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doi: 10.3810/psm.2010.12.1824
The Physician and Sportsmedicine: Volume 38: No.4
Current Concepts in the Diagnosis and Management of Exercise-Induced Bronchospasm
Jonathan P. Parsons, MD
Copyright 2010 All rights reserved. Cover and contents may not be reproduced in whole or in part without prior written permission. The Physician and Sportsmedicine is a registered trademark of JTE Multimedia, LLC. Sending and distribution of any document from this site is strictly prohibited either for free and or a service fee, and will be sited as a violation of copyright under the laws of THE UNITED STATES OF AMERICA

Abstract: Exercise-induced bronchospasm (EIB) is a common occurrence in individuals with asthma, though it can also affect individuals without asthma. It occurs frequently in athletes. Common symptoms include coughing, dyspnea, chest tightness, and wheezing; however, there can be a variety of more subtle symptoms. The differential diagnosis of EIB is broad and includes several pulmonary and cardiac disorders. During the initial evaluation, a complete history, physical examination, and spirometry should be performed. In most patients with EIB, the baseline spirometry is normal; therefore, bronchoprovocation testing is strongly recommended. Both pharmacologic and nonpharmacologic approaches are important in the treatment of EIB. Management of EIB on the sideline of athletic events requires preparation and immediate access to rescue inhalers.

Keywords: asthma; exercise; exercise-induced bronchospasm; diagnosis; treatment

Introduction

Exercise-induced bronchospasm (EIB) is defined as acute, transient airway narrowing that occurs in association with exercise. Exercise-induced bronchospasm can occur during or, more frequently, after exercise. It is most commonly characterized by symptoms of coughing, wheezing, and/or chest tightness; however, more subtle symptoms of fatigue and poor athletic performance may be the only complaint. Exercise is a very common trigger of bronchospasm in asthmatics.1-3 Exericse-induced bronchospasm is often the reason why patients with asthma initially present to health care providers. Exercise-induced symptoms also frequently take the longest time to resolve after an asthma exacerbation.4

Exercise-induced bronchospasm also occurs in approximately 10% of individuals who are not known to have asthma.5 These patients who have EIB but not asthma do not exhibit the typical features of chronic asthma (ie, frequent daytime symptoms, nocturnal symptoms, impaired lung function). Exercise can be the only stimulus that triggers respiratory symptoms in these patients.

Because EIB can occur in individuals with and without asthma, there has been controversy regarding the nomenclature. Exercise-induced bronchospasm is considered the more appropriate and inclusive term, as it does not consider whether the affected patient has underlying asthma. Exercise-induced asthma (EIA) is a frequently used term; however, it should only be used to describe bronchospasm that occurs as a result of exercise in patients with known underlying asthma.

Exercise-induced bronchospasm occurs quite commonly in athletes, and prevalence rates of bronchospasm related to exercise vary widely. Prevalences as high as 50% have been reported.3,6 This wide variability in reported prevalence rates is, in part, a consequence of variable testing methods, thresholds for diagnosis, and patient populations. However, despite EIB being common, it may be underdiagnosed. In some larger screening studies, up to 20% to 30% of athletes with no prior history of EIB were actually found to be EIB-positive.7 The explanation for this lack of recognition of EIB is multifactorial. Patients with EIB have been shown to be poor perceivers of symptoms of asthma, and often attribute symptoms they may experience during exercise to usual manifestations of intense exercise. For the same reason, health care providers, athletic trainers, parents, and coaches may not consider EIB as a possible explanation for respiratory symptoms occurring during exercise. Athletes are generally fit and healthy without comorbid health conditions, and the presence of a significant medical problem may not be considered. If symptomatic, the athlete is often labeled as “out of shape” or giving “poor effort,” and vague symptoms of chest discomfort, breathlessness, and fatigue are not interpreted as a manifestation of EIB. In addition, if athletes recognize they may have a medical problem, they may not express it due to fear of social stigma or losing playing time. This is one of the most significant barriers to making a diagnosis of EIB in competitive athletes.

