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 WHAT IS THE ASTHMA?
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The asthma is an illness chronic that it affects to the respiratory system. In her there produces to itself an inflammation of the conduits that take the air to the lungs, due to the annoyance that there produce certain stimuli as the mites or the pollen, but also the contamination, the smoke, some medicines, the emotions, the laugh, or the physical exercise.
This inflammation does that the conduits are more sensitive and answer with a contraction provoking a major tightening. The blockade to the step of the air, which can be more or less important depending on the sensibility of the individual, of the intensity of the stimulus or of his previous situation, does that the person with asthma has drowning, cough, pressure sensation in the breast and whistles on having breathed.
It is important that the asthma is well controlled to try to eliminate or reduce to the maximum the number and the intensity of the crises. The available treatments nowadays, generally they allow to control in a suitable way the asthmatic illness. |
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ASTHMA INDUCED BY THE EXERCISE (AIE)
It is the phenomenon for which the exercise achievement, instead of producing broncodilatación as in not asthmatic persons, it provokes the opposite broncoconstricción effect. The AIE owes to the cooling and relative dryness of the airline (loss of H2O) for increase of the ventilation during the exercise. The cooling and the dryness provoke changes in the osmolaridad of the mucous membrane, what it takes that, on the one hand, a mastocitos degranulación exists with mediators' liberation; and on the other hand, to which a stimulation happens vagal direct. The result is the broncospasmo appearance.
Causes of the asthma for exercise:
Cold of the inspired air
Low moisture of the inspired air Loss of heat of the airline
The characteristics that define the AIE are the following ones:
- It can appear at any age, and it is so frequent in the adults as in the children. The configurations pícnicas are more predisposed.
- It can turn out to be isolated or collaborate to any clinical form of bronchial asthma. In most of the asthmatic ones, the exercise provokes broncospasmo with transitory hyperblowing.
- The severity of the AIE is not predictable from basal function. The patients with normal pulmonary function in rest can present important AIE.
- Four typical phases:
- (Asymptomatic) initial Broncodilatación. As in not asthmatic persons, in the patients with asthma the exercise produces an initial broncodilatación, without symptoms.
- Clinical Broncospasmo. Spent 5-10 minutes since the effort was begun, when the cardiac frequency reaches approximately 160 beats per minute, the broncospasmo appears.
- Recovery phase. Between 30 and 60 minutes, after having begun the exercise, a return begins to the normality in the bronchial caliber and it eliminates the sensation disneica.
- Refractory period. In more than half of the cases of AIE, a period exists, from 2 until 4 hours of duration, during which the broncospasmo does not appear again, however much exercise keeps on being done.
The refractory period owes to depleción of broncoconstricción mediators and/or to generation of prostaglandin broncodilatadoras (PGE2) during the exercise. The refractory period can be induced by means of warming up, and be used so that the asthmatic one does not diminish his sports yield.
- The AIE can get ready with the inhalation or capture previous to some medicines. There are used for this end the beta2-mimetic ones of short and long action, the cromoglicato, the bromide of ipratropio, and the inhibiting ones of leucotrienos.
PHYSICAL ACTIVITY IN THE ASTHMATIC CHILD
The exercise and the game are necessary for all the children, and they provide happy moments to them simultaneously that teach them to be prepared for the adult's life. The asthmatic child must not be an exception, and must realize physical exercise of a suitable way. The advantages of the practice of the physical activity and the game in the child with asthma, between others, are the following ones:
- It improves the child development
- The integration is favored in the group
- It improves the physical condition and the proper tolerance to the exercise
- The attacks caused by the effort diminish or they are less strong
- The crises are controlled better.
- It helps to diminish the nervousness caused by the attacks.
80 % of the children with asthma will see his process aggravated with the sports practice (unless the suitable measures are taken). Nevertheless, and given the benefit psicoemocional and integrator of the sport, a big one is an error sobreproteger to the asthmatic child and a normal level of physical exercise prevents him. When we initiate a physical activity for the first time we all get tired, feel fatigue and drowning sensation. In the asthmatic child who has not gone in for sport earlier, these sensations are even stronger. For it, the adaptation of the child with asthma to the sports activity must be very progressive, so that with the time he learns to distinguish between the sensation of normal drowning for an intense exercise, and the drowning sensation for an asthma crisis.
