Asthma and Sport

Leuppi Jörg MD PhD^1,2, Späni Selina M Pharm¹

¹ Cantonal Hospital Baselland, Rheinstrasse 26, 4410 Liestal
² University of Basel, Rheinstrasse 26, 4410 Liestal

Abstract

Asthma is a chronic inflammatory disease of the airways affecting approximately 300 million people worldwide. Asthma causes recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing, typically occurring at night or early in the morning. The article discusses the pathophysiology of asthma, characterized by episodic, reversible airway constriction, airway hyperreactivity, and underlying inflammation. Diagnosis and management of asthma require precise methods and adjustments in lifestyle and medication to minimize exposure to known triggers and prevent severe exacerbations. Additionally, the relationships between asthma and COPD, as well as asthma and physical activity, particularly exercise-induced asthma, are explored. Recent developments in asthma treatment, such as the use of combined inhalation medications and the treatment of upper respiratory tract diseases to improve asthma symptoms, are also highlighted. Furthermore, the importance of spirometry as a diagnostic tool and correct inhalation techniques to maximize therapy efficiency are emphasized.

Zusammenfassung

Asthma ist eine chronisch entzündliche Atemwegserkrankung, die weltweit etwa 300 Millionen Menschen betrifft. Asthma führt zu wiederkehrenden Episoden von pfeifender Atmung, Atemnot, Brustenge und Husten, die typischerweise nachts oder frühmorgens auftreten. Der Artikel diskutiert die Pathophysiologie von Asthma, die durch episodische, reversible Atemwegsverengungen, Atemwegshyperreaktivität und zugrundeliegende Entzündungen charakterisiert ist. Die Diagnose und das Management von Asthma erfordern präzise Methoden und die Anpassung von Lebensstil und Medikation, um Expositionen gegenüber bekannten Auslösern zu minimieren und schwere Exazerbationen zu verhindern. Darüber hinaus werden die Beziehungen zwischen Asthma und COPD sowie Asthma und körperlicher Betätigung, insbesondere anstrengungsinduziertes Asthma, erörtert. Neue Entwicklungen in der Asthmabehandlung, wie die Verwendung kombinierter Inhalationsmedikamente und die Behandlung von Erkrankungen der oberen Atemwege zur Verbesserung der Asthmasymptome, werden ebenfalls hervorgehoben. Zudem wird die Bedeutung der Spirometrie als diagnostisches Werkzeug und korrekte Inhalationstechniken zur Maxi­mierung der Therapieeffizienz betont.

Schlüsselwörter: Asthma, Anstrengungsdyspnoe, Inhala­tionstherapie, Geräte

Introduction

Asthma is a chronic inflammatory disease of the airways that affects about 300 million people worldwide. It causes recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing, which occur primarily at night or early in the morning. A characteristic feature, particularly in the cough variant of asthma, is a typically non-productive, chronic cough that can dominate the clinical presentation [1].

1. Pathophysiology of Asthma
The pathophysiology of asthma involves episodic, reversible airway obstructions, airway hyperreactivity, and underlying inflammation [2–4]. The disease arises from the interaction of genetic predispositions with environmental factors such as allergens, tobacco smoke, and air pollution, which can trigger and exacerbate the condition. Cells like mast cells, eosinophils, T lymphocytes, macrophages, and neutrophils, as well as numerous cytokines, are involved in the chronic inflammation. In allergic asthma, mast cells, natural killer cells, and eosinophils are particularly prominent [1,4].

2. Diagnosis and Management
Early and accurate diagnosis is crucial for managing asthma. It enables tailored intervention strategies that improve patient outcomes and prevent severe exacerbations. Management includes the use of maintenance medications and lifestyle adjustments to minimize exposure to known triggers. Severe asthma treatment often involves collaboration with specialists such as pulmonologists [1,2].

3. Asthma and COPD
Asthma and chronic obstructive pulmonary disease (COPD) share many symptoms but differ in key aspects such as the reversibility of airway obstruction. Asthma-COPD overlap (ACO) exhibits features of both diseases, making diagnosis and treatment complex. Differential diagnosis is particularly challenging in older patients and smokers, as these groups may display symptoms of both conditions [1,2].

4. Asthma and Exercise
Exercise can exacerbate symptoms in asthmatics, known as exercise-induced asthma (EIA) or exercise-induced bronchoconstriction (EIB). EIB is defined as an acute narrowing of the airways occurring during or after physical exertion. This can be observed in both individuals with chronic asthma and those without existing disease. Preventive measures include the use of short-acting beta-agonists before exercise and specific warm-up routines [1,5].

5. Recent Developments in Asthma Treatment
The stepwise approach to asthma treatment has significantly evolved. The latest recommendations emphasize the use of combination preparations of inhaled corticosteroids (ICS) and beta-agonists instead of the sole use of short-acting beta-agonists (SABA). These combination therapies reduce the risk of severe exacerbations and improve overall asthma control [1,2,6].