Exercise-induced bronchospasm can occur in any athlete in any setting. Athletes who compete in high-ventilation or endurance sports that involve continuous periods of intense aerobic activity without a significant amount of interrupted play may be at increased risk for EIB.8 There also have been reports of increased likelihood of EIB in cold-weather athletes; however, data are conflicting.9-11 In addition, environmental triggers may predispose certain populations of athletes to an increased risk for development of EIB. Chlorine compounds in swimming pools; chemicals related to ice-resurfacing machinery in ice rinks, such as carbon monoxide and nitrogen dioxide; particulate matter; and air pollutants, such as ozone, may put exposed athletic populations at additional risk for experiencing asthma and/or EIB.12-15 Athletic fields in urban or high-traffic areas for vehicles may be more likely to induce asthma symptoms.12

Given the high prevalence of EIB, and the fact that EIB may be underdiagnosed, some have proposed screening for EIB in groups/teams of athletes. However, there is insufficient evidence to support population-based screening for EIB detection, as there is still much debate regarding its definition, clinical relevance in nonasthmatic patients, and the best method for making a diagnosis.16

Clinical Presentation

Clinical presentations of EIB are extremely variable and can range from mild impairment of performance to severe respiratory distress and even respiratory failure in rare cases.17 Common complaints of patients with EIB include coughing, wheezing, chest tightness, and shortness of breath. There are also more subtle indicators that EIB may be present. Athletes with symptoms that occur in specific environments (ie, ice rinks or heavily chlorinated swimming pools) may have EIB. Poor performance for conditioning level, such as not meeting typical goal times in track, cross-country, or swimming events is another potential subtle sign. In addition, avoidance of physical activity is commonly seen in school-aged children with EIB (Table 1).

View: (Table 1 ) - Common Symptoms of Exercise-Induced Bronchospasm

Most individuals initially experience transient dilation of their airways during exercise, and symptoms of EIB begin during or shortly after exercise. Symptoms may peak shortly after exercise ceases and can remain significant for much longer if no bronchodilator therapy is provided.18 Most athletes will spontaneously recover to baseline airflow within 60 minutes without intervention of bronchodilator therapy, though this is not a recommended approach.18 It is impossible to predict which athletes will recover without treatment; hence, immediate treatment with bronchodilators is essential. Athletes who experience symptoms for extended periods often perform at suboptimal levels for significant portions of their competitive or recreational activities.

Diagnosis
History and Differential Diagnosis

The presence of EIB can be difficult to diagnose clinically given the lack of specific symptoms and frequent misinterpretation as manifestations of vigorous exercise. Complete history and physical examination should be performed on each athlete with respiratory complaints associated with exercise. A history of specific symptoms occuring in particular environments or during specific activities should be elicited. Timing of symptom onset in relation to exercise and/or recovery is also helpful.

It should be noted that patient history and examination have limitations because the history is often nonspecific, and the examination at rest is normal. There are many mimics of EIB that present with similar symptoms, such as vocal cord dysfunction, cardiac arrhythmias, cardiomyopathies, and gastroesophageal reflux disease. Because of the wide differential diagnosis of exertional respiratory complaints, the diagnosis of EIB based on history and self-reported symptoms alone has been shown to be inaccurate.7,19,20 If health care providers rely on history alone to make a diagnosis of EIB, evidence shows they will be incorrect > 50% of the time.7

Because of the limitations and poor predictive value of the history and physical examination in the evaluation of EIB, objective diagnostic testing should be performed when EIB is suspected. Despite the data that suggest objective testing should be used to document the diagnosis of EIB formally when suspected, studies have shown that a diagnosis of EIB based on history alone is often made, and is often wrong.21,22

Objective Testing

Objective testing should begin with spirometry before and after inhaled bronchodilator therapy, which frequently identifies athletes who have abnormal baseline lung function and may warrant maintenance treatment for asthma. However, most individuals who experience EIB will have normal baseline lung function, and spirometry alone is not adequate to diagnose EIB. In patients evaluated for EIB who have a normal physical examination and normal spirometry, bronchoprovocation testing is recommended. Objective change (usually ≥ 10% decrease in forced expiratory volume in 1 second [FEV1]) between pre- and postbronchoprovocation testing values is necessary to confirm the diagnosis of EIB.23 There is debate on the appropriate threshold for making a diagnosis of EIB clinically and in research trials, with thresholds of 10% to 25% being used in different studies.24 A positive bronchoprovocation test indicates the need for treatment for EIB. In a patient with persistent exercise-related symptoms and negative physical examination, spirometry, and bronchoprovocation testing, alternative diagnoses should be considered.

