Breathing problems in high school age runner

[alanv]

My son is a high school junior, age 17. He runs pretty much year round for his high school cross country and track teams.  Last spring during the outdoor track season, he began to have problems breathing during races and hard workouts.  He was diagnosed as having exercise induced asthma and given Advair, Singular and Albuterol. They seemed to help and he got better over a 3-4 week period. He stopped taking the medicines at that point when the season ended. A month later he began training again and couldn't run for more than 15 minutes.  He again went on the asthma medicines but they did not help.  Over the last four months he has had a sinus cat scan, chest xray, EKG, echocargiogram, blood work, allergy tests and lung capacity and asthma tests from a pulmonary specialist.  All tests were normal and the asthma test proved conclusively that he does not have asthma.  Although better than he was in June he continues to have breathing problems and still cannot run as fast as he did last year.  His breathing gets increasingly labored over the course of a race.  We will be taking him to an ENT to have him tested for vocal cord dysfuntion.

Also he has had chronic post nasal drip for many months.   Any thoughts on what the problem could be?

[National Jewish]

There is a complex asthma test that is the gold standard for diagnosing asthma.  This is called a methacholine challenge.  Your son would have blown into a spirometer before and after each increasing dose of an inhaled medicine.  This test is positive for asthma if the result after the inhaled medicine is 20% lower than it was before the inhaled medicine.

Vocal Cord Dysfunction (VCD) is a condition that can mimic asthma.  However, VCD is not helped by asthma medicines.  While inhaling the vocal cords should open to let air into the lungs.  With VCD the vocal cords close together during inhalation.  This makes it difficult for air to get into the lungs.  A lot of the same things that trigger asthma can trigger VCD including upper respiratory infections, fumes, odors, cigarette smoke, singing, emotional upset, post-nasal drip and exercise.  Sometimes the trigger is not known.  Testing needs to be done while your son is having symptoms.  Breathing tests may be normal, but the “breathing in” or inspiratory part, also called a flow volume loop will show little airflow while he is inhaling.  A laryngoscopy is a procedure done by a specialized doctor using a camera at the end of a flexible tube to see how his vocal cords open and close.  VCD is treated by a speech therapist that will instruct your son in open throat breathing techniques.  Counseling can help him identify and deal positively with chronic stress, which may be an underlying factor in VCD.  Please read our Vocal Cord Dysfunction MedFact at http://www.nationaljewish.org/medfacts/vocal.html for more information.  It is good that you are taking him to an ENT for testing and appropriate treatment.

Postnasal drip is drainage from the nose and sinuses dripping down the back of the throat.  There could be several reasons for this drainage.  One is an allergic reaction to inhaling something.  A second reason is a non-allergic, non-infectious inflammation in the sinuses that can linger after a cold.  A third reason is chronic sinusitis.  Postnasal drip can cause breathing difficulty as a result of irritation of the throat and lungs.  Your son may experience the postnasal drip as a constant feeling of phlegm at the back of his throat.  As long as he is not on a fluid restriction he should be drinking 6 to 8 8-ounce glasses of non-caffeine non-alcoholic fluid daily.  This will thin the phlegm so that it moves more easily.  A nasal wash helps remove phlegm from the nose and sinuses.  This can temporarily reduce the postnasal drip and lessen breathing difficulty.  A prescription nasal steroid spray decreases nasal swelling and phlegm production.  This may prevent the postnasal drip and breathing difficulty.  To get the most out of a nasal steroid spray use it after doing a nasal wash.  A nasal steroid spray does not provide immediate relief of symptoms.  It may require several weeks of routine use to become effective.  Please read our Nasal Wash MedFact at http://www.nationaljewish.org/medfacts/nasal.html for more information about this technique.  Share this information with your son’s doctor to see if he would benefit from this daily treatment.

