Skip to main content

Advertisement

SpringerLink
Log in

Dyspneic athlete

  • Field Management of Sports Injuries (J Kinderknecht, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Breathing concerns in athletes are common and can be due to a wide variety of pathology. The most common etiologies are exercise-induced bronchoconstriction (EIB) and paradoxic vocal fold movement disorder (PVFMD). Although some patients may have both, PVFMD is often misdiagnosed as EIB, which can lead to unnecessary treatment. The history and physical exam are important to rule out life threatening pulmonary and cardiac causes as well as common conditions such as gastroesophageal reflux disease, sinusitis, and allergic etiologies. The history and physical exam have been shown to be not as vital in diagnosing EIB and PVFMD. Improvement in diagnostic testing with office base spirometry, bronchoprovocation testing, eucapnic voluntary hyperpnea (EVH) and video laryngoscopy are essential in properly diagnosing these conditions. Accurate diagnosis leads to proper management, which is essential to avoid unnecessary testing and save healthcare costs. Also important to the physician treating dyspnea in athletes is knowing regulations on medications, drug testing, and proper documentation needed for certain organizations. The differential diagnosis of dyspnea is broad and is not limited to EIB and PVFMD. Ruling out life threatening cardiac and pulmonary causes with a proper history, physical, and appropriate testing is essential. The purpose of this review is to highlight recent literature on the diagnosis and management of EIB and PVFMD as well as discuss other potential causes for dyspnea in the athlete.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Parsons JP. Exercise-induced bronchoconstriction. Otolaryngol Clin North Am. 2014;47:119–26. This recent review article summarizes current diagnosis and treatment guidelines for exercise induced bronchospasm.

    Article  PubMed  Google Scholar 

  2. Jaworski CA. “Pulmonary”. ACSM’s sports medicine, a comprehensive review. In: O’Connor F, editor. Wolters Kluwer Health. Lippincott Williams & Wilkins; 2013, p. 248–55.

  3. US Department of Health and Human Services. EPR-2. Expert panel report 2: guidelines for the diagnosis and management of asthma (EPR-2 1997). NIH Publication No. 97-4051. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program.

  4. Feinstein RA, LaRussa J, Wang-Dohlman A, Bartolucci AA. Screening adolescent athletes for exercise-induced asthma. Clin J Sport Med. 1996;6:119–23.

    Article  PubMed  CAS  Google Scholar 

  5. Parsons JP, Craig TJ, Stoloff SW, et al. Impact of exercise-related respiratory symptoms in adults with asthma: exercise-Induced Bronchospasm Landmark National Survey. Allergy Asthma Proc. 2011;32:431–7.

    Article  PubMed  Google Scholar 

  6. Gotshall RW. Exercise-induced bronchoconstriction. Drugs. 2002;62:1725–39.

    Article  PubMed  Google Scholar 

  7. Matrka L. Paradoxic vocal fold movement disorder. Otolaryngol Clin North Am. 2014;47:135–46. This recent review article summarizes current diagnosis and treatment guidelines for PVFMD. The term PVFMD is stated in this paper with a shift away from VCD.

    Article  PubMed  Google Scholar 

  8. Al-Alwan A, Kaminsky D. Vocal cord dysfunction in athletes: clinical presentation and review of the literature. Phys Sportsmed. 2012;40:22–7. This review article summarizes diagnosis and management of VCD.

    Article  PubMed  Google Scholar 

  9. Parsons JP, Mastronarde JG. Exercise-induced bronchoconstriction in athletes. Chest. 2005;128:3966–74.

    Article  PubMed  Google Scholar 

  10. Holzer K, Anderson SD, Douglass J, et al. Exercise in elite summer athletes: challenges for diagnosis. J Allergy Clin Immunol. 2002;110:374–80.

    Article  PubMed  Google Scholar 

  11. Wilber RL et al. Incidence of exercise-induced bronchospasm in Olympic winter sport athletes. Med Sci Sports Exerc. 2000;32:732–7.

    Article  PubMed  CAS  Google Scholar 

  12. Price OJ, Ansley L, Menzies-Gow A, Cullinan P, Hull JH. Airway dysfunction in elite athletes - an occupational lung disease? Allergy. 2013;68:1343–52.

