Asthma and the competitive swimmer
Introduction:
One in seven children and one in 25 adults in
Asthma is a disorder of the small airways of the lungs, which
become sensitive to certain triggers, leading to them narrowing down when they
become inflamed. This results in the child or adult becoming wheezy, short of
breath or having a cough. The underlying causes are partly genetic and partly
environmental.
The triggers vary from patient to patient but often include colds
and viral infections, pollens and moulds, pets, dust, tobacco smoke, emotion
and stress, cold air and some medications, such as aspirin. Unfortunately for
swimmers chlorine may also be a trigger in some asthmatics. Some people's
airways narrow down during exercise. This is known as E.I.A. or
exercise-induced asthma, which typically comes on after at least 5-10 minutes
of a training session.
However, swimming is a sport at which asthmatics can and often do
excel, as the warm moist air of the indoor pool doesn't trigger an attack. A
number of the current British team has asthma and at least six Olympic Gold
medallists in the aquatic events have been sufferers of the condition.
How is it diagnosed?
By asking a person to breathe as hard as they can into a meter, it
is possible to measure how quickly they can expel air from their lungs.
This is known as a 'peak flow test' and by relating this
information to the individual's age and height, we can determine whether or not
the person is asthmatic.
Diagnosis is confirmed if, after exercise or treatment by inhaler
there is a 15% variation from the person's optimum or 'predicted' peak flow.
People can also detect such variations themselves by carrying out
regular peak flow tests and maintaining a diary chart.
Declaration
Once asthma has been diagnosed, it is mandatory that the swimmer or his or her parents or coach declare
this to the A.S.A together with details of the medication that they are taking.
This is essential to avoid falling foul of Doping Control.
The notification must be done annually. Any subsequent changes in
medication should also be notified.
Remember:
it is your responsibility to keep
the A.S.A. informed.
How is the condition managed?
Modern management of asthma is a shared care process with the
patient taking some responsibility for their condition in conjunction with the
general practitioner. Nurse-led asthma clinics at most GP surgeries help to
maintain good control, check inhaler technique and monitor progress.
The peak flow meter, which every asthmatic should have, is the
cornerstone of management. This measures the performance of the lungs and if
charted gives a clear idea of how well controlled the asthma is.
The peak flow reading varies with the age, sex and height of the patient and
can be calculated from charts. Each asthma sufferer should know what their
optimum reading is and has a self-management plan.
Types of treatment
There are two types of medication to treat asthma Ð relievers and preventers. Both are inhalers and they are colour coded to
help identification. There has been a move to CFC inhalers over the last two
years.
1. Relievers Ð inhalers
colour coded blue - e.g. salbutamol (ventolin) - work to open up the airways. They are also
known as bronchodilators (or beta 2 agonists).
These are mostly used after symptoms appear but sometimes give
brief protection against triggers such as exercise before they appear.
It is important NOT to exceed the maximum dose of 2 puffs four
times daily.
2. Preventers
Ð if taken regularly can prevent an asthma attack occurring. They protect the
lining of the airways and make them less likely to narrow when triggered.
There are two main types: -
Steroid based inhalers Ð colour coded brown Ð e.g. beclomethasone (becotide)
Sodium cromoglycate Ð colour coded white
Ð e.g. Intal
They should NOT be used for treating an acute attack, as they do
not bring immediate relief. They can take about 14 days to be fully effective
if taken regularly.
Other long acting inhalers and oral tablets form a second line
treatment if the above do not adequately control the condition.
The Step Care approach to treatment
The current treatment of asthma follows guidelines laid down by
the British Thoracic Association. They take the form of a step care plan now
known as the British Guidelines for the Management of Asthma. This involves
stepping up the level of treatment until satisfactory control is achieved. It
is important not to overtreat and stepping down is
just as important if the asthma is well controlled.
Step 1.
Use an inhaled short acting bronchodilator (such as salbutamol) for symptom relief up to once or twice daily.
If you need more than this, move to step 2.
Step 2.
Use an inhaled short acting bronchodilator for symptom relief plus
a regular low dose inhaled steroid twice daily (e.g. beclomethasone,
or in some cases the regular preventer cromoglycate).
Step 3.
Use an inhaled short acting bronchodilator for symptom relief plus
either a regular high dose inhaled steroid via a large volume spacer, or low
dose steroids and a long acting bronchodilator.
For patients who present more of a management problem, two higher
steps are available. It is also worthwhile for all asthma sufferers to have a
flu vaccine.
Which drugs are legal and which illegal?
