By Guillermo Metz
Guillermo Metz is an Associate Editor at Athletic Management.
Athletic Management, 14.4, June/July 2002, http://www.momentummedia.com/articles/am/am1404/breathing.htm
Between 1980 and 1994, the number of asthma cases in the United States increased 75 percent. During that same time, the overall percentage of asthma sufferers who played sports also increased substantially, including athletes at the highest levels of competition. That’s the result of medical advances that have made asthma a very manageable condition.
But just because asthma has become manageable doesn’t mean every athlete manages his or her asthma well. While it’s uncommon for someone to die of asthma, Rashidi Wheeler’s case last August brought the condition to the fore. What happened the day the 22-year-old Northwestern strong safety suffered a fatal asthma attack is still unclear. But it does underscore the importance of everyone from the athletic director down to coaches having some basic knowledge about this often misunderstood condition.
What is asthma? How can athletes who have asthma participate safely? Should athletic trainers make asthma management a part of their operations? And what is the athletic director’s role in making sure everyone is on the same page regarding this issue?
What is Asthma?
Asthma is a chronic lung condition that makes the airways of the lungs especially sensitive to irritants, such as allergens (both external, such as pollen, and internal, such as foods) and pollution. When an asthma sufferer encounters such irritants, the lung muscles tighten and the airways swell and partially fill with mucus, making it difficult to breathe. Symptoms include shortness of breath, wheezing, coughing, and chest tightness.
Approximately 5,000 people in the U.S. die each year from asthma—which is a very small percentage of the roughly 15 million people who suffer from the condition in this country. Most of those deaths result from asthmatics poorly managing their condition, says Dr. Christopher Randolph, Associate Clinical Professor at Yale University School of Medicine and Chair of the Sports Medicine Committee of the American Academy of Allergy, Asthma, and Immunology.
“People don’t die of asthma unless they’ve really been neglectful of their medications or they have incredibly severe asthma that doesn’t respond to any medicine—but that’s extremely rare,” says Randolph. For most asthmatics, those medications involve a daily controller medication (an inhaled steroid that controls inflammation) and a bronchodilator (a “rescue inhaler” that is taken before exercising or as needed to control symptoms).
By conscientiously taking their medication, asthmatics should have few to no symptoms, according to Randolph. Wheezing, difficulty breathing, and other classic signs of asthma are an indication that an athlete’s asthma is not being properly managed and that they should be reassessed by their physician or a specialist.
“If a coach sees an individual wheezing on the field,” says Randolph, “that’s a very important sign that this individual needs to be in touch with a specialist and/or primary care doctor and be evaluated again. They may need more anti-inflammatory medicine.”
The same symptoms call for assessment in athletes who may have exercise-induced asthma, a widely misunderstood condition. According to Randolph, very few people have true exercise-induced asthma, a condition where someone experiences asthma symptoms only when exercising, particularly in cold weather. Instead, he says, what appears to be exercise asthma is almost always an indicator of underlying chronic asthma that is aggravated by exercise—the amount of air the athletes are breathing during exercise carries more irritants to their lungs, thus triggering asthma symptoms.
There are two main reasons athletic trainers and coaches need to be on the lookout for asthma and make sure athletes with even mild cases are managing their condition properly. First, if exposed to a high level of irritants, especially while heavily taxing the lungs through exercise, an athlete with asthma can have a full-blown attack, which could be life-threatening. Second, researchers increasingly believe that asthma, if left untreated, can cause long-term loss of lung function. The fibers in the lungs thicken, the muscles grow and progressively constrict the airways, and there may even be some scar tissue buildup.
“But I’d stress that asthma is very common and easily controlled,” says Randolph. “It should not interrupt athletes’ pursuits of their sports.”
A Management Issue
Rashidi Wheeler’s parents are suing Northwestern University, naming as defendants Athletic Director Rick Taylor, Head Football Coach Randy Walker, Head Athletic Trainer Tory Aggeler, Strength and Conditioning coach Larry Lolja, Coordinator of Football Operations Justin Chabot, and two assistants. At issue is whether the school provided proper medical care of Wheeler.
Due to the fact that there may have been as many as six athletic trainers on the field that day, several commentators have remarked that perhaps Wheeler wasn’t taking proper care of himself and staying on top of his asthma management. (The autopsy report showed that he had not taken his inhaler medication before exercising that day, since the active drug did not show up in his blood, although he had used it the day before, since traces were found in his urine). It’s an issue for the courts to work out, but before a similar case happens at your school, what can you do to protect yourself, your institution, and your student-athletes?
