Exercise-Induced Asthma – PediaCast 427

Show Notes


  • Breathing problems should not keep kids and teens from playing sports! Dr Tom Pommering and Allison Strouse visit the studio as we explore best practices for identifying exercise-induced asthma, treating symptoms and supporting young athletes on the playing field. We hope you can join us.


  • Exercise-Induced Asthma




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. 

It is Episode 427 for March 26th, 2019. We're calling this one "Exercise-Induced Asthma". I want to welcome everyone to the program.

So spring has officially arrived, which means a lot of things. First, increasing temperatures at least here in the Midwest. I know many of you live in more temperate realms such as the southeastern United States and the southwestern United States and other coastal regions, where perhaps it has already been warm or maybe warm most of the year. But hey, here in the Midwest, in Ohio at least, we get excited when spring gets here and we start seeing temperatures in the 50s instead of the 20s. 

It also means that trees and flowers will be blooming pretty soon and that equates to increased pollen in the air. And of course then, it's that time of the year when may student athletes are heading outside with outdoor activities, running, track and field, softball, baseball, lacrosse, rowing, tennis. And then, of course, just other outdoor activities, you may be bicycling. Maybe not swimming quite yet, at least here in the Midwest or the East Coast. But soon, soon it will be warm enough that we'll be out swimming. 


And the combination of these events can spell big trouble for those suffering from asthma. Asthma often gets worse in the spring and with exercise. However, exercise and sports certainly remain important for our overall physical and mental health. So when asthma worsens with exercise, and for some, it really is only a problem during exercise, rather than seeing our student athletes give up or quit because sports are important, we want to help them. 

So it's going to be important to identify which kids and teenagers are having difficulty understanding the changes in their bodies that are causing the problem. So that's where the health literacy thing comes in, like we talked about last week. And then, of course, confirm that the trouble really is asthma related, which may come as a surprise to some families because their child may have never been diagnosed with asthma before.

And then, of course, we want to manage their symptoms in such a way that they can safely continue participating in sports and other forms of physical activity. 


So it's an important consideration as we think about health and wellbeing of our children this time of the year. And to help us consider the topic of exercise-induced asthma, I have a couple of terrific studio guests joining me. Dr. Tom Pommering is chief of Sports Medicine here at Nationwide Children's Hospital. And Allison Strouse is a certified athletic trainer, again here at Nationwide Children's. 

Before we get to them, I do want to remind you that we are on social media. It's really easy to connect with PediaCast, both on Facebook and Twitter, also on Instagram. Facebook and Twitter, we really try to share on a daily basis news stories that could impact your role as a parent and taking care of your kids and your family.

So we try to have a handful of news articles and stories, things that aren't necessarily on the podcast every single day. Maybe we skip a weekend day here and there, but we try to get some great information. 


So just as an example, here are some of the things that we recently shared on Facebook and Twitter. What was it like when mumps was rampant? This is just I think a look into the past and what was mumps really like. We've heard a lot about measles. The MMR vaccine protects against measles, mumps, and rubella. So what was mumps like when that was running around before the vaccine? Kind of interesting story from folks who are alive at that time. 

And then, perinatal death tripled in home deliveries compared to hospital births. So delivering your baby at home is three times as dangerous as giving birth in the hospital. And this article goes into little bit more detail on that. 

Another important one, as spring approaches, how to protect your kids from drowning? This is from the American Academy of Pediatrics. None of us want our kids to drown and this article has some great ideas to help prevent that. 


Child anxiety treatment may be best targeted at parents. So, of course, we're going to treat kids who have anxiety. But part of that overall treatment plan is also treating parents for their own mental health disorders but also helping parents really empower them to help their kids who have anxiety. To know what to say, when to say it, how to say it, and the best support your kids can really make a difference when your children are suffering from anxiety. So this article goes into more details on that. 

And then, mothers are drowning in stress because it's impossible to fulfill all of the ideals that are placed upon women both at work and at home. It just really gets to be overwhelming. And so, a lot of women are drowning in stress and this article addresses that nicely. This is very important for moms in the crowd. 

So just a little sample of what we like to share on Facebook and Twitter. And hopefully, we can connect with you there. 

We're also on Instagram. Just look for PediaCast. Instagram, more of a peek into the studio, a peek into my personal life. And love to see inside your life as well, so if you connect with us on Instagram, expect us to connect back with you so that we can see what's going on in your world. 


Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination. 

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

I also want to remind you, it is easy to get in touch with us. Just head over to pediacast.org and look for the Contact link, if you would like to ask a question or point us in the direction of a news article or even a journal article maybe that you've seen or heard about. Really, any idea for topic suggestion on your part is much appreciated as we plan for future shows. 


All right, let's take a quick break and then we'll get our guests settled in to the studio. And then, we'll all be back to talk about exercise-induced asthma. That's coming up right after this. 



