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Evidence-based management of exercise-induced asthma

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Current Sports Medicine Reports

Abstract

Exercise-induced asthma (EIA) is a common, yet often unrecognized condition occurring in both known asthmatics and otherwise healthy individuals. Misdiagnosis, both over- and underdiagnosis, is not uncommon. In order to accurately diagnose EIA, a bronchoprovocation challenge test must be performed; the current recommended test is a eucapnic hyperventilation (EVH) challenge test. Although there are a number of treatment options available, both pharmacologic and nonpharmacologic, in most cases medications are required. A range of medications are currently available to either treat or prevent EIA. It is important that the medications used are individualized to the patients needs and monitored to ensure efficacy.

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References and Recommended Reading

  1. Anderson SD: Exercise-induced asthma. In Allergy: Principles and Practice, edn 4. Edited by Middleton E, Reed C, Ellis E, et al. St Louis: CV Mosby; 1993:1343–1367.

    Google Scholar 

  2. Adams F: The Extant Works of Arataeus the Cappadocian. London: Sydenham Society; 1856:316.

    Google Scholar 

  3. Floyer J: A Treatise of the Asthma. London: R Wilkin; 1698.

    Google Scholar 

  4. Randolph C, Randolph M, Fraser B: Exercise-induced asthma in school children. J Allergy Clin Immunol 1991, 87:341.

    Article  Google Scholar 

  5. Kawabori I, Pierson WE, Conquest LL, et al.: Incidence of exercise-induced asthma in children. J Allergy Clin Immunol 1976, 58:447–455.

    Article  CAS  PubMed  Google Scholar 

  6. Rupp NT, Guill MF, Brudno DS: Unrecognized exerciseinduced bronchospasm in adolescent athletes. Am J Dis Child 1992, 146:941–944.

    CAS  PubMed  Google Scholar 

  7. Anderson SD, Silverman M, Konig P, Godfrey S: Exerciseinduced asthma. A Review. Br J Dis Chest 1975, 69:1–39.

    Article  CAS  PubMed  Google Scholar 

  8. Waalkans HJ, van Essen-ZandvlietEEM, Gerritsen J, et al., and the Dutch CNSLD Study Group: The effect of an inhaled corticosteroid (budesonide) on exercise-induced asthma in children. Eur Respir J 1993, 6:652–656.

    Google Scholar 

  9. Barry DMJ, Burr ML, Limb ES: Prevalence of asthma among 12 year old children in New Zealand and New South Wales: a comparative survey. Thorax 1991, 46:405–409.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  10. Haby MM, Peat JK, Mellis CM, et al.: An exercise challenge for epidemiological studies of childhood asthma: validity and repeatability. Eur Respir J 1995, 8:729–736.

    CAS  PubMed  Google Scholar 

  11. Nish WA, Schwietz LA: Underdiagnosis of asthma in young adults presenting for USAF basis training. Ann Allergy 1992, 69:239–242.

    CAS  PubMed  Google Scholar 

  12. O’Donnell AE, Fling J: Exercise-induced airflow obstruction in a healthy military population. Chest 1993, 103:742–744.

    Article  PubMed  Google Scholar 

  13. Weiler JM, Metzger J, Donnelly AL, et al.: Prevalence of bronchial responsiveness in highly trained athletes. Chest 1986, 90:23–28.

    Article  CAS  PubMed  Google Scholar 

  14. Rupp NT, Brudno S, Guill MF: The value of screening for risk of exercise-induced asthma in high school athletes. Ann Allergy 1993, 70:339–342.

    CAS  PubMed  Google Scholar 

  15. Mannix ET, Farber MO, Palange P, et al.: Exercise-induced asthma in figure skaters. Chest 1996, 109:312–315.

    Article  CAS  PubMed  Google Scholar 

  16. Langdeau JB, Boulet LP: Prevalence and mechanisms of development of asthma and airway hyperresponsiveness in athletes. Sports Med 2001, 31:601–616.

