Asthma diagnosis and treatmentAmerican Academy of Allergy, Asthma & Immunology Work Group Report: Exercise-induced asthma
Section snippets
Epidemiology and pathogenesis
Although the pathogenesis of EIA is not fully elucidated, it is probably caused by exercise-induced hyperventilation and corresponding changes in airway physiology.4, 17, 18 An increased ventilatory rate is required to meet higher muscular oxygen requirements during exercise. This increased ventilatory rate challenges the ability of the airways to condition the inhaled air to the correct moisture and heat levels before the air reaches the alveoli. Vigorous exercise results in the inhalation of
Clinical presentation
The clinical features of EIA are cough, wheezing, chest tightness, and unusual shortness of breath or excess mucus occurring after a burst (eg, 6-8 minutes) of strenuous and continuous aerobic exercise.34, 35 In elite athletes such as female hockey players, Rundell et al36 found that cough was the most frequent symptom and developed significantly more frequently than wheeze or excess mucus (P < .05). Symptoms were not highly correlated with having a positive exercise challenge; however, cough
Prevalence
Prevalence of EIA varies from approximately 5% to 20% in the general population, to perhaps 30% to 70% in elite winter athletes and athletes who participate in summer endurance sports, to at least 90% in individuals with persistent asthma.12, 16, 34, 35, 43 As noted, it is likely that almost all individuals who have chronic asthma will be triggered to have an asthma flare with an appropriate exercise challenge, even though some reports suggest a prevalence of EIA of only 50% to 90% in this
Evaluation of EIA
The clinical presentation of EIA includes cough, wheezing, shortness of breath and/or chest tightness, generally occurring within 5 to 30 minutes after intense exercise. In a recent worldwide study of more than 10,000 patients with asthma currently taking asthma medications or having had symptoms within the last year,51 EIA symptoms were reported in a third to half of these patients. In adults who have had a previous diagnosis of asthma, the presence or appearance of EIA may be seen as a sign
EIA in competitive athletes
The evaluation of EIA in competitive athletes poses several issues unique to this population.66 We make the following observations and recommendations regarding competitive athletes:
The prevalence of EIA appears to be higher in competitive athletes than in other populations, and is particularly high in endurance sports such as swimming and winter sports.21, 45, 46, 47
Participation in some sports involves exposure to particular environmental asthmogenic agents such as allergens (pollens, mites,
Differential diagnosis
The differential diagnoses of EIA include respiratory or cardiac conditions that can cause exertional dyspnea, exercise-induced laryngeal dysfunction (eg, vocal cord dysfunction, laryngeal prolapse), gastroesophageal reflux, exercise-induced hyperventilation, and exercise-induced anaphylaxis (EIAna). Although a thorough clinical history and physical examination, together with spirometry, bronchial hyperreactivity assessment, and physiological and cardiac monitoring of an exercise challenge can
Treatment of EIA
In treating elite athletes, clinicians must deal with the dilemma of providing relief from the disorder without using mediations that enhance performance in athletes who do not have asthma.35, 66, 87, 88
Prophylaxis of EIA includes premedication and warm-up.66, 87, 88 Warm-up of 10 to 15 minutes should include calisthenics with stretching exercises with an objective of reaching 50% to 60% of maximum heart rate.35 A β-agonist should be used if asthma symptoms develop, and exercise should be
References (101)
- et al.
The effect of exercise on ventilatory function in the child with asthma
Br J Dis Chest
(1962) - et al.
The mechanism of exercise-induced asthma is…
J Allergy Clin Immunol
(2000) - et al.
The heterogeneity of allergic phenotypes: genetic and environmental interactions
Ann Allergy Asthma Immunol
(2001) - et al.
Exercise in elite summer athletes: challenges for diagnosis
J Allergy Clin Immunol
(2002) - et al.
Field exercise vs laboratory eucapnic voluntary hyperventilation to identify airway hyperresponsiveness in elite cold weather athletes
Chest
(2004) - et al.
Comparative effects of long-acting beta2-agonists, leukotriene receptor antagonists, and a 5-lipoxygenase inhibitor on exercise-induced asthma
J Allergy Clin Immunol
(2000) - et al.
Allergy and asthma in elite summer sport athletes
J Allergy Clin Immunol
(2000) - et al.
Bronchial hyperresponsiveness, airway inflammation, and airflow limitation in endurance athletes
Chest
(2005) - et al.
Effect of continuing or finishing high-level sports on airway inflammation, bronchial hyperresponsiveness, and asthma: a 5-year prospective follow-up study of 42 highly trained swimmers
J Allergy Clin Immunol
(2002) - et al.
Exercise-induced asthma in figure skaters
Chest
(1996)
A springtime Olympics demands special consideration for allergic athletes
J Allergy Clin Immunol
Asthma screening of high school athletes: identifying the undiagnosed and poorly controlled
Ann Allergy Asthma Immunol
Methods of exercise challenge
J Allergy Clin Immunol
Asthma in United States Olympic athletes who participated in the 1996 Summer Games
J Allergy Clin Immunol
Asthma in United States Olympic athletes who participated in the 1998 Olympic winter games
J Allergy Clin Immunol
Incidence of exercise-induced asthma in children
J Allergy Clin Immunol
Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys
J Allergy Clin Immunol
Exercise induced asthma in school children
J Allergy Clin Immunol
Responses to bronchial challenge submitted for approval to use inhaled beta2-agonists before an event at the 2002 Winter Olympics
J Allergy Clin Immunol
Pulmonary function electronic monitoring devices: a randomized agreement study
Chest
Revisiting the accuracy of peak flow meters: a double-blind study using formal methods of agreement
Respir Med
Why must Olympic athletes prove that they have asthma to be permitted to take inhaled beta2-agonists?