Dr. Mike Patrick: Dr. Tom Pommering is chief of Sports Medicine for Nationwide Children's Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine.  

Allison Strouse is a licensed and certified athletic trainer at Nationwide Children's and assistant athletic trainer at Ohio Dominican University. 

Thanks so much to both of you for being here today. 

Dr. Tom Pommering: Thanks, Mike. We're glad to be here. 

Allison Strouse: Yeah.

Dr. Mike Patrick: Really appreciate you stopping by. 

So as we think about exercise-induced asthma, what do we mean by that term, Tom?

Dr. Tom Pommering: Exercise-induced asthma, also called exercise-induced bronchospasm, is a reversible airway constriction that during which a lot of times, exercise is the thing that causes it or stimulates it. And you can see that in athletes who do not have underlying asthma as well as those who do.

Dr. Mike Patrick: As we think about the term, exercise-induced asthma, it almost make it sound like exercise causes asthma which is not really the case, right? 


Dr. Tom Pommering: Exercise does not cause asthma but it can cause the airways to constrict and behave like asthma temporarily. 

Dr. Mike Patrick: So when you'd mention exercise-induced bronchospasm, also exercise-induced bronchoconstriction, so basically, there's a smooth muscle that lines the inside of the airway. And if that muscle tenses up, it can cause the airway to be a smaller diameter, so then it's more difficult for air to kind of flow through because it's a smaller tube rather than a bigger tube. Is that... 

Dr. Tom Pommering: Exactly. You can imagine if you exercising, that's the worst thing you want. 

Dr. Mike Patrick: Yeah, absolutely. And then, I think it is important really to drive this home that exercise is not causing asthma. It's a trigger for that bronchospasm or bronchoconstriction in patients with underlying asthma. Although, for some folks, their asthma might be mild enough that you don't really notice it until you exercise. But in every case, there's some degree of underlying asthma that's already there. 


Dr. Tom Pommering: So, yes and no.

Dr. Mike Patrick: Am I wrong?

Dr. Tom Pommering: Yeah. 

Dr. Mike Patrick: Okay, yeah, yeah, yeah, correct me, please. 

Dr. Tom Pommering: So I would tell you that for folks who have underlying asthma, up to 90% of them will have exercise-induced bronchoconstriction. If you'll get elite athletes, this exercise-induced bronchospasm or bronchoconstriction affects 10 to 20% of them, they do not have underlying asthma.

So the thought is that when you exercise, you move air in and out of your lungs at a rapid rate and it drives the airway and causes an inflammatory response that causes a bronchoconstriction. So those athletes, if you test them at rest, they don't actually have underlying asthma. So you can have both situations. 

Dr. Mike Patrick: And especially in elite athletes who are really moving a lot of air and trying out that airway. For those folks, it may be more likely for not to have underlying asthma as a component. 

Dr. Tom Pommering: Yeah, absolutely. If they're endurance athletes where they're just doing tons of air over a long period of time, that gives that airways plenty of time to dry out. Also, exercising in cold and dry environments may be a trigger. And then, sometimes even being exposed to environmental pollutants like a chlorine layer above the pool. Or an ice rink sometimes, the chemicals they use that resurface can affect skaters. So even those types of things can induce exercise-induced bronchospasm or bronchoconstriction. 

Dr. Mike Patrick: We're kind of stuck with this term, exercise-induced asthma because that's what everybody has called it for so long. 

Dr. Tom Pommering: It is definitely a more commonly used term. 


Dr. Mike Patrick: Especially parents and patients with this problem have heard of asthma before, whereas bronchoconstriction and bronchospasm are kind of bigger more complicated words, even though they describe it a little bit better. 

Dr. Tom Pommering: Exactly. 

Dr. Mike Patrick: Another study that I came across as I was prepping for this show was that decreased physical activity is actually a risk factor for the development of asthma. So in some kids, actually being active can perhaps prevent or lessen the degree of asthma in children. 

Dr. Tom Pommering: Yeah, I'm glad you brought that up, Mike, because we don't want people to avoid exercise if they have asthma. In fact, a lot of times, it's really helpful for their treatment as long as their asthma is controlled. They need to condition those breathing muscles just like we need to condition our muscles for exercise. 


And then, Allison, as an athletic trainer, is this something that you see pretty commonly as you're dealing with student athletes? Is this something you come across? 

Allison Strouse: Yeah, definitely. So I think just about every team I've ever worked with, we have at least one kid that struggles with exercise-induced asthma. More often than not, they're able to have it under control pretty well, but it's definitely very common. We see a lot, especially with like Dr. Pommering said, athletes who are working out in colder weather. 

Dr. Mike Patrick: And the cold weather because the air is dryer and it really dries out the airways. And then, that causes that inflammatory response and irritation.

Allison Strouse: Yeah, absolutely. 