6. Asthma and Upper Respiratory Tract Diseases
The concept of «united airways» suggests that diseases like asthma, rhinitis, and sinusitis are interconnected and represent a continuous inflammatory pathology across the upper and lower airways. Treating upper respiratory tract diseases can improve asthma symptoms and often involves the use of intranasal corticosteroids and antihistamines [1,2].

7. Pulmonary Function Tests
Spirometry is a fundamental diagnostic tool in respiratory medicine. It measures lung volumes and airflow, including forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). These measurements are crucial for ­diagnosing asthma, as a reduced FEV1/FVC ratio is typical of obstructive patterns, which are often reversible in asthma [7,8]. Figure 1 shows a partially reversible airway obstruction.

8. Inhalation techniques
Inhalation techniques are also a critical aspect of asthma treatment, as incorrect use of inhalers can significantly reduce the effectiveness of therapy. Proper training and regular review of inhalation technique are essential to ensure patients gain the maximum benefit from their medications [9,10].
This comprehensive overview of asthma provides insights into the complex nature of this disease and the variety of strategies that can improve the quality of life for those affected. The continuous development of treatment protocols and a deep understanding of the different aspects of asthma are essential for the effective treatment and care of patients with this widespread respiratory disease.

General checklist for inhalation:
1. Correct preparation of the inhalation device
2. Assume an upright posture
3. Full exhalation before use of the inhaler – not in the inhalation device
4. Place lips and teeth around the mouthpiece
5. Inhalation (quickly & deeply or slowly & deeply – depending on the inhalation device)
6. Hold breath for 5 to 10 seconds or as long as possible
7. Slow exhalation – not in the inhalation device

Specific information for the most commonly used types of inhaler devices [11,12] see Figure 2:
(Medication-specific information can be found in the drug information)

Corresponding author

Jörg D. Leuppi, MD PhD
Chief Medical Officer Cantonal Hospital Baselland, Liestal
Rheinstrasse 26, 4410 Liestal
Switzerland

References

1. http://www.ginasthma.org
2. Rothe T, Spagnolo P, Bridevaux PO, Clarenbach C, Eich-Wanger C, Meyer F, Miedinger D, Möller A, Nicod LP, Nicolet-Chatelain G, ­Sauty A, Steurer-Stey C, Leuppi JD. Diagnosis and Management of Asthma – The Swiss Guidelines. Respiration. 2018;95(5):364-380. doi: 10.1159/000486797
3. Hallstrand TS, Leuppi JD, Joos G, Hall GL, Carlsen KH, Kaminsky DA, Coates AL, Cockcroft DW, Culver BH, Diamant Z, Gauvreau GM, Horvath I, de Jongh FHC, Laube BL, Sterk PJ, Wanger J; American Thoracic Society (ATS)/European Respiratory Society (ERS) Bronchoprovocation Testing Task Force.ERS technical standard on bronchial challenge testing: pathophysiology and methodology of indirect airway challenge testing. Eur Respir J. 2018 Nov 15;52(5):1801033. doi: 10.1183/13993003.01033-2018.
4. Rothe T, von Garnier C, Bridevaux PO, Charbonnier F, Clarenbach C, Gianella P, Jochmann A, Kern L, Nikolay P, Steurer-Stey C, Leuppi JD; members of the SIG Obstructive Lung Diseases of the Swiss ­Society of Pneumology. The clinical features of asthma exacerbations in early-onset and eosinophilic late-onset asthma may differ significantly. Respir Med. 2023 Jan;206:107067. doi: 10.1016/j.rmed.2022.107067. Epub 2022 Dec 9.PMID: 36563609
5. Leuppi JD, Kuhn M, Comminot C, Reinhart WH. High prevalence of bronchial hyperresponsiveness and asthma in ice hockey players. Eur Respir J. 1998 Jul;12(1):13-6. doi: 10.1183/09031936.98.12010013.
6. Leuppi JD, Bridevaux PO, Charbonnier F, Clarenbach C, Duchna HW, Gianella P, Jochmann A, Kern L, Meyer F, Pavlov N, Rothe T, Steurer-Stey C, Garnier. [Novelties in the Treatment of Asthma]. Praxis (Bern 1994). 2021;110(16):967-974. doi: 10.1024/1661-8157/a003760.
7. Rothe T. [Lung function testing in private practice]. Praxis (Bern 1994). 2012 Nov 14;101(23):1481-7. doi: 10.1024/1661-8157/a001109
8. Stanojevic S, Kaminsky DA, Miller MR, Thompson B, Aliverti A, Barjaktarevic I, Cooper BG, Culver B, Derom E, Hall GL, Hallstrand TS, Leuppi JD, MacIntyre N, McCormack M, Rosenfeld M, Swenson ER ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J. 2022 Jul 13;60(1):2101499. doi: 10.1183/13993003.01499-2021.
9. Gregoriano C, Dieterle T, Breitenstein AL, Dürr S, Baum A, Maier S, Arnet I, Hersberger KE, Leuppi JD. Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial. Respir Res. 2018 Dec 3;19(1):237. doi: 10.1186/s12931-018-0936-3
10. https://www.atemwegsliga.de/richtig-inhalieren.html
11. https://www.swissmedicinfo.ch
12. https://compendium.ch