Exercise Induced Asthma

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Kaitlyn Stahl & A.J. Walsh from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Kaitlyn Stahl, Lucinda hampton, Andrew Walsh, Kim Jackson, 127.0.0.1, Elaine Lonnemann, WikiSysop, Vidya Acharya, Kapil Narale, Laura Ritchie, Wendy Walker and Evan Thomas  

Definition/Description

Asthma is a reversible obstructive lung disease caused by increased reaction of the airways to various stimuli. It is a chronic inflammatory condition with acute exacerbations that can be life-threatening if not properly managed.

Prevalence

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Characteristics/Clinical Presentation

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Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values

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Etiology/Causes

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Systemic Involvement

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Medical Management (current best evidence)

Prevention:
American Academy of Allergy, Asthma, and Immunology (AAAAI) promotes utilization of self-management and prevention strategies for patients with asthma. A daily asthma management plan, as well as other information and resources, can be found on the AAAAI website. 

'Diagnosis:'

Exercise-Induced Bronchospasms (EIB) is often diagnosed based on the patient’s history of the following symptoms: cough, shortness of breath, chest pain or tightness, wheezing, or endurance problems during exercise. However, EIB has been shown to be misdiagnosed when based on patient history alone. Pulmonary function testing, involving a cardiovascular exercise challenge at 80% of heart rate maximum, is a primary diagnostic tool often used to augment clinical symptom findings. Diagnosis of EIB is indicated with 15-percent decrease in the patient’s PEF or FEV1.

Management:

If addressed and treated appropriately, exercise-induced asthma should not restrict one’s ability to fully participate in vigorous physical activity. Furthermore, adequate asthma control should allow for a patient to participate in any activity of choice without experiencing asthma symptoms. Management of EIB should include identifying any allergens the patient may have, educating the patient on avoiding asthma triggers, and use of asthma medications, when necessary. The EPR 3 Guidelines for Diagnosis and Management of Asthma recommend the following treatments for the medical management of EIA:

Long-term Pharmacotherapy (if appropriate): 
Anti-inflammatory medications, such as inhaled corticosteroids used to suppress airway inflammation, have been proven to decrease the frequency and severity of EIB when used on a daily basis for long-term control of asthma. Long-term control therapy is recommended for patients with poorly controlled symptoms, including frequent, severe episodes of EIB

Treatments Prior to Exercise:

1. Inhaled beta2-agonists:

• Short Acting Beta Agonists (SABA), often called ‘rescue inhalers’, are used acutely before exercise to control symptoms up to 2-3 hours
• Long Acting Beta Agonists (LABA) are used in conjunction with inhaled corticosteroids to provide additional protection from asthma   symptoms for up to 12 hours. LABA are not indicated for daily use but should be used as a pretreatment to exercise.

2. Leukotriene Receptor Antagonists (LTRAs): are medications used for allergy treatment and to prevent asthma symptoms. LTRAs have a longer onset of action and may take hours to provide symptom relief.

3. Exercise Warm Up: A period of warming up before exercise may help to decrease symptoms associated with EIB

4. Protection Against Cold: Wearing a scarf over the mouth prior to/during activity may help to decrease cold-induced EIB

Physical Therapy Management (current best evidence)

Acute Management:
Because EIB is triggered by exercise, physical therapists may be the first to identify asthma symptoms in a patient with undiagnosed EIB. For this reason, physical therapists must be aware of the associated signs and symptoms of EIB, as well as any red flags that may indicate a need for medical referral and treatment. If a patient has an acute asthma attack during therapy, the physical therapist should assess the severity of the attack, then position the patient in high Fowler’s position for diaphragmatic and pursed-lip breathing, if appropriate. If the patient has an inhaler available, the physical therapist should provide assistance to allow the patient to self-administer the medication, while helping the patient to relax.

Long-term Management
There are several factors that can deter patients with EIA from exercising, one being the belief that exercise is detrimental to their condition. Although there is insufficient evidence to support breathing exercises or inspiratory mm training in patients with asthma, there is strong evidence to support the benefits of physical activity for cardiovascular training in this patient population.Therefore, physical therapists can play a large role in management of care by providing patient education and exercise prescription.

The Preferred Practice Patterns for this patient population, according to the Physical Therapy Guide to Practice, include:

• Pattern 6B: Impaired Aerobic Capacity/Endurance Associated With Deconditioning
• Pattern 6C: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated With Airway Clearance Dysfunction
• Pattern 6E: Impaired Ventilation and Respiration/Gas Exchange Associated With Ventilatory Pump Dysfunction or Failure
• Pattern 6F: Impaired Ventilation and Respiration/Gas Exchange Associated With Respiratory Failure

Exercis and Medication:

Bronchodilators should be self-administered with a meter-dose inhaler (MDI) about 20-30 minutes prior before the patient participates in exercise. Mild stretching and a warm-up to exercise should also be performed during that time to help prevent the onset of asthma symptoms. Physical therapists must be aware of any adverse side effects or drug toxicity associated with asthma medications. Some symptoms that may suggest drug toxicity include nausea and vomiting, tremors, anxiety, tachycardia, arrhythmia, and hypotension. If the patient exhibits asthma symptoms during exercise that are not controlled with current medication, the physical therapist should notify the patient’s physician to alter the dosage.

Vital Signs:

It is important for the physical therapist to monitor the patient’s vital signs before, during and after exercise, to detect any abnormal changes in bronchopulmonary function. Auscultation of the lungs should be done routinely to detect any abnormal breath sounds, wheezing, or presence of rhonchi. Red flags that may indicate worsening asthma or drug toxicity can include tachypnea (increased respiratory rate above normative values), diarrhea, headache and vomiting. Asthma-related hypoxemia may be indicated with an abnormal rise in the patient’s blood pressure

Other Considerations:

Decreased bone mass density has been associated with long-term use of inhaled corticosteroids in patients with moderate to severe asthma. This chronic corticosteroid use also has an associated increased risk of fracture, in particular asymptomatic vertebral fractures. Physical therapists should be aware of the patient’s medication history and take precautions when exercising patients who may be at risk for fractures. Physical therapy can enhance medical management and play important role in the care of patients with status asthmaticus. Physical therapists can teach the patient various coughing, breathing, and positioning techniques to help clear secretions, reduce hypoxemia and improve V/Q matching. Aggressive treatments, such as forceful percussion, should be avoided in this population to prevent triggering of bronchospasms

Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

The most common differential diagnoses of EIB include:

• Vocal Cord Dysfunction
• Laryngeal/tracheal processes
• Respiratory tract infection
• Gastro-esophageal reflux
• Hyperventilation syndromes

EIB may also be associated with underlying conditions, such as:

• COPD
• Obesity
• Pectus Excavatum
• Diaphragmatic paralysis
• Interstitial Fibrosis
  
  

 

Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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