the International Olympic committee • A mixture of ( 21 % oxygen , 5% CO 2 , 74% nitrogen) for 6 minutes at a higher ventilatory rate • Spirometry at regular intervals • Fall of 10% in FEV 1 afterwards
Bronchoprovocative tests • Methacholine • Histamine • Mannitol • Cold air • If they are positive indicative of asthma ( Broncho hyperresponsiveness) • Many childhood asthmatics go into remission but BHR persists
Provoking factors • Chlorination of the pools associated with Asthma • Cold Air • Pollutants • Pesticides & fertilisers • Paint Bernard A, Nickmilder M, Voisin C. Outdoor swimming pools and the risks of asthma and allergies during adolescence. Eur Respir J 2008; 32(4): 979 -88 Bernard A, Carbonnelle S, de Burbure C, Michel O, Nickmilder M. Chlorinated pool attendance, atopy, and the risk of asthma during childhood. Environ Health Perspect 2006; 114(10): 1567 -73
Prevention – regular long term • Inhaled Corticosteriod • Monteleukast ( 10 % less drop in FEV 1 ) has a 24 hour action , no tolerance • LABA – tolerance effect lessens if used regularly • Budesonide-formoterol-SMART regimen , use before exercise (GINA) Lazarinis N, Jørgensen L, Ekström T, Bjermer L, Dahlén B, Pullerits T, Hedlin G, et al. Combination of budesonide/formoterol on demand improves asthma control by reducing exercise-induced bronchoconstriction. Thorax 2014; 69: 130 -6.
Prevention-before exercise • Treat the underlying Asthma most important • Mask if exercising in the cold (ATS) • warm up exercise ( systemic review) (ATS & GINA) • SABA 15 -20 minutes before the exercise (BTS) • Mast cell stabiliser before exercise ( Systemic review – 15 % less Drop in FEV 1 ) (ATS & GINA) • Monteleukast 2 hours prior to exercise (ATS) • Anticholinergic before exercise ( weak evidence-ATS)
Summary • Expression of poor asthma control • Athletes will have supranormal(high) lung volumes and flow loops , less correlation between symptoms and pulmonary function • High chance of tolerance with regular LABA use , might want to minimise use • No tolerance with monteleukast Parsons JP, Hallstrand TS, Mastronarde JG, Kaminsky DA, Rundell KW, Hull JH, Storms WW, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013; 187: 1016 -27.
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