[starion]

What tests were done to test his asthma?  Is he going to have a methacholine challenge with a laryngoscopy to see whether his vocal chords spasm, so he can be properly evaluated for vocal chord dysfunction (VCD)?  The treatment for VCD involves speech therapy & breathing exercises.  You may wish to visit www.nationaljewish.org/medfacts/vocal.html
Optimal treatment of your son's allergies & post nasal drip can only help his health, even if it doesn't affect his lung function.  A board-cetified allergist may be able to provide more help in this regard than the ENT.
Best of luck!
Starion

[Ellis7]

A cardiopulmonary stress test could help diagnose the problem;
heart and lung functions measured while exercising. See:
------------------------------
http://www.agmc.org/hrtprep/cardstress.htm
Cardiopulmonary Stress Test
Excerpts:
"A cardiopulmonary stress test allows your physician to learn how well your heart and lungs function when they are made to work harder. The test is done while you walk on a treadmill or pedal a stationary bicycle. During the test, an electrocardiogram (EKG) records the electrical activity of your heart and will be continuously monitored by experienced cardiac nurses. Arterial blood gases (ABGs) will be taken prior to and immediately after exercising"
------------------------------
http://www.chfpatients.com/tests/vo2.htm
"The Vo2max is also called the mVo2 test or the CPX test - for cardiopulmonary stress test. This test shows the maximum amount of oxygen your heart can provide to your muscles during sustained activity. Vo2max is the point at which your body cannot increase its intake of oxygen despite an increase in exercise intensity."
------------------------------
http://www.unm.edu/~ehpp/labstresstesting.htm
Exercise Physiology Lab Stress Test Information
=============================

Also measuring complelte PFTs [pulmonary function test] including DLCO [diffusion capacity] could help determine if there is lung disease.
========================
I presume he doesn't smoke?

[Ellis7]

Was your son tested for 'exercised-induced asthma'? See:
http://www.med.umich.edu/1libr/sma/sma_exindast_sma.htm
"How is it diagnosed?

Your health care provider will ask about your history of breathing problems during or after exercise. He or she may ask you to run on a treadmill or to exercise outside the office. When you return, your health care provider will then listen to your lungs with a stethoscope to see if you are wheezing after the exercise.

Your health care provider may give you a small device called a peak-flow meter, which measures how fast you can exhale air in
one breath. During a bout of exercise-induced asthma, this measurement will decrease from your normal measurement.

Exercise-induced asthma can be successfully treated with medication. The kind of medication usually tried first is an inhaled bronchodilator. Examples of these medications are albuterol (Ventolin, Proventil) and pirbuterol (Maxair). Your health care provider will instruct you to take two puffs of this medication about 15 to 30 minutes before your activity. If your provider tells you to, you may also use this medication during your activity if you get symptoms. "
=========================================

Sometimes this type of problem is better diagnosed at a Sports Clinic by a doctor who primarily treats athletes.

[alanv]

Thanks for your suggestions.  Our son is a health conscious and very serious distance runner; he does not smoke!  (:-)

It is not exercise induced asthma. Advair, Singular and Albuterol were all tried without success. He also zipped through the methacholine challenge with no reduction in capacity.  Our pulmonary doctor is going to do a cardiopulmonary stress test later this month.  And the ENT will be evaluating him for VCD in a few weeks.  Just thought I would see if there were other possibilities.

[alanv]

We didn't have much luck with the allergist who tested him but maybe should try another one after we go through the VCD evaluation and cariopulmonary stress tests.   We have a recommendation for an allergist who works regularly with athletes.

Thanks for your help!

[Concerned lady]

My husband and I were each diagnosed with VCD, at Nat'l Jewish, where they know the most about diagnosing and treating VCD, asthma, etc. The very day we each were seen at Nat'l Jewish, their Speech Pathologists taught each of us the special speech therapy methods with abdominal breathing, that helped us to be able to stop every VCD attack, immediately or very quickly.

But, we continued to have VCD attacks. With help from Nat'l Jewish, plus a lot of "homework", we finally discovered our underlying causes of our VCD (each VCD patient has his or her own unique set of causes). Then, we worked on getting rid of the causes, and this stopped our VCD, within several weeks. No more VCD attacks in over 3 years, for us.

Two major VCD causes for us, were GASTRIC REFLUX, and, BAD AIR QUALITY. In some cases, it seems that strenuous exercise plus food sensitivities, etc., can cause gastric reflux episodes, during the exercise, and the reflux can then cause VCD attacks. There can be many possible causes of VCD. Getting rid of the causes was the fastest way for us to get rid of the VCD.

