Transcript Asthma - The SC EBS

Asthma
Pharmacological
Management
In the
Athletic Setting
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
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
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Shortness of breath
Coughing
Chest tightness
Wheezing
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
Influencing Factors
Type of exercise
Duration of exercise
Intensity of exercise
Environmental conditions
Pulmonary disease
Dietary salt
Type of Exercise
 Activities that cause EIA
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Running
Cycling
X-country skiing
 Activities less likely to cause EIA
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Swimming
Dancing
Gymnastics
Rowing
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
Environmental Conditions
 Increased with cold, dry air, pollution,
allergens
 Decreased with warm / humid air
Other Factors
 Pre-existing conditions such as asthma,
bronchitis, emphysema
 Dietary salt
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High intake increases symptoms,
occurrence
Lower intake decreases symptoms,
occurrence
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
Diagnosis
 Refer for testing in clinical situation
 Must abstain from medications before
testing
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Beta agonists – 6 hrs.
Leukotriene inhibitors, oral meds.
 Have medications to treat bronchospasm
after testing
Nonpharmacological Rx
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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
Pharmacological Treatment
Beta agonists
Cromolyn sodium & nedocromil
Leukotriene inhibitors
Theophylline
Steroids
Ipratropium Bromide
Ca++ channel blockers
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
 Albuterol / Salbutamol / Terbutaline
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Commonly prescribed
Short acting
Long duration
 Salmeterol
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Long acting, helps with latent phase EIA
Commonly used with anti-inflammatories
 Metaproterenol
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Moderate duration
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
Leukotriene Inhibitors
 Long control medications
 Approved for use after 11 yrs. Old
 Convenience of pill vs. inhaler
 Zafirlukast (Accolate)
 Zileuton (Singulair)
Theophylline
 Dilate bronchial smooth muscle
 Increases diaphragm contractility
 Anti-inflammatory effects
 Long term control
 May help with nocturnal symptoms
Ipratropium Bromide
 Anticholergenic
 Causes bronchodilation
 Effective for quick relief of symptoms
 Not effective if underlying allergies,
asthma
 Atrovent
Steroids
 Long term medications
 Taken to control persistent asthma, not
EIA
 Inhaled used 1st - spacer makes delivery
more effective
 Advair
 Oral medications are reserved for severe
cases of asthma that don’t respond to
other therapy
 Long term use can suppress cortisol
production
Banned Substances
 Check list frequently as it changes with
new medications
 Generally
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Beta 2 agonists need documentation of
testing, hx. of use for IOC, not for NCAA
Clenbuterol is banned
Asthma
Asthma
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Etiology
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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
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Asthma - Characteristics
 Disease of the respiratory system
 Due to:
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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
Signs & Symptoms of
Asthma Attack
 tight chest
 wheezing
 coughing
 rapid, shallow breathing
 anxiety
 tachycardia
 pale color
 lack of endurance
Exercise Induced Asthma
 Onset of S/S w/in 30 min. post exercise
 Prevention of symptoms
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know environmental conditions
warm-up gradually & cool down
use a bronchodilator
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:
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Type of exercise
Environmental factors
Preexisting inflammation
Intensity of exercise
Treatment for Asthma Attack
 Calm the patient
 Controlled breathing
 Drink water
 Medications
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Bronchodilators
Corticosteroids
Leukotriene Receptor Antagonists
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
Preventive Measures
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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
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
Medications
 5-10% of asthma symptoms are worsened by NSAIDS
 Controller medications
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To prevent Sx
(ex) Long acting beta agonist – Salmeterol
 Reliever medications
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2-4 puffs just before exposure or as Sx present
(ex) Short acting agonist – Albuterol
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Cause dilation of smooth muscles around lung and inhibits release
of chemicals that cause inflammation
Usually inhaled, but also oral
(ex) Mast cell stabilizers
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Prevent release of contents of mast cells –therefore prevent
inflammation and brochoconstriction
Medications Bronchodilators
 Stimulate Beta2 receptors - causes
dilation of bronchials
 Decrease smooth muscle spasm
 For an acute asthma attack
**Long term / excessive use causes hyperresponsiveness
Bronchodilators - Examples
 Administration - Inhalation
 (Albuterol) Proventil
 (Piributerol) MaxAir
 (Salmeterol) Serevent
 (Epinephrine) Primatene Mist
 (Theophylline) TheoDur, SlowBid
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decrease release of prostaglandins
 Side effects - nausea, mental confusion,
irritability, restlessness
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
Corticosteroids - Examples
 Administration - Inhalation, Ingestion
 (Dexamethasone) Decadron
 (Cromolyn) Intal, NasalCrom
 Azmacort
 Tilade
 Vanceril
 Flonase – allergy corticosteroid
Medications - Leukotriene
Receptor Antagonists
 Prevents spasm and swelling within the
bronchial smooth muscles
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Leukotrienes cause constriction of airways
& promote mucous secretions
 Examples
 Singulair
 Accolate
Role of the ATC
1. Recognize decreased performance
caused by EIA
2. Measure peak flows and refer if
indicated
3. Monitor efficacy of Rx by tracking Sx
and tracking peak flows
4. Educate on proper inhaler use
Proper use of an inhaler
Diabetes
What is diabetes?
 A disease which involves the production
or function of insulin
 Normal blood sugar level =
80-90mg/100 ml blood
Diabetes - Types
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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
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Amaryl Glimepiride
Glucophage
Avandia
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
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Injection
Implant pumps
Effects of exercise on
diabetes
 Decreases need for insulin
Associated Conditions
 Diabetic Coma
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blood sugar elevated
develops over days
S/S - thirst, difficulty breathing, nausea,
vomiting, mental confusion, loss of
consciousness
Ketoacidosis
Rx. - call 911, insulin
Associated Conditions
 Insulin Shock (Hypoglycemia)
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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
Diabetes Mellitus
 1997 report by The Expert Committee on
Diagnostic and Classification of Diabetes
Mellitus
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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.”
Glucagon vs Insulin
Criteria for Diabetes
 2 fasting blood glucose levels >
126mg/dL or
 2 random draws > 200mg/dL
 Normal blood glucose level varies
between 80-120mg/dL
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
Treatment for Type I Diabetes
 Complications are reduced by 76% if
managed
 Recommendations for Treatment
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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
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
Diabetic Coma
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Etiology
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Sign and Symptoms
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Loss of sodium, potassium and ketone bodies through
excessive urination (ketoacidosis)
Extreme hyperglycemia
Labored breathing, fruity smelling breath (due to
acetone), nausea, vomiting, thirst, dry mucous
membranes, flushed skin, mental confusion or
unconsciousness followed by coma.
Management
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Early detection is critical as this is a life-threatening
condition
Insulin injections may help to prevent coma
Insulin Shock
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Etiology
Occurs when the body has too much insulin
and too little blood sugar
 Hypoglycemia
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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
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Management
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Adhere to a carefully planned diet including
snacks before exercise
Guidelines for Pre-exercise Caloric Intake
Based on Blood Glucose Levels
1. Eat when < 80mg/dL
2. Eat a high complex CHO snack before
exercise before exercise if < 100mg/dL
3. Exercise if 100 – 250mg/dL
4. Exercise > 1 hour, then eat 15g of CHO and
drink 250 mL every 15-20 min
5. >250mg/mL check urine for ketones
If ketones present or if >300mg/dL, then cancel
exercise and adjust insulin
**Sports Drinks?
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