Updated: 3/12/2021

Pulmonary Conditions in Athletes

Review Topic
  • This topic covers pulmonary conditions seen in the athlete and covers
    • Asthma
    • Exercise-Induced Bronchospasm (EIB)
    • Exercise-Induced Laryngeal Obstruction (EILO)
    • Exercise-Induced Anaphylaxis
    • Pneumothorax
    • Hemothorax
    • Pulmonary Embolism
  • Introduction
    • transient lower airway obstruction due to underlying hypersenstivity reaction
    • primarily an expiratory problem
    • exercise can be a trigger for asthmatic episode
      • known as exercise-induced asthma (EIA)
  • History
    • wheezing and shortness of breath
    • may have cough, though less common in classic asthma
    • chest tightness
  • Physical examination
    • expiratory labored breathing
    • respiratory retractions with use of accessory respiratory muscles 
    • expiratory wheezing or rhonchi
  • Diagnosis
    • pulmonary function testing
      • +/- bronchial provocation challenge with methacholine
        • tests airway hypersensitivity
      • low forced expiratory volume in 1 second (FEV1) and low FEV1/FVC ratio 
      • improves with administration of bronchodilators
  • Treatment
    • rest, controlled breathing rate, inhaled beta-2 agonist
      • acute exacerbation rest
      • albuterol Q15 minutes PRN
    • epinephrine (Epipen), transport to ER
      • severe and/or refractory episode
    • inhaled glucocorticoids    
      • maintenance therapy for moderate to severe asthma
  • Return to play
    • as tolerated
    • active wheezing is a contraindication to RTP
Exercise-Induced Bronchospasm (EIB)
  • Introduction
    • often thought of as exercise-induced asthma (EIA), though technically they are distinct disorders
      • EIA occurs in patients with an underlying asthma diagnosis in which exercise is a trigger
      • EIB occurs in athletes with no underlying asthmatic disease
    • transient lower airway obstruction resulting from exertion
    • primarily an expiratory problem
    • risk factors 
      • winter sports
        • drying and and cooling of mucosa leads to edema and constriction
      • endurance athletes
      • sports requiring high minute ventilation
  • History
    • classic triad of wheezing, shortness of breath and cough associated with exercise
    • nonspecific symtoms
      • "poor performance", fatigue, headache
    • onset 10-15 minutes after exertion
    • resolves with 20 minutes of rest
  • Physical examination
    • often normal
  • Differential diagnosis
    • exercise-induced hyperventilation 
      • "pseudo-asthma syndrome"
      • hyperventilation during exercise causes respiratory symptoms (wheezing, chest tightness)
      • not related to bronchial constriction
  • Diagnosis
    • pulmonary function testing
      • can be normal at baseline
      • eucapnic voluntary hyperventilation (EVH) test
        • gold standard for diagnosis of EIB
        • patient hyperventilates dry gas with a % carbon dioxide level to mimic exercise conditions
        • spirometry findings
          • > 10% reduction in FEV1 is diagnostic
      • improves with administration of bronchodilators
  • Treatment
    • prevention
      • warm-up, environmental control
      • "refractory period"
        • purposeful induction of asthmatic response
        • effective for ~50% of athletes
      • inhaled beta-2 agonist
        • albuterol 2 puffs 15-20 minutes prior to activity
    • rest, controlled breathing rate, inhaled beta-2 agonist
      • acute exacerbation 
      • albuterol Q15 minutes PRN
  • Return to play
    • as tolerated
    • active wheezing is a contraindication to RTP
Exercise-Induced Laryngeal Obstruction (EILO)
  • Introduction
    • transient upper airway obstruction caused by paradoxical closure of the vocal cords or narrowing of the supraglottic structures during heavy exertion
    • inspiratory problem 
    • has prominent psychological component
  • Types
    • supraglottic
    • glottic (vocal cord dysfunction)
    • mixed supraglottic and glottic
  • History
    • ranges from mild shortness of breath to severe respiratory distress
    • more rapid onset than bronchospastic disorders
    • throat tightness and choking sensation
      • compared to chest tightness seen in asthma, EIA, EIB
      • "breathing through a straw"
    • failure to respond to bronchodilator treatment
      • often misdiagnosed as EIA/EIB and prescribed beta-2 agonist inhaler
  • Physical examination
    • inspiratory labored breathing
    • inspiratory stridor (high pitched)
  • Diagnosis
    • pulmonary function testing
      • can be normal at baseline
      • may show blunted inspiratory portion of flow-volume loop
    • continuous exercise laryngoscopy (CEL) test  
      • gold standard to diagnose EILO
      • flexible laryngoscope to assess laryngeal movement while patient performs exercise
      • distinguishes supraglottic from glottic and allows grading of obstruction 
  • Treatment
    • nonoperative
      • mainstay of treatment
      • psychotherapy
        • laryngeal control therapy (LCT)
          • focuses on breathing with lower abdominal movement and controlled exhalation through mouth
      • speech therapy 
      • SSRIs
      • botulinum toxin injections
    • operative
      • rare
      • surgical debulking of redundant tissue
Exercise-Induced Anaphylaxis
  • Introduction
    • rare life-threatening systemic hypersensitivity response triggered by physical exertion
      • type I hypersensitivity reaction (IgE mediated)
    • can be preceeded by ingestion of food allergen prior to exercise
      • known as food dependent exercise-induced anaphylaxis (FDEIA)
      • thought to be due multifactorial
        • increase gastrointestinal permeability
        • alterations in tissue enzymatic activity and plasma pH
        • redistribution of mast cells from gut with concomitant transport of recently ingested allergens to other areas of the body and subsequent intensification of prior low-grade allergic reaction
  • History
    • onset usually within 30 minutes of initiating exercise