The first step is to examine what you and your staff are doing presently. And you can start by looking at your emergency procedures. Following Wheeler’s death last year, Pete Carlon, Director of Athletics at the University of Texas-Arlington and a member of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, says he and his staff sat down and examined if they would be prepared to handle a similar emergency.
“We reviewed our entire emergency care plan and also what kinds of services we were providing in the summer months, when we have some students here conditioning on their own,” Carlon explains.
A few basic points in any emergency plan include the following: Emergency medical procedures should be detailed in a manual and reviewed regularly by all athletic training staff. Everyone should know his or her role in handling a medical emergency. Every ambulance and police vehicle in your area should be equipped with up-to-date maps of how to get to every athletic venue on your campus. Every athletic trainer should have a cellular phone or radio unit. Insofar as asthma is concerned, every athlete with asthma should have his or her rescue inhaler available at all times. And every athletic trainer and coach should know which team members have asthma and any medications they are on. (For more information on emergency medical plans, see Sidebar, “Resources” at the end of this article.)
Since knowing which athletes have asthma is key, another area to look at is your department’s preparticipation procedures. “It’s a matter of knowing their history,” says Matthew Gerken, Head Athletic Trainer at the University of Southern Maine. “My staff knows every member of a team who has asthma, or any other type of medical condition, and what type of medication they’re on.
“Ideally, you would want to set up your forms so that that information can then be passed on to coaches or anyone else who needs to know,” Gerken continues.
Asthma Action Plans
If an athlete states on the preparticipation form that he or she has asthma, then what? “Generally what we do is question them on their medical history about how severe it is, what type of weather conditions may contribute, whether it’s exercise-induced or systemic, and how it is managed,” says Bill Wissen, Athletic Trainer at Hastings High School in Alief, Texas. “We need to know the regimen their physician prescribed, including their medications, modifications to exercise, if any, and environmental problems that make it worse.
“Then, we communicate with the parents and physician, especially if we have any problems,” he continues. “If the child has been prescribed an inhaler, we try to keep that type of inhaler with us or nearby the athlete so in case we need it, we have it close by.”
Something else your athletic trainers should keep on hand is a peak flow meter. These are simple, inexpensive (as low as about $10) devices that show how well someone’s lungs are working by measuring how much air someone can breathe out in one large breath.
“A peak flow meter can be really useful,” says Gerken. “It’s a simple device and every athletic trainer should have one with him or her all the time. If you take peak flow readings when someone is having an attack, you can intervene early to determine if they may need to go to the hospital or be given drugs beyond the inhaler. Sometimes they don’t even exhibit many signs, but when you do a peak flow test, you find that they’re about to have an attack and don’t even know it.”
Claudia Baier, Director of Health Education for the American Lung Association of Metropolitan Chicago, conducts dozens of asthma education programs a year, primarily with children between the third and sixth grades. But, she says, many elements of these programs are important for asthmatics of any age. Perhaps the most important part is having each child create what is called an asthma action plan, copies of which are kept on file with each of the student’s teachers, coaches, and the school nurse.
“The asthma action plan lists things like the child’s asthma triggers, his or her medications, and when the medications should be used,” says Baier. “This is a document that the responsible adult can look at and know step by step what to do if the child is having an attack, in order to prevent a full-blown attack.
“The plan itself will say when the child should take the medication, and that’s usually based on symptoms and a peak flow meter reading,” she continues. “So, if a child is starting to show some symptoms or isn’t feeling well, you want to slow them down, figure out what might be triggering it, and take a peak flow reading. The action plan covers that particular child’s normal range for peak flow. If the reading is within the child’s range, you may not need to medicate them. It may just be a matter of having them take a break. If they have some decrease in pulmonary function, you may have to use a medication, usually some type of rescue inhaler.”
If these simple measures don’t do the trick, you may have a life-threatening situation on your hands. “If two puffs of the inhaler, receiving oxygen, if it’s available, and breathing through the nose fail within 15 minutes, then immediate EMS transport should be arranged,” says Randolph. “The rescue inhaler and oxygen should be continually administered while waiting.”
Usually, the simple measures do work. An athlete who is forced to use his or her inhaler more than once during a practice or competition is an athlete whose asthma is not being well controlled and he or she should be reassessed by a physician. If, however, the athlete’s symptoms are relieved by one dose (two puffs) of his or her inhaler, he or she may be able to return to that practice or competition. The simplest way to determine if the athlete is okay is through a peak flow meter test. If the score is within 10 percent of the athlete’s normal score, they can safely return to participation, though they should be watched closely.
The Unaware Athlete
Making sure preparticipation procedures are comprehensive and that athletic trainers, and possibly even coaches, know how to manage every student-athlete with asthma is critical. But what about those students who don’t know they have asthma?