Dr. Mike Patrick: And then, really, when you think about this, from an athletic standpoint and universities and colleges, I know you work with Ohio Dominican, those are maybe more high level. Maybe not elite to the point of like Olympics, but do you find at that level, you're seeing more of this compared to middle school and high school students? 


Allison Strouse: For me, I don't know if I see necessarily more or less. I do know that a lot of the times the kids that come to me working collegiately had already been diagnosed. So in my experience, it's typically something that presents a little bit younger. By the time they're in collegiate athletics, it's kind of already there. 

Dr. Tom Pommering: Yeah, I think it's hard to know. But probably the instance is similar, I think where people are always surprised at is how the elite level athletes make it to where they are with the diagnosis of exercise-induced asthma. So it can be managed and controlled. 

Dr. Mike Patrick: That's a really good point. The prevalence at the Beijing and Athens Summer Olympics, if you took all of the folks in various sports at those summer Olympics, it ended up being swimming, 18% of the athletes basically said, "Hey, I have this, so I need an exemption to be able to use my medicine to control it appropriately." So 18% of swimmers, 16% of cyclists, 13% for pentathlon, and 12% for triathlon, 7% for rowing. 


And in those particular sports, you're really moving a lot of air in and out, right? 

Dr. Tom Pommering: Exactly. 

Dr. Mike Patrick: And so, you're going to have more of that irritation of the airway to cause that bronchoconstriction.

So let's talk about actually sort of at the cellular level is, what is causing this? 

Dr. Tom Pommering: So it still remains a little bit of a debate, but the main theory right now is the airway gets dried out just from frequent ventilation. It dries up the airway and it causes release of chemical mediators that will cause inflammation and constrict the airways. So that's the prevailing theory. 

There's another theory about changing the temperature of the airway, but I think most people feel like it's more of a drying effect. 


Dr. Mike Patrick: And especially in the springtime, for folks who are outdoors, a lot of people in addition to their asthma also have allergies. And those allergies, the allergens that you're reacting to are trigger not only for runny nose, itchy eyes and that, but also for their asthma. And so, if you're outside running during track and field and it's also your pollen season, that's really going to add to this problem. 

Dr. Tom Pommering: Yeah, for sure. I think if you have underlying allergies or chronic sinus issues, you need to get those managed. Otherwise, it's tough to manage your exercise-induced asthma. And there are things you can do.

And there are things you can do. Pollen counts are highest in the morning, so maybe move your exercise to later in the day. 

Dr. Mike Patrick: Yeah, that can be helpful. 

Allison, what does this look like then? You have a student athlete and maybe they aren't aware that they have a problem with this. Now, what does it kind of look like in the individual athlete that could get your radar up that, "Hey, this may be a problem that we can help with you?" 


Allison Strouse: So the first thing that I typically notice is that the coughing and then you start to hear them catching their breath. And hopefully, it doesn't get to this point, but when they start wheezing for sure, especially if they have underlying allergies. But it starts off with kind of cough, starting to struggle, catching their breath.

A lot of times, they'll come up to me and say, "Hey, I've really struggled today at practice. I'm not sure if you noticed. But my chest feels really tight. I'm having a hard time catching my breath. This is really new for me." And then, we can start having that conversation about, "Okay, well, what's going on?" And hopefully, we can get them a referral to one of our doctors. 

Dr. Mike Patrick: I mentioned this could be a little bit difficult especially at the beginning of a season because some of these kids aren't conditioned for whatever sport that they're going to be involved with. And so, they may be out of breath or feel like they have a little trouble breathing. But that cough and wheezing part of it kind of distinguishes this to some degree. 


Allison Strouse: Yeah, definitely. Especially once they start having a hard time catching their breath and they start getting those wheezing symptoms, that's typically not just being out of shape. 

Dr. Mike Patrick: Now again, I really didn't know a lot about the nuts and bolts and details of this disorder until I started prepping it for this program. But I found something. And we do have a considerable number of physicians who listen to PediaCast. And I think they'd be interested to know that, initially, folks who have this, there may be in the first few minutes actually some bronchodilation, which increases the movement of air. But then, that bronchoconstriction kicks in and peaks at about 10 to 15 minutes of exercise. 

So usually, you are going to see this. It's not like you've been exercising for an hour and you see that it's usually within a few minutes. And then, for a lot of the kids by an hour out. So if you're really in more of an endurance kind of sport, like you're playing soccer or lacrosse or field hockey that it can actually even get better by about an hour out because you start to make some inhibitory factors, prostaglandin. And then, you can have a refractory period. 


And then, repeated exertion causes less bronchoconstriction. So it seems like it's more of a problem within the first half hour, but maybe it gets better even naturally on its own as you exercise? 

Dr. Tom Pommering: Yeah, I think that's true. As long as you're not exercising in an environment that's really cold or polluted or full of environmental allergens, knowing that physiology, sometimes people can actually induce refractory period in a preventative way if they will do some exercise, warm-up that's fairly vigorous before their actual competition. And sometimes, they can induce refractory period up to a couple of hours. 

