A Practical Approach to the or Moisture-associated Skin Damage, due to Perspiration: Expert Consensus on Best Practice Consensus panel R. Gary Sibbald MD Professor, Medicine and Public Health University of TorontoToronto, ON Judith Kelley RN, BSN, CWONHenry Ford Hospital – Main CampusDetroit, MI
Microsoft word - pol 3.9 - asthma policy.doc
To outline requirements for Asthma
All operational levels of Life Saving Victoria
Bronchial asthma or wheezy bronchitis, is a common condition within
the community and may affect all groups from infancy to advanced
In its most severe form it requires hospitalisation in an Intensive Care
Ward but in its milder form does not prevent sporting competition at
the highest level. There are several examples of world and Olympic
champions who have suffered asthma for years and whose case
histories have been described in Medical Journals.
There is considerable evidence that exercise is very helpful in the
overall management of people with asthma1. A history of asthma by
itself should be no deterrent to participation in any aquatic activity
including teaching, being taught, examining, competing, or practical
lifeguarding providing the lifeguard or student concerned is following
the advice of a medical practitioner who is fully conversant with the
implications of these activities.
Asthma is a very variable condition and LSV recognises that a
lifeguard with asthma may be fully fit at some times but not fit for
various lifeguarding activities at other times. The responsibility for the
individual's management at all times rests with the person and the medical adviser concerned. EFFECTIVE DATE: 01/10/2004 Asthma
Asthma is a breathing problem resulting from the progressive or
sudden narrowing of the air passages in the lungs. Exercise,
LSV SOP 3.9 – Asthma Policy Page 1
infection, smoke, cold environments, anxiety or emotional stress,
dust or other allergic reactions can trigger it.
Asthma may be recognised by rapid breathing, breathing difficulty
and often, an "expiratory wheeze".
Note: Patients with severe asthma may have no audible wheeze.
However, they will have an obvious severe breathing problem.
Patients will be pale, sweating, and may have slight blueness of lips, earlobes and fingertips. In very severe cases, the person may become unconscious. In severe asthma, the small air tubes in the chest are grossly narrowed from: - 1. Constriction (tightening) of the bronchi (the tubes leading from the airway into the lung), and the smaller air passages, especially during expiration. 2. Blockage, or gross narrowing of the bronchi and smaller air passages with thick mucus. The combined effect of these two factors prevents the easy escape of air (expiration) from the lungs and the chest becomes over-inflated. This is also the reason that people who have stopped breathing from severe asthma are very difficult to resuscitate, as it is also very difficult for the rescuer to blow air into the over-inflated lung, and for that air to escape. * If this should occur the rescuer will perform EAR to the best of their ability, using mouth to mask with oxygen, or a bag and mask with 100% oxygen, whilst calling for urgent medical aid. It is essential that asthma be treated with preventative treatment (sprays or medication): simply treating asthma with reliever sprays on a regular basis does not help, does not improve the general fitness and health of an individual and should not be used without assessment by a Doctor. Treatment
These open the airways to improve breathing and are the best for emergency treatment (see below). They can be bought over the counter which, although being of benefit for the acute asthmatic LSV SOP 3.9 – Asthma Policy Page 2
attack, frequently leads to abuse – both purposeful and accidental –
and causing its own problems.
Note: In competition these can only be used by asthmatics confirmed
as such by their Doctor, and approved by the State Medical Officer
(for local and state competition) and the National Medical Officer (for
national and international competition) on receipt of a signed letter by
that treating Doctor (see above).
These sprays are the cornerstone of treatment of chronic (long-term)
asthma and are based on cortisone. They are the most important
inhaler to prevent breathing problems, particularly in the chronic
asthmatic. As the main effect of asthma is long-term irritation of the
bronchi by spasm and mucus, a cortisone spray that prevents or
reduces both of these conditions will best treat it. A Doctor only can
Containing both the above medications in the one inhaler. To date
there is only one ("Seretide"®) but more can be expected shortly.
Include cortisone taken orally (prednisone) and other less common
medications. These can only be prescribed for competitors under
strict medical guidelines, which include their treatment plan from a
certified Respiratory Physician, and permission MUST be requested
each time this medication is used (i.e. there is no "blanket"
permission for a season).
Emergency Treatment of Asthma2
• Remain calm yourself, reassure and encourage the patient to
remain calm – this will help reduce their need for air and their breathing rate. • Encourage the person to use 4 puffs of their "reliever" puffer (note: these are usually blue, or have blue markings). It is
preferable, though not essential, to use a "spacer" (see below) to inhale this medication, unless the puffer is an "autohaler" (these work automatically when the patient breathes in). If either the patient medication or the spacer is not available, use stock from the first aid room. LSV SOP 3.9 – Asthma Policy Page 3
• Sit the patient upright, in the most comfortable position. If possible, support their arms at shoulder level and in front of body on a table or the back of a chair. This takes a little weight off the chest allowing it to lift easier and thus help reduce the effort of breathing. • Give oxygen therapy, if a qualified operator and oxygen are • If after 4 minutes the patient is still breathless, then repeat 4 puffs of the reliever and send for immediate medical aid. Whilst waiting, 4 puffs of reliever puffer can be used every 4 minutes to a maximum of 16 puffs. No harm results from giving a reliever puffer to a young adult patient who has breathing difficulty, even if presenting for the first time with asthma. Relieving puffers should be used with caution in patients over the age of 35 years presenting with breathing difficulty for the first time, as there is a possibility that the patient has suffered a heart attack. In doubt, commence treatment with the inhalers, whilst sending immediately for the ambulance. Should the patient be unconscious, not breathing and needing expired air resuscitation, inflation of the lungs will be much more difficult (see above). Whilst waiting for medical aid the rescuer will need to blow harder to try to inflate the lungs. Care must be taken to: 1. Ensure the airway is as clear as possible with jaw thrust and mask, or with head tilt and jaw support. 2. Use oxygen, preferably 100% with a bag and mask; if this is not available, then use mouth to mask with 15 litres of oxygen a minute. If a person qualified in the use of an oropharyngeal airway is present and the correct size is available, then this should be used to assist airway control.
