Pediatr Clin N Am 49 (2002) 709 – 721

Pulmonary problems and management

concerns in youth sports
David M. Orenstein, MD
Antonio J. and Janet Palumbo Cystic Fibrosis Center, Children’s Hospital of Pittsburgh,
Pittsburgh, PA 15213, USA
School of Medicine and School of Education, University of Pittsburgh, 3705 Fifth Avenue,
Pittsburgh, PA 15213, USA

In the overwhelming majority of exercising youngsters, exercise tolerance is

limited by cardiovascular and muscular factors, not the lungs. Even at exhaustion,
pulmonary reserve is considerable. Yet some young athletes do experience
respiratory problems with exercise. These problems can be assigned to several
categories, including those related to underlying acute and chronic respiratory
conditions (principally respiratory tract infections, asthma, cystic fibrosis, chest
wall deformities, and neuromuscular disorders), and apparent but nonpathological
problems (the heavy breathing of anaerobic exercise, relative deconditioning, and
anxiety). There are also situations that seem to be problematic, but need not be
(having the diagnosis of asthma or cystic fibrosis). Pharmacologic management
of respiratory problems and perceived problems can be difficult, and will be
discussed with the particular disorder.

Problems related to underlying acute and chronic respiratory conditions

Asthma
Asthma is the most common chronic illness of children and adolescents,
affecting between 5% and 15% of the population, or some 2.5 million young
people in the United States. It is characterized by periodic airways obstruction that
is at least partially reversible, either spontaneously or with treatment. The airway
obstruction is caused by spasm of bronchial smooth muscle, endobronchial

E-mail address: [email protected] (D.M. Orenstein).

0031-3955/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
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710 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721

inflammation, or both. There is increased sensitivity of the bronchi to various

stimuli [1]. Asthma has a major impact on lifestyle and accounts for millions of
missed school days each year. Thirty percent of young people with asthma have
limited activity, compared with 5% of youngsters without asthma [2].

Exercise-induced asthma
Nearly everyone with asthma has exercise-induced asthma (EIA), with
worsened symptoms during and especially after exercise [3]. These symptoms
can include cough, difficulty breathing, chest pain, chest ‘‘tightness,’’ wheezing,
or a combination of these symptoms. Wheezing is frequently absent, a fact that
causes many cases of EIA to go undiagnosed. The incidence of EIA varies with
the population being studied and the method used for diagnosing it, for example,
questionnaire, field testing, or sophisticated laboratory testing.
Many young people, including athletes with no history of asthma, also have
EIA. As many as 10% to 15% of high school [4] and college [5] athletes have
EIA. Elite athletes are not protected from EIA, nor does asthma preclude
successful competition at the highest level of sport. This fact is demonstrated
by such well-publicized asthmatic Olympic athletes as Jackie Joyner-Kersee
(track and field), Bill Koch (cross-country skiing) [6] and Tom Dolan and Amy
Van Dyken (swimming) [7]. In the 1996 Olympics, 14% to 15% of the athletes on
the United States team had a previous diagnosis of asthma, had recorded use of an
asthma medication, or both; 30% of those who had asthma earned medals [8].

Clinical presentation
EIA can occur in association with virtually any type of exertion, but it is most
likely to happen with 6 to 8 minutes of relatively vigorous activity in cool, dry
environments. Exercise that lasts less than 6 minutes or more than 8 minutes may
elicit a less serious EIA response [9,10]. Short, extremely strenuous, supra-
maximal exercise may also provide a potent stimulus to EIA [11]. In a typical
case of EIA, cough, chest tightness, or wheezing begins shortly after exercise and
persists for 30 to 90 minutes before abating spontaneously. In some patients, there
may be a recurrence of these symptoms hours later; this is known as the late
asthmatic response [12]. Some patients with EIA exhibit the phenomenon known
as the ‘‘refractory period,’’ or a second exercise challenge repeated within 30 to
120 minutes that elicits a less serious EIA response [13]. The symptoms of EIA
correlate with reduced pulmonary function test values, particularly those measures
that reflect the caliber of the smallest, peripheral airways [10].
It has long been recognized that some forms of exercise are more likely to
induce asthma; running is the most likely, and swimming is the least likely
[14]. It now appears that many of the apparent differences among various
exercise stimuli had more to do with the volume, temperature, and humidity of
the inspired air than with the character of the exercise itself [14]. There re-
mains, however, an unexplained distinction between swimming and other
activities; even when allowing for the inspired air conditions and the intensity
 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721 711

of the exercise challenge, swimming is less asthmagenic than other forms of

exercise [15].