Doesn't work for everybody, but it's a really simple thing to try and there's no medication or danger involved. 

Dr. Mike Patrick: That's really interesting. And with that, you'd probably want to do it in like warm air, maybe indoors if you're going to be outdoors, that sort of thing. 

Dr. Tom Pommering: Yeah, exactly.


Dr. Mike Patrick: So that your initial symptoms aren't quite as severe. 

Dr. Tom Pommering: Right. 

Dr. Mike Patrick: But you'll still get the refractory benefit. 

Dr. Tom Pommering: Yeah, hopefully, you will. I mean, again, it doesn't work for everyone but it's worth trying. 

Dr. Mike Patrick: We mentioned one in terms of just not being conditioned, what are some other processes that could cause similar signs and symptoms? So what's in our differential diagnosis when we have a kid who's having some trouble breathing with exercise? 

Dr. Tom Pommering: That's really an important question because we want to think about other things so that we don't miss something more serious. Certainly, cough and wheezing and feeling shortness of breath or tightness are common symptoms. But we want to make sure that someone isn't having cardiac symptoms such as syncope or pre-syncope, feeling that they're going to pass out with exercise, palpitations. 

You want to ask about family history of cardiac disease, especially early death before the age of 50 or arrhythmias or unexplained drowning. 

So you do start out with a broad approach to this. Other things that sort of really mimic exercise-induced asthma are something called vocal cord dysfunction. And this will really look and sound like asthma, but what it is is the vocal cords are actually closed when they should be opening while you're breathing in. And it makes that stridor's high-pitched wheezing type noise. 


But when you listen to their lungs, they sound good. And when you do testing on them, they don't have any abnormal lung function. So that's something that's often mimicked, probably the most often mimicker of exercise-induced asthma. 

Dr. Mike Patrick: And with that particular one, you still feel like they have some difficulty breathing even though they're moving air just fine, right? 

Dr. Tom Pommering: Yeah, they're convinced that they're not getting air in, but if you actually look at them, they're pink and warm in there. If you had a pulse ox, their oxygen levels will be perfect. But they really kind of creates a lot of anxiety and panic, and it feels like asthma to them. 

Dr. Mike Patrick: And then, you can actually have exercise-induced anaphylaxis where you can actually go into more of an allergic shock kind of thing. But fortunately, that's rare. I mentioned it because folks may come across seeing that as they're researching this. 

Dr. Tom Pommering: Yeah, definitely rare, but in much more seriousness. Folks will present with more hives and itchiness and rash and more anaphylaxic types of symptoms, as well as breathing issues. 


Dr. Mike Patrick: And then, other folks may actually have some reflux issues when they exercise. So some stomach acid comes up, and then that can also irritate the airway. But it's not quite that you'd treat that a little bit differently than you would exercise-induced asthma but also could cause similar signs and symptoms. 

Dr. Tom Pommering: Yeah, absolutely. So again, when you're doing your history, ask about reflux symptoms and dyspepsia and if they take in acids, or if they need to take something like that. 

Dr. Mike Patrick: So the take-home here is that make sure that you talk your student athlete's medical provider because they're going to know all these other things that it could be and really sit down with and get a good history, and take all those data points into consideration as they try to figure out exactly what it is that's going on. 

But as you mentioned, heart stuff is a concern, especially if you have syncope or passing out or feeling dizzy or lightheaded. That could be a concern. Although also not hydrating enough, not enough water can also cause similar symptoms to that. 

Allison Strouse: Right. 

Dr. Mike Patrick: And chest pain, obviously, would be very concerning, especially if it comes and goes and it's related to exercise. 


Dr. Tom Pommering: Right. And the symptoms often overlap. So if there's any concern about a cardiac issue, we really attack that first and work that up before we start talking about exercise-induced asthma. 

Dr. Mike Patrick: So then how do you go about making the diagnosis that exercise-induced bronchospasm or bronchoconstriction, those muscles tightening up and narrowing the airway, how do you determine that really as what's going on? 

Dr. Tom Pommering: So it is really important to establish that diagnosis because historically, basing the diagnosis on symptoms reported by athletes is notoriously inaccurate. And that seems a little counterintuitive because we make a lot of diagnosis based on what patients tell us when we take a careful history. But they often are not good historians when it comes to this, so you really need a confirmatory test. 

The main test that we use is an exercise breathing test where we actually measure how much air they can push out in the first second of their expiration called the FEV1 and then we use that as a baseline. And then, having them exercise until they become symptomatic and check them again. And then, give them a trial of a bronchodilator or a typical asthma inhaler and then check them again. 


So you need to see a drop in at least 10, preferably 15% of their FEV1 to establish that diagnosis accurately.