    • early fatigue, generalized pruritis and urticaria
    • abdominal pain, nausea / vomiting, cramps
    • shortness of breath and throat tightness
  • Treatment
    • prevention
      • refrain from exercise 4-6 hours after eating
      • avoid exercise in extreme temperature (very hot/humid or very cold)
      • avoid Aspirin or NSAID use prior to exercise
    • epinephrine (Epipen), antihistamines, corticosteroids
      • acute episode
    • allergist consultation
  • Return to play
    • only after evaluation by allergy specialist and comprehensive action plan made
    • patient should always have Epipen and exercise with a partner
  • Introduction
    • presence of gas within the pleural cavity between the lung and chest wall causing collapse of the lung
    • etiology
      • spontaneous
        • risk factors
          • smoking
          • male gender
          • family history of pneumothorax
          • connective tissue disorders (Marfan's, Ehlers Danlos)
      • traumatic
        • penetrating vs. blunt trauma
        • contact athletes (ice hockey) at highest risk
      • iatrogenic
        • interscalene nerve block
  • Types  
    • closed pneumothorax
      • no communication between outside and pleural cavity
        • pleural cavity pressure = pulmonary pressure
      • pleural cavity pressure < atmospheric pressure
      • ex. spontaneous pneumothorax secondary to rupture of pulmonary bleb
    • open pneumothorax  
      • communication between outside and pleural cavity
      • air enters the pleural cavity during inspiration and exits during expiration
      • pleural cavity pressure equilibrates to atmospheric pressure, no "tension" 
    • tension pneumothorax
      • communication between outside and pleural cavity
      • air enters the pleural cavity during inspiration but is unable to exit, resulting in further accumulation of air within the cavity and increased pleural pressure ("tension")
      • elevated pleural pressure further compresses the lung and mediastinal structures, causing tracheal deviation and progressive cardiopulmonary compromise
      • life-threatening emergency
  • History
    • sudden onset, unilateral, pleuritic chest pain
      • sharp pain with inspiration
    • shortness of breath
    • syncope
  • Physical examination
    • anxious
    • visible deviation of trachea and jugular venous distention in cases of tension pneumothorax
    • tachypnea and tachycardia
    • unilateral decreased or absent breath sounds
    • hyperresonant to percussion
  • Diagnosis
    • ultrasound
      • absent lung sliding  
    • chest XR
      • findings
        • pleural line formed by visible edge of collapsed lung  
        • loss of lung markings (air appears black)
        • shift of the mediastinal structures (heart, trachea) and depression of the hemidiaphragm seen in tension pneumothorax  
  • Treatment
    • emergent needle decompression followed by chest tube placement 
      • first line of treatment for tension pneumothorax
      • place a needle into the fifth intercostal space in the midaxillary line (adults) 
        • the second intercostal space, midclavicular line is still recommended for pediatric patients
      • then transport to emergency department for chest tube placement
    • chest tube placement, admission to hospital
      • pneumothorax > 20% (lung edge > 2cm from chest wall)
    • supplemental oxygen, observation, repeat CXR
      • pneumothorax < 20% (lung edge < 2cm from chest wall) and patient clinically stable
      • observe for 4-6 hours
      • supplemental oxygen increases rate of pleural air absorption and can accelerate resolution 
      • repeat CXR prior to discharge from observation and at 12-48 hour post-discharge
    • NO flying for 2-4 weeks
      • decreased pressure on airplane can increase volume (size) of pneumthorax
  • Return to play
    • following radiographic resolution of pneumothorax, usually ~4 weeks
    • pain is the primary factor limiting RTP
  • Introduction
    • most common result of major chest wall trauma
    • can be penetrating or blunt injuries  
    • 30% patients with rib fractures have pneumohemothorax
  • History
    • acute onset chest pain
      • less pleuritic compared to pneumothorax
    • shortness of breath 
  • Physical examination
    • anxious
    • tachypnea and tachycardia
    • hypotensive in large hemothorax
    • unilateral decreased or absent breath sounds
    • hyporesonsant (dullness) to percussion
  • Diagnosis
    • chest XR  
      • opacification of hemithorax
  • Treatment
    • chest tube placement, repeat CXR
      • initial treatment of choice
      • repeat CXR after 4-6 hours and again at 24 hours to assess resolution
    • thoracoscopy (VATS) or thoracotomy
      • indications
        • > 1500cc initial chest tube output
        • > 200cc/hr for 3+ hours
        • increasing size of hemothorax
        • incomplete resolution fo hemothorax despite 2 chest tubes placed
Pulmonary Embolism
  • Introduction
    • athletes thought to be at increased risk due to 
      • higher rate of musculoskeletal injuries (+/- immobilization)
      • athlete-specific repetitive motions (pitchers, tennis players)
      • frequent long-distance travel
  • History
    • sudden onset, pleuritic chest pain
    • shortness of breath
    • lightheaded, dizziness, syncope
  • Physical examination
    • tachycardia and tachypnea
    • hypotensive if large PE
    • hypoxia
  • Diagnosis
    • helical chest CT scan
      • first line imaging modality
    • pulmonary angiography
      • gold standard for diagnosis
    • nuclear ventilation perfusion scan (VQ scan)
  • Treatment
    • systemic anticoagulation 3-6 months
      • IV heparin drip or Lovenox injections, followed by conversion to oral anticoagulant
      • minimum of 3 months treatment
  • Return to play
    • returning to sport while on systemic anticoagulation therapy is controversial
      • contact athletes usually withheld from sport for duration of anticoagulation due to bleeding risk
    • average time to RTP is ~ 6 months

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