    Article  CAS  PubMed  Google Scholar 

  17. Chiumello D, Pristine G, Slutsky AS: Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome. Am J Respir Crit Care Med 1999, 160:109–116.

    Article  CAS  PubMed  Google Scholar 

  18. Slutsky AS: Lung injury caused by mechanical ventilation. Chest 1999, 116:9S-15S.

    Article  CAS  PubMed  Google Scholar 

  19. Boulet L-P, Turcott H, Laprice C, et al.: Comparative degree and type of sensitisation to common indoor and outdoor allergens in subjects with allergic rhinitis and/or asthma. Clin Exp Allergy 1997, 27:52–59.

    Article  CAS  PubMed  Google Scholar 

  20. Warner JO: Bronchial hyperresponsiveness, atopy, airway inflammation and asthma. Pediatr Allergy Immunol 1998, 9:56–60.

    Article  CAS  PubMed  Google Scholar 

  21. Helenius IJ, Tikkanen HO, Haahtela T: Association between type of training and risk of asthma in elite athletes. Thorax 1997, 52:157–160.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Koren HS: Enviromental risk factors in atopic. Int Arch Allergy Immunol 1997, 113:65–68.

    Article  CAS  PubMed  Google Scholar 

  23. Drobnic F, Freixa A, Casan P, et al.: Assessment of chlorine exposure in swimmers during training. Med Sci Sports Exerc 1996, 28:271–274.

    Article  CAS  PubMed  Google Scholar 

  24. Gilbert IA, McFadden ERJr: Vascular Mechanisms in exerciseinduced asthma. In Asthma and Rhinitis. Edited by Busse WW, HolgateST. Boston: Blackwell Scientific; 1995:1196–1205.

    Google Scholar 

  25. Anderson SD, Togias AG: Dry air and hyperosmolar challenge in asthma and rhinitis.In Asthma and Rhinitis. Edited by Busse WW, HolgateST. Boston: Blackwell Scientific; 1995:1178–1195.

    Google Scholar 

  26. Anderson SD: Is there a unifying hypothesis for exerciseinduced asthma? J Allergy Clin Immunol 1984, 73(5Pt2):660–665.

    Article  CAS  PubMed  Google Scholar 

  27. Gilbert IA, Fouke JM, McFadden ERJr: Heat and water flux in the intrathoracic airways and exercise-induced asthma. J Appl Physiol 1987, 63:1681–1691.

    CAS  PubMed  Google Scholar 

  28. Rundell KW, Im J, Wilber RL, Schmitz HR: Self reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc 2001, 2:208–213. The authors of this study showed a relatively low correlation between the presence of exercise-related symptoms and exercise-induced bronchoconstriction in athletes.

    Article  Google Scholar 

  29. Tikkanen HO, Peltonen JE: Asthma-cross-country skiing. Med Sci Sports Exerc 1999, (Suppl):S99.

  30. Rice SG, Bierman CW, Shapiro GG, et al.: Identification of exercise-induced asthma among intercollegiate athletes. Ann Allergy 1985, 55:790–793.

    CAS  PubMed  Google Scholar 

  31. Anderson SD: Exercise-induced asthma. In Allergy and Allergic Diseases. Edited by Kay AB. Boston: Blackwell Scientific; 1997:692–711.

    Google Scholar 

  32. Rodwell LT, Anderson SD, du Toit J, Seale JP: Different effects of inhaled amiloride and furosemide on airway responsiveness to dry air challenge in asthmatic subjects. Eur Respir J 1993, 6:855–861.

    CAS  PubMed  Google Scholar 

  33. Eliasson AH, Phillips YY, Rajagopal KR, Howard RS: Sensitivity and specificity of bronchial provocation testing. An evaluation of four techniques in exercise-induced bronchospasm. Chest 1992, 102:347–355. This study compared the sensitivity and specificity of four commonly used bronchoprovocation challenge tests: the exercise challenge test, the methacholine challenge test, the EVH with dry air, and the EVH with cold gas. The study revealed that although the exercise challenge is highly specific for EIB, it has a low sensitivity. It also supported the validity of the EVH challenge as a bronchoprovocation challenge for airway hyperreactivity.

