Asthma diagnosis and treatment
American Academy of Allergy, Asthma & Immunology Work Group Report: Exercise-induced asthma

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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

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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].

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