Exercise-Induced Asthma

Aka: Exercise-Induced Asthma, Exercise-Induced Bronchospasm, Exercise Induced Bronchospasm, EIB

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II. Pathophysiology

  1. Hyperventilation of dry, cool air
  2. Loss of heat or water from lungs during Exercise

III. Epidemiology

  1. Occurs in 90% of Asthmatics
  2. May occur in as many as 29% of athletes
    1. Cold Weather athletes appear more susceptible
    2. Occurs in 50% of olympic cross country skiers

IV. Symptoms

  1. Timing
    1. Onset during or after Exercise
    2. Does not usually affect first 5 minutes of Exercise
    3. Symptom duration of 5 minutes or longer
  2. Exercise-related symptoms
    1. Shortness of Breath
    2. Wheezing
    3. Decreased Exercise endurance
    4. Chest tightness
    5. Cough
    6. Epigastric Pain
    7. Pharyngitis

V. Signs

  1. Cardiopulmonary exam normal at rest
  2. Exclude associated conditions (see differential diagnosis below)

VI. Differential Diagnosis

  1. Cardiovascular disorder
    1. Congestive Heart Failure
    2. Coronary Artery Disease
    3. Arrhythmia
    4. Hypertrophic Cardiomyopathy
    5. Heart Valve Disorders
    6. Pulmonary AV Malformation
  2. Lung disorder
    1. Chronic Asthma
    2. Chronic Obstructive Pulmonary Disease (COPD)
    3. Cystic Fibrosis
    4. Interstitial Lung Disease
    5. Pectus Excavatum
    6. Scoliosis
    7. Tracheobronchial malacia
  3. Head and neck disorders
    1. Chronic Sinusitis
    2. Allergic Rhinitis
    3. Nasal Polyps
    4. Septal deviation
    5. Vocal Cord Dysfunction
  4. Miscellaneous disorders
    1. Deconditioning or Obesity
    2. Myopathy
    3. Anxiety Disorder or Hyperventilation

VII. Diagnostics

  1. Obtain FEV1 or Peak Flow at rest (exclude Asthma)
  2. Exercise Challenge with Pulmonary Function Testing
    1. Not required for classic presentation
    2. Most patients may be treated empirically

VIII. Management: General Measures

  1. Maintain regular Exercise for physical conditioning
  2. Warm up and cool down for 10 minutes before and after
  3. Exercise in humidified, warm environment
  4. Cover nose and mouth during Cold WeatherExercise
    1. Consider heat exchange mask (available at sporting good stores)
  5. Avoid Exercise within 2 hours following a meal
  6. Avoid Exercise in high allergen, ozone or pollution

IX. Management: Medications

  1. Treat related conditions
    1. Asthma
    2. Allergic Rhinitis
  2. Primary Agents
    1. Short-acting Beta Agonist (Albuterol, Pirbuterol)
      1. Use 2 puffs, 15-30 minutes before Exercise
  3. Secondary Adjunctive Agents
    1. Step 1: Leukotriene Modifiers (preferred if comorbid Allergic Rhinitis)
      1. Taken on regular schedule
      2. Montelukast (Singulair)
        1. Montelukast is associated with increased risk of Major Depression and Suicide
        2. https://www.fda.gov/news-events/press-announcements/fda-requires-stronger-warning-about-risk-neuropsychiatric-events-associated-asthma-and-allergy
      3. Zafirlukast (Accolate)
      4. Zileuton XR (Zyflo CR)
        1. Other Leukotriene Modifiers are preferred due to adverse effects including hepatotoxicity
    2. Step 2: Mast Cell Stabilizer 15 minutes before Exercise
      1. Mast Cell Stabilizers are low efficacy agents that are not included in current Asthma guidelines
      2. Consider using on regular schedule 2-4 times daily
      3. Cromolyn (Intal)
      4. Nedocromil (Tilade)
        1. Discontinued in U.S. in 2008 after CFC ban
    3. Step 3: Inhaled Corticosteroid trial (preferred in underlying Asthma)
      1. Obtain initial Exercise challenge with PFTs
      2. Inhaled Corticosteroid (e.g. Qvar, Pulmicort, Flovent, Asmanex) for 4 weeks
      3. Obtain follow-up Exercise challenge with PFTs
      4. Continue Inhaled Corticosteroid if benefit seen
      5. Consider in combination with inhaled Long-Acting Beta Agonist (e.g. Advair)
    4. Step 4: Ipratropium Bromide (Atrovent)
      1. Inhaled 2 puffs up to qid
    5. Other interventions with unproven benefit
      1. Vitamin C 2 grams before Exercise
      2. Dietary salt reduction
      3. Omega 3 Fatty Acid supplementation
    6. Avoid Long-Acting Beta Agonists (e.g. Salmeterol) in Exercise-Induced Asthma (unless Moderate Persistent Asthma)
      1. Consistent use results in worsening symptoms and decreased short-acting Bronchodilator (rescue Inhaler) effect
      2. If Long-Acting Beta Agonists are used in Exercise-Induced Asthma, avoid use >3 days per week

