Dear Boathouse Doc,

Sometimes I cough and feel chest tightness after rowing. My coach says I should get checked for asthma. Will it help to use inhalers, even if I don’t actually have asthma?
        
Sincerely,

Concerned rower

Dear Concerned Rower,

That’s a really good question. Asthma is becoming more and more common, and 80 percent of asthmatics have exercise-induced asthma (EIA). And then there are many who have EIA and not asthma. In fact, depending on the sport, prevalence rates for EIA range from seven to 50 percent. Among 1996 Olympic athletes, 20 percent had EIA. At the Athens Olympics in 2004, six rowers on the U.S. team required asthma medications. So, your coach is right to think about asthma in his/her rowers that cough, wheeze or complain of tightness in the chest after exercise. But asthma isn’t the only thing that gives you those symptoms -- more about that later.

Asthma is a condition of airway hyper-responsiveness to an environmental trigger. The airway cells react in such a way to a trigger that an inflammatory response happens. This inflammatory response causes the airways to fill with mucus and the muscles around the airways to tighten. The net result is that the airways narrow. Then it becomes really hard to breathe, like trying to breathe through straw. In EIA, the trigger is cooling, drying and then re-warming of airways. During the cooling period, airway cells become super-susceptible to inflammation. As blood flow to airways happens in response to the cooling and drying period, the airways re-warm and the inflammatory response begins. The good news is that after the athlete recovers from this re-warming inflammation, the inflammatory response doesn’t recur. This works well for EIA sufferers because they can suffer through the re-warming period after their pre-race warm up and then be all right for the race.

When evaluating an athlete with symptoms like yours, a physician can make his or her decision as to whether it is EIA or not based on diagnostic tests. There are several diagnostic tests available. First, lung functions tests can be performed before and after exercise. A test is diagnostic for asthma if the athlete’s airways show evidence of constriction after exercise. Next, the physician can demonstrate that the athlete’s symptoms get better with asthma medicine. Finally, a physician can administer an agent known to trigger airway constriction in asthmatics and measure the lung’s response to them.

Treatment is aimed at both controlling the inflammatory response and at immediately relieving the airway-muscle constriction. The same medications are used for both EIA and asthma. Your question about a whether you’ll get a competitive advantage using these medications, even if you don’t have asthma, is a good one. In fact, inhaled asthma medications are banned by the World Anti Doping Administration and the IOC Medical Committee. The thinking has been that there is a competitive advantage to using these medications. However, many studies have been done that show no competitive advantage to using inhaled beta agonists or inhaled steroids.

If it turns out that you are asthmatic and/or have EIA, know your triggers and know how to use the refractory period to your advantage. I am reminded of an athlete I treated a couple of years ago. During international competition, this athlete’s symptoms began to get out of control in spite of proper medication use. When I made a “house call” to the athlete’s hotel room, I found wet clothes hanging from everywhere. The smell of mold wafted into the hallway. It became immediately clear that mold was likely overwhelming the athlete. Removing the wet clothes and a trip to the laundry helped a lot.

If international competition is in your future, know that the use of inhaled asthma meds in competition requires special permission. The “therapeutic use exemption” (TUE) form must be completed by the team physician. This form certifies that the athlete’s symptoms and/or test results meet the definition of asthma or EIA.  

If it turns out asthma medications don’t help your wheezing, coughing and shortness-of-breath, go back to your doctor. It could be that you don’t have asthma. There are many conditions (vocal cord dysfunction, exercise hyperventilation syndrome, and heart conditions, to name a few) that act just like asthma but aren’t.

Sincerely,

Boathouse Doc