Research Sheds Light on Asthma in Athletes

By Mona Luke-Zeitoun, MD

If you cough, wheeze, or experience shortness of breath shortly after exercising, you might have exercise-induced asthma. Exercise is a very common asthma trigger in people with underlying asthma, as are allergens and cold, dry air. In some people, especially athletes, exercise is the only trigger. That is called exercise-induced asthma—defined by a narrowing of the airways as a result of exercise.

Patients with exercise-induced asthma often present with classic asthma symptoms—shortness of breath, cough, and wheezing—shortly after they stop exercising. However, in over 50% of patients, symptoms are nonspecific and resemble decreased stamina or overtraining. If left undiagnosed, exercise-induced asthma can result in unnecessary distress, decreased performance, and long-term damage to the airways.

A diagnosis of exercise-induced asthma can be made with exercise tests that are performed in lung function laboratories. Generally, up to 60% of athletes test positive for exercise-induced asthma in the laboratory.

Treatment of asthma symptoms that are triggered by exercise in patients with classic asthma has been extensively studied. For those patients, warm-up exercises and administration of inhaled drugs that open up the airways (called beta agonists) before exercise are effective in preventing symptoms or an asthma attack. However, little is known about the causes of and optimal treatments for isolated “sports asthma” in athletes who don’t have underlying asthma.

At the University of California, San Francisco, my colleagues and I are studying exercise-induced asthma in elite athletes to gain insight into how it develops and can best be treated in this population. We found that exercise-induced asthma is activated by the parasympathetic nervous system, a branch of the autonomic nervous system, which controls unconscious bodily functions. The parasympathetic nervous system causes slowing of the heartbeat and narrowing of the airways.

Researchers at Columbia University in New York found that the activity level of the parasympathetic nervous system changes with physical training—the higher your fitness level, the more active your parasympathetic nervous system becomes. A study I co-authored showed that the degree of exercise-induced asthma gradually increased over time in elite triathletes. These studies suggest that years of endurance training may put an athlete at risk for developing exercise-induced asthma, since higher parasympathetic activity would lead to increased airway narrowing and an increased likelihood of triggering asthma. The good news is that having asthma does not decrease an athlete’s performance. In fact, Olympic athletes with asthma are more successful in their athletic careers than their non-asthmatic peers, and it is not because their treatment enhances performance.

The theory that asthma in athletes is tied to the autonomic nervous system has led my research team to study the effect of a drug called ipratropium bromide, which blocks the parasympathetic nervous system, on exercise-induced asthma in this population. Our research is generously supported by a grant from The CHEST Foundation, the philanthropic arm of the American College of Chest Physicians.

If ipratropium bromide is effective in preventing exercise-induced asthma in athletes, it could become an appropriate and well-tolerated treatment option in this population. We aspire to help young athletes with exercise-induced asthma perform safely at their best by preventing breathing difficulties from repeated airway narrowing during exercise and unnecessary airway damage in the long-term.

Remember, most patients with exercise-induced asthma can lead an active lifestyle and successfully participate in sports at all levels. The following are simple steps you can take to prevent asthma symptoms if you have exercise-induced asthma:

  • Do a low-intensity jog for 6-10 minutes or repeated 30-second runs 10 minutes before starting your workout.
  • Wear a face mask to warm and humidify the air you inhale when exercising on cold days.
  • Choose a sport that is less likely to trigger asthma, such as swimming, gymnastics, board diving, downhill skiing, water polo, football or baseball.
  • Use an inhaler containing a beta agonist alone or in combination with an anticholinergic 15 minutes before you exercise (talk to your doctor about the best medication for you).
Download “Controlling Your Asthma,” a patient education resource from The CHEST Foundation and the American College of Chest Physicians. Also available in Spanish. For information on exercising safely and links to helpful resources, check out OneBreath’s exercise area.

Photo: Neil Gould/stock.xchng

Mona Luke-Zeitoun, MD, is a Clinical Instructor in the Division of Pediatric Pulmonology at the University of California, San Francisco, School of Medicine and recipient of The CHEST Foundation California Chapter Clinical Research/Medical Education Award. She specializes in the evaluation and treatment of exercise problems in young athletes and children with a variety of medical problems. 