Pathophysiology
It is unclear why the airways of people with asthma are susceptible to the
development of bronchospasm, inflammation, and edema that characterize the
asthmatic response to various stimuli. Our understanding of the stimuli and some
of the intermediate steps leading towards the airway changes has increased over
the past decade [14,16 –18].
It has long been recognized that cold air is more likely than warm air to trigger
EIA [14,19,20]. Dry air has also been recognized as more asthmagenic than
humidified air [21]. The temperature, volume, and humidity of inspired air, and
the total respiratory system heat loss are important in determining the degree of
EIA [15,22]. Anderson has postulated that water loss from the airways is the
principal stimulus for EIA [16]. Breathing cold, dry air induces EIA in the sus-
ceptible airway much more readily than breathing warm, humid air. Breathing
cold, dry air causes airway narrowing in the exercising, but not resting, subject.
At rest, the upper airways warm and humidify the inspired air very efficiently. In
contrast, the greater volume of air breathed during exercise overwhelms the
ability of the upper airway to warm and humidify the air. In Deal’s important
early investigation, patients had the same degree of EIA if they exercised or
breathed large volumes while they sat still, provided that the volume, temper-
ature, and humidity of the inspired air was the same [22].
It is likely that the appropriate (or perhaps inappropriate) volume, heat, and
humidity of the inspired air cause airway narrowing by triggering the releasing of
various inflammatory and bronchospastic chemical mediators [14]. Among the
many studies suggesting the role of inflammatory mediators, especially those of
mast cell origin, in the genesis of EIA include those showing that EIA is blocked
by cromolyn sodium [23], a mast cell stabilizer that is not by itself a broncho-
dilator. Other studies have shown elevated circulating levels of histamine,
neutrophil chemotactic factor (now known to be interleukin-8), or both, are
coincident with EIA [24, 25]. More recently, pre-exercise leukotriene blockers
have been shown to block EIA [26, 27]. Very recent data in dogs [28] suggest that
repeated bouts of breathing frigid, dry air at high volumes, as happens with cross
country ski athletes, not only causes EIA during the exposure, but also renders
the airways chronically hyperresponsive [28].

Diagnosis
The diagnosis of EIA is usually straightforward; a young athlete known to
have asthma complains of cough, chest tightness, shortness of breath, or chest
pain during and especially after exercise. This youngster can usually and safely
be assumed to have EIA, and be treated appropriately [14]. In an adult, where the
possibility of coronary artery disease cannot be ignored, more extensive evalu-
ation is warranted. Other considerations also apply to the young athlete whose
712 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721

story is atypical, or who does not respond promptly to pre-exercise albuterol,

cromolyn, or both, by inhalation.
For most patients, even those with some atypical features, (eg, no previous
diagnosis of asthma, or symptoms during exercise) the first diagnostic test should
usually be a therapeutic trial of inhaled albuterol prior to exercise [14]. The
disappearance of the symptoms while on this regimen confirms the diagnosis.
Often, pulmonary function testing can be helpful, particularly if it shows reduced
flows from peripheral airways. If flows increase significantly after bronchodilator
inhalation, the diagnosis of underlying asthma is fairly well established, and
therefore, the case for EIA is strong. Sometimes an exercise challenge can be
diagnostic. The exercise challenge should be intense enough to raise the patient’s
heart rate to 80% of its maximum, and should last 6 to 8 minutes [9,10]. Pulmonary
function should be assessed before exercise and again at 3 to 5 minute intervals
beginning immediately after exercise and continuing for 20 minutes. A decrease of
10% to 20% in forced expired volume in one second (FEV1) after exercise is one
commonly used criterion for diagnosing EIA. We like to see such a change in
FEV1 or maximal midexpiratory flow rate, a parameter more sensitive to flow from
the peripheral airways. Having the subject breathe frigid, dry air probably
increases the sensitivity of the exercise test [29]. Some laboratories compare the
highest values of the chosen pulmonary function parameters after bronchodilator
administration with the lowest obtained after exercise rather than simply looking at
the decrease after exercise [14]. In our EIA protocol, we administer albuterol
20 minutes after exercise both to increase comfort for the patient who has had EIA,
and to increase the sensitivity of the test in the patient who has not had a dramatic
post exercise decrease in pulmonary function. With any laboratory protocol, there
is a large false-negative rate in testing for EIA [30].

