Zusammenfassung
Als Anstrengungsasthma wird das Auftreten von asthmatypischen Symptomen nach einer körperlichen Belastung bezeichnet. Es ist häufig bei Kindern und Jugendlichen mit einem Asthma bronchiale (Prävalenz 40–90 %), kann aber auch ohne zugrunde liegende Erkrankung bei Spitzensportlern auftreten. Genauer beschrieben wird die Problematik durch die beiden internationalen Begriffe des „exercise-induced asthma“ (EIA) und der „exercise-induced bronchoconstriction“ (EIB). EIA steht dabei für die klinischen Symptome wie Atemnot, Husten, Giemen mit thorakaler Enge, EIB für die exspiratorische obstruktive Ventilationsstörung nach einer definierten Belastung. Ursächlich für beides ist, neben einem überproportionalen Abkühlen und Feuchtigkeitsverlust der Atemwege mit Vasokonstriktion der Bronchialgefäße und sekundärer reaktiver Hyperämie, eine Aktivierung von Entzündungszellen mit relevanter Ausschüttung von Mediatoren und Ausbildung einer chronischen Entzündungsreaktion bei wiederholten Ereignissen. Das Entzündungsmuster kann sich dabei hinsichtlich der Genese, eosinophil allergisch mit früher Manifestation („early onset phenotype“) gegenüber neutrophil-eosinophil irritativ („late onset phenotype“) bei später Manifestation unterscheiden. Die Diagnose wird zwingend über die Anamnese und den Nachweis einer obstruktiven Ventilationsstörung in der Belastungs- oder Methacholin-Provokation gestellt, gelegentlich ist der eukapnische Hyperventilationstest, die inhalative Mannitol-Provokation oder ein Feldtest hilfreich. Eine behandlungsbedürftige Problematik konnte bei Olympiateilnehmern im Zeitraum von 1996 bis 2006 bei bis zu 20 % der Spitzenathleten in einzelnen Sportarten (Schwerpunkt Ausdauersportarten) festgestellt werden. Die relevanten und häufig unterdiagnostizierten Differenzialdiagnosen sind die „vocal cord dysfunction“ mit dem Leitsymptom des inspiratorischen Stridors, verminderte Fitness sowie das Übertraining. Entsprechend der entzündlichen Ursache orientiert sich die Therapie an den Empfehlungen zur Asthmabehandlung mit frühzeitigem Einsatz von einer antientzündlichen Medikation (inhalative Steroide, Leukotrienrezeptorantagonisten) sowie der bedarfsweisen Anwendung inhalativer β2-Mimetika mit Berücksichtigung der Antidopingregeln bei Wettkampfatheleten. Fehlendes Ansprechen der Inhalationstherapie muss frühzeitig an die Differenzialdiagnosen denken lassen.
Abstract
Exercise can provoke asthmatic symptoms, such as dyspnea, especially in children and adolescents with asthma with a prevalence of 40–90 %; however, asthma-like symptoms can also occur in athletes without an underlying asthma. To obtain a straightforward definition of exercise-provoked symptoms is was decided that the term exercise-induced asthma (EIA) covers the symptoms and signs of asthma, such as recurrent breathlessness, coughing, wheezing and chest tightness, whereas exercised-induced bronchoconstriction (EIB) describes an expiratory obstructive reaction in lung function after a standardized exercise test. In both conditions, the pathophysiology includes cooling of the airways, an increased loss of moisture from the respiratory tract and activation of inflammatory cells of the airways with a relevant release of mediators. This could in the long term, induce a chronic inflammatory response of the bronchi, which could be predominantly eosinophilic (allergic; early onset phenotype) or predominantly neutrophilic/eosinophic (irritative; late onset phenotype). Diagnosis of EIA or EIB must include a typical anamnesis in combination with a positive lung function testing due to exercise reaction or metacholine provocation. In some athletes, especially the late onset phenotype, a eucapnic hyperventilation test, a mannitol bronchial provocation or a field exercise test may be helpful. For participants of the Olympic Games from 1996 until 2006, a sport-specific incidence of up to 20 % among athletes applying inhaled β2-agonists with a verified diagnosis of asthma were recognized with an emphasis on endurance disciplines. Clearly, before diagnosing EIA or EIB, differential diagnoses favoring vocal cord dysfunction, poor physical fitness or overtraining have to be considered. Adequate warm-up helps to reduce symptoms. Due to the inflammatory basis of the disease, inhaled corticosteroids and/or leucotrien receptor antagonists are considered useful drugs for long-term control and prevention. In addition inhaled β2-agonists are effective drugs for immediate inhibition of bronchoconstriction. Further diagnostic evaluation has to be considered if adequate inhalative treatment does not control asthma symptoms. Anti-doping regulations have to be applied for competitive athletes.
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Interessenkonflikt. S. Sorichter war als Referent für die Firmen Actelion, Almirall, AstraZeneca, Bayer, Boehringer Ingelheim, Chiesi Pharmaceuticals, GlaxoSmithKline, Lilly, Novartis, Nycomed, MSD, Takeda und Talecris Biotherapeutics/Grifols tätig und erhielt ein Beraterhonorar von den Firmen Actelion, Chiesi, Lilly, MSD und Takeda. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Sorichter, S. Athleten, Asthma und Anstrengung. Pneumologe 10, 400–408 (2013). https://doi.org/10.1007/s10405-013-0709-0
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DOI: https://doi.org/10.1007/s10405-013-0709-0
Schlüsselwörter
- Anstrengungsasthma
- Belastungsinduziertes Asthma
- Belastungsinduzierte Bronchokonstriktion
- Vocal cord dysfunction
- Inspiratorischer Stridor