References

Luke-Zeitoun M, W.-T.B., Ghio E, Luke AC, Nielson DW, Hatamiya N, Gold WM, Lazarus SC, Atropine Blocks Post-Exercise Airway Obstruction In Asthmatic Elite Swimmers. American Journal of Respiratory and Critical Care Medicine, 2012. 185: p. A2406.

De Meersman, R.E., Respiratory sinus arrhythmia alteration following training in endurance athletes. Eur J Appl Physiol Occup Physiol, 1992. 64(5): p. 434-6.

Goldsmith, R.L., et al., Comparison of 24-hour parasympathetic activity in endurance-trained and untrained young men. J Am Coll Cardiol, 1992. 20(3): p. 552-8.

Knopfli, B.H., et al., High incidence of exercise-induced bronchoconstriction in triathletes of the Swiss national team. Br J Sports Med, 2007. 41(8): p. 486-91; discussion 491.

Fitch, K.D., et al., Asthma and the elite athlete: summary of the International Olympic Committee’s consensus conference, Lausanne, Switzerland, January 22-24, 2008. J Allergy Clin Immunol, 2008. 122(2): p. 254-60, 260 e1-7.

 

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Of Herbs and Acupuncture: What Integrative Medicine Can Do for Cancer Patients

By Gary Deng, MD, PhD

Nowadays, one of the first things most cancer patients do after a cancer diagnosis is search the Internet for treatment options. The search can lead to information overload, both informing and confusing the patient. Among the search results are therapies that are outside the realm of conventional Western medicine, ranging from “alternative cancer cures” to “tricks and tips” forwarded by well-meaning friends and relatives. Around 40% to 50% of cancer patients are interested in unconventional therapies. Patients may ask their oncologist: “What kind of food should I eat? Is noni-juice anti-cancer? How about ozone therapy? Will acupuncture help my cancer treatment?” Often the oncologist is equally puzzled by these questions and searching for answers too.

These so-called complementary and alternative medicine therapies are so numerous and so diverse that their value to cancer patients varies widely. At one end of the spectrum are therapies that have been shown in clinical trials to be safe and beneficial. These are called complementary therapies because they complement—support—conventional cancer care. Combining them with mainstream cancer treatment to reduce symptoms, improve quality of life, and strengthen the body, mind, and spirit is what integrative oncology is about.

At the other end are bogus “alternative” cancer therapies, often promoted as secret cancer “cures” that have been suppressed by conspirators. Pursuing these ineffective and risky therapies can actually be harmful if they delay or prevent the patient from getting real medical treatment.

How do we pick one therapy versus another? We cannot rely on stories or testimonials such as “a friend of my uncle was told he had only 3 months to live and is still alive after a year because he has been taking xyz herb.” When you investigate further, you may find he has also been taking a drug with proven efficacy.

A more reliable way to make a treatment decision is to rely on data from carefully designed and conducted clinical studies. To help oncologists and patients sort out the array of complementary and alternative therapies, a group of experts working in integrative medicine systematically searched all the professional literature published in the past 10 years for high-quality research on common complementary therapies. They evaluated the findings, graded the strength of the evidence, assessed risks and burdens to patients, and came up with a set of recommendations for clinicians taking care of cancer patients, especially lung cancer patients. The recommendations are presented in the chapter “Complementary Therapies and Integrative Medicine in Lung Cancer” of Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, which were published in May 2013.

The guidelines recommend that all cancer patients should be asked about their use of and interest in complementary and alternative medicine because not informing their doctors about their use can lead to a variety of problems. This is particularly important for patients interested in taking herbs or supplements, as they may have side effects or interact in a bad way with other medications. For example, an herb may make the blood too thin, thus raising the risk of bleeding during surgery or chemotherapy, or it may change the blood level of a chemo drug, leading to less effectiveness or more side effects. Clinicians are urged to have an open, receptive, yet evidence-based discussion with the patient about the pros and cons of these therapies, including what they can and cannot achieve. Simply stating, “Don’t use any of them” won’t be very effective. Patients are exploring complementary therapies for a reason, be it the lack of effective treatment options, the desire to feel empowered, or the belief that “anything natural is good.” These underlying needs must be addressed if the doctor wants to provide high-quality care.