Under- and over-diagnosis

EIA may be unique in the frequency with which it is both under- and over-
diagnosed. EIA is frequently undiagnosed if the affected youngster has no
history of asthma, does not wheeze, or both. Unfortunately, the under-diagnosis
of EIA denies many boys and girls the pleasure of an active exercise and sports
life. In recent years, EIA has probably been over-diagnosed, especially in
affluent neighborhoods. Common sights include multiple-metered dose inhalers
on the pool deck during swimming practice or in two-thirds of the parents’
pocketbooks on the sidelines during a soccer game. Au courant parents and
coaches are familiar with EIA; if a child breathes heavily, EIA is a convenient,
and perhaps more palatable, explanation than ‘‘out of shape.’’ Even the highly
conditioned athlete will have greatly increased minute ventilation with intense
exercise. This is not pathologic, but is sometimes considered abnormal by the
naı̈ve observer or athlete.

Treatment and prevention

Asthma symptoms following exercise typically disappear spontaneously
within 30 to 90 minutes, but can be relieved much more quickly by the
 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721 713

administration of an inhaled beta-agonist bronchodilator such as albuterol [17]. If

the underlying airway inflammation is well-controlled, EIA can be prevented in
virtually all patients, with inhalation of either cromolyn sodium [23] or
nedocromil sodium [31], a beta agonist (eg, albuterol or terbutaline), or both
[32] 15 minutes prior to exercise. The protection lasts about 2 hours for either
cromolyn or terbutaline [17]. Interestingly, the combination of cromolyn and
terbutaline doubles the duration of protection, to 4 hours [32]. Albuterol gives
4 hours of protection [17], and salmeterol protects against EIA for as long as
12 hours [33]. If a patient experiences EIA despite these medications, there is
probably an inadequately controlled underlying airway inflammation. Unrecog-
nized airway inflammation is the likely explanation for the fact that children who
take budesonide by inhalation for 1 to 3 weeks have less severe EIA than they
had before starting the drug [34].

Asthma drugs and international competition

Table 1 lists drugs used for asthma, their route of administration, effective-
ness, whether they are legal or banned for international competition, and whether
their use is prophylactic or therapeutic. The United States Olympic Committee
Drug Control Program maintains a ‘‘hotline’’ (1-800-233-0393) to keep the

Table 1
Drugs used for exercise-induced asthma
Drug Route of administration Effectiveness Legal or banned
Cromolyn sodium Aerosol Good Legal
Nedocromil sodium Aerosol Good Legal
Beta 2 agonistsa
Albuterol Aerosol Excellent Legala
Oral Fair Banned
Salmeterol Aerosol Excellent Legala
Terbutaline Aerosol Excellent Legala
Orciprenaline Aerosol Excellent Legala
Clenbuterol Aerosol Excellent Banned
Theophylline Oral Good Legala
Ipratropium bromide Aerosol Fair Legala
Steroids
Beclosmethasone Aerosol ?b Legal
Budesonide Aerosol Fair Legal
Prednisone Oral ? Banned
Prednisolone Oral ? Banned
Leukotiene inhibitors
Montekukast Oral Good Legal
a
Aerosol beta agonist bronchodilators are legal in athletes with written notification from a
physician that the athlete has asthma or exercise induced asthma. At the Olympics, permission will be
given only after review by an independent panel.
b
These inhaled steroid agents are useful for prophylaxis, more than for treatment.
714 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721

public up-to-date concerning the latest banned drugs. Recent news reports have
indicated that instead of pursuing serious abuses of performance-enhancing
drugs, the International Olympic Committee and the World Anti-Doping Agency
will focus on the overuse of asthma medications. They will require a letter from
an athlete’s physician stating that the athlete has asthma or EIA, and requires
the medication.