Dr. Mike Patrick: We're going to talk about treatment here in a moment, but having that accurate diagnosis is not only important, of course, to identify the correct problem and treat it correctly. But also I would imagine that if you're taking medications that help you perform at sports better, that there would be a reason why schools and athletic organizations and, of course, the International Olympic Committee would really want an actual diagnosis. 

Dr. Tom Pommering: I think Allison can comment on that from the NCA perspective? 

Allison Strouse: Yes. So anytime we have athletes that come in and we go through their physical, we look at that. Always to look at NCA red flags that we might see. Asthma will always be something that comes up. So we need to have them have a written documentation from their healthcare provider stating, "Yes, I have asthma. This is what I'm taking. This is how much I take," just through the NCAA to make sure. 


Because it can increase your heart rate and it can be used to help performance. So we need to really make sure that they are not abusing that. 

Dr. Mike Patrick: So you really want the diagnosis. It's important. 

Allison Strouse: Yes. 

Dr. Mike Patrick: Something else I thought of, when you do the exercise test, I would imagine that it's inside a controlled environment with nicely humidified air. Could you have sort of false negative test. But then, when someone is outside and dry air and cold air really is a problem, how do you differentiate that? 

Dr. Tom Pommering: Yeah, that's a good point because we are definitely creating an artificial environment to do these tests in all these athletes. The elite athletes especially have super normal pulmonary function. So they can pass the test under perfect conditions, but when you take them out into their exercise environment, they can become symptomatic.


So when you hear that story, they are not making that up. It's probably true. And so, there are other confirmatory tests that we can do in the laboratory that can tease out that diagnosis.

It's a little bit tough to test them on site, at the field. But if you have pulmonary equipment you can do that. But again, you really want to have pulmonary function machine to do the testing to make sure your measurements are accurate, not just based on what they're telling you. 

Dr. Mike Patrick: There are some kind of interesting ways that folks can then artificially irritate the airway to try to mimic this. And one is having a higher degree of carbon dioxide in the air that they breathe in.

I have read about that Mannitol powder, which we think a mannitol is like treating, preventing cerebral edema or brain swelling in folks with diabetes. But the powder can be irritating to the airway in much the same way that dry air can be. So that was one I've read. 


Is that the sort of thing you guys do? Or this is more now we're talking only elite athletes where you really need the diagnosis documented. 

Dr. Tom Pommering: Yeah, if an athlete's competing internationally and their governing body requires specific diagnosis for asthma to allow them to take a medicine that may or may not be in the banned list, they have to get one of those more sophisticated laboratory tests. And we don't do those. Those are done at our main hospital through the pulmonary department.

So you have to search around. There's not a lot of labs that do that level of testing. But the traditional pulmonary function stress tests are done, that's what we do. That's what were done, probably more widespread. 

Dr. Mike Patrick: And for the vast majority of especially student athletes, that's going to tease out who has this problem and who doesn't.

Dr. Tom Pommering: Yes. Right. 

Dr. Mike Patrick: So let's say that you've done an exercise challenge test in a kid with typical symptoms of exercise-induced asthma. So we've arrived at that diagnosis. How then do we go about treating this condition? 

Dr. Tom Pommering: Well, obviously, we talked about prevention to the degree that the athletes have control over their practice environment. They always don't. Sometimes, they're at the mercy of when their team practices and where they practice. But if they're training on their own, we try to get them train in less dry, less cold environments. 


We talked a little bit earlier about a little bit of pre-exercise warm-up to try to induce refractory period. But beyond that, we will add inhalers. Either a typical asthma inhalers like albuterol type medicines beta-agonists. You can also take inhaled steroids and there are some other oral tablets that will sort of prevent that immune response. 

We'll just start with the inhaler about 20 minutes before exercise. It's important to teach them how to use that inhaler correctly so that more medicines get into their lungs and not down their throat or use a spacer. 

Dr. Mike Patrick: Tell us about the spacer, Allison. Do you have difficulty convincing student athletes to use one?

Allison Strouse: Right. So a lot of the athletes that we have with inhalers actually don't have a spacer. So you have to educate them. You can still use your inhaler but you have to do it a little bit differently than what you would think. 

So when you use the inhaler, I guess Dr. Pommering kind of mentioned what can happen is if you put it right up to your mouth and you don't inhale quickly enough, it can just hit the back of your throat. And you really need to have that medication go into your lungs. 


So what we recommend to them is actually hold it just a little bit outside of their mouth. And what a lot of people forget is before you take your inhaler, you're supposed to fully exhale and then inhale right before you administer the medication. So that you're inhaling it and it's not just spraying the back of your throat. 

Dr. Mike Patrick: And so, the inhaler, if you use a spacer, it attaches to the spacer. And then, when you do the puff, the spray itself isn't going into your mouth that's aerosolized into that chamber of air. And then, when you suck that air in, you're more likely to get the medicine down into your lungs. 