    Article  PubMed  CAS  Google Scholar 

  13. Helenius IJ, Rytila P, Metso T, et al. Respiratory symptoms, bronchial responsiveness, and cellular characteristics of induced sputum in elite swimmers. Allergy. 1998;53:346–52.

    Article  PubMed  CAS  Google Scholar 

  14. Bougault V, Boulet LP. Airway dysfunction in swimmers. Br J Sports Med. 2012;46:402–6.

    Article  PubMed  Google Scholar 

  15. Rundell KW. High levels of airborne ultrafine and fine particulate matter in indoor ice arenas. Inhal Toxicol. 2003;15:237–50.

    Article  PubMed  CAS  Google Scholar 

  16. Rundell KW, Caviston R, Hollenbach AM, et al. Vehicular air pollution, playgrounds, and youth athletic fields. Inhal Toxicol. 2006;18:541–7.

    Article  PubMed  CAS  Google Scholar 

  17. Barnes PJ. Poorly perceived asthma. Thorax. 1992;47:408–9.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  18. Barnes PJ. Blunted perception and death from asthma. N Engl J Med. 1994;330:1383–4.

    Article  PubMed  CAS  Google Scholar 

  19. Rundell KW, Im J, Mayers LB, et al. Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc. 2001;33:208–13.

    Article  PubMed  CAS  Google Scholar 

  20. Thole RT, Sallis RE, Rubin AL, et al. Exercise-induced bronchospasm prevalence in collegiate cross-country runners. Med Sci Sports Exerc. 2001;33:1641–6.

    Article  PubMed  CAS  Google Scholar 

  21. Moran W. Jackie Joyner-Kersee races against asthma. USA Today. 2002.

  22. Storms WW, Joyner DM. Update on exercise-induced asthma: a report of the Olympic exercise asthma summit conference. Phys Sportsmed. 1997;25:45–55.

    PubMed  CAS  Google Scholar 

  23. Storms WW. Exercise-induced asthma: diagnosis and treatment for the recreational or elite athlete. Med Sci Sports Exerc. 1999;31(Suppl):S33–8.

    Article  PubMed  CAS  Google Scholar 

  24. Anderson SD. Single dose agents in the prevention of exercise-induced asthma: a descriptive review. Treat Respir Med. 2004;3:365–79.

    Article  PubMed  CAS  Google Scholar 

  25. Anderson SD, Brannan JD. Long-acting beta2-adrenoceptor agonists and exercise-induced asthma: lessons to guide us in the future. Paediatr Drug. 2004;6:161–75.

    Article  Google Scholar 

  26. Parsons JP, Kaeding C, Phillips G, Jarjoura D, Wadley G, Mastronarde JG. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc. 2007;39:1487–92.

    Article  PubMed  Google Scholar 

  27. Thole RT, Sallis RE, Rubin AL, Smith GN. Exercise-induced bronchospasm prevalence in collegiate cross-country runners. Med Sci Sports Exerc. 2001;33:1641–6.

    Article  PubMed  CAS  Google Scholar 

  28. Tikkanen HO, Peltonen JE. Asthma-cross-country skiing. Med Sci Sports Exerc. 1999;31(Suppl):S99.

    Article  Google Scholar 

  29. Rundell KW, Wilber RL, Szmedra L, et al. Exercise-induced asthma screening of elite athletes: field vs laboratory exercise challenge. Med Sci Sports Exerc. 2000;32:309–16.

    Article  PubMed  CAS  Google Scholar 

  30. Eliasson AH, Phillips YY, Rajagopal KR, et al. Sensitivity and specificity of bronchial provocation testing. An evaluation of four techniques in exercise-induced bronchospasm. Chest. 1992;102:347–55.

    Article  PubMed  CAS  Google Scholar 

  31. Holley AB, Cohee B, Walter RJ, Shah AA, King CS, Roop S. Eucapnic voluntary hyperventilation is superior to methacholine challenge testing for detecting airway hyper-reactivity in nonathletes. J Asthma. 2012;49:614–9. EIB is common in nonathletes with exercise induced symptoms and EVH is the preferred test.

