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CORSO DI AGGIORNAMENTO
“I FENOTIPI DELL’ASMA’ ”
Arenzano 16 Febbraio 2008
Exercise-induced
bronchospasm:
a different phenotype?
EIA è presente in circa il
70-80% dei bambini non in
terapia con steroidi inalatori
L’asma da sforzo allontana i
bambini dallo sport!
Exercise training on disease control and quality
of life in asthmatic children
Fanelli A, Med Sci Sports Exerc 2007
In trained children:
• physiological variables at peak and submaximal exercise
• Severity of exercise-induced bronchoconstriction (EIB) and
postexercise breathlessness
• Pediatric Asthma Quality of Life Questionnaire (PAQLQ)
scores
• Daily doses of inhaled steroids
Exercise-induced asthma (EIA), connotes transient
airflow obstruction associated with physical
exertion.
1962 : Jones and collegues reported that the effect of exercise on the
asthmatic airway was dependent on the duration of activity.
•Being unfit
•Breathlessness in the overweight/obese
•Vocal cord dysfunction
•Exercise hyperventilation syndrome
Exercise-induced vocal
cord dysfunction
Pseudo-asthma: when cough, wheezing,
and dyspnea are not asthma.
Weinberger, Pediatrics Oct 2007
Exercise-induced vocal
cord dysfunction
Although most
exacerbations are self-
limited or subside readily
with medication, sudden
fatal asthma exacerbations
occur in both competitive
and recreational athletes,
and can be precipitated
by sporting activity
15 – 14%
579 ch.<12 yrs
playing
10 –
baseball
or soccer
5 –
80/579
Parents
reported
0
asthma
A PILOT SURVEY OF ß2-AGONIST INHALER AVAILABILITY FOR
CHILDREN WITH ASTHMA DURING ORGANIZED SPORTING EVENTS
Cardona Ann. Allergy Asthma Immunol. 2004; 92: 340
reported 0
asthma
History
Free-range running
Frequency and Severity ( 47% PEF )
Swimming,kayaking,walking ( 15%)
Anderson, Br J Dis Chest 1975 ; Fitch, JAMA 1976
For many years, it was generally assumed that this was
EFFECT OF EXERCISE TYPE
because the severity of exercise was also different.
Free-range running
Is the increase in ventilation produced
Frequency and Severity
by exercise and not the kind of exercise
( 47% PEF )
that is crucial in EIA
of EIA Running on a treadmill
Any exercise can lead to EIA if ( 33% )
it is performed hard enough or
Cycling ( 25%)
long enough to increase the
amount of air being inhaled
Swimming,kayaking,walking ( 15%)
Anderson, Br J Dis Chest 1975 ; Fitch, JAMA 1976
Asmogenicità delle attività sportive
(in ordine crescente)
Gruppo di studio di Broncopneumologia pediatrica (SIP), 1994
Nuoto Baseball
Pallanuoto Calcetto
Canottaggio Pallacanestro
Sci di fondo Tennis
Pallavolo Atletica leggera
(corsa veloce – 100 mt)
Arti marziali Calcio
Discesa libera Ciclismo
Marcia Corsa libera
Higher rates of hay fever.
Adverse effects on
the Clara cell
Indoor swimming pools, water chlorination
and respiratory health
80 – 76%
50 ch. 70 –
Chest pain in children
referred for 60 –
is rarely of
chest pain 50 –
cardiac origin
40 –
Physical 30 –
examination 30 –
and ECG 20 – 12%
10 – 8% 4%
0 –
musculo- EIB gastric psycogenic
skeletal problem
pain
Exercise-induced
Asthma :
Pathophysiology
Exercise-induced Asthma :
Pathophysiology
AIRWAY NARROWING
Anderson EJRD 1982; 63: 459 - Mc Fadden J. Clin. Invest. 1986; 78: 18
Anderson All. Proc. 1989; 10: 215
Increased urinary excretion of LTE4
after exercise
Maximal FEV1
decrease after
exercise in asthmatic
children with EIB at
baseline and after 3
days of treatment with
montelukast
INFLAMMATION
Airway
Hyperresponsiveness Airflow Obstruction
Percentages of
subjects with EIB
according to the
degree of blood
eosinophils
Cys-LT levels in
EBC of asthmatic
children with EIB,
asthmatic children
without EIB, and
healthy control
children
Anderson SD, Curr Allergy Asthma Rep. 2005 Hallstrand TS, J Allergy Clin Immunol. 2005
Role of MUC5AC in the
pathogenesis of exercise-
induced bronchoconstriction
Mucus plugs
Athletes and exercise-induced
bronchoconstriction
Same inflammation ??