And like you said, you want to breathe out first so you can fully breathe back in to get all that medicine down to your lungs.

Allison Strouse: Yeah. And then, typically, you're encouraged to hold your breath for that ten seconds before exhaling again. 


Dr. Mike Patrick: Now, folks will hear do two puffs. Do you do two puffs like right away? Do you wait in between? How does timing work with using an inhaler? 

Dr. Tom Pommering: Well, I always tell them, use the amount that works. I think it is good to wait. It's hard to make people... You can tell them to wait a minute, but they won't always wait a minute. I usually don't have them use more than two puffs. And then again, timing, 20 minutes before the exercise. 

The other thing I would mention is sometimes athletes overuse their inhalers. Because there is an anxiety component to feeling like you can't breathe and so, they want to grab their inhaler every time they feel out of breath. So it's important to teach them the difference between you just did a really hard exercise and you're supposed to be short of breath versus you're not performing well because your airways aren't open. 

Dr. Mike Patrick: And that could be tricky. 

Dr. Tom Pommering: Yeah, it really can be. So that's where our great athletic trainers like Allison come in who are at the sideline, at the courtside. They know these athletes really well and they can kind of help educate them and coach them through that process. 


Dr. Mike Patrick: And for a lot of these kids who do have underlying asthma, so they don't only have symptoms when they exercise, they may have some other medicines that their healthcare provider have them use to control their asthma including inhalers. 

So the bronchodilators that we're talking about, things like albuterol or Xopenex, those a couple of the brand names that folks have heard of, it's important to distinguish those from controller medication, so like steroid medicines. 

Talk a little bit about the difference between rescue inhalers and controlling inhalers and why it's so important for families to understand the difference between the two. 

Dr. Tom Pommering: Yeah, well, the main importance is if you overuse your rescue inhaler, it won't work anymore. There's this thing called downregulation that will happen and inhaler doesn't work. And then, they keep using it more often, thinking they need more medicine. It just continues not to work. So it's not important to not overuse your rescue inhaler. 

Your control medicines are the medicines that kind of control your baseline asthma, if you have baseline asthma. They are going to be either different types of steroid inhalers or long-acting beta-agonists inhaler. They may be other oral medications that you take, but you need to keep those... Those are taken regularly whether you're exercising or not. 


And then, the medicines that you use before or during exercise are your rescue medicines. 

Dr. Mike Patrick: And those controller medicines are really aimed at decreasing inflammation, which is a longer process. So when you do that inhaler, you're not going to get immediate relief like you do with the rescue inhaler which is actually relaxing the muscle to make the diameter of the airway bigger so the air can flow in and out. 

But when you have the controller one and you're trying to deal with inflammation, that takes being on day in and day out over much longer period of time for it to work. 

Dr. Tom Pommering: Yeah, exactly. So it is important for them to know which inhaler does what so they're grabbing the right inhaler.

Dr. Mike Patrick: And then, there are medications that can be used to treat asthma as well. I would imagine that some of those are also helpful with exercise-induced asthma, too. 


Dr. Tom Pommering: Yeah, there are few that cross over. Certainly, inhaled steroids or inhaled corticosteroids are helpful. There are some different medicines  like leukotriene, receptor blockers that will help as well.

But there's just a few that we use for exercise-induced asthma when that's their main problem. Of course, the kids with chronic underlying asthma will have a larger array of medicines that they will take as controller medicines. 

Dr. Mike Patrick: And I wonder if you get asked these questions sometimes, but as I was researching this, this came up a few times over and over on the internet. So I'm sure that families come across this. And that is dietary modifications for exercise-induced asthma, even for athletic performance enhancers. 

Is there anything with diet? Omega-3 fatty acids came up, vitamin C, lycopene supplements. Is there any evidence to support that modifying diet could help? 

Dr. Tom Pommering: So that stuff does pop up in the internet really often and right now, there isn't a lot of great evidence that that will work. Now, if those things are ingested in reasonable amount, it's not harmful, but I don't think that's usually our mainstay of treatment. 


Dr. Mike Patrick: And so, certainly, you'd want to have that rescue inhaler available and that's what really going to help the most. And we know that it's going to help, and we know that it's safe, has been used for many, many, many, many, many years, right? 

Dr. Tom Pommering: Exactly. 

Dr. Mike Patrick: In kids with good safety profile. 

So we talked about the importance of treating this. What are some of the consequences of poorly treated asthma in student athletes? What are some of the things you see, Allison, in terms of kids who struggle with this? And you know that they could have better control. What are some of the consequences that they face? 

Allison Strouse: The most basic would just be struggling to do well in their sports. So the kids who continually are not keeping up with the rest of their athletes, the rest of their teammates, and just the underlying struggle that they have day in and day out. 


That's why it's so important to make sure that we educate them and tell them that, "Hey, these are steps that you need to take. If you do that, you'll be successful. And don't leave your inhaler in your locker room." 