J Allergy Clin Immunol
Exercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm
Ann Allergy Asthma Immunol
Inspiratory stridor in elite athletes
Chest
Abnormal movement of the arytenoid region during exercise presenting as exercise-induced asthma in an adolescent athlete
Chest
Adult laryngomalacia: an uncommon clinical entity
Am J Otolaryngol
Laryngomalacia induced by exercise in a pediatric patient
Int J Pediatr Otorhinolaryngol
Vocal cord dysfunction in patients with exertional dyspnea
Chest
Concurrent laryngeal abnormalities in patients with paradoxical vocal fold dysfunction
Otolaryngol Head Neck Surg
Exercise-induced hyperventilation: a pseudoasthma syndrome
Ann Allergy Asthma Immunol
Transglutaminase-mediated cross-linking of a peptic fraction of omega-5 gliadin enhances IgE reactivity in wheat-dependent, exercise-induced anaphylaxis
J Allergy Clin Immunol
Protection against cold air and exercise-induced bronchoconstriction while on regular treatment with Oxis
Respir Med
Reduced protection against exercise induced bronchoconstriction after chronic dosing with salmeterol
Respir Med
National Heart, Lung, and Blood Institute's Asthma Clinical Research Network. Use of regularly scheduled albuterol treatment in asthma: genotype-stratified, randomised, placebo-controlled cross-over trial
Lancet
Proceedings of the first Jack Pepys Occupational Asthma Symposium
Am J Respir Crit Care Med
Exercise testing in children
Guidelines for methacholine and exercise challenge testing: 1999
Am J Respir Crit Care Med
Evidence of airway inflammation and remodeling in ski athletes with and without bronchial hyperresponsiveness to methacholine
Am J Respir Crit Care Med
A 10-year follow-up study of pulmonary function in symptomatic elite cross-country skiers: athletes and bronchial dysfunctions
Scand J Med Sci Sports
Asthma, airway inflammation and treatment in elite athletes
Sports Med
Phenotypes in asthma: useful guides for therapy, distinct biological processes, or both?
Am J Respir Crit Care Med
Definition and clinical categories of asthma
Exercise-induced asthma: a practical guide to definitions, diagnosis, prevalence, and treatment
Allergy Asthma Proc
Identifying exercise-induced bronchospasm: treatment hinges on distinguishing it from chronic asthma
Postgrad Med
Airway narrowing in athletes: a different kettle of fish?
Am J Respir Crit Care Med
Exercise-induced asthma
Thermally induced asthma and airway drying
Am J Respir Crit Care Med
Inhalant corticosteroids inhibit hyperosmolarity-induced, and cooling and rewarming-induced interleukin-8 and RANTES production by human bronchial epithelial cells
Am J Respir Crit Care Med
L Lymphoid aggregates in endobronchial biopsies from young elite cross-country skiers
Am J Respir Crit Care Med
Bronchoscopy and bronchoalveolar lavage findings in cross-country skiers with and without “ski asthma.”
Eur Respir J
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S.B. is in part supported by grants from the Italian Ministry of Health, Commission for Vigilance and Doping, the Italian Institute of Health, and the European Commission Network of Excellence GA2LEN-FOOD-CT-2004-506378.
Disclosure of potential conflict of interest: J. M. Weiler owns stock in, has patent licensing arrangements with, and is employed by CompleWare Corporation and Iowa Clinical Research Corporation. S. Bonini has consulting arrangements with Lofarma, Almirall, and Pfizer; has received grant support from Almirall, Bioallergy, Lofarma, and Schering-Plough; is employed as a member of the Research and Development Commission of the Italian Drug Agency; and is on the speakers' bureau for Alcon, Allergopharma, Allergy Therapeutics, ALK-Albelló, Almirall, Aventis, Sanofi-Synthelabo, Stallergens, UCB, and Zambon. R. Coifman is employed by Allergy and Asthma of South Jersey. D. Passali has consulting arrangements with Lofarma, Sanofi-Aventis, and Angelini and is on the speakers' bureau for Schering-Plough, Valeas, GlaxoSmithKline, Mercury, and Amplifon. C. Randolph is on the speakers' bureau for GlaxoSmithKline, Schering-Plough, Novartis, Genentech, Merck, and AstraZeneca. W. Storms has consulting arrangements with Adams, Alco, Altana, AstraZeneca, Consumer Reports/Consumer Union, Efficas, Exaeris, Genentech, Greer, GlaxoSmithkline, Hoffman, Laroche, Inspire, Isis, Ivax, King, Medpointe, Merck, Nexcura, Novartis, Sanofi-Aventis, Schering-Plough, Sepracor, Strategic Biosciences, Strategic Pharmaceutical Advisors, TREAT Foundation, and Wyeth; owns stock in Strategic Biosciences, Strategic Pharmaceutical Advisors, and Exaeris; has patent licensing arrangements with Strategic Biosciences; has received grant support from Alcon, Altana, AstraZeneca, BMS, Genentech, GlaxoSmithKline, Medpointe, Merck, Novartis, Sanofi-Aventis, and Schering-Plough; and is on the speakers' bureau for Abbott, Alco, AstraZeneca, Genentech, Medpointe, Merck, Novartis, Pfizer, Sanofi-Aventis, and Schering-Plough. The other authors have declared that they have no conflict of interest.
∗This report was prepared by an Ad Hoc Committee of the Sports Medicine Committee of the American Academy of Allergy, Asthma & Immunology.
This statement is not to be construed as dictating an exclusive course of action, nor is it intended to replace the medical judgment of health care professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. This statement reflects clinical and scientific advances as of the date of publication and is subject to change.
Reprint requests: Lauri Sweetman, American Academy of Allergy, Asthma and Immunology, 611 East Wells St, Milwaukee, WI 53202. E-mail: [email protected].