Case Study 1: Medical History: Ms. JR is a 22 yr old Caucasian college senior. T

Question

Case Study 1:

Medical History:
Ms. JR is a 22 yr old Caucasian college senior. Throughout high school she was active in competitive sports including soccer, swimming, and field hockey. On occasion throughout high school she would develop an increase in shortness of breath and a cough. Her primary care physician told her that she had bronchitis and that she should not worry about it. After entering college, she continued with competitive soccer and swimming. At the end of a long run during soccer games she would note an increase in cough and slight wheeze. She did not note any symptoms following her swimming practice. She continued to exercise but noticed an increase in coughing and wheezing over the ensuing year.

Diagnosis:
Her parents became concerned about her discomfort and tried to convince her not to exercise because “it makes you feel much worse and could be dangerous.” With ongoing symptoms, she withdrew from soccer. She sought advice of the college physician, who told her that she might have asthma given the symptoms of wheezing. Spirometry revealed an FEV1 of 3.09 L (96% predicted), an FVC of 3.54 L (95% predicted), a peak expiratory flow rate (PEFR) of 6.97 L (95% predicted), and an FEV1/FVC ratio of 87%. Given these results, showing “normal” pulmonary function, the patient was told that she did not have asthma but rather bronchitis and was advised to continue her exercise (after a course of antibiotics). She continued to swim but would note that at the end of a training session she was slightly more short of breath than usual and had anterior chest heaviness.

Exercise Test Results:
Ms. JR sought the advice of another physician, who ordered an exercise test with the measurement of expired gases during progressive incremental bike exercise. Spirometry was performed at 15, 30, and 60 min following the exercise test. Maximal oxygen consumption was 3.13 L · min1 (52.2 ml · kg1 · min1). Flow rates were as follows:
• FEV1 (L): preexercise = 3.09; 15 min postexercise = 2.87; 30 min postexercise = 2.20; 60 min postexercise = 2.24
• FVC (L): preexercise = 3.54; 15 min postexercise = 3.32; 30 min postexercise = 2.97; 60 min postexercise = 3.03
• PEFR (L/s): preexercise = 6.97; 15 min postexercise = 6.00; 30 min postexercise = 5.25; 60 min postexercise = 5.26

Exercise Prescription:
As a result of these studies, a diagnosis of asthma (exercise induced) was made. The patient was started on a short-acting b-agonist (albuterol sulfate) administered 30 min before exercise. She was instructed to warm up for 15 min with low- to moderate-intensity exercise or swimming before starting a high-intensity swim practice. Exercise tolerance subsequently improved while exercise-associated symptoms became rare (for the most part abated).

Questions:
1. Why was the initial diagnosis of asthma not entertained?

2. How was the actual diagnosis of asthma (exercise induced) made? What tests should be useful in this determination?

3. How did the recommendations improve the patient’s exercise tolerance? Why was swimming initially better tolerated than soccer?

4. Discuss the intensity, frequency, and duration of exercise training for patients with asthma.

5. How would the development of asthma symptoms at the end of a 3 h practice session influence the choice of medication (e.g., short-acting vs. long-acting b-agonist)?

Explanation / Answer

1   At the initial diagnosis patient showed normal FEV1 and FVC ratio which is an indicator of air flow in lungs, in the case condition of asthma FEV1/FVC ratio will be less than 75% but the patient showed FEV1/FVC ratio of 87%, FEV1 was 3.09 L (96% predicted) normal to that of diseased state which is less than 89% for women and FVC was normal while PEFR which is the maximum speed to require to exhale air ate 95 % one these values were below than their normal values there could be possible chance of blockade of air passage but all the tests done to diagnosed asthma were negative hence in the first instance chance of asthma was declined.

2 In the diagnosis the test were made at two intervals one before the exercise and one after interval of exercise both values were recorded as in each case the vale was lowered than the normal the doctor was able to diagnosed the Exercise Induced Asthma.

Eucapnic voluntary hyperventilation (EVH) challenge in this test dry air along with oxygen, carbon dioxide and nitrogen is allowed to inhaled by the patient, as the air is dry the air passage become narrow making the oxygen unavailable for lungs by Exercise induced asthma can be confirmed.

3 A warm up of 15 minutes before exercise will cause stretching of muscle and enhanced lung function And also prepares body mentally and physically of the long exercise.

Swimming can be good exercise for asthma than soccer as in soccer due to physical activity body heats up and loses heat quickly making the lungs dry and narrowing the passage of lungs and blocking air passage while in case of swimming as body remains in water there is no loss of water and body heat is seen, moist and warm air enters the lungs making the air passage clear that reduces the risk of bronchioconstriction allowing free flow of air to lungs.

4 Enhanced lung function in case of asthma is proven to better lung exercise can be practiced for proper lunch function, inhaling exercise can be practiced but heavy inhalation should be avoided. Aerobic exercises can be started with moderate intensity for at least 150 minutes a week and muscle strengthening exercises on daily basis flowed by flexibility exercise on daily basis. Any of the comfortable activities can be choose for regular exercise like cycling and walking.

5 Short acting agonist are preferred over long acting beta agonist which are generally used for long term treatment within combination of steroids these long acting beta agonist increases the risk of death hence to be taken cautiously along with steroid while short acting agonist are quick relieving and can relieve any sudden attack of asthma by relaxing the muscles lining the air passage an allowing free passage of air and relieved symptoms of asthma for 3 to 6 hours.

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