Sports Medicine with Dr. Jeffery MacLeod

ASTHMA IN CHILDREN’S SPORT; THE COACH’S ROLE

While conducting pre-competition medical screening for a Bermudian national men’s sporting team this year, I identified two players in the 30 man squad that were functioning on 60% of normal respiratory function; both these players are asthmatic, although only one of them was aware of the diagnosis. As a sport physician, I was incredulous that anyone competing at this level could have such a significant disability and either not know about it, or not be managing it optimally. The national coaching team were also unaware of the disability. Needless to say, an athlete trying to compete with only 60% of their respiratory function is significantly impaired. One of the players commented – “no wonder I’m gasping for breath at training.” Not only does this considerably impair the athlete’s performance, it is also potentially dangerous – and this is especially the case with children. Asthma is a common and dangerous disease, causing wheezing, difficulty breathing and coughing and untreated asthma can cause permanent lung damage; even worse, a severe exacerbation can lead to death. According to the CDC, approximately 7% of white children (0-18 years) in the USA have asthma, compared to 16% of black children; this makes it especially relevant to the Bermudian population. Each year, 1 in 6 asthmatic children attend the ER, and 1 in 20 are hospitalised with asthma. Additionally, exercise is one of the most common triggers for an asthma exacerbation, so it is essential that the child or adolescent athlete, the parent and the coaching team all know what their role is to enable both safety and maximum performance. It is not all bad news for exercise, however – quite the contrary. Growing evidence suggests that physical activity (PA), although it can be a trigger for an acute exacerbation, is actually protective and reduces the incidence and severity of asthma in the long run. Reflecting this relationship, over the past 30 years PA has significantly decreased among children, while at the same time the incidence of asthma has increased. Furthermore, there is ample evidence that children who exercise on a regular basis have better mental health, better bone health, lower risk of obesity and high blood pressure, decreased risk of diabetes and better lung function. Therefore, it is essential that children are encouraged to exercise. Nonetheless, asthma in sport needs to be recognised and managed, and the coach or trainer must play an important role. It should be a sobering thought that up to 1 in 6 of the children in a coach’s team might have asthma. Does the coach know who they are? Do they know what signs to look for? Do they know if the child or adolescent has appropriate asthma medication? Do they know that it is readily accessible during training sessions and sports events? Do they know how to assist treatment if necessary? Do they know what the individual’s asthma management plan is? The pathophysiology of asthma is extremely

complex and not completely understood. However, there are three main factors contributing to respiratory impairment in asthma which are well-recognised: constriction of the smooth muscle in the airway wall leading to airway narrowing; inflammation in the airway wall that leads to further airway narrowing; and increased mucous production which both narrows airways and can plug them completely. If untreated, in the long term these changes can become permanent. The triggers for this reaction in the airways are various but, effectively, it is an over-reaction of the immune system that is to blame.

Effective treatment needs to address all of these physiological changes. Historically, the shortacting Beta2 agonist (SABA) salbutamol – most commonly branded as Ventolin and coming in a blue inhaler – was the mainstay of treatment. It provides near immediate relief of symptoms but may not last very long – typically around 4 hours. It works by relaxing the smooth muscle in the airway wall and allowing the airways to dilate, however, it does nothing for the inflammation and mucous production. More recently, long-acting Beta-2 agonists (LABA) have been developed and these offer around 12 hours of smooth muscle relaxation and airway dilation. Inhaled corticosteroids have become the mainstay of asthma treatment however, as these address all the changes occurring in asthma. Corticosteroids are an essential human hormone that has powerful antiinflammatory and immune-suppression qualities and, when inhaled into the lungs, they counter the overactivity of the immune system. Over a period of days-to-weeks inhaled corticosteroids reduce the inflammation in the airways allowing function to return to normal. There are further options for more treatment-resistant asthma, but the majority of cases can be managed with a combination of these three medications. The first step to managing asthma in children is recognising the signs. If they are already diagnosed with asthma, a coach will want to know that the child is being actively managed by their doctor. However, a child whose exercise-tolerance seems unusually low, who gets excessively short of breath, or who develops wheezing or an irritating cough, should be assessed by their doctor for potential asthma. If the child suffers from hayfever or eczema, or if members of their immediate family have asthma, the likelihood that they have asthma is also increased. Once a child is diagnosed, they need to have an asthma management plan. Asthma is something that often varies in severity both seasonally as well as on a daily basis. Therefore an effective management plan will allow seamless escalation and reduction of treatment depending upon requirement, including what to do during a sudden exacerbation or emergency. All parties should have access to this and know what their role is – the child or adolescent, the parents and the coaching team or trainer. Everyone should know what medication is used and how it should be administered.

A couple of essential accessories are worth noting. First, a very cheap, simple device called a Peak Expiratory Flow meter which allows assessment of the state of the airways and can be

used anywhere. It is a small hand-held device that does not even require batteries, and can assess the percentage to which an individual’s airway is compromised. This percentage then helps inform what immediate treatment is appropriate. For some reason these meters are not commonly used in Bermuda, and most the asthmatics that I have assessed have never actually seen one.

They should be a standard tool for asthmatics, however, and should be available during exercise. The other device that is often neglected is the asthma spacer. Again these are a simple device, and they ensure that inhaler medication is delivered effectively. Without a spacer, even with the best inhaler technique, only 30% of the inhaled medication gets where it needs to be – the rest is just sprayed around the mouth and pharynx. All aerosol inhalers should be used through a spacer and they are so effective that they have replaced nebulisers almost completely. The take home message is that although asthma is common, and exercise is a common trigger for an exacerbation, exercise is also protective in the long run and has multiple other health benefits so should be encouraged. Coaches and trainers need to be prepared to play their role in asthma management with their athletes, however. Awareness and diagnosis is the first step. A clear and shared asthma-management plan is the next. As always, communication between all vested parties is essential. If a coach or trainer has any concerns or uncertainties, they should communicate with the player and the parents, and the athlete’s doctor should be included if anything seems unclear. Another fantastic resource in Bermuda is Open Airways, a free asthmaspecialist service that your doctor can refer you to. There are some good, clear guidelines for coaches online that will take them through the important steps and, once in place, children and adolescents with asthma should be able to train and compete both safely and at their maximum potential.

Dr Jeff MacLeod FRCGP MRCGP MFSEM BMBS PGDip(SEM) MA BA(Hon) General Practitoner and Sports Medicine Specialist

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