Sports Induced Asthma, RAD, Asthma, Help! What has my son got?

[kexbluejay]

January 10, my 17 year old son's coach came to us after a wrestling match and expressed concern about him having difficulties breathing during that prior week's practice.  He was hyperventilating.  Monday our MD advised him to have a stress test and see a pulmanary specialist. At this point he's been diagnoised with asthma.  His symptons only occur when he wrestles, no other time.  He handles the first period of his match and than you can see a transition take place.  He slows down on his moves and within seconds puts his arms over his head and starts gasping for air and goes into hyperventilation and cannot use his inhaler correctly.  The coaches try to talk him through this but they are stunned as to what has happened in the last few weeks.  
What other posibilities are there?  How does a completely healthy 17 year old instantly come up with a deblitating breathing problem like this.  He has never had any previous problems.  He now takes singular am and pm, inhaler and nebulizer treatments prior to his wrestling match, but nothing helps.  He now can not make it through a 3 period match.  This is crippled him mentally and he is frightened.  I have never witnessed such a tramatic event as I have the last three weeks.  He has worked so hard to condition and prepare himself to be a state qualifier in this sport and now this has happened.  Please, can anyone offer any information to aid us in helping him cope with this problem.

[National Jewish]

Viral infections like a cold or croup can cause inflammation of the airways of the lungs.  Usually when this occurs, your son may cough when he is active or laughs.  This inflammation can cause wheezing and coughing.  After the cold is gone, it is possible for the inflammation to linger.  This inflammation can last for several weeks.  Sometimes this inflammation may linger for 3 to 6 months.  Eventually the inflammation will go away, and then the wheezing and coughing will stop.  This is called reactive airways disease (RAD) and behaves a lot like asthma.  When this inflammation is treated with an inhaled steroid, which is used to treat asthma, it often clears more quickly.

When this continues, it is generally considered to be asthma.  Testing can be helpful to show if your son’s symptoms are due to asthma or RAD.  Generally testing starts with a simple breathing test called spirometry.  This test provides detailed information about how his lungs are working.  It will show if there is obstruction in his airways.

To really test for asthma it is best to repeat this test after using a rescue inhaler, an inhaled bronchodilator.  This measures how much the bronchodilator helps his lungs by reversing the problem.  When there is a 20% increase, the test is positive for asthma.

There are a variety of things that can make asthma worse.  These things are called triggers.  Exercise is a common trigger for asthma.  For some people it is the only thing that causes asthma symptoms.  In well-conditioned athletes, symptoms of exercise-induced asthma (EIA) may only occur with the most vigorous activity or exercise.  Using the inhaler 10 to 15 minutes before his wrestling match is called pre-treating.  This quickly opens the airways and should prevent asthma symptoms.  An exercise challenge is a test used to determine whether or not your son has EIA.  He will walk or run on a treadmill or ride an exercise bicycle.  Before and after this exercise his spirometry will be checked.  If his spirometry drops by 20% after exercising the test is positive for EIA.  Please read our Exercise-Induced Asthma MedFact at http://www.nationaljewish.org/medfacts/induced.html for more information.

As far as other possibilities please talk with your son’s doctor about vocal cord dysfunction (VCD).  This 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.  These attacks are also often seen with panic attacks.  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 an inspiratory flow volume loop, will show little airflow while your son is inhaling if VCD is the problem.  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 in open throat breathing techniques.  Counseling can help 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 important for your son to be evaluated by a doctor to determine the diagnosis and appropriate treatment.

[ozark]

does he have any heart issues like an arrythmia?  he should probably have a stress test done just to rule it out....it has occured before and sometimes the respiratory issue is the first to appear....esp since the medication doesnt seem to be working...good luck

[Concerned lady]

Check into the possibility of VCD/Vocal Cord Dysfunction (laryngospasm).

You can telephone the LUNG LINE and speak with a Lung Line nurse, by calling 1-800-222-LUNG(5864), 8am-4:30pm Mountain Standard Time (Colorado), Mon-Fri.

I hope your son gets diagnosed and treated quickly.

Concerned lady
http://cantbreathesuspectvcd.com

[kexbluejay]

Thank you so much for your input...he has had a stress test and the doctor also mentioned VCD. I will be contacting the doctor today to further discuss our options since the nuebulizer and inhalers are not giving him any relief.
Through my own research, I'm wondering if this is sinus related.  Along with the first attack, he was suffering with a severe sinus infection.  When I took him to the MD he was put on an antibiotic for two weeks.  Perhaps he has not gotten rid of the infection and it is causing this flare up of attacks.