Dr. Mike Patrick: Yeah, absolutely. And I suspect that there are some folks who are not athletes, who would have been, could have been, but they did give up because they just thought, "I'm just not built to be an athlete." And so they got discouraged and quit and their life may be completely different had they continued on with good treatment. 

Dr. Tom Pommering: Yeah, certainly kids who are just getting involved in a sport that's very rigorous, an endurance-based sport. If they can't keep up or don't do well and no one puts together that their coughing or their out of breath is really could be sign of exercise-induced asthma, then they sort of give up and don't do that sport, maybe any sport. And we know that exercise is so important for our general health and we want it to be a life-long activity. 

Dr. Mike Patrick: Yeah, so there really are even quality of life kind of issues at play here in identifying these kids and getting them the appropriate treatment that they need. 

Dr. Tom Pommering: Exactly. 


Dr. Mike Patrick: And then, Allison, what is the role of the athletic trainer in identifying and educating and supporting these athletes? It seems you're like frontline in terms of figuring what's going on and making sure these kids are getting the treatment that they need. 

Allison Strouse: Frontline is the exact word that I was going to use. So yeah, we're there every practice, every game. We see these kids day in and day out. And we have a relationship with them, we know what's kind of considered normal. So when we do have a kid that we see as really struggling we're able to identify those potential symptoms. And then have that conversation with them, talk to them about what they're feeling. And then, from there, we can get them the referral that they need. 

And I think the education piece is super important because when an athlete is struggling, the first thing they want to do is understand what's happening to their body. And helping them understand that they're not just out of shape and this is something that's happening to them, so it gives them ownership of their body. 


I would imagine that it can be tricky with how you approach this because some student athletes may be embarrassed by the fact that maybe they're not performing as well as their expectations are or their coaches expectation. And then, when you mentioned it could be a health related issue, do you sometimes get folks sort of clamming up and not wanting to discuss that? 

Allison Strouse: My experience honestly has been kids are very often about talking with us about it. Usually, we build that relationship of trust with them. But for the most part, in my experience, they're worried more often than not, and they really want to make sure that they're okay. So they come to you expressing these symptoms and really want the reassurance that they're going to be taken care of. 

Dr. Mike Patrick: That's fantastic. 

Dr. Tom Pommering: I think you see both extremes. I think, luckily, Allison, her colleagues really develop great rapport with their athletes, so they're more likely to report things to them. But across, pretty much all age spans at all levels of competition, from amateur to elite, we have kids always say, "I didn't say anything because I didn't want you to hold me out." 

Allison Strouse: That's true, too.  


Dr. Tom Pommering: So there is that going on. So the stress of not performing as well as they think they should often causes them to seek out their own resources and treatments. And those aren't always the best thing.

Dr. Mike Patrick: And so, it's really important for athletic trainers to have a good eye for this because you may be identifying kids who are struggling, who aren't coming to you or making a big deal of it. 

Allison Strouse: Yeah, absolutely. Again, really building a relationship with the kids that you're working with whether they're younger, middle-aged, or if you are working with elite athletes who are older, just being able to recognize that. And that's what our job is, that's what we're specifically looking for. 

Dr. Mike Patrick: I'm a little bit of out touch with the high school environment in terms of athletic trainers. Are you guys at every school, everywhere across the country, or are there schools who do not have athletic trainers? 

Allison Strouse: Yeah, there schools that do not have athletic trainers. And we're still in March, which is still athletic training month. 


Dr. Tom Pommering: Across the country. 

Allison Strouse:  Across the country. Shout out to my fellow athletic trainers. But we are really pushing on education and the importance of having an athletic trainer every event. Because exactly what we are saying, we are there specifically to look. We're not there to watch the game, even though we want our teams to win, obviously. But that's what we're there for, to recognize emergency situations and therefore, injuries. So we're really there to help save lives. 

Dr. Mike Patrick: And this is an area where parents who are listening could really be an advocate within their school district and ask that question, "Hey, is there an athletic trainer in the sport that my child is participating in?" Or just sports in general at that school. And are they at events? You can be the squeaky wheel that perhaps get athletic trainers at your school and at these events and involved with sports, if that's not the case. 

Allison Strouse: Exactly. And having an athletic trainer at a school is so so important because we build those emergency action plans. In a worst case situation, there should be a plan in place. And if there's an athletic trainer there that's help to establish that, that can save lives. 


Dr. Tom Pommering: Yeah, the athletic trainers are often the first responders and also the primary caregivers for these athletes. So they really serve an important role. And I think maybe I'm not sure the statistic is completely accurate, but it is something like 50% of all high schools across the United States do not have an athletic trainer. 

Dr. Mike Patrick: So say that again, 50%. 