Not all bronchoprovocation techniques are equally valuable or accurate in assessing EIB in athletes. The International Olympic Committee recommends eucapnic voluntary hyperventilation (EVH) challenge as the test recommended to document EIB in Olympic athletes.25 Eucapnic voluntary hyperventilation involves hyperventilation of a gas mixture of 5% CO2 and 21% O2 at a target ventilation rate of 85% of the patient’s maximum voluntary ventilation in 1 minute (MVV). The MVV is usually calculated as 35 times the baseline FEV1. The patient continues to hyperventilate for 6 minutes, and assessment of FEV1 occurs at specified intervals up to 20 minutes after the test. This challenge test has been shown to have a high specificity26 for EIB. Eucapnic voluntary hyperventilation has also been shown in some studies to be more sensitive for detecting EIB than methacholine27 or field- or laboratory-based exercise testing.26 Eucapnic voluntary hyperventilation can also be performed successfully and safely to document EIB in populations of patients who are not elite athletes.28

Treadmill- or ergometer-based testing in lung function laboratories are effective methods for diagnosing EIB, but may result in false-negatives if the exercise stimulus is not intense enough. The optimal exercise challenge is 8 minutes in duration and allows the patient to achieve > 90% of maximum predicted heart rate by 2 minutes into the challenge and maintain it for the remaining 6 minutes of the challenge.23,24

Field-exercise challenge tests that involve the athlete performing the sport in which they are normally involved and assessing FEV1 after exercise have been shown to be less sensitive than EVH29 and allow for little standardization of a protocol. Mannitol inhalation is a promising new method for documenting EIB,30,31 and was recently approved for use in the United States. Pharmacological challenge tests, such as the methacholine challenge test, have a lower sensitivity for detection of EIB in athletes and are also not a recommended first-line approach in the evaluation of EIB.32

Treatment Options
Pharmacologic Therapy

First-line treatment to minimize or prevent symptoms of EIB is the prophylactic use of short-acting bronchodilators (eg, albuterol) shortly before exercise. Treatment with 2 puffs of short-acting β2-receptor agonists shortly before exercise (usually 15–30 minutes) will provide peak bronchodilation in 15 to 60 minutes and protection from EIB for at least 3 hours in most patients.33 Long-term prophylactic use of short-acting bronchodilators may result in reduced efficacy over time,34 or tachyphylaxis, but are still recommended as a first-line treatment unless athletes need to use albuterol daily for pretreatment. In these situations, combination therapy with inhaled steroids or leukotriene modifiers may be necessary.32

Long-acting bronchodilators work in a similar manner as short-acting bronchodilators; however, the bronchoprotection afforded by long-acting β2-receptor agonists has been shown to initially last up to 12 hours, whereas the bronchoprotection of albuterol is no longer significant after 4 hours.35 Tachyphylaxis also has been shown to occur after repeated use of long-acting β2-receptor agonists,36 and they are no more effective than short-acting bronchodilators as early as after 1 month of use;32 thus, close follow-up is recommended if a patient uses these medications. In addition, controversy regarding the use of long-acting β2-receptor agonists as monotherapy in asthmatics should caution health care providers about the use of these agents alone in asthmatics with EIB.37,38

Inhaled corticosteroids are a first-line therapy in terms of controller medications for athletes who have asthma and experience EIB.33 If a patient is on inhaled steroids, they should still use prophylactic, short-acting bronchodilators in addition before exercise. Airway inflammation is also often present in nonasthmatic athletes who have EIB,15,39 and therefore inhaled corticosteroids may be an effective medicine for treatment. However, the efficacy of corticosteroids in this cohort is unclear. In addition, inhaled corticosteroids must be taken daily and are not medications that can be taken prophylactically before exercise in contrast with short-acting bronchodilators.