The rescue inhalers such as salbutamol (ventolin) and terbutaline (bricanyl) are permitted substances under ASA and FINA law
as are the common steroid based inhalers such as beclomethasone
(becotide), budenoside (pulmicort) and fluticasone (flixotide).
The preventative inhaler cromoglycate (intal) can be used legally as can the recently introduced
oral leukotrine antagonists such as montelukast (singulair) and salmeterol (serevent) inhalers.
However for the competitive swimmer salbutamol
tablets are NOT permitted and the older inhalers (although very rarely used)
such as isoprenaline, ephedrine, orciprenaline
are banned.
Sometimes a short course of oral corticosteroid drugs is necessary
to bring the asthma under control. If this is the case the swimmer must not compete until at least two
weeks after the course has finished.
The reason why declaration of asthma is essential is that the beta
agonists and steroid drugs may enhance performance (by stimulatory and anabolic
effects on the body) if used by an athlete without asthma.
The Medical Commission of the International Olympic Committee has
recently toughened its stance against the misuse of asthma medication. In
future Olympic athletes seeking authorization to use asthma medication during
the Olympic Games will be required to produce clinical and laboratory proof of their
ailment.
When tested at doping control you must declare the asthma
medication you are taking.
Never let another swimmer use your inhaler for fun. Believe it or
not, this does happen sometimes and the consequences can be extremely serious.
List of Asthma Drugs that are permitted in Sport
· Salbutamol - e.g. ventolin
- by inhaler only
· Terbutaline - e.g. Bricanyl
- by inhalation only
· Beclomethasone - e.g. becotide - by inhaler only
· Salmeterol - e.g. serevent
· Sodium cromoglycate - e.g. Intal
· Montelukast - e.g. Singulair
· Budesonide - e.g. Pulmicort-
by inhaler only
· Fluticasone- e.g. Flixotide-
by inhaler only
· Theophylline- e.g. Nuelin
There is a maximum permitted level of salbutamol
so the recommended dosage of the salbutamol inhaler -
2 puffs four times daily must not be exceeded.
What delivery devices are available?
A number of delivery systems are available to meet individual
requirements. The commonest are simple meter dose aerosol inhalers but there
are also breath-activated inhalers and ones, which employ dry powders. The
aerosols are currently being switched to C.F.C. with new propellants to avoid
damaging the ozone layer and for younger patients or people who have trouble
getting on with inhalers or higher dose steroid the dose can be given via a
spacer device (large chamber - volumatic).
How do you know if the asthma is not well controlled?
Measuring the peak flow is one of the best ways of determining
good control. Detection of a lower than optimum level or a declining levels
should prompt an active review of treatment. The swimmer may complain of
night-time coughing or wheezing or may have to get out of a
training session due to wheeziness, coughing or
shortness of breath.
When should the swimmer take their inhaler relative to training or
an event?
The relief inhaler (e.g. salbutamol or ventolin) should be taken if necessary between 15 and 30
minutes before training or competing to allow maximum time to work properly.
One to two puffs is particularly useful in those patients who suffer from
exercise induced asthma.
The swimmer should NOT keep getting in and out of the water during
a training session for a quick puff of their inhaler and coaches should
actively discourage this habit. This usually means that the asthma is not well
controlled and the treatment needs to be reviewed.
The swimmer's 'rescue' inhaler should however be readily at hand
if needed and swimmers should never share inhalers.
What to do if a swimmer has an asthmatic attack in the water.
The swimmer concerned should be removed immediately from the
water.
The swimmer should be reassured and calmed, advised not to
hyperventilate and given one to two puffs of their usual rescue inhaler.
If there is no response after 10 minutes this can be repeated
If after this has been done the swimmer is still distressed,
unduly short of breath, has a rapid pulse or respiratory rate or is blue
(cyanosed), medical help should be sort urgently and if necessary an ambulance
called. If available, oxygen can be given whilst awaiting help.
Useful addresses
National Asthma Campaign
Publishes numerous booklets about asthma care e.g. peak flow
measurement, asthma at school, taking control of asthma etc.
Asthma help-line 0345-010203 Monday to Friday 1-9.00pm for the
price of a local call.
Peak flow charts and self-management plans are available through
GP surgeries and peak flow meters on FP10 (prescriptions)
Doping Control at the
If you are worried whether what you are taking is a banned
substance, telephone the drug information line 0207-380-841-9530 or e-mail ead@uksport.gov.uk.
The web site www.uksport.gov.uk is another useful information source and
the address is Ethics and Anti-doping,
References
1.
Thorax
1993: 48 supplements S1 -S24 British Thoracic Society Guidelines.