    Article  CAS  PubMed  Google Scholar 

  34. Argyros GJ, Roach JM, Hurwitz KM, et al.: The refractory period after eucapnic voluntary hyperventilation challenge and its effect on challenge technique. Chest 1995, 108:419–424. The authors in this study established the use of the 6-minute singlestep protocol for the EVH challenge test.

    Article  CAS  PubMed  Google Scholar 

  35. Hurwitz KM, Argyros GJ, Roach JM, et al.: Interpretation of eucapnic voluntary hyperventilation in the diagnosis of asthma. Chest 1995, 108:1240–1245.

    Article  CAS  PubMed  Google Scholar 

  36. Phillips YY, Jaeger JJ, Laube BL, Rosenthal RR: Eucapnic voluntary hyperventilation of compressed gas mixture: a simple system for bronchial challenge by respiratory heat loss. Am Rev Respir Dis 1985, 131:31–35.

    CAS  PubMed  Google Scholar 

  37. Anderson SD: Issues in exercise-induced asthma. J Allergy Clin Immunol 1985, 76:763–772.

    Article  CAS  PubMed  Google Scholar 

  38. Anderson SD, Argyros GJ, Magnussen H: Eucapnic voluntary hyperpnea challenge for identifying exercise-induced bronchoconstriction. International Olympic Committee submission 2001, in press. This article highlights the importance of the EVH challenge in the diagnosis of EIA. It outlines the physiology underlying the challenge and explains the various protocols.

  39. Schoeffel RE, Anderson SD, Altounyan REC: Bronchial hyperreactivity in response to inhalation of ultrasonically nebulized solutions of distilled water and saline. Br Med J 1981, 283:1285–1287.

    Article  CAS  Google Scholar 

  40. Anderson SD: Bronchial challenge by ultrasonically nebulized aerosols. Clin Rev Allergy 1985, 3:427–439.

    CAS  PubMed  Google Scholar 

  41. Smith CM, Anderson SD: Inhalation provocation tests using nonisotonic aerosols. J Allergy Clin Immunol 1989, 84:781–790.

    Article  CAS  PubMed  Google Scholar 

  42. Smith CM, Anderson SD: Inhalational challenge using hypertonic saline in asthmatic patients: a comparison with responses to hyperpnea, methacholine and water. Eur Respir J 1990, 3:144–151.

    CAS  PubMed  Google Scholar 

  43. Anderson SD, Brannan J, Spring J: A new method for bronchial provocation testing in asthmatic subjects using a dry powder of mannitol. Am J Respir Crit Care Med 1997, 156:758–765.

    Article  CAS  PubMed  Google Scholar 

  44. Custovic A, Arifhodzic N, Robinson A, et al.: Exercise testing revisited: the response to exercise in normal and atopic children. Chest 1994, 105:1127–1132.

    Article  CAS  PubMed  Google Scholar 

  45. Nisar M, Spence DPS, West D, et al.: A mask to modify inspired air temperature and humidity and its effect on exerciseinduced asthma. Thorax 1992, 47:446–450.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  46. Shturman-Ellstein R, Zeballos RJ, Buckley JM, et al.: The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Respir Dis 1978, 118:65–73.

    CAS  PubMed  Google Scholar 

  47. Togias AG, Proud D, Lichenstein LM, et al.: The osmolality of nasal secretions increases when inflammatory mediators are released in response to cold dry air. Am Rev Respir Dis 1988, 137:625–629.

    Article  CAS  PubMed  Google Scholar 

  48. Anderson SD, Togias A: Dry air and hyperosmolar challenge in asthma and rhinitis. In Asthma and Rhinitis. Edited by Busse W, Holgate S. Oxford: Blackwell Scientific; 1994:1178–1195.

    Google Scholar 

  49. Cochrane LM, Clark CJ: Benefits and problems of a physical training programme for asthmatic patients. Thorax 1990, 45:345–351.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  50. Varray A, Mercier J, Savy-Pacaux AM, Prefaut C: Cardiac role in exercise limitation in asthmatic subjects with special references to disease severity. Eur Resp J 1993, 6:1011–1017.