Dr. Tom Pommering: I think it's 50%. It may even be higher. I'm trying not to spill any myths, but I think it is an extremely high percentage, more than you would think. And it's probably more common in the rural school settings. 

Dr. Mike Patrick: And so again, parents, ask and be an advocate for that because it really can improve the lives of all student athletes in that school district, not just your own children. 

What is the long-term outlook for student athletes who have exercise-induced asthma? Is this something that they outgrow? I would imagine if it's affecting folks at the Olympic level, it can happen throughout their age span. But what's your experience with that? 


Dr. Tom Pommering: I don't think they outgrow if they retire from their sport and probably get better. Of course, the more elite they get, and if they have this, the more they have to manage this. But in general, it's really a good prognosis. I can't think of any athlete in my experience that has been disqualified or had to leave a sport because of exercise-induced asthma. So it can be managed.

Again, all the things we talked about are important. And having this sort of team approach with your athletic trainer, with your primary care doctor, with the patients and the family, making sure everyone's on the same page really creates a successful plan.

Dr. Mike Patrick: Great. And then, tell us about the Sports Medicine Program at Nationwide Children's. You not only take care of kids with exercise-induced asthma, but lots of conditions. 

Dr. Tom Pommering: Yeah. So we have been around since 2001. There are nine full-time sports medicine physicians in our group. We are already in locations around Columbus and we take care of some 15 high schools division to university, and tons of clubs of any sports. And we take care of everything that can happen to you during your competition, whether it's bone injury, a brain injury, breathing problem. You name it, we're happy to help you tackle that. 


Dr. Mike Patrick: And Allison, give us a glimpse on the daily life of an athletic trainer here at Nationwide Children's. There may be some folks who are interested in that as a career. What's it like? 

Allison Strouse: Absolutely. So working in Nationwide Children's, we have kind of two jobs. So we work at our school, whether you're at a high school or in my case, a college. 

My day usually starts in the morning because we work with adults. We work with collegiate athletes. So in the morning, we will do injury assessment, rehabilitation, what have you. And then, we go out to practice in the afternoon to cover all of the practices that need to be covered. At a high school, typically, it will be a little bit later in the morning of a start because kids are usually in class.


And then, we also have the opportunity to work in our clinics, which is very fun. So we work alongside our physicians, helping them with patients. And we kind of see a lot of different types of injuries that way. 

Dr. Mike Patrick: What is the educational path to become an athletic trainer?

Allison Strouse: So that's actually changing. When I went through college, it was a four-year undergraduate. From there, you would sit for your board and then you can decide if you want to pursue a further career. That's what I chose to do so I got my masters in exercise science, so that's another two-year thing. And you can even go on from there and get your PhD if that's something that you're interested in doing. 

But they are transitioning to an entry-level masters program. So that's something that's happening actually quite quickly. So it's just a little change in dynamic. 

Dr. Mike Patrick: Yeah. And then, I would imagine that makes a little bit more of a struggle for other school districts to recruit because there's an increase educational requirement to do. Maybe it'll be fewer coming out of those programs? Maybe? Yes?


Allison Strouse: Yeah. It's going to be really interesting to see where our profession goes from here. So it's exciting to see what we're going to have available. 

Dr. Tom Pommering: I think it's important for people to know that athletic trainers are highly educated and they have to pass a national board exam. So they're also licensed. So they're very qualified and very important to the care of the athletes at the schools. I think the schools also need to arrange their priorities because a lot of their teachers have masters level degrees. So it's a matter of just deciding what's important for you school district.

Dr. Mike Patrick: Absolutely. We have wonderful athletic trainers here at Nationwide Children's, a whole lot of them. And you can find out a lot more about the sports medicine program here at Nationwide Children's by following the link that we'll have in the show notes for you. Episode 427 over at pediacast.org. We'll put a link to the sports medicine program. 

A couple of other links that I found helpful, Exercise-Induced Bronchoconstriction with the Asthma and Allergy Foundation of America has some great family resources there.


Allison, you wrote a blog post for our 700 Children's blog, Managing Exercise-Induced Asthma in Athletes. And Dr. Dave Stukus, one of our allergists here and frequent contributor on PediaCast, also wrote a blog post called Asthma Myth: Exercise and Sports. And we'll put links to all of these resources in the show notes for folks over at pediacast.org. 

All right, well, once again, Dr. Tom Pommering and Allison Strouse, both with Nationwide Children's, with Sports Medicine, thanks to both of you being here today. 

Dr. Tom Pommering: Thanks, Mike. 

Allison Strouse: Yeah, thanks. 

Dr. Tom Pommering: Great to be here. 



Dr. Mike Patrick: We are back with just enough time to say, once again, thanks to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that.

Also thanks to our guests this week, Dr. Tom Pommering, chief of Sports Medicine at Nationwide Children's Hospital and Allison Strouse, certified athletic trainer, also at Nationwide Children's.

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All right, that wraps up the program today. Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.


Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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