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Exercise-induced bronchoconstriction

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Exercise-induced bronchoconstriction (EIB) occurs when the airways narrow as a result of exercise. This condition has been referred to as exercise-induced asthma (EIA); however, this term is no longer preferred.[1] While exercise does not cause asthma, it is frequently an asthma trigger.[1]

Exercise-induced Bronchoconstriction
Other namesEIA
SpecialtyPulmonology Edit this on Wikidata
SymptomsShortness of breath on vigorous exercise
Usual onsetRapid, on exercise
DurationFor the duration of activity and some time afterwards
CausesModerate to high intensity exercise

It might be expected that people with EIB would present with shortness of breath, and/or an elevated respiratory rate and wheezing, consistent with an asthma attack. However, many will present with decreased stamina, or difficulty in recovering from exertion compared to team members, or paroxysmal coughing from an irritable airway.[2] Similarly, examination may reveal wheezing and prolonged expiratory phase, or may be quite normal. Consequently, a potential for under-diagnosis exists. Measurement of airflow, such as peak expiratory flow rates, which can be done inexpensively on the track or sideline, may prove helpful. In athletes, symptoms of bronchospasm such as chest discomfort, breathlessness, and fatigue are often falsely attributed to the individual being out of shape, having asthma, or possessing a hyperreactive airway rather than EIB.[3]

Cause

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While the potential triggering events for EIB are well recognized, the underlying pathogenesis is poorly understood.[4] It usually occurs after at least several minutes of vigorous, aerobic activity, which increases oxygen demand to the point where breathing through the nose (nasal breathing) must be supplemented by mouth breathing. The resultant inhalation of air that has not been warmed and humidified by the nasal passages seems to generate increased blood flow to the linings of the bronchial tree, resulting in edema. Constriction of these small airways then follows, worsening the degree of obstruction to airflow. There is increasing evidence that the smooth muscle that lines the airways becomes progressively more sensitive to changes that occur as a result of injury to the airways from dehydration. The chemical mediators that provoke the muscle spasm appear to arise from mast cells.[4] Mouth breathing as a result of decreased nasal breathing also increases lung surface exposure to irritants, pollutants, and allergens, causing neutrophilic inflammation in response to reactive oxygen species formation; research has found that individuals with genetically hindered glutathione counteraction of this oxidative stress are likely at a higher risk of developing EIB.[5]

Diagnosis

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Exercise-induced bronchoconstriction can be difficult to diagnose clinically given the lack of specific symptoms[2] and frequent misinterpretation as manifestations of vigorous exercise. There are many mimics that present with similar symptoms, such as vocal cord dysfunction, cardiac arrhythmias, cardiomyopathies, and gastroesophageal reflux disease. It is also important to distinguish those who have asthma with exercise worsening, and who consequently will have abnormal testing at rest, from true exercise-induced bronchoconstriction, where there will be normal baseline results. Because of the wide differential diagnosis of exertional respiratory complaints, the diagnosis of exercise-induced bronchoconstriction based on history and self-reported symptoms alone has been shown to be inaccurate[6][7] and to result in an incorrect diagnosis more than 50% of the time.[8] An important and often overlooked differential diagnosis is exercise-induced laryngeal obstruction (EILO). The latter can co-exist with EIB and is best differentiated using objective testing and continuous laryngoscopy during exercise (CLE) testing.

Spirometry

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Objective testing should begin with spirometry at rest. In true exercise-induced bronchoconstriction, the results should be within normal limits. Should resting values be abnormal, then asthma, or some other chronic lung condition, is present. There is, of course, no reason why asthma and exercise-induced bronchoconstriction should not co-exist but the distinction is important because without successful treatment of underlying asthma, treatment of an exercise component will likely be unsuccessful. If baseline testing is normal, some form of exercise or pharmacologic stress will be required, either on the sideline or practice venue, or in the laboratory.[9]

Exercise testing

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Treadmill or ergometer-based testing in lung function laboratories are effective methods for diagnosing exercise-induced bronchoconstriction, but may result in false negatives if the exercise stimulus is not intense enough.

Field-exercise challenge

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Field-exercise challenge tests that involve the athlete performing the sport in which they are normally involved and assessing FEV1 after exercise are helpful if abnormal but have been shown to be less sensitive than eucapnic voluntary hyperventilation.[10]

Eucapnic voluntary hyperventilation challenge

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The International Olympic Committee recommends the eucapnic voluntary hyperventilation (EVH) challenge as the test to document exercise-induced asthma in Olympic athletes.[11] In the EVH challenge, the patient voluntarily, without exercising, rapidly breathes dry air enriched with 5% CO2 for six minutes. The presence of the enriched CO2 compensates for the CO2 losses in the expired air, not matched by metabolic production, that occurs during hyperventilation, and so maintains CO2 levels at normal.[12]

Medication challenge

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Medication challenge tests, such as the methacholine challenge test, have a lower sensitivity for detection of exercise-induced bronchoconstriction in athletes and are also not a recommended first-line approach in the evaluation of exercise-induced asthma.[13]

Mannitol inhalation[14][15] has been recently approved for use in the United States.