    CAS  Google Scholar 

  51. Fitch KD, Morton AR, Blanksby BA: Effects of swimming training on children with asthma. Arch Dis Child 1976, 51:190–194.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  52. Fitch KD, Blitvich JD, Morton AR: The effect of running training on exercise-induced asthma. Ann Allergy 1986, 7:90–94.

    Google Scholar 

  53. Bunsgaard A, Ingemann-Hansen T, Schmidt A, Halkjaer-Kristensen J: Effect of physical training on peak oxygen consumption rate and exercise-induced asthma in adult asthmatics. Scand J Clin Lab Invest 1982, 42:9–13.

    Article  Google Scholar 

  54. Henriksen JM, Nielsen TT: Effect of physical training on exercise-induced bronchoconstriction. Acta Paediatr Scand 1983, 72:31–36.

    Article  CAS  PubMed  Google Scholar 

  55. Svenonius E, Kautto R, Arborelius M: Improvement after training of children with exercise-induced asthma. Acta Paediatr Scand 1983, 72:23–30.

    Article  CAS  PubMed  Google Scholar 

  56. Haas F, Pasierski S, Levine N, et al.: Effect of aerobic training on forced expiratory airflow in exercising asthmatic humans. J Appl Physiol 1987, 63:1230–1235.

    CAS  PubMed  Google Scholar 

  57. Morton AR, Fitch KD, Davis T: The effect of (warm up) on exercise-induced asthma. Ann Allergy 1979, 42:257–260.

    CAS  PubMed  Google Scholar 

  58. Morton AR, Hahn AG, Fitch KD: Continuous and intermittent running in the provocation of asthma. Ann Allergy 1982, 48:123–129.

    CAS  PubMed  Google Scholar 

  59. Schnall RP, Landau LI: Protective effects of repeated short sprints in exercise-induced asthma. Thorax 1980, 35:828–832.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  60. Reiff DB, Choudry NB, Pride NB, Ind PW: The effect of prolonged submaximal warm-up exercise on exerciseinduced asthma. Am Rev Resp Dis 1989, 139:479–484.

    Article  CAS  PubMed  Google Scholar 

  61. McKenzie DC, McLuckie SL, Stirling DR: The protective effects of continuous and interval exercise in athletes with exerciseinduced asthma. Med Sci Sports Exerc 1994, 26:951–956.

    Article  CAS  PubMed  Google Scholar 

  62. Edmunds A, Tooley M, Godfrey S: The refractory period after exercise-induced asthma: its duration and relation to the severity of exercise. Am Rev Respir Dis 1978, 117:247–254.

    CAS  PubMed  Google Scholar 

  63. O’Byrne PM, Jones GL: The effect of indomethacin on exercise-induced bronchoconstriction and refractoriness after exercise. Am Rev Respir Dis 1986, 134:69–72.

    PubMed  Google Scholar 

  64. Margolskee DJ, Bigby BG, Boushey HA: Indomethacin blocks airway tolerance to repetitive exercise but not to eucapnic hyperpnoea in asthmatic subjects. Am Rev Respir Dis 1988, 137:842–846.

    Article  CAS  PubMed  Google Scholar 

  65. Wilson BA, Bar-Or O, O’Byrne PM: The effects of indomethacin on refractoriness following exercise both with and without bronchoconstriction. Eur Respir J 1994, 12:2174–2178.

    Article  Google Scholar 

  66. Anderson SD, Rodwell LT, Daviskas E, et al.: The protective effect of nedocromil sodium and other drugs on airway narrowing provoked by hyperosmolar stimuli: a role for the airway epithelium? J Allergy Clin Immunol1996, 98(5 Pt 2):S124-S134; discussion S140-S142.

    Article  CAS  PubMed  Google Scholar 

  67. Anderson SD: Exercise-induced asthma: stimulus, mechanism and clinical management. In Asthma: Basic Mechanisms and Clinical Management. Edited by BarnesPJ, RodgersIW, ThomsonNC. Cambridge: Academic Press; 1988:505–522.