Nonpharmacologic considerations
Nonpharmacologic steps can be helpful in lessening the effects of EIA.
Knowing that swimming is the least asthmagenic of all sports, and that sports that
require short or less intense, less prolonged exercise are not as likely to cause EIA
is unlikely to convince a competitive athlete to change sports. On the other hand,
parents of an asthmatic toddler can help shape the future athlete’s career by
directing him/her to swimming or sprint-type sports.
For athletes who experience the refractory period, warm-up exercises
45 minutes to 1 hour before competition may help prevent EIA. The most
effective warm-up for blocking EIA has not been determined, but short sprints
[35] and prolonged submaximal exercise [36] have been shown to be protective.
The warm-up exercise need not induce EIA to be protective [36]. For athletes
exercising in cold air, a scarf or mask around the face can lessen EIA, probably
by warming and humidifying the inspired air [37].
Patients with asthma can improve cardiopulmonary fitness with exercise train-
ing. The benefits of exercise programs are both subjective (increased participation
in activities, improved emotional status, decreased intensity of wheezing attacks
[14]), and objective (improved running performance [38], increased aerobic fitness
[39,40]). Whether or not improved fitness influences the severity of the underlying
asthma is unclear. Early studies, performed before we understood the importance
of minute ventilation in the initiation of EIA, often concluded that the underlying
asthma was less severe after conditioning. This was because patients suffered less
severe EIA in the exercise laboratory after conditioning, for an identical exercise
challenge, than they did before conditioning. The problem with these studies is that
the exercise challenges before and after conditioning used similar workloads and
did not establish a control for minute ventilation. Subjects with improved fitness
employ a lower minute ventilation for a given workload compared to what they
required in the unfit state. This means that an equal workload presents a lower
minute ventilation and, therefore, a less intense EIA stimulus compared with the
pretraining situation [14]. Most [39,41], but not all [42] studies that have
controlled, equal minute ventilation have shown EIA responses after conditioning
equal to those seen before. Exercise conditioning is good for patients with asthma,
but probably does not lead to decreased underlying airway reactivity.
Aerobic conditioning does not influence airway responsiveness, and con-
versely, the degree of airway obstruction does not predict the degree of overall
fitness and exercise tolerance of individuals with asthma. In 1996, Amy van
Dyken became the first American woman to win four gold medals in a single
 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721 715

Olympics; her smaller airway function was measured at 35% of predicted just the
week before [7]. There is a poor relationship between airway obstruction and
fitness among people with asthma, but there is a close relationship between
fitness and habitual activity level [43,44]
Asthma need not interfere with an athlete’s ability to become fit and to com-
pete successfully, especially if the athlete is given appropriate pharmacologic
and nonpharmacologic treatment, including the encouragement to participate
and excel.

Asthma: summary
Most patients known to have asthma, and many with no history of asthma,
have exercise-induced asthma, with cough, chest tightness, or wheeze, during or
especially after exercise. In most patients, these symptoms can be prevented by
taking inhaled medications prior to exercise, and young athletes with asthma can
have a successful athletic career. Fitness levels among people with asthma
correlate more closely with habitual physical activity than with the degree of
airway obstruction.

Cystic fibrosis
Cystic fibrosis (CF) is the most common inherited, profoundly life-shortening
disorder among white populations, and is found in every ethnic group. The gene
for CF is located on chromosome 7, and encodes a protein known as CFTR
(cystic fibrosis transmembrane conductance regulator). This protein serves as the
epithelial cell’s principal chloride channel, and also helps regulate the trans-
membrane movement of other ions. Its absence or dysfunction ultimately leads to
the clinical picture of CF. This includes dry, thick bronchial mucus and
progressive bronchial infection and inflammation that lead to exercise intol-
erance, and ultimately, respiratory failure and premature death [45]. In the
pancreas, thick mucus blocks ductules, leading to pancreatic insufficiency,
maldigestion, malabsorption, and failure to thrive. Sweat glands produce sweat
that is much higher in sodium and chloride concentrations than normal.
Treatment of the lungs includes various nebulized medications, antibiotics,
and airway clearance. Airway clearance can be accomplished with techniques
that include manual chest physical therapy, a vibrating mechanical vest, di-
rected forced expiratory maneuvers, and exercise. Exercise is more effective for
mucus clearance than cough, but by itself is probably not as effective as the
other techniques.
The survival of CF patients has improved considerably since 1938 when CF
was first described as a clinical entity; at that time few children reached their first
birthday. The current median survival age is just over 30 years [46]. Survival has
been shown to correlate with a number of independent parameters, including
pulmonary function, nutritional status, and respiratory tract pathogens. Strikingly,
the factor with the strongest correlation to survival among patients with CF is
aerobic fitness [47].
716 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721