“Knowing who is asthmatic is going to take care of 99 percent of your cases of asthma attacks,” says Gerken, “because it’s rare for someone to have a serious attack who doesn’t already know they have asthma. They may not be as prepared as they should be, but generally speaking, the kids who develop asthma problems develop them in grade school—they tend to know by the time they reach high-school age.”
The exception is those athletes with exercise-induced asthma. “As many as 20 to 30 percent of athletes who have exercise-induced asthma are undiagnosed,” says Randolph, “in part because denial is a major problem in athletes, particularly teenagers. Therefore, it’s very important that athletic trainers not just react to those athletes who report they have asthma, but they also need to be on the lookout for it in all athletes.”
Amazingly, researchers in the sports medicine program at Temple University found high rates of poorly treated and undiagnosed exercise asthma even among NFL players they tested. The reasons go beyond denial or secrecy. Researchers have known for some time that the people most susceptible to fatal or near-fatal asthma attacks are those who have what is referred to as a blunted perception of dyspnea, meaning they have labored breathing but don’t know it. Some believe that athletes are prone to this because they’re accustomed to pushing through discomfort.
“That’s why it’s such a good idea to do peak flow,” says Randolph. “We’ve known for years that the physical presentation doesn’t tell the whole story. You need to do an objective test.”
Another phenomenon for staff to be aware of is that some people’s asthma seems to subside at certain periods of their lives. “A lot of times, as children develop and their lungs get a little bigger and their bodies get a little stronger, their asthma often goes into a latency period,” warns Baier. “They think their asthma is cured or has gone away completely, but in reality, their body is just able to handle the allergens a little better. They may even still have some symptoms but they’ve lived with them so long that they simply don’t recognize them anymore.
“All of those things can come into play, and then suddenly a teenager can have an asthma attack when they thought they were through it, and it catches them off guard,” she continues. “They don’t have their emergency medicines with them. They may not intervene early enough. So, we see an increase in mortality in this age group.”
For this reason, Randolph recommends screening all athletes for asthma. “First, you have everyone complete a questionnaire for allergy and asthma,” he says (see Sidebar, “History Quiz,” at the end of this article). “About half the people you questioned may give you histories that are worrisome. You refer them to a specialist who will do spirometry [a device that measures lung air capacity] both before and after using a bronchodilator. About half of those or less will have abnormal spirometry. Those who have normal spirometry and no response to a bronchodilator should undergo a running test or a challenge in whatever their normal sport is and be checked with a peak flow before and after to see if they have any pure exercise asthma in isolation of chronic asthma.”
In addition to tackling the problem through the student-athletes, it’s important to educate coaches about asthma. “Coaches need to have baseline education,” says Baier. “There are some coaches who would push kids to just keep exercising, because of a lack of understanding. And then there are some who won’t allow a person with asthma to play. So, there are some kids sneaking in who want to play but who are afraid to tell anyone they have asthma. And that’s dangerous.”
The key is to foster an open atmosphere where student-athletes feel safe discussing their conditions and openly taking their medications. “That may mean having someone come in and talk to everyone as a group or having someone work with the coaches, stressing to them that they are influential in these people’s lives,” says Baier. “Coaches and athletic trainers need to be open to discussing these things, finding resources, and creating a safe, yet fair, atmosphere for their players.
“And, at the beginning of the season the coach should discuss asthma openly with the team,” Baier continues. “He or she can say things like, ‘Get your asthma action plan to us. Make sure you carry your rescue inhaler with you. And talk to me when you’re not feeling well.’ That helps create the natural communication that should be happening between an athlete and a coach.”
But how should an athletic director handle a coach who doesn’t have much patience for kids dealing with asthma? Wissen advises having the athletic trainer speak with him or her one on one.
“It’s a communication issue,” he says. “You’ve got to sit down and talk with them and make sure they understand the disease and the ramifications of it. If you continue to push someone into a pseudo-asthma attack or an actual attack, the results can be devastating. They also need to understand that if it’s treated correctly, generally they don’t have too many problems. Once the coaches understand that, they tend to be very supportive.”
A great way for that information to be passed on is through workshops. But the impetus must often come from the athletic director, says Leroy Heu, Head Athletic Trainer at the University of California-Santa Barbara.
“I think we all need more information on it, but the time factor prevents us from scheduling it as a regular workshop,” he says. “A year and a half ago, we had one of our health center clinical coordinators give about an hour lecture to the athletic training staff on asthma, but that [directive] came from the athletic director.”