JACI , June 2007
Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Prevalence of EIA
Hallstrand found 9% of school children had
EIA
Hallstrand TS, J Pediatr 2002
Method: sport-specific
challenge testing in
nonathletes
KEEPING CHILDREN WITH EXERCISE-INDUCED
ASTHMA ACTIVE Milgrom H Pediatrics 1999; 104 :38
100 -
90 -
% subjects with EIB 90%
80 -
70 -
60 -
50 -
40 - 40%
30 -
20 -
10 - 6-12%
0
General Rhinitis Asthma
population
subjects with
British study: EIA (>15% fall in FEV1) in 29/100
sequentially referred potential recruits with a
history suggestive of asthma in childhood but no
asthma symptoms or therapy in the last 4 years.
BAL obtained from dogs after the race had significantly higher macrophage
and eosinophil counts compared with sedentary control dogs
Exercise-induced
Asthma :
diagnosis
ASTHMA SCREENING OF HIGH SCHOOL ATHLETES: IDENTIFYING
THE UNDIAGNOSED AND POORLY CONTROLLED WITH FREE-
RUNNING CHALLENGE
Ann All Asthma Imm 2002; 88: 380
Modest specificity
(82%) and low
sensitivity (50%) of
children’s descriptions
Normal VCD
History and/or p.e. compatible
with EIA
Valutare il bambino
mediante test da
sforzo
Il test da sforzo appare particolarmente adeguato in età
pediatrica poiché rappresenta uno stimolo fisiologico che
riproduce circostanze di “vita reale”, quotidiane
Test da sforzo eseguito in
laboratorio
Tapis Roulant Bicicletta
4
Normal subject
FEV1 in Litres
3
Drop in FEV1 10% = positive test
2 Asthmatic patient
Spirometry
Exercise
1
0 8 14 20
Time in Minutes
EIB after different exercise loads
130
85% load
95% load
120
FEV1 % predicted
110
100
90
80
Salbutamol
inhalation
70 Exercise
-6 0 3 6 10
Minutes
130
The most specific test is to85%
test
load the
95% load
athlete in the field in
120
their sport;
This is more specific110than exercise
FEV1 % predicted
testing in laboratory (but temperature
and humidity cannot be100 controlled with
exercise in the90 field).
80
Salbutamol
Rundell, Med Sci sports
70
Exerc
Exercise
1999 inhalation
-6 0 3 6 10
Minutes
• 6min of hyperpnoea
– dry air 50
– 4.9% CO2
% Fall in FEV1
40
20
• Specific for diagnosis of EIA
(Rundell et al. 2004) 10
0
• Recommended by the IOC n = 22
6 min 6 min
EVH Exercise
IBAs USE SYDNEY vs ATHENS
Attuare la
prevenzione non
farmacologica
EIA:terapia non farmacologica
ALLENAMENTO INTERMITTENTE
Esecuzione,durante il
preriscaldamento,di sprint
brevi(10-12),della durata di 20-30
secondi,intercalati da periodi di
recupero di 1-2 min,per indurre FRANÇOIS-PIERRE COUNIL,
refrattarietà all’EIA senza J Pediatr 2003
provocare broncoostruzione
clinicamente significativa
ASMA DA SFORZO (EIA) - ALLERGIA
esposizione
allergeni
aumento
EIA
infiammazione
sforzo reattività
bronchiale
aspecifica
ASMA DA SFORZO ED INQUINAMENTO ATMOSFERICO
Bronchoconstriction in
asthmatics exposed to
sulfur dioxide during
repeated exercise.
Roger
J.Appl.Physiol. 1985
Pianificare la
protezione
farmacologica
TERAPIA E PREVENZIONE
DELL’ASMA DA SFORZO
1. Premedicazione
• ß2-agonisti
• Cromoni
• Montelukast
TERAPIA E PREVENZIONE
DELL’ASMA DA SFORZO
2. Terapia di fondo
• Steroidi inalatori
• Montelukast
TERAPIA E PREVENZIONE
DELL’ASMA DA SFORZO
1. Premedicazione
• ß2-agonisti
• Cromoni
• Montelukast
Long-acting beta-agonists
P = 0.0001
• Exercise at 1 and 12 hours
35
P = 0.0002
P = 0.0002
30
after drug, on day 1 and 28 25
20
ns
15
10
5
• ß2-agonisti
• Cromoni
• Montelukast
51%
TERAPIA E PREVENZIONE
DELL’ASMA DA SFORZO
2. Terapia di fondo
• Steroidi inalatori
• Montelukast
Bambini con broncostruzione indotta
da esercizio fisico
Inhaled corticosteroids
used for 4 weeks or more
before exercise testing
significantly attenuated
exercise-induced
bronchoconstriction
In asthmatic patients ICSs not only attenuate
exercise-induced bronchospasm but also improve
arterial blood oxygenation during exercise
JACI 2007
50%
• Studio in doppio
cieco (n=64)
Montelukast contro
placebo per 8
settimane, seguito
da crossover di
parte del gruppo
trattato (28/40) per
ulteriori 8 settimane
Prolonged Effect of Montelukast in Asthmatic Children
With EIB
Kim Pediatr Pulmonol, 2005
Assolutamente vietati
per via sistemica
-------------------------
macottini@alice.it