Exercise in CF
Although patients with CF suffer progressive exercise intolerance, many
children and adolescents have normal or near normal exercise tolerance, and
can lead physically active lives. Patients with CF have completed marathons
[48] and other long-distance endurance events. It is not uncommon for
youngsters with CF to cough during and after exercise. As this cough is
helpful in clearing airway mucus, and does not pose an infectious risk to
others, it should never be stifled.
Patients with CF who perform an exercise test with progressively greater
workloads have a normal heart rate response and increase minute ventilation
as work increases. Their ventilatory demands may be so great that they limit
exercise long before cardiovascular limits are reached. This means that
children with CF may give a maximal effort and be limited by their lungs,
with heart rates as low as 150 bpm at peak work (compared with the 200± 10
expected of a healthy youngster). Their highest workload is likely to be lower
than that of healthy peers, yet their ventilation may be greater than normal for
a given workload, as they may have considerable pulmonary dead space
where ventilation is wasted [49]. Sicker patients (those whose forced expired
volume in one second is less than 50% of predicted) may experience
oxyhemoglobin desaturation at heavier workloads, but most patients will not
desaturate [50]. Patients with CF are able to tolerate repeated bouts of
exercise, and increase ventilatory muscle endurance [51] and, just like their
healthy peers, increase their aerobic fitness (maximum work capacity, and
peak oxygen consumption) [51]. As mentioned previously, higher aerobic
fitness is correlated significantly with improved survival [47], making it
tempting to conclude that an exercise program can prolong life. Very recent
evidence suggests that exercise may even help correct the cellular defect, with
improved transmembrane ion transport [52]. Some patients with CF will also
have exercise-induced asthma. Most experts feel that exercise poses no danger
to children with CF, with the possible exception of exercising in the heat.
Patients with CF can exercise safely in the heat, but they lose significantly
more sodium and chloride in their sweat than healthy individuals [53], and
may develop hypochloremia and hyponatremia [53]. After exercise and heat
stress, they correct their electrolyte and fluid deficiencies [54] but during
exercise, they underestimate their fluid needs and do not drink enough,
particularly if they drink unflavored deionized water [55]. If they drink water
with both salt (50 mmol/L) and sugar, they come much closer to correcting
their losses [56].

Cystic fibrosis: summary

Children with CF should be allowed, and, in fact, encouraged to exercise,
up to their limits. They should not be excluded from gym class or sports
because of their diagnosis. They should be allowed to determine their own
limits, however, and to take short breaks if needed. These breaks could be
 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721 717

considered ‘‘breathers.’’ If they exercise in the heat, they should be encour-

aged to drink more than they feel they need.

Musculoskeletal problems

Chest wall problems

Scoliosis
In most cases, scoliosis does not influence exercise tolerance, but when the
curve is pronounced, somewhere around 60%, it can impinge on chest expansion,
causing a restrictive defect, and a reduction of vital capacity. The reduced vital

Fig. 1. Pieter van den Hoogenband, Olympic champion, world record holder. Note pronounced
pectus excavatum.
718 D.M. Orenstein / Pediatr Clin N Am 49 (2002) 709–721

capacity, in turn, reduces exercise tolerance. With more severe curves, exercise
tolerance can indeed be extremely limited.

Pectus excavatum
This common problem is often unfairly blamed for reduced exercise tolerance.
Pectus excavatum, while occasionally having emotional consequences, is seldom
of physiologic import. The outstanding success of Dutch swimmer Pieter van den
Hoogenband in the Sydney Olympics should help physicians and coaches
convince parents and children that pectus need not limit their participation and
success in sports. ‘‘Hoogie’’ was named Swimmer of the Year for 2000, and has
such a pronounced pectus deformity (Fig. 1) that newspaper commentators in
Sydney discussed whether he had an unfair advantage by being able to skim
above the water like a catamaran.

Nonpathologic heavy breathing

Most heavy breathing that occurs during athletic competitions and practices is
normal. As metabolic demands increase, minute ventilation must increase to
supply more oxygen to exercising muscles, and especially to remove carbon
dioxide. If the exercise is so intense that the oxygen supply to the exercise
muscles is outstripped by the demand, the main source of energy becomes
anaerobic metabolism, with the consequent production of lactic acid. With
the buffering of lactic acid, excess carbon dioxide is produced, and needs to be
eliminated via the lungs, thus stimulating a large increase in breathing volume.
So, intense exercise will of necessity, result in heavy breathing. This is normal
and healthy, but may be misinterpreted as pathologic. The less conditioned the
athlete, the lower the workload that will require anaerobic metabolism and,
therefore, the quicker the onset of heavy breathing. Therefore, all athletes will
have large increases in ventilation at heavy workloads, and unfit youngsters will
have similar increases in ventilation at lower workloads, all without underlying
pulmonary pathology. The anxious child, perhaps new to competition, or worried
about not living up to a parent’s or coach’s expectations, may hyperventilate. This
hyperventilation, too, can be misinterpreted as asthma. This incorrect diagnosis
may not only result in the child taking unnecessary drugs, but may also
perpetuate the child’s exposure to an unhealthful competitive environment.

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