All That Wheezes is not Asthma

author : AMSSM

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Finding the correct cause and most effective treatment will return the athlete to competitive form most quickly, and should be done under the guidance of a well qualified physician.

By Ronald Hanson MD Provo, UT. Member AMSSM and

Jim Ngatuvai MD Provo, UT. Member AMSSM

Introduction

Wheezing can be a distressing symptom to the athlete who is accustomed to pushing for peak performance. When accompanied by shortness of breath, wheezing is even more upsetting. Fortunately, most causes of wheezing are benign and reversible; however, an accurate diagnosis and treatment plan are essential. Dr Rochelle Nolte provided an excellent article on exercise-induced asthma in a March 2006 article for Beginner Triathlete. This article explores common causes for wheezing other than asthma.

A wheeze is a melodic sound produced during breathing. Wheezing is caused by obstruction to the normal flow of air through the respiratory tract. Depending on the cause and location of the obstruction, wheezing can occur during inspiration, expiration or a combination of both. Accompanying symptoms, exacerbating/relieving factors, physical examination, testing, and trials of various therapies will help establish the underlying cause and correct treatments. Finding the correct cause and most effective treatment will return the athlete to competitive form most quickly, and should be done under the guidance of a well qualified physician.

Specific Conditions

Many conditions cause wheezing. In this section, we will consider some of the most common and most detrimental causes of wheezing. This section is summarized in the table below.

Upper Respiratory Congestion

We have all experienced congestion in our upper airway due to colds, allergies, and other conditions. The post-nasal drip that accompanies congestion is the single most common condition that causes wheezing during exercise. Mucus from the nasal cavity drains and accumulates in the area around the vocal cords, which becomes the site of relative obstruction. Recent nasal congestion, post-nasal drip, coughing that is independent of activity and becomes worse when laying on one’s back, and a relative lack of shortness of breath are often found on history.

On examination, a physician may find an inflamed nose, mucus in the throat, tender sinuses, and clear lungs. No further testing is needed unless the condition is recurrent. In that case, congestion may be caused by blockage to normal drainage by structures such as a nasal polyp, which may require surgical resection. If the symptoms occur at a particular time of the year, seasonal allergies are the possible cause, and testing for specific allergies may be indicated. For normal cases, regularly removing the offending irritant with saline rinses is the most beneficial intervention. Nasal steroids, expectorants, decongestants, antihistamines, and, in severe cases, antibiotics are all additional choices for treatment.

Vocal Cord Dysfunction

Vocal cord dysfunction refers to the abnormal motion of the vocal cords during inspiration. Normally, the vocal cords open widely during inspiration; however, in vocal cord dysfunction, they narrow. The result is an obstruction at the level of the vocal cords. Athletes describe wheezing that occurs very early in exercise, wheezing during high anxiety situations, a sense of smothering, rapid resolution of the wheeze after exercise, and a lack of symptoms when calm.

Few findings are evident during a physical exam; however, if the wheeze is present, it should be heard best over the throat. If this diagnosis is suspected, direct visualization of the vocal cords may be necessary. This is done during forceful breathing with a flexible scope inserted through the nose. A diagnosis is made when the vocal cords close during inspiration. Specialized therapists can teach the athlete to breathe correctly.  Working on mechanisms to calm anxiety is also an appropriate intervention. This diagnosis can be confused with exercise-induced bronchospasm (asthma), because athletes sometimes respond to the inhaled medications used for asthma.

 Vocal cords normally 

 open widely during

inspiration, as in the

picture to the left.

In someone who has

VCD, the vocal

cords close during inspiration,

as in the picture to the right.

Acid Reflux Disease

Acid reflux disease refers to an irritation of the esophagus due to abnormal release of gastric contents.  Approximately 65% of the population has suffered from the most common symptom, which is heartburn (pain mimicking a heart attack).  Other symptoms of acid reflux include regurgitation, trouble swallowing, asthma-like bronchospasms, abdominal pain,  chronic cough, laryngitis, throat redness,  or a globus sensation.  The cause of reflux disease is thought to be an inappropriate relaxation of the lower esophageal sphincter, which allows for the abnormal release of gastric contents back into the esophagus.  Mostly the causes of sphincter relaxation are unknown, but things known to cause relaxation include certain foods, certain medications, pregnancy, and even chronic belching. 

