Approach Considerations
The optimal treatment for EIA is to prevent the onset of symptoms. After controlling the patient's underlying and contributing factors (eg, respiratory infection, allergy, allergic asthma), a combination of drugs can be used to prevent EIA. [1] The basis of treatment is with preexercise short-acting β2 -agonist administration. [1] A role also exists for long-acting β2 -agonists and mast cell stabilizers. Antileukotriene drugs have been shown to be effective as well (see Medications). [8, 9]
Although rare, as with any asthma attack, progression of exercise-induced asthma (EIA) can result in status asthmaticus and even death. Treatment for this condition should be provided immediately and the situation taken seriously.
Go to Asthma, Pediatric Asthma, Exercise-Induced Anaphylaxis, Angioedema, and Urticaria for more information on these topics.
Treatment of the athlete who is experiencing an acute attack of EIA is the same as in any asthma attack situation and includes immediately removing the patient from competition or play.
Provide immediate administration of a rapid onset, short-acting β2 -agonist (eg, albuterol); this has the highest therapeutic yield. The usual dose is 2 puffs of albuterol via a metered dose inhaler (MDI). If the patient's response is not satisfactory, transportation to an emergency facility should be initiated, because the EIA attack may escalate. If available, the use of a spacer device can help to transport the medication to the area of greatest need, especially when an athlete is distracted in the midst of competition or anxious from dyspnea and unable to concentrate.
If the initial response to treatment was adequate, patient observation and monitoring need to continue for several hours in case of a relapse. If mild, residual symptoms persist in the patient after relief of the acute symptoms, a repeat administration of albuterol is advisable; the recommended dosing interval is 4 hours.
If the initial treatment fails or is unavailable, or if patient relapse is immediate, immediate transfer of the patient to an acute care facility should occur. Subcutaneous epinephrine can be administered in such life-threatening situations.
On the playing field, consultation is rarely available and is not needed in the acute EIA attack; however, access to the emergency medical system should be readily available.
Nonpharmacologic Measures
Sports selection and altering breathing and/or warm-up techniques are measures can also be taken in the treatment of EIA.
Sports selection can be helpful in guiding an athlete toward the performance of sports in environments that are less likely to cause bronchospasm. In addition, if the athlete has a choice, he or she can choose a time or place to exercise where the air is warmer and the humidity is higher. Likewise, a flexible athlete can change sports to be more active in these sorts of environments (eg, changing from running to swimming automatically increases the humidity of the environment). As indicated in Pathophysiology above, focusing on sports with less prolonged aerobic demands (eg, sprinting, weight lifting, baseball, football) is better tolerated by affected athletes.
An example of altering breathing techniques is changing from predominant mouth breathing to nasal breathing, which can result in less bronchospasm with the performance of an activity, because the inhaled air is both warmed and humidified.
The coordination and timing of competition with medication use can also maximize exercise performance with regard to bronchospasm. To minimize the likelihood of bronchospasms, the athlete can time the warm-up so that the competition coincides with a refractory phase (see Phases of EIA above). This is most likely to occur by initiating a 15-30 minute warm-up, followed by a 15-minute rest period, at which time the medication is administered. This entire period should be timed to result in commencement of the competition 15-30 minutes after medication administration.
Return to Play
The severity of an EIA attack varies greatly. Although cases of respiratory arrest and even death have been reported, the usual scenario is of a mild respiratory difficulty during play, which either spontaneously resolves or immediately responds to inhaled albuterol. Oftentimes, the athlete self-medicates and never leaves play or alerts the trainer or doctor.
Although no clear-cut guidelines exist, a player who is removed from play for an asthma attack should be kept out of play until his or her respiration has normalized. This should occur within 5-10 minutes of medication administration. The athlete should be monitored closely for signs of relapse over the next several hours. If the symptoms do not completely resolve with sideline medication, the athlete should not return to play and should be referred for further treatment. Depending on the severity of the patient's symptoms, this may require transportation via ambulance.
-
Pathogenesis of asthma. Antigen presentation by the dendritic cell with the lymphocyte and cytokine response leading to airway inflammation and asthma symptoms.