A relatively recent review of the literature has concluded that there is currently insufficient available evidence to conclude that either mannitol inhalation or eucapnic voluntary hyperventilation are suitable alternatives to exercise challenge testing to detect exercise-induced bronchoconstriction and that additional research is required.[16]

Treatment

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Further information: Asthma § Management

Lifestyle

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The best treatment is avoidance of conditions predisposing to attacks, when possible. In athletes who wish to continue their sport or do so in adverse conditions, preventive measures include altered training techniques and medications.

Some take advantage of the refractory period by precipitating an attack by "warming up," and then timing competition such that it occurs during the refractory period. Step-wise training works in a similar fashion. Warm up occurs in stages of increasing intensity, using the refractory period generated by each stage to reach a full workload.[17]

Medication

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There is no evidence supporting different treatment for EIB in asthmatic athletes and nonathletes.[18] The most common medication used is a beta agonist taken about 20 minutes before exercise.[18] Some physicians prescribe inhaled anti-inflammatory mists such as corticosteroids or leukotriene antagonists, and mast cell stabilizers have also proven effective.[18]

In May 2013, the American Thoracic Society issued the first treatment guidelines for EIB, recommending use of "a short-acting β2-agonist before exercise in all patients with EIB. For patients who continue to have symptoms of EIB despite the administration of a short-acting β2-agonist before exercise, strong recommendations were made for a daily inhaled corticosteroid, a daily leukotriene receptor antagonist, or a mast cell stabilizing agent before exercise."[19]

There is conflicting information about the value of theophylline and other methylxanthines as prophylaxis against exercise-induced bronchoconstriction.[20]

Research

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A crossover study compared oral montelukast with inhaled salmeterol, both given two hours before exercise, showing that the drugs had similar benefit.[21]

A meta-analysis of preliminary research indicated that vitamin C may be useful to relieve respiratory symptoms such as cough during exercise.[22]

Prevalence in athletes

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Olympic swimmers Tom Dolan, Amy Van Dyken, and Nancy Hogshead, Olympic track star Jackie Joyner-Kersee, baseball Hall of Famer Catfish Hunter, and American football player Jerome Bettis are among the many who have the condition. Tour de France winner Chris Froome reported that he suffers from the condition, after being spotted using a nasal inhaler during race.[23] Other athletes with EIB include racing cyclist Simon Yates, distance runner Paula Radcliffe[24] and cross-country skier Marit Bjørgen.[25] Research by sports scientist John Dickinson found that 70 percent of UK-based members of the British swimming team had some form of asthma, as did a third of Team Sky cyclists, compared to a national asthma rate of eight to ten percent,[24] whilst a study by the United States Olympic Committee in 2000 found that half of cross-country skiers had EIB.[25]