Keep Nat'l Jewish in mind, in case your son should ever need them. They are kind, nice, and very knowledgable.

Sincerely, Concerned lady
<a href=http://cantbreathesuspectvcd.com>http://cantbreathesuspectvcd.com</a>

[Gatorguy]

You sound like you are traveling the same ground we are. We have not found a solution yet but I offer the following for whatever you can get out of it.

In our case it is a soccer player not a distance runner.

My son was treated for mild asthma for several years. However, about the time of his junior year the treatments were becoming less effective. He would start a game but have to leave after about 10 minutes. After a brief rest and using an inhaler or a natural remedy, he could return to the game and cope for the remainder of the game but he was never 100%. It would vary some based on field, weather etc. but there was never complete relief and at times the problem was severe. Based on symptoms, he was diagnosed as exercise induced asthma and continued on with Singular and inhalers with marginal to no improvement.

As long as he was playing high school soccer he could cope. But when he began trying out for colleges and was no longer able to get by with reduced breathing capabilities we realized there was something more going on.

Recently in preparation for an exercise induced asthma test, he was given a high dosage of prednisone. The exercise induced asthma test was negative but he experienced 5 days of strenuous pre-season practice with 100% breathing capability - the first time in years. That was followed with a couple days of the worst symptoms he has ever had. We assume it was the predinisone that reduced swelling somewhere. However, the prednisone raised his blood pressure and pulse rate to dangerous levels. Even at low dosages, his pulse rate is too high.

His symptoms are very consistent. Within 1/4 to 1/2 mile of training he develops a feeling of restriction in his throat and a wheezing - mostly on inhalation. His physical condition does not impact the symptoms.

Thus far he has been diagnosed with severe dust mite allergy and a lung infection. A bronchoscopy revealed evidence of allergy in the nasal passages and possible inflammation in the throat below the voice box. Two weeks on antihistamines and anitbiotics have not provided any relief. A positive diagnosis has not been made only the assumption that the allergies and lung infection are the likely sources of the problem.

Reflux treatment had no effect.

He is being treated for anxiety and mild depression which would make VCD a consideration but his symptoms don't match VCD very well and I am guessing that prednisone would not give relief from VCD.

His flow volume loop during exercise is nearly identical to the loop at rest. No loss of capacity but he has to breathe very hard to keep his volume up to that level which is inadequate for competition. Am I correct on this?

Have you tried a sports medicine specialist? That is our next idea. We are trying a natural cortisone and are going to start on allergy shots. I would like to get a positive diagnosis rather than simply attacking symptoms but we are trying to provide as much immediate relief as we can.

[Concerned lady]

Gatorguy,

Sometimes, acid blocking meds can have side effects, including,...gastric reflux. This can be one reason that such meds don't always "work".

Sometimes, temporary dietary changes (temporarily eliminating foods that he may be sensitive to, such as milk, cheese, wheat, etc.) can help to stop "silent" reflux, sometimes better than acid blockers. Some have found that temporarily avoiding very acid foods & beverages (including citrus fruits, tomatoes, vinegar, lemonade, soda pop, etc.) can be helpful.

You can telephone the LUNG LINE nurses, at 1-800-222-LUNG(5864), (between 8am & 4:30pm, weekdays, Mountain time) to see about possibly making an appointment with Nat'l Jewish, where they could help you and your son to find out exactly what's going on with his breathing, during exercise. Nat'l Jewish is a very excellent respiratory medical center, and they know a LOT about VCD, asthma, etc.

Or, the LUNG LINE nurses can maybe refer you to doctors in your area, who trained at Nat'l Jewish, and who are familiar with both VCD, asthma, etc, to help your son get accurately (fully) diagnosed & treated.

VCD can be caused by many physical things, and is not just a stress related condition.

Good luck in getting this all sorted out.

Sincerely, concerned lady
<a href=http://cantbreathesuspectvcd.com>http://cantbreathesuspectvcd.com</a>