On the high school level, in-services or workshops can be coordinated through the school district. “Our school district brings in nurses to train everyone in the athletic department on CPR every year, including me, coaches, and our athletic trainers,” says June Morrissey, Athletic Director at Millard North High School in Omaha, Neb. “As part of that, we learn how to use the nebulizer for asthma.”
Such discussions and instruction are the best defense for asthma. Medically speaking, there is no cure for the condition, but by increasing everyone’s awareness of asthma, you can help your student-athletes lead safe, highly productive athletic careers.
The American Lung Association has educators on staff, as well as medical advisers available for conducting seminars. For starters, check with your local affiliate or go to the national association’s Web site, lungusa.org. Various affiliates also publish fact sheets that may be of interest. For example, the Wisconsin affiliate has put together some information on asthma that’s specifically for coaches; they can be reached at (262) 703-4200.
The New York City Department of Health also has great asthma resources, including a sample asthma action plan. It can be downloaded from their Web site, www.nyc.gov/html/doh/html/asthma/asthma.html, or they can be reached, toll free, at (877) 278-4620.
Members of the Sports Committee of the American Academy of Allergy, Asthma, and Immunology (AAAAI) try to meet with athletic trainers on a regular basis—such as at the NATA annual convention. Speakers from the Academy are also available for ongoing training. For more information, Dr. Randolph can be contacted directly through e-mail at email@example.com. You can also find someone through the AAAAI’s toll-free Physician Referral and Information Line at (800) 822-2762.
The McKinley Health Center at the University of Illinois at Urbana-Champaign has a wealth of information available to students and non-students alike through their Web site, including links to a dozen asthma Web sites and other sources of reliable asthma information. It can be accessed at www.mckinley.uiuc.edu/clinics/asthma/asthmaclinic.html.
For more information on exercise-induced asthma, see our interview with Dr. Randolph, entitled “When the Breathing Gets Tough,” in the October 2000 issue of our sister publication, Training & Conditioning. For more on emergency medical plans, see “Controlling Catastrophe” in the September 2001 issue of Training & Conditioning. These articles can be accessed through the search engine on our Web site, www.AthleticSearch.com.
Dr. Christopher Randolph, Chair of the Sports Medicine Committee of the American Academy of Allergy, Asthma, and Immunology, recommends adding questions about asthma to your preparticipation physical exam form. Not only will this indicate which athletes have asthma, but it is also the first step in identifying any cases of undiagnosed asthma among your student-athletes. Each question can be followed by three answer boxes: yes, no, not sure.
1. Have you ever been told you have (had) asthma or exercise-induced asthma?
2. Do you ever have chest tightness?
3. Do you ever have wheezing?
4. Do you ever have itchy eyes?
5. Do you ever have itching of the nose or throat or sneezing spells?
6. Does running ever cause chest tightness, coughing, wheezing, or prolonged shortness of breath?
7. Have you ever had chest tightness, coughing, wheezing, asthma, or other chest (lung) problems which made it difficult for you to perform in sports?
8. Have you ever missed school because of chest tightness, coughing, wheezing, or prolonged shortness of breath?
Credit: Dr. John Weiler, Professor, Internal Medicine, University of Iowa College of Medicine, 2000.
Warming Up to Asthma
While it’s critical that asthmatics properly manage their condition with medication, there are a few who can overcome their symptoms by warming up before going into full activity. These are a subgroup of asthmatics who have exercise-induced asthma—asthma that only bothers them when they exercise, particularly in cold weather.
“A lot of the exercise-induced asthmatics have a refractory period,” says Bill Wissen, Athletic Trainer at Hastings High School in Alief, Texas. “Warm them up, get their heart rate and ventilation/expiratory volume up, usually for 15 to 30 minutes, and then have them sit down and relax for 10 or 15 minutes. Usually, the circulating catecholamines in the bloodstream can then actually slow the release of histamines in the bronchial tubes and the tubes will naturally open themselves back up.
“So, by doing basic warm-up exercises—the same types of things all athletes should do—the asthma will often resolve itself spontaneously. It just means they need to get out there earlier and be through the refractory period by the time the rest of the team goes to warm up.”
“Exercise-induced asthma is something athletes can get through,” agrees Dr. Christopher Randolph, Associate Clinical Professor at Yale University School of Medicine and Chair of the Sports Medicine Committee of the American Academy of Allergy, Asthma, and Immunology. “The histamine reaction that is causing the athlete’s symptoms subsides after some time and then the athlete is fine. And in order to avoid the chest tightness and wheezing that can occur after exercise, the athlete should slowly cool down.
“The problem is that most people—something like 90 percent—with exercise asthma have underlying chronic asthma that may not be diagnosed. And that’s something you can’t just exercise through. So it really depends on a proper diagnosis, and then you have to continue to monitor them.”