[ozark]

what was he on for an antibiotic? he may need a stronger one to really get into the sinus infection and may need longer treatment....good luck

[Concerned lady]

I'm glad that your son's doc will work on finding out everything that may be causing your son's symptoms. If it is VCD, there can be more than one cause. And, he might have more than one condition, at the same time.

Nat'l Jewish knows a lot about VCD, and about sinus problems, etc. A visit to Nat'l Jewish would be helpful, if possible. They are knowledgable and kind (My husband and I know this firsthand, having been diagnosed there).

They (call their LUNG LINE) may also be able to recommend VCD-knowledgable doctors in your area, who spent some time working and learning, at Nat'l Jewish.

It sounds like you're on the way to getting your son fully and correctly diagnosed!

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

[gavinellis]

PLEASE let me know what you find out. My 13 y/o son came down with the exact symptoms in Nov of 2002. He had the sinus problems also. After increasing meds to the max including steriods, he is still non repsonsive. Pulmonologist recently suggested VCD. Went to speech therapist but she did not do a scope while symptomatic. We are going to an ENT for evaluation later this month for VCD. I will not leave with out a scope while symptomatic.

During these episodes-

Does you son experience difficulty breathing IN only?
Does he have pain in the chest at sternum?
Wheezing?
Chronic cough/throat clearing?
No probles unless exercising?
History of sinus problems?

Mine does. He is 13 y/o, 6'1" and can jump...it is killing his basketball game!

I will let you know what I find out with my son. Please let me know what you find out.

Concerned lady and her husband have an excellent website on VCD.

Gavin Ellis

PS: He describes it as havinng a pillow on his face or breathing in through a straw.

[kexbluejay]

Tuesday the doctor recommended we put him on a 2 week dose of steriods to reduce inflammation.  He is on prednesone / 3 10 mg pills at one time for 1 week, 2 10 mg pills at one time for 4 days / down to 1 10 mg pill for 3 days.  I again asked him if there could possibly be a correlation between the sinus infection he had along with this first bout of astmatic systems and he said it was possible.  I requested that my son be placed on another dose of antibiotics however he wanted to go this route with the steriods.
I took the sinus situation in my hands and now my son is doing a sinus rinse with a neti-pot, sleeps with the vaporizer at night, and uses a nasal strip to free up breathing.  Prior to this (2 days ago) he didn't show any signs of sinus problems (I just felt he still had the infection), however, he is now blowing frequently and bringing up a lot of phelm.  
Last night he wrestled and by the middle of the first period he started to have problems again.  He did make it through the match and ended up pinning his opponent.  The sad part is that no one enjoys watching him wrestle this way...he struggles for every breath and uses all his injury time.  Immediately after the match we have to talk him through to get his breathing under control and then we give him a neublizer treatment.  He complains only of burning in his chest prior to his treatment.
As a parent, I want him to stop at this point, however, as a young 17 year old athlete he struggles to continue.
This is where we are at to date.

[gavinellis]

kex,

Thank you and good luck with your son. Below is a reference to EIA that caught my attention. The symptom of difficulty breathing OUT may indicate EIA. My son has difficulty breathing IN only and it has progressivly begun to come on sooner after starting exercise. You said your son "struggles" for every breath. Could you see if it is while breathing in, out or both? .


This is on EIA

http://www.emedicinehealth.com/articles/8677-1.asp

>>
The swelling and extra mucus partially block or obstruct the airways. This makes it more difficult to push air out of your lungs (exhale).
>>



This is on VCD, note the problem can be breathing in, out or both.

http://www.nationaljewish.org/medfacts/vocal.html

>>
Symptoms include shortness of breath, wheezing, cough, even chest tightness. These symptoms are a result of an abnormal closing of the vocal cords (VCD) rather than inflammation of their airways (asthma). Based on these symptoms, many people with VCD may be diagnosed with asthma and treated with asthma medications, including oral steroids. Since VCD is not asthma, the symptoms do not improve or only minimally improve with this treatment. When VCD is not identified, patients are often treated with asthma medications. They may develop significant side effects. These are often seen with long-term use of oral steroids, without much benefit. Incorrect diagnosis and treatment may also lead to frequent emergency room visits and hospitalizations, even intubation. An important factor to be aware of is that some people have a combination of asthma and VCD.

