Transcription:
Exercise Related Respiratory Difficulties In Children

Melanie Cole (Host): If you’ve ever had a child wheezing or trying to catch their breath during exercise, you know how scary it can be. Exercise intolerance is an important and common symptom in the evaluation of pediatric respiratory disorders. My guest today is Dr. Gary Kohn. He specializes in pediatric pulmonary and critical care medicine at Summit Medical Group. Welcome to the show, Dr. Kohn. Let’s talk about pediatric respiratory disorders in general, and EIB with bronchospasms, what are these? What do these entail?

Dr. Gary Kohn (Guest): Well, these are conditions where children have difficulty breathing. Certainly, they can have it independent of exercise, which is more classic asthma. And then there are children that specifically have problems just with exercise and we try to distinguish, whether or not it’s asthma with an exercise component, or whether or not it’s an entity called exercise-induced bronchospasm. There could be other entities such as vocal cord dysfunction or a component of deconditioning.

Melanie: So, a parent sees their child wheezing, trying to catch their breath, and as I said, it’s pretty scary. Do they run to the emergency room? Do they call a doctor, such as yourself? What’s the process and how do you diagnose what’s going on?

Dr. Kohn: Well, typically, obviously, while at the field, the first thing to do is to attend to the child. Usually, if it’s EIB or it’s a bronchospasm, they can just have the child stop, rest, drink some water. Most children will recover in 10 to 15 minutes. If they see that trend continuing every time the child is out on the field, then they certainly need to have the child evaluated for one of the entities that we discussed.

Melanie: How do you evaluate them? How do you find out if this was an effort-induced bronchospasm, something general, or something really more specific?

Dr. Kohn: Well, when they come in to see us, we certainly take a good history to see if there is any clues in the history that point to one direction or the other. We do baseline breathing tests called spirometry or pulmonary functions that give us a hint as to whether or not there are any baseline markers pointing towards asthma in the background. We could also have them undergo an exercise challenge, usually with dry cold air, which is known to be an irritant to the airways, to see if they developed exercise-induced bronchospasm. And also during these studies, we can sometimes pick up on something called vocal cord dysfunction.

Melanie: Then what? What are the treatments for these things? Give parents some ideas of living and managing with these kinds of symptoms.

Dr. Kohn: Well, the first and most important thing is for the parents to know that if we manage a child correctly, they can continue to participate in all the activities just like any other child. Typically, we use medications known as bronchodilators, which help relax the muscles during exercise, so they don’t develop the bronchospasm, and that is if they have the EIB. If the child turns out to have asthma, then they would need alternative medications on a daily basis to help control background inflammation that’s associated with asthma. If it turns out to be deconditioning, then we talk about good cardiorespiratory exercise, aerobic exercise on a regular basis, for the body to become better conditioned. Vocal cord dysfunction, which can occur primarily in adolescent females, usually requires work with either speech therapy or sometimes with a sports psychologist to work on relaxation techniques and anti-anxiety.

Melanie: Dr. Kohn, we want our children not to necessarily rely on these rescue medications. But how do we teach them when is the time to use something like that? Suppose you’ve put them on one of these inhaled corticosteroids, when do we teach them, “That’s the time you use it.” Or, “No, you don’t want to use that all the time.”

Dr. Kohn: It’s a long educational process, and we work with the families to try to teach them what symptoms to look out for. We know that certain children will be triggered at different times of the year, depending on whether they have allergies, whether or not cold air induces it, and with time and effort, we sort of teach the kids what symptoms to watch out for and let their parents know. Not all children need inhaled corticosteroids. For the exercise-induced bronchospasm, they may just need short-acting beta agonist on an as-needed basis. Also, we know that some children will benefit from warm-up exercises prior to their long run and whichever sport they’re participating in, and that can induce a refractory period which would reduce their risks for symptoms and need for medicine during the event.

Melanie: Is there any truth to the theory about breathing through your nose to warm that air before it goes into your lungs, or keeping your mouth and nose covered if your children are playing outside in the cold weather, or if they’re in football in the cold weather – any of those kinds of things?