    Article  PubMed  CAS  Google Scholar 

  32. Anderson SD, Argyros GJ, Magnussen H, et al. Provocation by eucapnic voluntary hyperpnoea to identify exercise induced bronchoconstriction. Br J Sports Med. 2001;35:344–7.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  33. Rundell KW, Slee JB. Exercise and other indirect challenges to demonstrate asthma or exercise-induced bronchoconstriction in athletes. J Allergy Clin Immunol. 2008;122:238–46.

    Article  PubMed  Google Scholar 

  34. Fitch KD, Sue-Chu M, Anderson SD, Boulet LP, Hancox RJ, McKenzie DC, et al. Asthma and the elite athlete: summary of the International Olympic Committee's consensus conference, Lausanne, Switzerland, January 22-24, 2008. J Allergy Clin Immunol. 2008;122:254–60.

    Article  PubMed  Google Scholar 

  35. Cockcroft D, Davis B. Direct and indirect challenges in the clinical assessment of asthma. Ann Allergy Asthma Immunol. 2009;103:363–9. quiz: 369–72, 400.

    Article  PubMed  CAS  Google Scholar 

  36. Brannan JD, Anderson SD, Perry CP, et al. The safety and efficacy of inhaled dry powder mannitol as a bronchial provocation test for airway hyper-responsiveness: a phase 3 comparison study with hypertonic (4.5 %) saline. Respir Res. 2005;6:144.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Mannix ET, Manfredi F, Farber MO, et al. A comparison of two challenge tests for identifying exercise-induced bronchospasm in figure skaters. Chest. 1999;115:649–53.

    Article  PubMed  CAS  Google Scholar 

  38. Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American thoracic society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013;187:1016–27. The clinical practice guidelines recommend use of SABAs prior to exercise in all patients with EIB. For symptoms that continue despite SABA use, the use of daily inhaled corticosteroids, daily leukotriene receptor antagonists, or mast cell stabilizers prior to exercise is recommended.

    Article  PubMed  CAS  Google Scholar 

  39. National Asthma Education and Prevention Program: Expert Panel Report 3 (EPR-3). Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120:S94–138.

  40. Ferrari M, Segattini C, Zanon R, et al. Comparison of the protective effect of formoterol and of salmeterol against exercise-induced bronchospasm when given immediately before a cycloergometric test. Respiration. 2002;69:509–12.

    Article  PubMed  CAS  Google Scholar 

  41. Philip G, Villaran C, Pearlman DS, et al. Protection against exercise-induced bronchoconstriction two hours after a single oral dose of montelukast. J Asthma. 2007;44:213–7.

    Article  PubMed  CAS  Google Scholar 

  42. Edelman JM, Turpin JA, Bronsky EA, et al. Oral montelukast compared with inhaled salmeterol to prevent exercise-induced bronchoconstriction. A randomized, double-blind trial. Exercise Study Group. Ann Intern Med. 2000;132:97–104.

    Article  PubMed  CAS  Google Scholar 

  43. Anderson SD, Schoeffel RE. Respiratory heat and water loss during exercise in patients with asthma. Effect of repeated exercise challenge. Eur J Respir Dis. 1982;63:472–80.

    PubMed  CAS  Google Scholar 

  44. McKenzie DC, McLuckie SL, Stirling DR, et al. The protective effects of continuous and interval exercise in athletes with exercise-induced asthma. Med Sci Sports Exerc. 1994;26:951–6.

    Article  PubMed  CAS  Google Scholar 

  45. Rundell KW, Spiering BA, Judelson DA, et al. Bronchoconstriction during cross-country skiing: is there really a refractory period? Med Sci Sports Exerc. 2003;35:18–26.

    Article  PubMed  Google Scholar 

  46. Schachter EN, Lach E, Lee M, et al. The protective effect of a cold weather mask on exercised-induced asthma. Ann Allergy. 1981;46:12–6.

    PubMed  CAS  Google Scholar 

  47. Mickleborough TD, Gotshall RW. Dietary salt intake as a potential modifier of airway responsiveness in bronchial asthma. J Altern Complement Med. 2004;10:633–42.

    Article  PubMed  Google Scholar 

  48. Mickleborough TD, Ionescu AA, Rundell KW, et al. Omega-3 Fatty acids and airway hyper-responsiveness in asthma. J Altern Complement Med. 2004;10:1067–75.