About 80% of people that do have reflux can be diagnosed by a thorough history of the symptoms alone.  Other methods used for diagnosis include pH testing of the lower esophagus, esophageal manometry, or gastric analysis via endoscopy.  Sometimes a gastrointestinal specialist will do an esophagogastroduodenoscopy (EGD) to look at the damage to the esophagus due to the reflux, as well as look for possible ulcers in the lining of the stomach and duodenum (the first part of the small intestine).  Treatment usually includes lifestyle changes and avoidance of chocolate, high-fat foods, alcohol, tobacco, and caffeinated beverages.  It is recommended not to lie down after a meal, and to elevate the head when going to sleep.  Medications used for treatment include antacids or other medications designed to reduce acid secretion, known as H2 blockers or proton pump inhibitors.  If medications don’t work, surgical intervention may be necessary.  Your primary care doctor can help you decide which option is best for you.

Bronchiolitis

Bronchiolitis refers to the inflammation of the tiniest airways located in your lungs. It can be a very devastating disease for children, especially in the first two years of life, because they are unable to clear their airways.  For many of us, it causes symptoms similar to the common cold or upper respiratory congestion (see previous entry).  Symptoms usually include a cough with thick mucous production, wheezing, irritability, fever, increasing respiratory effort.  It usually has a pretty quick time of onset.  Viruses known to cause symptoms include the Respiratory Syncytial Virus (RSV), Parainfluenza viruses, Adenoviruses, and the Influenza viruses. It is for this reason that young children at risk should receive the flu shot. Scientists are also working on developing an effective vaccine against the RSV virus which is usually the most common cause. 

Diagnosis can be made by taking a sputum sample or a nasal swab and testing for the virus.  An X-ray can be helpful to eliminate other causes that may cause respiratory distress.  If the virus is detected, most of the treatment involved includes supportive care.  This includes such things as encouraging fluid intake, using a humidifier, using expectorants to loosen the mucous, or even adding an antibiotic in prolonged cases.  A respiratory therapist can be very helpful in providing the appropriate therapy.  Because of the complications that may arise, you should speak with your health care provider regarding appropriate therapy and for help with the diagnosis if you suspect your child has bronchiolitis.           

Tumors, Growths & Cancers

Potentially the most frightening possible cause of wheezing is a cancerous growth. Though some growths in this area are benign, all need to be dealt with quickly and thoroughly. These conditions are very uncommon in younger populations, but older athletes and especially athletes with a long history of smoking need to take wheezing seriously. Tumors often cause chronic coughing, bleeding with cough, a change in voice, unexplained weight loss, or the feeling of a mass in the neck or throat.

A physician may hear wheezing at any part of the respiratory cycle depending on the location of a growth, and may be able to feel a mass on examination. If an athlete’s history and physical exam are concerning, the physician may wish to visualize the throat directly with a laryngoscope, and may order advanced imaging to look at the structures in the neck and chest. If a growth is found, a biopsy will likely be necessary to determine what type of growth it is. Depending on the type of growth, its size and location, many options from surgical removal to radiation and monitoring the growth may be recommended.

View the summary chart of common causes of wheezing in the athlete

Conclusions

Wheezing is a symptom that is caused by narrowing of the airway, and has many different reasons for happening. While most conditions that cause wheezing are benign and self limited, many causes are serious and can affect the performance and health of the athlete. We suggest that wheezing occurring longer than two weeks accompanied by shortness of breath, cough with bloody sputum, or difficulty breathing outside of activity should be evaluated as soon as possible by a well-qualified physician.

Ronald Hanson MD Provo, UT. Member AMSSM

Jim Ngatuvai MD Provo, UT. Member AMSSM

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date: June 5, 2006