Next, the guidelines make recommendations about individual therapies that have been found to be generally safe and helpful for specific problems. These include “mind-body” therapies, such as meditation; yoga, t’ai chi, and qigong; hypnosis; relaxation techniques, and music therapy, which can help improve anxiety, mood, sleep, pain, and anticipatory chemotherapy-induced nausea and vomiting (feeling nauseated just thinking about upcoming chemo). Massage therapy can be considered when anxiety and pain are not adequately controlled by standard care. For patients with compromised lung function, supervised exercised-based treatment is suggested. Acupuncture can be included for patients having nausea and vomiting from chemotherapy or radiation therapy, or pain that is not controlled by conventional treatment. A diet rich in nonstarchy vegetables and fruits and low in red meat and processed meat is suggested to reduce the risk of lung cancer. For patients who are losing weight or muscle mass, high-calorie and protein supplementations or omega-3 fatty acids are recommended, respectively.

These guidelines will help doctors feel more confident in answering patients’ questions about complementary therapies, knowing the current state of scientific data on these therapies. They will also encourage doctors to consider incorporating these therapies for patients who are not responding to treatment of bothersome symptoms or those who have too many treatment side effects. Keep in mind that none of the therapies will shrink cancer itself. But they can help reduce suffering and strengthen resilience, which, in quality cancer care, is equally important as treating the cancer itself.

So if you have questions about or are using complementary and alternative medicine, we encourage you to let your doctor know. Doing so will keep everyone on the same page and reduce the risk of your taking something that may harm you. Meanwhile, you might want to take advantage of some of the safe and beneficial therapies that can make cancer treatment easier bear. If your doctor does not initiate the conversation and you are interested in these therapies, simply bringing up the subject will do you a lot of good.

Photo: Mark Hooper/Getty Images

The American College of Chest Physicians has a webpage dedicated to its lung cancer guidelines. For patient education materials on lung cancer, see The CHEST Foundation’s website, onebreath.org.

Gary Deng, MD, PhD, is an attending physician with the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York. His clinical expertise is in cancer supportive care and integrative medicine. He served as topic editor of the chapter on integrative medicine in Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, released in May 2013.

 

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“Paging Dr. House!” What Is Sarcoidosis?

by Cecilia M. Smith, DO

Sarcoidosis is an elusive disease. Even the TV series “House,” about the brilliant (but surly) Dr. Greg House and his team of brilliant (but demoralized) subordinates, picked up on that fact. Faced with the weekly challenge of diagnosing a mysterious and deadly disease, at some point during each episode, one of House’s protégés inevitably would suggest, “Maybe it’s sarcoidosis.” And with the disease’s wide variety of symptoms, the many organs it can affect, and the other diseases it can mimic, it was perhaps a diagnosis worth considering.

April is National Sarcoidosis Awareness Month, a good time to learn about this puzzling disease. It is often thought of as a lung disease because the organ most commonly involved is the lungs. But it can affect any organ of the body, such as the lymph glands, eyes, skin, liver, or salivary glands, without causing lung disease. In other cases, only the lungs are affected, a condition called pulmonary sarcoidosis. Pulmonary sarcoidosis can reduce the amount of air the lungs hold and cause breathing problems.

Sarcoidosis is characterized by granulomas—tiny lumps of cells that cluster together in a unique way within the tissue of the organs involved. To help the doctor diagnose the disease, the tissue must be biopsied and examined in a laboratory, and this unique cluster pattern must be present.

To complicate the matter, sarcoidosis is not the only disease associated with the formation of granulomas in tissue. Granulomas can also occur in certain infectious diseases and environmental/occupational exposures. So if granulomas are found, further investigation is needed to determine which disease is causing them.