    Article  PubMed  Google Scholar 

  49. Tecklenburg SL, Mickleborough TD, Fly AD, et al. Ascorbic acid supplementation attenuates exercise-induced bronchoconstriction in patients with asthma. Respir Med. 2007;101:1770–8.

    Article  PubMed  Google Scholar 

  50. Newman KB, Mason UG, Schmaling KB, et al. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med. 1995;152:1382–6.

    Article  PubMed  CAS  Google Scholar 

  51. Cohen SM, Belluci E. Health utilization among patients with vocal cord dysfunction. Nurs Forum. 2011;46:177–85.

    Article  PubMed  Google Scholar 

  52. Mikita J, Parker J. High levels of medical utilization by ambulatory patients with vocal cord dysfunction as compared to age and gender matched asthmatics. Chest. 2006;129:905–8.

    Article  PubMed  Google Scholar 

  53. Hanks CD, Parsons J, Benninger C, Kaeding C, Best TM, Phillips G, et al. Etiology of dyspnea in elite and recreational athletes. Phys Sportsmed. 2012;40:28–33.

    Article  PubMed  Google Scholar 

  54. Rundell KW, Spiering BA. Inspiratory stridor in elite athletes. Chest. 2003;123:468–74.

    Article  PubMed  Google Scholar 

  55. Boulet LP. Cough and upper airway disorders in elite athletes: a critical review. Br J Sports Med. 2012;46:417–21.

    Article  PubMed  Google Scholar 

  56. Brugman SM, Simons SM. Vocal cord dysfunction: don't mistake it for asthma. Phys Sportsmed. 1998;26:63–85.

    Article  PubMed  CAS  Google Scholar 

  57. Seear M, Wensley D, West N. How accurate is the diagnosis of exercise induced asthma among Vancouver schoolchildren? Arch Dis Child. 2005;90:898–902.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  58. Kenn K, Schmitz M, et al Prevalence of vocal cord dysfunction in patients with dyspnea. First prospective clinical study. Am J Respir Crit Care Med. 155:A965.

  59. Newman KB, Dubester SN. Vocal cord dysfunction: masquerader of asthma. Semin Respir Crit Care Med. 1994;15:161–7.

    Article  Google Scholar 

  60. Chiang T, Marcinow AM, Silva BW, Ence BN, Lindsey SE, Forrest LA. Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management. Laryngoscope. 2013;123:727–31. This review article summarizes diagnosis and management of PVFMD.

    Article  PubMed  Google Scholar 

  61. Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion: classification and treatment. Laryngoscope. 2012;122:844–53.

    Article  PubMed  Google Scholar 

  62. Sant'Ambrogio G, Sant'Ambrogio FB. Role of laryngeal afferents in cough. Pulm Pharmacol. 1996;9:309–14.

    Article  PubMed  Google Scholar 

  63. Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Curr Sports Med Rep. 2009;8:65–70.

    Article  PubMed  Google Scholar 

  64. Husein OF, Husein TN, Gardner R, Chiang T, Larson DG, Obert K, et al. Formal psychological testing in patients with paradoxical vocal fold dysfunction. Laryngoscope. 2008;118:740–7.

    Article  PubMed  Google Scholar 

  65. Ayres JG, Gabbott PL. Vocal cord dysfunction and laryngeal hyper-responsiveness: a function of altered autonomic balance? Thorax. 2002;57:284–5.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  66. Bucca C, Rolla G, Brussino L, De Rose V, Bugiani M. Are asthma-like symptoms due to bronchial or extrathoracic airway dysfunction? Lancet. 1995;346:791–5.

    Article  PubMed  CAS  Google Scholar 

  67. Morrison M, Rammage L, Emami AJ. The irritable larynx syndrome. J Voice. 1999;13:447–55.

    Article  PubMed  CAS  Google Scholar 

  68. Guss J, Mirza N. Methacholine challenge testing in the diagnosis of paradoxical vocal fold motion. Laryngoscope. 2006;116:1558–61.

    Article  PubMed  CAS  Google Scholar 

  69. Patel NJ, Jorgensen C, Kuhn J, Merati AL. Concurrent laryngeal abnormalities in patients with paradoxical vocal fold dysfunction. Otolaryngol Head Neck Surg. 2004;130:686–9.