What happens with VCD?
To understand VCD, it is helpful to know how the vocal cords function normally. When you breathe in, or inhale, and out, or exhale, the vocal cords open. This allows air to flow into or out of your windpipe (trachea). However, with Vocal Cord Dysfunction, the vocal cords close together, or constrict, during one or both parts of the breathing cycle. This leaves only a small opening for air to flow through to your windpipe.
>>

Concerned lady has an excellent picture of this on her site.

[gavinellis]

NJC,

My 13 YO son has been diagnosed with EIA over a year ago. He has been non-responsive to a braod range of meds including steriods and fast acting inhalers before exercise and at onset of symptoms. He is 6'1" 130#'s, extremely active, no prior problems. His symptoms are difficulty breathing IN only (like breathing in through a straw or pillow on face) and pain in the sternum area. Symptoms go away with rest. The onset has progressed to the point that only little to moderate exercise brings it on. He has demonstarted signs of hypoxnia (sp ?) with color change during strenuous exertion (grayish color).

The pulmonologist is now thinking VCD and referred us a speech pathologisy who observed the vocal cord while non-symptomatic and it was normal (I saw it on the screen). She would not do it while symptomatic nor recommend we have an actual scope done while symptomatic. She only said he probably has VCD and counseled on breathing techniques.

We have an appt with a pediatric ENT Airway Clinic this month. I was assured by the nurse a scope would be done if needed. However, I was given no instructions for not eating prior to the clinic nor discontinuation of any meds. They also said they did not need any prior med recs.

Does the difficulty on inspiration only and non-responsiveness to meds indicate a scope is almost mandatory while symptomatic? Is this not the most reliable indicator of VCD? (I realize he could well have both EIA and VCD). I will probably be the parent from heck if a scope is not done unless I am given a good reason not to.

Thanks,
Gavin Ellis

[Concerned lady]

Dear Gavin,

You can telephone a LUNG LINE nurse, and ask your good questions! Call 1-800-222-LUNG(5864).

Also, if you'd like to compare notes, my email is ***@****

Concerned lady

[PERSISTANT]

This is mainly to the parent with the wrestling son. My daughter17 yr old daugter who has always excelled in several sports including basketball did almost the same thing your son did at age 15. We spent 2 years going to several different doctors trying to find the problem. In addition to the onset of severe breathing problems during athletics, she then developed fatigue symptems.  When she do longer had the strength to do athletics it was all she could do to get through a day a school and then come home and sleep. A pulminologists finally sent us to national jewish because he could not find any thing wrong with her lungs. After several tests even for VCD, nathional jewish doctors were  a little stumped also. But after about a month they called us and said that the had recieved some results from samples taken during the scope to her lungs and she a tested positive for mycoplasma pneumonia. This does not show up on lung exrays or in blood work most of the time. They put her on a strong antibiotic for about 5 months and told her not to do any athletic type things for 3 months. She did this and in Oct. they did a test through her nasal passages to check for the pneumonia and the test was negative. She started working out at a slow pace and would stop and rest when she was haveing trouble breathing and gradually she has gotten better. She can run now but she is still far from being on the 3 relay teams in track that she used to be on. She does use inhalers for asthma now and that does seem to help, but in the beginng, I guess while she had the pneumonia and didn't know it, the asthma meds didn't help. Good luck. God bless. I know what you are going through. My daughter had to miss two years of sports. She is playing goal keeper on the soccer team now because she doesn't have to run. She is enjoying it but still working on getting better at running. We don't know if she will ever be able to run like she used to.
Persistant.

[kexbluejay]

Thank you for your information.  To date my son has had to quit wrestling.  This past weekend he was at sectionals and was doing quite well considering.  The doctors advised us that he could not get into a full blown attack because it was now affecting his heart.  Unfortunately, Saturday afternoon he was wrestling and had another terrifying attack in which the ref had to stop the match and we told our son "it is over", "no more".  He is devastated, depressed, and can't believe that this is what he has to deal with now.  You mentioned that your daughters diagnois was mycoplasma pneumonia, what is the procedure to making this diagnois???
My son does not experience severe fatigue.  We are scheduled for the Cleveland Clinic this Thursday and I will definately mention this to the doctor.  
His wrestling season is over, however, he wishes to play baseball and then during the summer get ready for football.  We are eager to see if he experiences any breathing problems during baseball conditioning.  At first we were not going to pursue Cleveland Clinic since this only happened during intense one on one contact and not during running...but we decided to take a proactive approach and continue with what he experienced in the event it continues on to his next sporting events.  Thank you again for your information and I'm glad your daughter is on the road to recovery.

