Respiratory Distress in the Athlete
(or When You Can’t “Just Suck It Up”)

George C. Phillips, MD, FAAP, CAQSM

Sports Medicine Rounds

September 22, 2005

Case 1

•      High school female cross-country athlete

•      Coach approaches ATC staff:  “Can somebody please help this girl?”

•      During intervals, athlete had sudden onset of respiratory distress

•      “I can’t get any air in!” 

•      Loud inspiratory noise with expiratory sound similar to a moan

Case 2

•      High school female basketball player

•      New onset respiratory distress during practices and games for ~ 6-8 weeks

•      Occurs within the first few minutes of a game or hard practice, but not with other conditioning activities

•      Loud, inspiratory noise with throat tightness

•      No help from albuterol inhaler

What makes us breathe…

•      Respiratory centers in brain

•      C3-5 controls diaphragm

•      Phrenic nerve

•      Negative thoracic pressure

•      Chest wall expansion 

•      Intercostal muscles assist

•      Repsiratory tree

•      Surface tension of alveoli

•      Capillary gas exchange

What goes wrong …

•      Respiratory centers in brain

•      C3-5 controls diaphragm

•      Phrenic nerve

•      Negative thoracic pressure

•      Chest wall expansion 

•      Intercostal muscles assist

•      Repsiratory tree

•      Surface tension of alveoli

•      Capillary gas exchange

•      Intracranial injury

•      C-spine injuries

•      Diaphragmatic injury

•      Rib fracture

•      Intercostal muscle injury

•      Tracheal/bronchial injury

•      Pneumothorax

•      Aspiration

•      Airway constriction

Remember the ABC’s

•      Airway

•      Breathing

•      “Look, listen, feel”

Opening the Airway

When do they make a noise?

•      Inspiration

•      Expiration

•      Both

•      Neither

•      Stridor

•      Wheezing

•      Obstruction or Hypervent.

•      Obstruction, Arrest, PTX

Stridor

•      Larger, upper airway obstruction

•      Classic for infections such as croup

•      Occurs with inspiration

•       

Wheezing

•      Smaller, lower airways

•      Classic for asthma

•      Occurs with expiration

•       

On-the-Field Injuries

•      Rib fractures

–   Pneumothorax, hemothorax are common complications of displaced rib fractures

–   Lower left rib fracture – 20% have splenic injury

–   Lower right rib fracture – 10% have liver injury

–   Multiple rib fractures can result in “flail chest”

Pneumothorax

•      Trauma is #1 cause

•      Can occur  spontaneously

–    Tall, thin males

•      Sudden onset of chest pain, dyspnea, decreased breath sounds, tachycardia

Tension Pneumothorax

•      Dyspnea and tachycardia

•      Tachypnea, hypotension

•      Neck vein distension

•      Tracheal deviation away from the pneumothorax

Pulmonary Contusion

•      Traumatic force to the lung damages alveoli

•      Blood and proteins leak into alveoli

•      Alveolar collapse and consolidation

•      CP, SOB, Cough, Hemoptysis

•      Tachypnea, Rales

In the office/training room…

•      Exercise-Induced Asthma

–   Most asthmatics will have exercise induced symptoms

–   Close to 50% of patients with allergic rhinitis will have some component of EIA

–   An estimated 10% of athletes have EIA

•      Controversy surrounding Olympic athletes

What happens in EIA?

•      The small airways in the lungs get smaller.

–   Smooth muscle bronchoconstriction

–   Inflammation of the airway linings

–   Dilation of the capillaries in the bronchial walls

•      Why?

–   Heat loss; water loss; irritants/allergens;

–   Viral respiratory infections

How to test for EIA?

•      FEV1 or PEFR

•      Formal pulmonary function testing

–    Can you mimic the real conditions of exercise?

•      Office testing

•      Methacholine challenge

•      Peak flow meter

How to treat EIA?

•      Bronchodilator

–    Albuterol

•      Antiinflammatory

–    Mast cell stabilizers

–    Inhaled steroids

–    Leukotriene inhibitors

•      Anticholinergic

–    Ipratropium (Atrovent)

Acute treatment of EIA

•      Albuterol is far and away the most effective treatment

•      Daily use linked with more events and less effective response

•      No ergogenic effects

•      Method of delivery

Prevention of EIA

•      Short, repeated warm-ups (SRWUs)

–    Refractory period

•      Control allergic rhinitis

•      Monitor frequency of albuterol symptoms

–    Controller medications

•      Conditioning

Did any of those conditions sound like our cases?

•      Case 1

•      Cross country female

•      Sudden onset

•      Loud inspiratory and some expiratory noise

•      Panicky

•      Case 2

•      Basketball female

•      Minutes into hard w/o

•      Not with “lighter” w/o

•      Throat tightness and inspiratory noise

•      No help from albuterol

Case 1

•      Hyperventilation

•      Lactic acid buildup

•      Dehydration

•      Inefficient breathing mechanics

•      Panic/stress/anxiety

•      Rapid breathing blows off too much CO2

Case 2

•      Inspiratory sound, no response to albuterol

•      Working diagnosis: vocal cord dysfunction

•      Paradoxical closure of vocal cords during inspiration

VCD vs. EIA

Case 2

•      Formal PFTs

•      No evidence of obstructive airflow or other asthma patterns

•      No change with albuterol

•      Symptoms reproduced

When the athlete can’t breathe…

•      Remember: ABC’s and look, listen and feel

•      What do you hear?

–   Stridor, wheezing, rales, nothing

•      For athletes with EIA, keep albuterol handy

–   Albuterol does not treat deconditioning

•      Watch your athletes with allergic rhinitis 

What can we do better?

•      We ask about allergies, asthma, and meds…

•      Should we get baseline peak flow data? 

•      When do we get PFTs for known asthmatics?  What’s a known asthmatic?

•      Should we provide peak flow meters for our ATCs to use?  How often should we check our athletes?  

•      Should we have written action plans for athletes with EIA symptoms?