Updated: 6/2/2021

Pulmonary Conditions in Athletes

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  • Overview
    • 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
  • Asthma
    • 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
  • Pneumothorax
    • 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 2nd or 5th 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
  • Hemothorax
    • 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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