[ozark]

one thing that comes to mind since it only seems to happen with wrestling, is a vagal response of his heart secondary to the type of activity such as holding one's breathing and forcing down type maneuver...maybe he could be checked for this during his visit also.........good luck

[gavinellis]

Took my son to a breathing clinic conducting by an ENT. From history and physical exam he immediatley thought VCD was not the problem and began to suspect reflux. There is family history of it but with different symptoms. He scoped him while symptomatic (ran up and down a flight of stairs). The vocal chords were opening but the area around them was red, which would indicate reflux. He was taken off all asthma meds and put on Previcid. He mentioned OTC Prilosac would probably work as well.

We have scheduled a return trip in 3 weeks to be scoped past the vocal chords which requires anesthesia to rule out any obstruction or voice box problems. He will also do a biopsy which can determine if reflux is present. A 24 hour ph monitor would have been done if he was only checking reflux.

We started him on the previcid tonight. I plan on seeing if that works. If it does I plan to talk to the doctor about whether the second scope in necessary.

I'll let you know what happens.

Gavin

[nikl]

Just wondering if it was the acid reflux or if you found out something else?

[JSouth]

I think you should check into something called "exercise-induced hyperventilation". It mimics asthma but is completely different. I played basketball for 18 years and came down with this disorder. I can now play at a leisuring pace but if I try to exert myself, I quickly lose my breath and have to grab my knees as I work to regain myself. This came on out of nowhere and is driving me crazy. I was diagnosed with exercise-induced asthma originally but that has been disproven by testing. Not a lot is known about exercise-induced hyperventilation but for some reason the body seems to forget how to properly breath during hard exertion. Your son should see a specialist on this condition to learn about possible treatments, most of which are behavioral adjustments and retraining. Good luck.

[gavinellis]

nikl,

The pathology from the scope is still not back. The Doctor did say what he saw was consistant with reflux/gerd but waiting on the path report before making a conclusive diagnosis. I will post results as soon as I hear.

jsouth,

Thank you so much for your input. If there is any question as to the final diagnosis we will certainly look into this. Do you have more trouble breathing in? My son can breath out OK, but can not breath in when he has problems.

Gavin

[gavinellis]

The nurse called and said the path for reflux was negative. The doctor is out this week so we do not know the next step. We thought we might be getting closer to a solution but I guess not.

I will certainly mention hyperventilation.

Thanks,
Gavin

[JSouth]

When I have the problems I feel as if I can't get enough air and my breathing becomes erratic and I have to stop what I'm doing and gasp for breath. I sometimes cough as well and that seems to eleviate some of the discomfort. After 10 to 15 seconds, I feel better and can play ball again but it's always in the back of my mind and I worry about the next attack.

Good luck with your son.

[JSouth]

I think you and your son should read this article:

http://www.aboutbreathing.com/articles/sports-induced-breathing-problems.htm

[gavinellis]

OK, Went back to the ENT as a follow up to the scope. One biopsy was negative and one was NOT, not what the nurse first said. His problems have lessened greatly since he has been on Previcid. He has had no sinus problems and has quite constantly clearing his throat. He is not completely back to normal but tolerates exercise much better. The ENT  has referred him to a grastroenterologist. The ENT is also going to monitor progress. He said said he does not have the classic reflux symptoms. He seems to "spill" acid during exercise and breathes it in causing the problem. Your lungs feel the acid coming in and react to it by closing up.

When he does have problems it always breathing in that is difficult. All things are pointing to reflux which is in the family history.

[gavinellis]

Upper GI shows moderate reflux 3 on a scale of 5 at rest, even though he is on previcid. Also a sliding esophogeal hernia. Everything is indicating reflux. Also family history of reflux.

http://verlag.hanshuber.com/ezm/index.php?ShowIssue=972&ezm=ACI

My child fits this study perfectly.