Asthma: The Silent and Not So Silent Wheezer

by  Leonard Marks, MD

Last fall, about 3 weeks after the soccer season began, Amber (name changed) was brought to my office by her Mom. Amber is a cute 11 year old athlete with a twinkle in her blue eyes and a perennial smile on her face. She stated that her new coach did a lot of high speed running games in which she would get out of breath sooner then the others on her team. After a few minutes of running she would start coughing and described trouble “getting air”. If she sat and rested for a few minutes she would breath better but the cough would continue. Her coach mentioned this to her mother with the recommendation that she see her physician.

This is a classical description of exercised induced asthma. While most known asthmatics will wheeze in response to varying amounts of exercise, Amber had a more subtle presentation.

There are several aspects to asthma; however, for our purposes, we should consider it to be condition in which the lung muscles surrounding the air passages go into spasm and tighten up. Instead of having a wide open airway, the bronchi are narrowed or constricted. This inhibits one’s ability to breathe air in and to exhale. The difficulty in exhaling is manifested in the “wheeze.”

Often the patient/athlete will have a history of frequent bouts of bronchitis when younger or a significant reaction to smoke or irritants. In many cases, there is no history of the above. While there are tests a physician can do, they are time consuming and expensive. The diagnosis is usually made on the basis of the history. In the office the kids are rarely wheezing. While exercising the patient in the office might induce an attack this is often not practical. With known asthmatics, the diagnosis is fairly obvious; in patients like Amber there are several approaches to the diagnosis. Some physicians prefer testing. I prefer trying medications to ascertain a response. Both of these approaches work.

I will usually start my suspected exercise induced asthma patients on one of the many forms of inhalers designed to “open up” or dilate the air passages. These are called “bronchodilators” the most common of which is albuterol. The newer inhalers have a very gentle puff and kids can use them effectively with a little instruction. The generic inhalers (as well as many of the older ones) have a very strong puff and a “spacer” is required; otherwise, the blasted medicine will bounce all over the place and not get into the lungs. The spacer is a long tube with a port for the inhaler at one end and a mouthpiece at the other.. Usually two puffs ½ hour prior to sports will do the trick.

If this helps but there is continued breakthrough coughing/wheezing, one can always give the albuterol during the game; however, it is preferable to try to prevent the symptoms from occurring. Once you start wheezing you have already lost a significant percentage of your lung function and the performance will be compromised. Medication such as Singulair can be taken as a pill once a day. Another inhaler, Cromalyn or Intal, can be given one hour prior to sports. Both of these work well. A third inhaler, Atrovent, is highly effective in exercise induced asthma but has the unfortunate side effect of drying the mouth. I will use this as last resort with a spacer ½ hour prior to sports (with albuterol).

How does the physician determine what to do?

This is where you, the coach, is critical.

First, keep an eye on the athletes. If you notice any coughing or wheezing in response to exercise, mention it to a family member. Many teens will never mention it to their parents.

If the child is prescribed an inhaler, make sure he/she takes it appropriately prior to the game. Many with the older inhalers will deliberately forget their spacer. If they do this, it is less likely that the prescribed amount of medicine will be absorbed. If the athlete still wheezes while taking medicine, again, mention it to their parents. There are several treatment modalities; unfortunately, follow-up is often poor and the athlete will continue to wheeze.

Finally, warm-up is critical. The asthmatic patient requires a longer warm-up gradually building up to top speed. If the asthmatic is a sub, have him jog on the sidelines for 10 to 15 minutes prior to going in.

As I mentioned, with most cases of exercise induced asthma, the history and description of events is critical. Treatment involves trying a medicine and, if not effective, adding more. As a physician, I rely on feedback from both the athlete who is often in denial and the parent (who hears from you, the coach).

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