Use of "Spacer"
Spacers are used to help the patient inhale their medication,
especially if they have difficulty. There are two main types.
1. A "balloon spacer", which consists of two large transparent plastic pieces that fit together to look rather like a rugby ball with two At one end is an opening to insert the patient's inhaler. At the other end is the patient mouthpiece, containing a one way valve. This enables the patient to breathe the contents of the spacer in, LSV SOP 3.9 – Asthma Policy Page 4
but prevents them blowing into the spacer, thus diluting the contents. 2. A "mini" spacer, which looks like an elongated plastic tube. Similar to the balloon spacer it has the patient mouthpiece at one end, and the inhaler is inserted at the other end. Disposable cardboard tubes should be used to cover the mouthpiece end of a spacer from the First Aid room, so that they do not have to be washed between every patient – washing too often helps reduce the efficiency of the inhaled medication. The spacer should be cleaned approximately every ten uses, or if the plastic starts to look cloudy, or dirty. If no disposable mouthpiece is available the spacer is used, then cleaned immediately after each patient use.
• A spacer can be used on the unconscious patient who is
• If a spacer is not available, a fairly effective temporary spacer can be made from a paper bag.
Cleaning the spacer
• Dismantle and wash with warm soapy water
• Soak the mouthpiece and valve in 5% alcoholic chlorhexidine or 10% bleach, as recommended in the LSV communicable
diseases policy. Make sure both solutions are thoroughly
washed off, then dried, before use.
Asthma Medication and Competition
LSV condemns the use of performance enhancing substances in
sport as both dangerous to the health of the participant, and contrary
to the ethics of the sport3. The SLSA Doping Policy4 applies to all
competitors and testing may be carried out at any LSV / SLSA
In relation to the Doping Policy mentioned above, medications used to treat asthma may contain drugs that are either prohibited or subject to certain restrictions. It is not the intent of SLSA's Doping Policy to penalise lifesavers who genuinely suffer chronic or recurring asthma. However, it is wholly on the lifesaver and his medical attendants to provide indisputable evidence of this fact. LSV SOP 3.9 – Asthma Policy Page 5
Most asthmatic conditions can be treated by medications that are
permitted or approved; however notification to the LSV Medical
Officer is still required.
WARNING: Do not alter your asthma treatment without first
consulting your physician.
To ensure you are taking a permitted medication and have notified
the relevant authority, follow the checklist below.
Make sure that:
• A physician has diagnosed your asthma
• The asthma medication5 you are taking has been prescribed by • The medication, which has been prescribed by the physician, is permitted (see below) • You have sent notification, in writing and from your family doctor, to include the name, strength and dose of medication used. • You have notified: - The State Medical Officer, Phone (03) 9567 0000 INDEX 3.9:POL:1 EFFECTIVE DATE: 01/10/2004 LSV SOP 3.9 – Asthma Policy Page 6
Approved Aerosol Sprays – 1st September 2001
These MUST be approved PRIOR to competition.
Company Spray Name
Asmol, Airomir, Respolin, Respax, Respolin, Ventolin Eformoterol fumarate
NOTE: from 1st September ONLY
Optrol, Serovent Ipratropium bromide Atrovent, DBL Ipratropium, Ipratin Becotide, Becloforte, Qvar, Respocort Fluticasone proprionate – Fluticasone proprionate Sodium cromoglycate Nedocromil sodium LSV SOP 3.9 – Asthma Policy Page 7
Reliever Spray Name
If you have any questions about the use of asthma medications,
• ASDA Drugs in Sport Hotline 1800 020506
(03) 9567 0000 or
• Surf Life Saving Australia (02) 9130 7370
• Medications may change each year
• You MUST renew your approval EVERY YEAR
References / Further reading
1Oxford Textbook of Medicine 3rd edition. Oxford. 1990.
2National Asthma Foundation. Recommended guidelines 1999.
3Drugs in Sport Handbook. Australian Sports Drug Agency - PO Box
345, Curtin ACT 2605
4Anti-Doping Policy. Surf Life Saving Australia, Sydney 2004.
5MIMS Annual (all medications available) – www.mims.com.au
INDEX 3.9:POL:1 EFFECTIVE DATE: 01/10/2004 LSV SOP 3.9 – Asthma Policy Page 8
ORIGINAL CONTRIBUTION Fluoxetine After Weight Restorationin Anorexia NervosaA Randomized Controlled Trial B. Timothy Walsh, MD Context Antidepressant medication is frequently prescribed for patients with an- Allan S. Kaplan, MD, FRCPC orexia nervosa. Objective To determine whether fluoxetine can promote recovery and prolong time-