ASTHMA AND SPORT
Except the diving with air gas cylinders, an asthmatic child can practise any sport. But there exists a series of sports less "asmógenos" than others.
The free career, which is the base of the jogging, of the athletics, and of sports like the soccer or the basketball, is the activity that more broncospasmo can produce: Based on the recounted on the refractory period, it is understood that to run of intense and continued form provokes a major broncospasmo to realize the exercise of intermittent form.
Activities that cause Asthma for exercise (in gravity order):
Free career Career in band without fín Cycling Swimming
On the other hand, sports as the swimming in covered and air-conditioned swimming pool (humid and warm air), the gymnastics, the march on foot, the golf, the trekking and the bicycle in flat area are great less asmógenos. The tennis and the games of ball, although they need many free career, usually realizes in the shape of intermittent intense efforts, for what also they are advisable, as the martial arts (judo, karate, taekwondo), the fencing, etc. The depth diving with air gas cylinders is not an advisable activity, for the changes of pressure that it bears, and for the inability to face to an asthma crisis to a certain depth: In the middle of a shortness of breath crisis, it can turn out to be very difficult to carry out the necessary decompression maneuvers to emerge to the surface without barotrauma risks. The sports of high mountain in asthmatic (mountaineering, alpine skiing and of fund, etc) only have the problem of the respiration of cold and dry air, which can be minimized by means of the use of masks or helmets. In the Olympic Games of Barcelona (1992) it was proved that between 8 and 12 % of the competitors were asthmatic. Since it is well-known, big asthmatic sportsmen exist in cycling (Alex Zülle, Miguel Induráin), athletics (Jordi Llopart, Patricia Morales), (Theresa Zabell) watches, taekwondo (Gabriel Esparza), swimming (Mark Spitz), in sync swimming (Bet Fernández), judo, basketball, etc.
DIAGNOSIS OF THE ASTHMA INDUCED BY THE EXERCISE
A history of cough, shortness of breath, sibilancias, thoracic oppression or problems of yield during the exercise AIE suggests. The assertion diagnosis usually needs a test of exercise, which can be carried out:
- in laboratory conditions, by means of rolling tape or bicycle ergométrica and with cardiac and respiratory monitoring. The child must cover it of sufficiently intense form as to increase the basal cardiac frequency in 80 % as maximum, during 4 to 6 minutes.
- career outdoors, trying to reproduce the situation that provokes the symptoms. There is evaluated the distance covered in 10-12 minutes and the excellent incidents along this test.
In any of two cases, they are realized espirometrías earlier and after the exercise at intervals of 5 minutes and during 20 to 30 minutes. A descent of 15 % in the VEMS or FEV1 it is compatible with AIE.
HANDLING OF THE ASTHMA INDUCED BY THE EXERCISE
The program of training of the child with bronchial asthma must include the same phases as other rules of training:
- warming (very gradual)
- stretchings pre-exercise
- achievement of the established training
- stretchings post-exercise
- period of relaxation and recovery.
The type of exercise, intensity of achievement, duration and frequency are determined by the aerobic level of the child. This one is evaluated valuing the maximum cardiac frequency that is capable of tolerating without there breaking loose symptoms of shortness of breath and anxiety. The patients with a well-known functional limitation must not overcome an increase of 30 % on the cardiac rest frequency in the supported exercise.
Facilitators of the asthma for exercise:
* The recovery is worse if after the exercise the air is warmer than on having initiated the exercise.
* The nasal obstruction worsens the asthma induced by exercise since the inspired air is not dampened and warmed in the nose.
* The environmental pollutants (like the sulfide dioxide).
* Environmental allergens (high accounts of pólenes).
* Viral infections of the airways.
Inhibiting of the asthma for exercise:
* Soft warming up during 10 to 15 minutes.
* Humid warm ambience. The moisture of the ambience must be between 60 and 70 % and the temperature between 24 and 30ºC.
* Sports in closed ambiences.
* To stop the exercises of slow form.
* Refractory period from 1 until 2 hours. There can be realized exercises of high intensities, of few duration and with almost finished recoveries between the exercises.