    Google Scholar 

  68. Rocchiccioli KMS, Riley PA: Clinical pharmacology of nedocromil sodium. Drugs 1989, 37(Suppl 1):123–126.

    Article  PubMed  Google Scholar 

  69. Richards R, Phillips GD, Holgate ST: Nedocromil sodium is more potent than sodium cromoglycate against AMPinduced bronchoconstriction in atopic asthmatic subjects. Clin Exp Allergy 1989, 19:285–291.

    Article  CAS  PubMed  Google Scholar 

  70. Albazzaz MK, Neale MG, Patel KR: Dose duration of nedocromil sodium in exercise-induced asthma. Eur Respir J 1992, 5:967–969.

    CAS  PubMed  Google Scholar 

  71. Konig P, Hordvik NL, Kreutz C: The preventative effect and duration of action of nedocromil sodium and cromolyn sodium on exercise-induced asthma (EIA) in adults. J Allergy Clin Immunol 1987, 79:64–68.

    Article  CAS  PubMed  Google Scholar 

  72. Morton AR, Ogle SL, Fitch KD: Effects of nedocromil sodium, cromolyn sodium, and a placebo in exercise-induced asthma. Ann Allergy 1991, 68:1443–1448.

    Google Scholar 

  73. Anderson SD: Exercise-induced asthma: stimulus, mechanism and management. In Asthma: Basic Mechanisms and Clinical Management. Edited by Barnes PJ, Rodger IW, Thomas NC. San Diego: Academic Press; 1988:503.

    Google Scholar 

  74. Bhagat R, Kalra S, Swystun A: Rapid onset of tolerance to the bronchoprotective effect of salmeterol. Chest 1995, 108:1235–1239.

    Article  CAS  PubMed  Google Scholar 

  75. Randolph C: Exercise-induced asthma: update on pathophysiology, clinical diagnosis, and treatment. Curr Probl Pediatr 1997, 27:53–77.

    CAS  PubMed  Google Scholar 

  76. Rupp NT: Diagnosis and management of exercise-induced asthma. Phys Sportsmed 1996, 24:77–87.

    Article  CAS  PubMed  Google Scholar 

  77. Ferrari M, Balestreri F, Baratieri S, et al.: Evidence of the rapid protective effect of formoterol dry-powder inhalation against exercise-induced bronchospasm in athletes with asthma. Respiration 2000, 67:510–513. This study provides evidence for the use of inhaled formoterol as both a short- and long-acting β agonist in the treatment of asthma and EIA.

    Article  CAS  PubMed  Google Scholar 

  78. Makker HK, Lau LC, Thomson HW: The protective effect of inhaled leukotriene D4 receptor antagonist ICI 204, 219 against exercise-induced asthma. Am Rev Respir Dis 1993, 147:1413–1418.

    Article  CAS  PubMed  Google Scholar 

  79. Leff JA, Busse WW, Pearlman D, et al.: Montelukast, a leukotriene antagonist for the treatment of mild asthma and exercise-induced bronchoconstriction. N Engl J Med 1998, 339:147–152.

    Article  CAS  PubMed  Google Scholar 

  80. Henriksen JM, Dahl R: Effects of inhaled budesonide alone and in combination with low dose terbutaline in children with exercise-induced asthma. Am Rev Respir Dis 1983, 128:993–997.

    CAS  PubMed  Google Scholar 

  81. Waalkans HJ, van Essen-Zandvliet EEM, Gerritsen J, et al., and the Dutch CNSLD Study Group: The effect of an inhaled corticosteroid (budesonide) on exercise-induced asthma in children. Eur Resp J 1993, 6:523–526.

    Google Scholar 

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Holzer, K., Brukner, P. & Douglass, J. Evidence-based management of exercise-induced asthma. Curr Sports Med Rep 1, 86–92 (2002). https://doi.org/10.1007/s11932-002-0055-1

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