Table 1

Questions to ask athletes and physically active individuals presenting with a complaint of dyspnoea during exercise

General symptoms and history 
Please describe your symptoms in detailIt is useful to have athletes attempt to first describe their symptoms without any leading questions that can bias their account
Important information such as the presence of respiratory noises, fatigue/malaise, time of onset and factors that exacerbate the condition may be noted
Please describe what your breathing feels like when you experience these symptoms“Dyspnoea” is a general term, so identifying specific sensations such as sharp pain, dull ache, chest tightness, difficulty inspiring, difficulty expiring, etc., may provide some insight into the nature of the issue
When did you first notice these symptoms?This information may be connected to a specific event (e.g. trauma during a game, beginning or discontinuation a medication or a change in environment/location); for instance, a change in performance level (recreational team to competitive team) may indicate higher intensity or duration of exercise, or psychological factors (i.e. competition anxiety)
Did you note any specific incidents or changes in your routine associated with this time period?
Do you only experience these symptoms during exercise, and not at rest?Symptoms experienced only during exercise generally suggest that exercise itself is a triggering event (e.g. EIB without asthma)
Suspicion of exercise as a trigger for symptoms should prompt more specific questions related to the exercise itself; however, it is also possible for some conditions to first be noticed only during exercise (when cardiorespiratory demands are greatest) and then eventually progress to being present at rest
Do you experience any symptoms in your heart, such as chest tightness, chest pain, unusually rapid pulse or unusual heart rhythms?A feeling of chest tightness is common in asthma and EIB but may also be present in other cardiopulmonary conditions (e.g., pericarditis)
The presence of actual pain should be investigated further to determine if it is cardiopulmonary (e.g. ischaemia) or musculoskeletal (e.g. costochondritis) in origin
Although athletes with noticeable dysrhythmias (e.g. supraventricular tachycardia) are likely to describe their symptoms as a chief complaint, it may be useful to confirm that the patient is not experiencing such symptoms
Did the symptoms come on suddenly or did they develop gradually over time?This may be useful for identifying acute conditions, such as spontaneous pneumothorax, dyspnoea associated with trauma, etc
Are your symptoms becoming more severe or have you developed new symptoms beyond your breathing issues?This may provide some insight into the time course of the condition and whether it is systemic (i.e. infectious disease) or localised (i.e. EILO); for instance, overtraining syndrome and infectious diseases may initially cause shortness of breath during high-intensity exercise but progress to new symptoms such as general fatigue and muscle pain
Is breathing painful, and if so, where is the pain?Some causes of dyspnoea are associated with pain (e.g. pneumothorax and costochondritis) whereas EIB and EILO generally are not
Have you recently experienced any physical trauma (e.g. tackles in football or an automobile accident)?Muscular contusions or tears, joint dislocations and skeletal fractures that could influence the mechanics of breathing must be considered
Do you ever feel lightheaded or dizzy while experiencing these symptoms?These symptoms suggests the individual may be developing hypoxaemia (e.g. inadequate alveolar gas exchange) or inadequate blood flow to the brain during exercise (e.g. inadequate blood pressure or vertebrobasilar artery insufficiency)
Aside from your respiratory symptoms, have you been feeling unusually tired or exhausted when you are not exercising?Overtraining syndrome and infectious disease (e.g. Lyme disease, mononucleosis or influenza) are common and may contribute to general fatigue, malaise and unusual soreness
Emotional illness (e.g. clinical depression) may also be considered
Less common conditions that influence metabolic dysfunction (e.g. mitochondrial myopathy) may also be considered
Do you have unusual muscle or joint pain, beyond what you would normally expect from exercise?
Exercise-specific symptoms
How long have you been doing the type of exercise in which you experience these symptoms?It is important to understand the individual’s reference point for the dyspnoeic symptoms reported; for instance, an individual with a long history of recreational running is likely to be familiar with their ventilatory response during running, whereas they may feel unusually out of breath in unaccustomed forms exercise with different neuromuscular demands (e.g. swimming) or intensity (e.g. sprint-interval sports like soccer)
Have you recently advanced to a higher level of participation (e.g. changed from a junior high school team to high school team, or started with a college team)?Athletes who have recently moved up to a higher level of participation may simply be less fit than the others around them, and therefore be breathing significantly harder and feel they are underperforming as a result
Do you wheeze or make noises during breathing?#Expiratory wheezing is common in asthma and EIB
If so, do you think it is during inhalation or exhalation?
A high pitched inspiratory stridor is common in EILO
The presence of these noises should lead to appropriate diagnostic methods for the respective condition; however, EIB and EILO may occur without these noises
EIB and EILO can also be comorbid with one another
Do you only experience these symptoms during certain types of exercise?If certain types of exercise are tolerable but others are not, clinicians should try to identify differentiating factors; for instance, exercise posture and musculoskeletal demands can influence symptoms in dyspnoea of musculoskeletal origin (e.g. upper body movement during running may aggravate costochondritis but cycling at a similar intensity may not cause signs of dyspnoea)
Additionally, environmental factors may also be identified (e.g. athletes with EIB may experience symptoms while running outdoors but not during stationary cycling indoors due to differences in ambient air)
Are the symptoms consistent each time you exercise or do they vary from day to day?This can provide further insight into possible triggering factors (e.g. environmental conditions, venue, exercise type, exercise intensity and psychological stress)
Do these symptoms occur during practice, competition or both?Psychogenic factors may contribute to dyspnoea, including anxiety during competition
In addition to psychological factors, exercise-intensity, exercise duration and venue/environment may also account for differences between practice and competition
Environment-specific questions
Do your symptoms seem better or worse in any specific type of weather or season of the year?Allergies and rhinoconjunctivitis may cause dyspnoea themselves or trigger seasonal EIB
Humidity can also influence airway responses (i.e. dry air can trigger EIB)
Athletes may also switch between venues between different times of year (e.g. more indoor training in during certain periods), which could introduce periodic variation in dyspnoea symptoms
Do your symptoms seem better or worse at any specific location?Airborne pollutants, such as vehicular exhaust from fossil-fuelled automobiles and ice resurfacers, may trigger airway responses
Likewise, indoor pools with high levels of chloramines may also trigger airway responses
Certain venues may also contain other respiratory irritants (e.g. chalk dust at gymnastics centres and climbing gyms)
Different venues for the same sport may have large variability in air quality (i.e. electric ice resurfacers, dust collection systems and nonchlorine filtration systems), which can account for differences in symptoms between sites
Other questions
Have you donated blood, had surgery or experienced any major blood loss recently?While the latter two questions should be obvious, they should be included if other suspected causes are not obvious
Is it possible that you are pregnant?In the early stages of pregnancy, athletes may not yet be aware they are pregnant
Do you enjoy the exercise/sport/activity you are doing?
What is your motivation for doing the exercise/sport/activity?Although unusual, some individuals may simply no longer want to participate in a specific activity and attempt to find a medical excuse to limit/end participation
Answers to these questions may be biased in the presence of a parent, coach, team member or other influential individual
  • Responses to these questions are meant to provide guidance for determining the most likely differential diagnoses to pursue through further diagnostic testing procedures. Diagnosis should not be based on reported symptoms and question responses alone, due to poor diagnostic accuracy. Rather, these questions should be viewed as additional questions beyond those routinely asked during a clinical exam (i.e. personal medical history, family medical history, medication use, etc.). Additionally, responses to these types of questions may be useful in determining whether interventions are successful and whether the condition is progressing positively or negatively over time. EIB: exercise-induced bronchoconstriction; EILO: exercise-induced laryngeal obstruction. #: Including demonstration of such noises if possible.