X. Medications: Sporting organization rules regarding restricted medications for Asthma

  1. Organizations
    1. United States Olympic Committee (USOC)
    2. National Collegiate Athletic Association (NCAA)
  2. No approval needed
    1. Ipratropium Bromide
    2. Leukotriene Modifiers
      1. Montelukast (Singulair)
      2. Zafirlukast (Accolate)
    3. Theophylline
    4. Mast Cell Stabilizers
      1. Cromolyn (Intal)
      2. Nedocromil (Tilade)
  3. Prior approval required
    1. Inhaled Corticosteroids (requires declaration of use by USOC)
    2. Inhaled Beta Agonist (permitted only with prescription by NCAA, USOC)
      1. Albuterol (Proventil, Ventolin)
      2. Pirbuterol (Maxair)
      3. Terbutaline (Brethine)
      4. Salmeterol (Serevent)
  4. Prohibited
    1. Oral (not inhaled) beta 2 Agonists

XI. References

  1. Krafczyk (2011) Am Fam Physician 84(11): 427-34 [PubMed]
  2. Sinha (2003) Am Fam Physician 67(4):769-74 [PubMed]
  3. Tan (2002) Ann Allergy Asthma Immunol 89:226-35 [PubMed]
  4. Tan (1998) Sports Med 25:4 [PubMed]

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Related Studies

Ontology: Asthma, Exercise-Induced (C0004099)