Dr. Kohn: Certainly, those are triggering events, as I mentioned, or exercise challenges done with cold air. The hard part is, from a practical standpoint, it’s hard to make your kid be the only one on the soccer field wearing a scarf over their face. The second is most children won’t breathe purely in through their nose and out through their mouth once they’re exerting themselves on a pretty extensive basis, just because there’s not enough bulk flow in through the nose and out through the mouth. Even though it, out there, is a possible treatment to modify the disease, it’s practically very difficult to get the children to do those items.

Melanie: A big question that I hear a lot is avoiding triggers. I mean how do you avoid triggers? If this is allergy-related, or even asthma-related, and you spoke about vocal cord dysfunction, how do you avoid those triggers with your child without just keeping them in all the time?

Dr. Kohn: Exactly. You have to balance it. This our conversation with the parents about risk benefits of therapies. Certainly, if you avoid exercise, you could avoid the medications, but then the flip side is, then your child may be leading a more unhealthy life by not routinely participating in exercise. So in that scenario, we tend to feel that the balancing of the medications and the exercise outweighs the risk of the medication. However, keeping that in mind, we reevaluate the children pretty much every three to six months to make sure they still need the medication, as we know that their bodies are changing during childhood, and the process may resolve on its own.

Melanie: What is the outlook for children with these respiratory disorders? Is this something that’s going to follow them through life?

Dr. Kohn: We tell them most children in the 0 to 6 category will have resolution of asthma if it’s particularly induced by viruses and respiratory infections. Older children that have pure exercise-induced bronchospasm tend to resolve in the college years and beyond, but mainly because the rest of their life takes hold and they don’t have the opportunity to be playing soccer or lacrosse all day long, which was their trigger.

Melanie: Okay. So it’s definitely something that parents can have hope now. Does it ever become serious? They’ve got their medications. You’ve given them education about warm-up and triggers. Does it ever become so serious that a parent says, “Okay, this isn’t working”?

Dr. Kohn: It’s pretty rare for anybody with exercise-induced bronchospasm to be hindered, the children that have more difficulty, the ones that really have underlying asthma, with a significant exercise component. And usually, those children are ones with moderate to severe persistent asthma. In most cases, we try to work in their background medications, so they do have the ability to participate in all activities like any other child. There are very few that really don’t have the ability to do that, or they may be limited only during certain times of the year, where their triggers may be more persistent.

Melanie: Dr. Kohn, is there any limit to exercise? Is there anything you want parents to know about activities that their children should or shouldn’t do? Are there any exercises or activities that are off-limits?

Dr. Kohn: There is nothing that is off-limits in my opinion. We want the kids to pick whatever sports that they like. The two sports that we do sometimes see increased trouble or difficulty with is ice jockey, just because of the cold, dry air inside the arenas, which, as we mentioned, can be a trigger. The other, sometimes, is swimming, if the chlorine content is very elevated in the indoor pool that they’re at and there is not good ventilation. But, again, we usually try to work with the children so they continue to participate in those activities if that’s their wish.

Melanie: What about the daily stresses of living with this exercise-induced or effort-induced bronchospasms for you children? How do you educate parents and their children to not let this stress them out so much that that in itself can propagate the situation?

Dr. Kohn: For the most part, we’ve been pretty lucky because once we start treating the children, they’re actually less stressed because now they’re being able to participate in the activities that they want to. I haven’t had too many children that are stressed so much by the diagnosis of the EIB. They’re for the most part happier that it’s under good control and they can play their friends and not be limited.

Melanie: That’s excellent information. And, Dr. Kohn, in just the last minute or so, tell listeners why they should come to Summit Medical Group for their respiratory care.

Dr. Kohn: Well, fortunately we’re a large multidisciplinary group which allows us to work in a very comprehensive and integrative approach with our colleagues, both the primary care physicians of the patients, as well as allergists, if the patients have allergies, or the ear, nose and throat physicians, as well as our audiologists and speech therapists. It allows for a very nice, comprehensive team approach for the children, and we have all the equipment and abilities to evaluate the children right here at Summit Medical Group.

Melanie: Thank you so much, Dr. Gary Kohn. You’re listening to SMG Radio. For more information, you can go to summitmedicalgroup.com. That’s summitmedicalgroup.com. This is Melanie Cole. Thank you so much for listening and have a great day.