References

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  1. ^ a b Khan, DA (Jan–Feb 2012). "Exercise-induced bronchoconstriction: burden and prevalence". Allergy and Asthma Proceedings. 33 (1): 1–6. doi:10.2500/aap.2012.33.3507. PMID 22370526.
  2. ^ a b Parsons JP, Cosmar D, Phillips G, Kaeding C, Best TM, Mastronarde JG (March 2012). "Screening for exercise-induced bronchoconstriction in college athletes". J Asthma. 49 (2): 153–7. doi:10.3109/02770903.2011.652329. PMC 3832203. PMID 22276571.
  3. ^ Parsons JP, Mastronarde JG (24 December 2015). "Exercise-Induced Bronchoconstriction in Athletes". Chest. 128 (6): 3966–3974. doi:10.1016/S0012-3692(15)49641-2. PMID 16354868. S2CID 38398971. Retrieved 28 November 2020.
  4. ^ a b Anderson SD, Kippelen P (March 2005). "Exercise-induced bronchoconstriction: Pathogenesis". Current Allergy and Asthma Reports. 5 (2): 116–22. doi:10.1007/s11882-005-0084-y. PMID 15683611. S2CID 11816261.
  5. ^ Gerow, M; Bruner, PJ (January 2023). "Exercise-Induced Bronchoconstriction". Exercise-Induced Asthma. Treasure Island (FL): StatPearls Publishing LLC. PMID 32491486.
  6. ^ Hallstrand TS, Curtis JR, Koepsell TD, et al. (September 2002). "Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction". J. Pediatr. 141 (3): 343–8. doi:10.1067/mpd.2002.125729. PMID 12219053.
  7. ^ Rundell KW, Im J, Mayers LB, Wilber RL, Szmedra L, Schmitz HR (February 2001). "Self-reported symptoms and exercise-induced asthma in the elite athlete". Med Sci Sports Exerc. 33 (2): 208–13. doi:10.1097/00005768-200102000-00006. PMID 11224807.
  8. ^ Parsons JP, Kaeding C, Phillips G, Jarjoura D, Wadley G, Mastronarde JG (September 2007). "Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes". Med Sci Sports Exerc. 39 (9): 1487–92. doi:10.1249/mss.0b013e3180986e45. PMID 17805078.
  9. ^ Carlsen KH, Anderson SD, Bjermer L, et al. (April 2008). "Exercise-induced asthma, respiratory and allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: Part I of the report from the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN". Allergy. 63 (4): 387–403. doi:10.1111/j.1398-9995.2008.01662.x. PMID 18315727.
  10. ^ Mannix ET, Manfredi F, Farber MO (1999). "A comparison of two challenge tests for identifying exercise-induced bronchospasm in figure skaters". Chest. 115 (3): 649–53. doi:10.1378/chest.115.3.649. PMID 10084470. S2CID 2599863.
  11. ^ Douglas B. McKeag; James L. Moeller; American College of Sports Medicine (3 July 2007). ACSM's Primary Care Sports Medicine. Lippincott Williams & Wilkins. p. 167. ISBN 978-0-7817-7028-6. Retrieved 21 April 2012.
  12. ^ Rosenthal, Richard. "Eucapnic Voluntary Hyperventilation (EVH) A Test for the Presence of Asthma". Archived from the original on 2014-05-31. Retrieved 2014-05-30.
  13. ^ Weiler JM, Bonini S, Coifman R, Craig T, Delgado L, Capão-Filipe M, et al. (2007). "American Academy of Allergy, Asthma & Immunology Work Group report: exercise-induced asthma". J Allergy Clin Immunol. 119 (6): 1349–58. doi:10.1016/j.jaci.2007.02.041. PMID 17433829.
  14. ^ Brannan JD, Koskela H, Anderson SD, Chew N (1998). "Responsiveness to mannitol in asthmatic subjects with exercise- and hyperventilation-induced asthma". Am J Respir Crit Care Med. 158 (4): 1120–6. doi:10.1164/ajrccm.158.4.9802087. PMID 9769270.
  15. ^ Muñoz PA, Gómez FP, Manrique HA, Roca J, Barberà JA, Young IH, et al. (2008). "Pulmonary gas exchange response to exercise- and mannitol-induced bronchoconstriction in mild asthma". J Appl Physiol. 105 (5): 1477–85. doi:10.1152/japplphysiol.00108.2008. PMID 18756011. S2CID 17712937.
  16. ^ Stickland MK, Rowe BH, Spooner CH, Vandermeer B, Dryden DM (September 2011). "Accuracy of eucapnic hyperpnea or mannitol to diagnose exercise-induced bronchoconstriction: a systematic review". Ann Allergy Asthma Immunol. 107 (3): 229–34. doi:10.1016/j.anai.2011.06.013. PMID 21875541.
  17. ^ Stickland MK, Rowe BH, Spooner CH, Vandermeer B, Dryden DM (March 2012). "Effect of warm-up exercise on exercise-induced bronchoconstriction". Med Sci Sports Exerc. 44 (3): 383–91. doi:10.1249/MSS.0b013e31822fb73a. PMID 21811185. S2CID 343413.
  18. ^ a b c Carlsen KH, Anderson SD, Bjermer L, et al. (April 2008). "Treatment of exercise-induced asthma, respiratory and allergic disorders in sports and the relationship to doping: Part II of the report from the Joint Task Force of European Respiratory Society (ERS) and European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN". Allergy. 63 (4): 492–505. doi:10.1111/j.1398-9995.2008.01663.x. PMID 18394123.
  19. ^ Parsons JP, Hallstrand TS, Mastronarde JG, et al. (May 2013). "An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction". American Journal of Respiratory and Critical Care Medicine. 187 (9): 1016–27. doi:10.1164/rccm.201303-0437ST. PMID 23634861. S2CID 32941118.
  20. ^ Pigakis, Konstantinos M; Stavrou, Vasileios T; Pantazopoulos, Ioannis; Daniil, Zoe; Kontopodi, Aggeliki K; Gourgoulianis, Konstantinos (3 January 2022). "Exercise-Induced Bronchospasm in Elite Athletes". Cureus. 14 (1): e20898. doi:10.7759/cureus.20898. PMC 8807463. PMID 35145802.
  21. ^ Philip G, Pearlman DS, Villarán C, et al. (2007). "Single-dose montelukast or salmeterol as protection against exercise-induced bronchoconstriction". Chest. 132 (3): 875–83. doi:10.1378/chest.07-0550. PMID 17573489.
  22. ^ Hemilä, H (7 June 2013). "Vitamin C may alleviate exercise-induced bronchoconstriction: a meta-analysis". BMJ Open. 3 (6): e002416. doi:10.1136/bmjopen-2012-002416. PMC 3686214. PMID 23794586.  
  23. ^ "Froome surprised at controversy over in-race inhaler use". 10 June 2014.
  24. ^ a b Walker, Peter (29 April 2016). "Why do so many elite athletes have asthma?". theguardian.com. Retrieved 29 April 2016.
  25. ^ a b Gardner, Amanda (17 February 2010). "For Olympians and weekend warriors, winter sports can trigger asthma". cnn.com. Retrieved 29 April 2016.
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