Definition (MSH) Asthma attacks following a period of exercise. Usually the induced attack is short-lived and regresses spontaneously. The magnitude of postexertional airway obstruction is strongly influenced by the environment in which exercise is performed (i.e. inhalation of cold air during physical exertion markedly augments the severity of the airway obstruction; conversely, warm humid air blunts or abolishes it).
Concepts Disease or Syndrome (T047)
MSH D001250
SnomedCT 139202009, 195983001, 31387002
English Asthma, Exercise Induced, Asthma, Exercise-Induced, Asthmas, Exercise-Induced, Exercise Induced Asthma, Exercise-Induced Asthma, Exercise-Induced Asthmas, Exercise induced asthma, EXERCISE IND ASTHMA, ASTHMA EXERCISE IND, exercise-induced asthma, exercise-induced asthma (diagnosis), EIA (exercise-induced asthma), Asthma exercise induced, Asthma, Exercise-Induced [Disease/Finding], exercised induced asthma, asthma exercise induced, asthma induced exercise, exercise induced asthma, Exercise-induced asthma (finding), Exercise-induced asthma, EIA - Exercise-induced asthma, Exercise-induced asthma (disorder)
Spanish asma inducida por el ejercicio (trastorno), asma inducida por el ejercicio, asma inducido por el ejercicio (trastorno), asma inducido por el ejercicio, Asma inducida por el esfuerzo, Asma Inducida por Ejercicio
German anstrengungsbedingtes Asthma, Belastungsasthma, Asthma, belastungsinduziertes, Belastungsinduziertes Asthma
Portuguese Asma induzida pelo exercício, Asma induzida pelo esforço, Asma Induzida por Exercício
Swedish Astma, ansträngningsutlöst
Japanese ｳﾝﾄﾞｳﾕｳﾊﾂｾﾞﾝｿｸ, 運動誘発性気管支けいれん, 気管支喘息-運動誘発性, 運動誘発喘息, 気管支けいれん-運動誘発性, 運動誘発性気管支喘息, 運動誘発性喘息, 喘息-運動誘発性, 運動誘発気管支痙攣
Czech astma z námahy, Námahové astma, Astma námahové, astma vyvolané námahou
Finnish Rasitusastma
Russian ASTMA BRONKHIAL'NAIA, SPROVOTSIROVANNAIA FIZICHESKOI NAGRUZKOI, BRONKHOSPAZM, SPROVOTSIROVANNYI FIZICHESKOI NAGRUZKOI, ASTMA FIZICHESKOGO USILIIA, АСТМА БРОНХИАЛЬНАЯ, СПРОВОЦИРОВАННАЯ ФИЗИЧЕСКОЙ НАГРУЗКОЙ, АСТМА ФИЗИЧЕСКОГО УСИЛИЯ, БРОНХОСПАЗМ, СПРОВОЦИРОВАННЫЙ ФИЗИЧЕСКОЙ НАГРУЗКОЙ
Polish Astma wysiłkowa, Dychawica oskrzelowa wysiłkowa
Hungarian Fizikai terhelés által kiváltott asthma, Terhelés-indukálta asthma
Italian Asma da sforzo, Asma da esercizio fisico
Norwegian Astma, anstrengelsesutløst, Anstrengelsesutløst astma, Anstrengelsesastma
Dutch inspanningsastma, Asthma, 'exercise-induced', Asthma, Exercise-induced
French Asthme d'effort, Asthme induit par l'exercice, Asthme dû à l'exercice, Asthme à l'effort, Asthme à l'exercice
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Bronchospasm, Exercise-Induced (C0015263)

Definition (NCI) Sudden contraction of the smooth muscles of the bronchial wall that occurs during or following exercise.
Concepts Disease or Syndrome (T047)
MSH D001250
ICD9 493.81
ICD10 J45.990
English Bronchospasm, Exercise Induced, Bronchospasms, Exercise-Induced, Exercise Induced Bronchospasm, Exercise-Induced Bronchospasm, Exercise-Induced Bronchospasms, EXERCISE IND BRONCHOSPASM, BRONCHOSPASM EXERCISE IND, exercise-induced bronchospasm (diagnosis), exercise-induced bronchospasm, Exercise-induced bronchospasm, Exercse ind bronchospasm, Exercise induced bronchospasm, exercise induced bronchospasm, Bronchospasm, Exercise-Induced
Dutch door inspanning ontstaan bronchospasme, Bronchospasmen, inspanninggeïnduceerde, Inspanninggeïnduceerde astma
German belastungsverursachter Bronchienspasmus, Bronchospasmen, belastungsinduzierte, Belastungsinduzierte Bronchospasmen
Portuguese Broncospasmo induzido pelo exercício, Broncoespasmo Induzido por Exercício
Spanish Broncoespasmo inducido por el esfuerzo, Broncoespasmo por Ejercicio
Japanese 運動誘発性気管支痙攣, ｳﾝﾄﾞｳﾕｳﾊﾂｾｲｷｶﾝｼｹｲﾚﾝ
French Bronchospasme déclenché par l'effort, Bronchospasme à l'exercice, Bronchospasme d'effort, Bronchospasme induit par l'exercice, Bronchospasme à l'effort
Czech Námahový bronchospasmus, bronchospazmus indukovaný cvičením, cvičením vyvolaný bronchospazmus, cvičením vyvolaný bronchospasmus
Hungarian Testgyakorlat-által kiváltott bronchospasmus
Italian Broncospasmo da sforzo, Broncospasmo da esercizio fisico
Norwegian Anstrengelsesutløst bronkospasme, Bronkospasme, anstrengelsesutløst
Derived from the NIH UMLS (Unified Medical Language System)

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