Leukotriene modifiers have also been shown to be effective in treating EIB.40-42 There does not appear to be tachyphylaxis associated with leukotriene modifiers. It is important to note that prophylactic dosing is recommended to occur at least 2 hours before exercise.

Nonpharmacologic Therapy

Many athletes find that a period of precompetition warm-up reduces the symptoms of EIB that occur during their activity. This phenomenon has been termed the refractory period, and occurs in some athletes.43-45 However, the refractory period has not been consistently proven across different athletic populations and has not been well documented in EIB-positive athletes who are not asthmatic.46

There are other nonpharmacologic strategies that can be employed to help reduce the frequency and severity of EIB systems. Breathing through the nose rather than the mouth may also help reduce EIB by warming, filtering, and humidifying the air, which subsequently reduces airway cooling and dehydration. Wearing a face mask during activity warms and humidifies inspired air when outdoor conditions are cold and dry, and is especially valuable to elite and recreational athletes who exercise in the winter. Dietary modifications, including low-salt diet, or ascorbic acid and/or fish oil supplementation may reduce the risk or severity of EIB.47-49 These studies are small and need to be confirmed in larger trials, but may be effective adjunctive management strategies.

Sideline Management of EIB

Acute sideline management of an athlete who experiences an acute episode of EIB requires preparation. All athletic trainers should have pulmonary function measuring devices such as peak flow meters at all athletic events, including practices. In addition, a rescue inhaler should be available during all games and practices.50 Spacers are recommended to be used with the rescue inhalers.

On-field management of asthma begins with awareness of the signs and symptoms of respiratory distress. Any athlete presenting with any of these symptoms should be removed from competition and be evaluated immediately by a physician. It is recommended that any athlete with a peak expiratory flow of < 80% of his or her personal best be removed from activity until his or her peak flow returns to ≥ 80% of his or her personal best.51

Criteria for safe return to play after an acute episode of EIB are based on expert opinion only. Most experts agree that no athlete should return to play until lung function returns to near baseline. However, there is no consensus return-to-play protocol, and each athlete must be evaluated on an individual basis for his or her fitness for returning to play after an acute episode of EIB. An example of a return-to-play algorithm is shown in Figure 1.

View: (Figure 1 ) - Sideline management of EIB and criteria for return to play.
Conclusion

Exercise-induced bronchospasm occurs commonly in asthmatics, nonasthmatics, and athletic populations, but overall is likely underrecognized. Recognition of EIB requires a high index of suspicion. The diagnosis of EIB based on symptoms alone is extremely inaccurate. Objective testing is necessary with bronchoprovocation testing to make a confident diagnosis of EIB. Both pharmacologic and nonpharmacologic approaches are important in the treatment of EIB. Sideline management of EIB requires preparation and immediate availability of bronchodilators.



Conflict of Interest Statement
Jonathan P. Parsons, MD discloses a conflict of interest with Teva, Inc.
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Jonathan P. Parsons, MD 1

1The Ohio State University Medical Center, Ohio State University Asthma Center, 201 Davis Heart/Lung Research Institute, 473 W.12th Ave., Columbus, OH 43210., [email protected]

Correspondence: Jonathan P. Parsons, MD, 201 Davis Heart/Lung Research Institute, 473 W.12th Ave., Columbus, OH 43210.,
Tel: 614-366-3413,
Fax: 614-293-4799,
E-mail: [email protected]
Disclaimer
In an effort to provide information that is scientifically accurate and consistent with accepted standards of medical practice, the editors and publisher of The Physician and Sportsmedicine routinely consult sources believed to be reliable. However, readers are encouraged to confirm this information with other sources. For example and in particular, physicians are advised to consult the prescribing information in the manufacturer's package insert before prescribing any drug mentioned.




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