    Article  PubMed  Google Scholar 

  70. Suttithawil W, Chakkaphak S, Jaruchinda P, Fuangtong R. Vocal cord dysfunction concurrent with a nutcracker esophagus and the role of gastroesophageal reflux disease. Ann Allergy Asthma Immunol. 2006;96:373–5.

    Article  PubMed  Google Scholar 

  71. Koufman JA. Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease. Ear Nose Throat J. 2002;81(9 Suppl 2):7–9.

    PubMed  Google Scholar 

  72. Hoyte FC. Vocal cord dysfunction. Immunol Allergy Clin North Am. 2013;33:1–22.

    Article  PubMed  Google Scholar 

  73. Christopher KL, Wood RP, Eckert C, et al. Vocal cord dysfunction presenting as asthma. N Engl J Med. 1983;308:1566–70.

    Article  PubMed  CAS  Google Scholar 

  74. Heimdal JH, Roskund OD, Halvorsen T, et al. Continuous laryngoscopic exercise test: a method for visualizing laryngeal dysfunction during exercise. Laryngoscope. 2006;116:52–7.

    Article  PubMed  Google Scholar 

  75. Sullivan MD, Heywood BM, Beukelman DR, et al. A treatment for vocal cord dysfunction in female athletes: an outcome study. Laryngoscope. 2001;111:1751–5.

    Article  PubMed  CAS  Google Scholar 

  76. Morris MJ, Allan PF, Perkins PJ, et al. Vocal cord dysfunction, aetiologies and treatment. Clin Pulm Med. 2006;13:73–86.

    Article  Google Scholar 

  77. Maillard I, Schweizer V, Broccard A, et al. Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest. 2000;118:874–7.

    Article  PubMed  CAS  Google Scholar 

  78. Weir M. Vocal cord dysfunction mimics asthma and may respond to heliox. Clin Pediatr. 2002;41:37–41.

    Article  Google Scholar 

  79. Tsung AH, Williams JB, Whitford AC. Sixteen-year-old athlete with chest pain and shortness of breath due to pulmonary emboli. J Emerg Med. 2013;44:939–42.

    Article  PubMed  Google Scholar 

  80. Kahanov L, Daly T. Bilateral pulmonary emboli in a collegiate gymnast: a case report. J Athl Train. 2009;44:666–71.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135:98–107.

    Article  PubMed  CAS  Google Scholar 

  82. Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of wells criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44:503–10.

    Article  PubMed  Google Scholar 

  83. Leiber MJ, Phan NT. Pneumomediastinum and subcutaneous emphysema in a synchronized swimmer. Phys Sportsmed. 2005;33:40–3.

    Article  PubMed  Google Scholar 

  84. Pierce MJ, Weesner CL, Anderson AR, Albohm MJ. Pneumomediastinum in a female track and field athlete: a case report. J Athl Train. 1998;33:168–70.

    PubMed  CAS  PubMed Central  Google Scholar 

  85. Dyste KH, Newkirk KM. Pneumomediastinum in a high school football player: a case report. J Athl Train. 1998;33:362–4.

    PubMed  CAS  PubMed Central  Google Scholar 

  86. Sadarangani S, Patel DR, Pejka S. Spontaneous pneumomediastinum and epidural pneumatosis in an adolescent precipitated by weight lifting: a case report and review. Phys Sportsmed. 2009;37:147–53.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

David Krey and Thomas Best declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

No human or animal studies performed by the authors:

This article does not contain any studies with human or animal subjects performed by any of the authors.

Human studies done by authors (but no animal studies)

This article does not contain any studies with animal subjects performed by any of the authors. With regard to the authors’ research cited in this paper, all procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

Animal studies done by authors (but no human studies)

This article does not contain any studies with human subjects performed by any of the authors.

With regard to the authors’ research cited in this paper, all institutional and national guidelines for the care and use of laboratory animals were followed.

Author information

Authors and Affiliations

  1. The Ohio State University Sports Medicine Center, 2050 Kenny Road, Suite 3100, Columbus, OH, 43221, USA

    David Krey & Thomas Best

Authors
  1. David Krey
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas Best
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas Best.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Krey, D., Best, T. Dyspneic athlete. Curr Rev Musculoskelet Med 7, 373–380 (2014). https://doi.org/10.1007/s12178-014-9236-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-014-9236-9

Keywords

Search

Navigation