What causes these clusters of cells to form is not known. Researchers suspect that exposure to certain substances may cause a reaction within a person’s immune system, but they don’t know what those triggers are.

Researchers do know that there is nothing a person “does” to cause sarcoidosis. It is found in every sex, age, race, and country of birth, although it occurs more commonly in Northern Europe and, within the United States, among African Americans. It affects younger adults, between 20 and 40 years of age, more than the very young or the elderly.

Diagnosing sarcoidosis can be tricky. Symptoms can vary widely, depending on the part of the body involved, or there may be no symptoms. When symptoms occur, they may be vague and not specific to sarcoidosis—such as weight loss, fever, depression, night sweats, and sleep problems. If a doctor is not considering it as a possibility, it is likely to be missed or misdiagnosed.

There is not one definitive test to diagnose sarcoidosis. A good history and physical is essential, including family members’ health history. It is important for the patient to mention even vague symptoms, as they could possibly be a clue. Further testing will focus on the organ of the body involved.

Once a diagnosis of sarcoidosis is established, not all individuals require treatment. It depends on which organ of the body is affected. For instance, when the eyes are involved, drug therapy is required. When the lymph nodes are involved, however, no therapy is needed. Treatment is aimed at reducing symptoms and preventing organ damage. Because sarcoidosis can clear in the lungs without therapy, there is some controversy among medical professionals as to when to treat for lung involvement.

Like everything else with this disease, prognosis for people diagnosed with sarcoidosis varies. Many individuals live a long life, while in others the disease progresses and causes organ damage. In rare cases it can be fatal. Comedian Bernie Mac died from complications of sarcoidosis in 2008.

For more on sarcoidosis, including information on living with the disease and chapters on specific organ involvement, see “Sarcoidosis: A Primer,” electronically published by the American College of Chest Physicians. Too bad Dr. House and his team didn’t have access to this great resource!

Photo: Fox TV

Cecilia M. Smith, DO, is a Clinical Professor of Medicine at Jefferson Medical College in Philadelphia and chairs the Department of Medicine at Reading Health System in West Reading, Pennsylvania. She served as co-editor of “Sarcoidosis: A Primer,” published by the Interstitial and Diffuse Lung Disease Network of the American College of Chest Physicians.

 

 

 

 

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DSPD: A Sleep Disorder Common to Plugged-In Teenage “Night Owls”

by Harish Rao, MD, MBBS

All of us have an “internal clock” or circadian rhythm that regulates our sleep and wake cycles. For most of us, our internal clock is more or less in synch with the natural day/night cycle, which is why we sleep at night and are awake during the day. But for some people, that “internal clock” is shifted late. The problem usually presents as trouble falling asleep at night and trouble waking up in the morning, especially for school or work. These people are often called night owls or, worse, lazy.

Sound like any teenagers you know? The disorder is common among adolescents, although it can occur at any age. One study reported a prevalence of 1 in 1,000 people, but it is several times higher in adolescents. Sometimes called night-owl disorder, the actual name of the problem is delayed sleep phase disorder, or DSPD.

This shift in the internal clock most often occurs when a person’s weekday and weekend wake-up times differ by more than 1 or 2 hours, and may be aggravated by daytime naps and caffeine. In many individuals, DSPD is a genuine neurological disorder with a probable genetic basis. These individuals live in a state of sustained jet lag. They are often thought of as lazy or irresponsible, as it is difficult for others to understand that the abnormal sleep hours are out of the sufferer’s control.

Among teenagers and young adults, PSPD is often a “social malady,” the result of chronic late-night exposure to electronic and social media compounded by peer pressure to be connected at all hours. But biological changes during adolescence can also contribute to the problem. Many sleep experts have been calling for delayed school start times for adolescents to address this concern.

Many people try to cope with DSPD by forcing themselves to keep a normal schedule (ie, waking earlier than desired by the internal clock), leading to sleepiness/grogginess on waking as well as a chronic sleep deficit. This sleep deficit manifests as fatigue, depression, and inability to focus at work or school. DSPD symptoms are frequently misdiagnosed as insomnia, chronic fatigue syndrome, or attention deficit disorder.