TREATMENT OF THE SHARP CRISES
Rapid Anamnesis. To establish the time passed from the beginning of the crisis, the medication that usually continues, possible desencadenantes of the current crisis (symptoms of respiratory infection, exhibition to allergens, treatment with some anti-inflammatory not esteroideo, suspension of the medication, etc.).
Physical exploration. The following gravity signs will be valued especially: taquipnea, use of incidental muscles (printing), sudoración, cianosis, lengthening of the exhalation, incapability to adopt the supine decubitus, etc.
Gasometría of arterial blood (balance acid - base). Initially hyperventilation takes place and it diminishes the CO2, what it produces alcalosis respiratory. As the crisis progresses, more CO2 is retained and one is entering respiratory acidosis and hipoxia every time major.
Pulsioximetría: It measures the saturation of O2 of the arterial blood by means of a sensor in the finger. It is correlated very well with the gasometría, and is a much more rapid method, which it does not need neither to puncture the patient nor to wait for results of the laboratory, avoiding, then, many gasometrías.
Measurement of the air flow. It is easy to realize by means of the peak-flow to put, with that there determines the flow peak espiratorio (PEF), which is correlated by the volume espiratorio maximum for second (VEMS or FEV1). The asthma crisis is serious when the PEF is < 30-50% del basal o mejor personal (establecido cuando el asmático está asintomático).
Oxygen. All the patients are administered initially, across mask type Ventimask ® of 28 to 35 %, fitting according to the arterial gasometría and/or the pulsioximetría.
Hydration. In the serious sharp asthma attack there is tendency to the dehydration. The patient must be stimulated so that it consumes a sufficient liquids quantity. During the sharp crisis there usually use wheys IV (glucosado to 5 % or glucosalino) to rhythm of 500 mL/6 hours.
Medication in the sharp asthma crises:
- BRONCHODILATORS ADRENÉRGICOS
* Beta-2-adrenérgicos nebulizados. Salbutamol solutions are used to 0,5 % (Ventolín ®), terbutalina to 0,5 % (Terbasmin ®) and hexoprenalina to 0,25 % (Ipradol ®), which can be used to dose of 0,25-0,5 ml of solution dissolved in 3 ml of saline whey, with a maximum of 3 meetings from 5 until 10 minutes of duration every 20-30 minutes.
* Subcutaneous Adrenérgicos. Salbutamol (Ventolín ®; 0,5 mg/ampolla) and hexoprenalina (Ipradol ®; 0,005 mg/ampolla) to initial 1/4 dose ó 1/2 it blisters in every arm, which can recur to 20-30 minutes. Also there is used the proper adrenaline (0,2-0,3 ml of solution to 1/1000), with what a rapid, intense effect is obtained and of short duration (less than one hour). It can be used like medicine of the first election in major and adolescent children, with serious crises. - CORTICOESTEROIDES PARENTERALES
They are indicated if the crisis is serious and does not answer to the initial treatment bronchodilator in one hour. Steroids of short action can be used, like hidrocortisona (Actocortina ®), or of intermediate action like metilprednisolona (Urbasón ®, Solu-Moderin ®). The beginning of the therapeutic effect of the corticoids takes place after several hours. When they want to be suspended, it can be done in a sudden way if his administration has not been supported any more than 3 ó 4 days. If it is not like that, the dose will come down to the half every 24-48 hours up to coming to 20 mg/día and from this dose 5 will diminish mg every 4 days up to suspending them. As soon as beech improvement must pass to the oral administration route. - ANTICOLINÉRGICOS
The solution of bromide of ipratropio (Atrovent ®) nebulizada can provoke an increase of the broncodilatación when beta - 2-adrenérgicos is used in combination with bronchodilators. - METILXANTINAS PARENTERALES
They produce relaxation of the bronchial smooth muscle, but his exact action mechanism is not known. - ANTIBIOTICS
They must collaborate if there is observed purulent sputum, fever or pulmonary infiltrators.
Repetition of the evaluation in the Room of Urgencies. After the first hour of treatment the answer to the same one must be valued. According to the answer to the initial treatment the patient can be discharged, continue the treatment or value revenue.
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