To address the problem, wake-up time must be controlled to help re-set the internal clock. Sleep charts and actigraphy (watch-like devices with motion sensors that can monitor rest/activity cycles) are extremely useful in tracking an individual’s sleep schedules. Use of low-dose melatonin at night and well-timed exposure to light in the morning (either daylight or a light box) corrects the problem in many individuals. A light box (with light intensity of 10,000 lux) is useful during times when daylight is scarce, such as during the winter in many parts of the world.

Sleep phase chronotherapy is used in more difficult cases with close monitoring by a sleep physician. During chronotherapy an attempt is made to move bedtime and rising time later and later each day, around the clock, until the person is sleeping on a normal schedule.

Good “sleep hygiene” is then required to maintain an appropriate sleep/wake cycle:

• Wake up at the same time every day to readjust internal clock.

• In the morning be up, active, and exposed to bright light, and eat breakfast. Being active sends the brain a strong message that it is morning, and will help your body clock adjust.

• Have a calm bedtime routine, such as reading with a dim light for 15 minutes before turning out the light. Turn off music before falling asleep.

• Avoid bright lights and TV, computer, cell phone, or other screens for 1 to 2 hours before bedtime. Keep all screens outside of the bedroom.

• Avoid caffeine after 12:00 pm (coffee, tea, chocolate milk, cola, energy drinks).

• Avoid daytime naps.

Important tip for parents of night-owl adolescents:

• Do not let your child’s weekday and weekend wake-up time differ by more than 1 or 2 hours.

• If your child’s sleep schedule is off during vacation, you can correct the schedule by bringing wake time forward by 30 minutes every 2 or 3 days.

And be sure to see a sleep physician if you are a “night owl” and are struggling to correct your sleep schedule.

Learn more about healthy sleep habits and sleep disorders, and explore our collection of useful links and resources at onebreath.org. OneBreath is an initiative of The CHEST Foundation, the philanthropic arm of the American College of Chest Physicians.

Photo: Bruce Rogovin, Photolibrary

Harish Rao, MD, MBBS, is a Fellow at the Center for Pediatric Sleep Disorders at Boston Children’s Hospital. He sees four to five patients with DSPD each week.

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Confessions of an Ex-Smoker Part 2: Celebrating One Year!

by Steve Storms

It’s Wednesday, “hump” day. For me, this particular Wednesday – March 27, 2013 – marks a more significant “hump” than usual. For today I have been cigarette-free for 365 days.

After all my previous failed attempts at quitting, I have to admit that I had serious doubts that I could succeed. But quitting smoking proved to be easier than I thought it would be, once I really and truly made up my mind to quit.

It’s a cliche, but I will say it anyway: If I can do it, so can you. It takes making a vow to yourself and keeping it. You have to really want it. You have to be serious about it. You have to be strong, very strong. But it’s worth it.

I smoked my first cigarette when I was 12 years old, and smoked for 46 years. For those keeping score, that means the underdog nonsmoking team is still way behind: Smoking Years: 46  – No-Smoking Years: 13.

But the underdog has grit and determination on his side. If I am lucky and blessed, the game will last long enough for me to at least even the score. Only 33 more “humps” to go!

So today, join me in celebrating my one-year smoke-free anniversary. I am more than just a little proud of myself for remaining true to my vow.

Read Steve’s earlier post about his quit-smoking experience for inspiration, and for expert advice from the American College of Chest Physicians, check out the Tobacco Dependence Treatment Tool Kit. This great source of free information for people thinking about quitting or struggling to quit includes “Thinking about Stopping Smoking?” and “You Deserve to Stop Smoking Comfortably.”

 

Steve Storms works for IBM at Research Triangle Park, North Carolina, and is the team lead for Global Memory Procurement. In his spare time he plays with a Raleigh-based acoustic Americana band, the Gravy Boys.

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