exercise induced asthma essay

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Exercise-induced asthma.

Marie Gerow ; Paul J. Bruner .

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Last Update: August 7, 2023 .

• Continuing Education Activity

Exercise-induced bronchoconstriction (EIB) describes a transient and reversible contraction of bronchial smooth muscle after physical exertion that may or may not produce symptoms of dyspnea, chest tightness, wheezing, and cough. This activity outlines the evaluation and management of EIB and highlights the role of the interprofessional team in managing care for patients with this condition.

• Describe the etiology of exercise-induced bronchoconstriction (EIB).
• Summarize the pathophysiology of exercise-induced bronchoconstriction.
• Identify the typical management considerations for patients with exercise-induced bronchoconstriction.
• Review the importance of collaboration and communication among the interdisciplinary team to enhance care coordination for patients affected by exercise-induced bronchoconstriction.
• Introduction

Exercise-induced bronchoconstriction (EIB) occurs during physical exertion and involves a narrowing of the airway. [1] [2]  EIB occurs in 40% to 90% of people with asthma and up to 20% of those without asthma. [1] [3] [4]  The benefits of regular exercise for all people are well established, and activity is an integral part of a healthy lifestyle. People suffering from EIB may avoid exertion due to symptoms of breathlessness, cough, chest tightness, and wheezing. Exercise avoidance has been shown to increase social isolation in adolescents, and it can lead to obesity and poor health. [3]  Exercise has paradoxically been shown to improve EIB severity, pulmonary function, and reduce airway inflammation in people with asthma and EIB. [3] [2]  Early detection, diagnosis confirmed by the change in lung function during exercise, and treatment can improve quality of life and, when managed appropriately, allows patients to participate freely in exercise without limiting competition at the elite level. [3] [5]  Non-pharmacologic treatments addressing the root cause of EIB, an acute steep increase in ventilation and demand on the respiratory system, including warm-up exercises, and protecting the airway from cold, dry air, pollutants, and allergens is recommended. Pharmacologic treatments aimed at the pathophysiologic processes involved in the symptomatic bronchoconstriction, including short-acting beta-agonists (SABA), inhaled corticosteroids (ICS), leukotriene receptor antagonists (LTRA), and mast cell stabilizing agents (MCSA) are effective and without significant side effects.

Exercise-induced bronchoconstriction (EIB) describes a transient airway narrowing occurring during physical exertion. The name EIB is favored over exercise-induced asthma (EIA) as recommended by the American Thoracic Society (ATS), and American Academy/College of Allergy, Asthma, and Immunology. EIB can also be denoted as EIB with asthma (EIBa), and EIB without asthma, (EIBwa). [1] [2]  It is caused by an acute large increase in the amount of air entering the airways that require heating and humidifying. In susceptible individuals, this results in inflammatory, neuronal, and vascular changes ultimately resulting in contraction of the bronchial smooth muscle and symptoms of dyspnea, cough, chest tightness, mucus production, and wheezing. [6]

• Epidemiology

Exercise-induced bronchoconstriction occurs in 40% to 90% of people with asthma and up to 20% of the general population without asthma. [1] [3] [2]  Elite athletes have an increased prevalence of 30% to 70%, especially in winter sports athletes and women. [1] [3]  Athletes frequently seek medical attention for respiratory symptoms. [7]  Asthma is a significant health concern, and EIB can indicate poor asthma control. [3]  Approximately 400 million people are projected to have asthma in 2024, with a large percentage expected to have EIB. [3] [8]  Annually, 250,000 people die from asthma complications. There is no cure for asthma, and quality of life is significantly impacted, including sleep, work, school, and exercise. Treatment for asthma is well established and similar to treatment for EIB. The treatment effectively decreases mortality in asthma patients. [8]  Therefore, EIB detection, appropriate diagnosis, and treatment can have a significant impact. [3]

EIB occurrence is dependent on what sport is played. High-risk sports include long episodes of exercise greater than 5 to 8 minutes in certain environments such as cold, dry air or chlorinated pools such as long-distance running, cycling, cross country or downhill skiing, ice hockey, ice skating, high altitude sports, swimming, water polo, and triathlons. Medium risk sports include soccer, rugby, football, basketball, volleyball, baseball, cricket, and field hockey, where athletes rarely perform more than 5 to 8 minutes of continuous exercise. Low-risk sports include non-long distance track events inducing sprints, tennis, fencing, gymnastics, boxing, golf, weightlifting, bodybuilding, and martial arts. [2]

Screening for EIB is not supported by quality evidence, and further research and development of a symptom measurement tool is needed. [1] [6]

• Pathophysiology

Exercise-induced bronchoconstriction results from the alteration of normal lung physiology occurring with evaporative water loss, thermal changes, and irritant exposure induced by a large increase in minute ventilation and demand on the respiratory system to heat and humidify air with exercise-related hyperpnea. [9] [10] [1]  Ventilation increases by 200 L/min, and airway cooling with mucosal dehydration occur. As cells are dehydrated, there is an increase in osmolality, and the cells shrink in size, leading to an increase in cough, mucus, and loss of the physical barrier function of the epithelium. [9]  Decreased osmolality and increased electrolyte concentrations are thought to cause a regulatory increase in cell volume pulling fluid from the submucosal layer resulting in edema and release of inflammatory mediators, including histamine, leukotrienes, cysteine, tryptase, prostaglandins and mast cell degranulation. Bronchial blood flow is increased. [1] [10] [9] [6]  Reactive oxygen species are generated with increased lipid peroxidation. [8]  Sensory and autonomic nerves are activated. [1]  The results are direct and neuronal activation of bronchoconstriction. [1] [10]

Also, nasal breathing becomes insufficient, leading to mouth breathing and increased exposure of lung surfaces to pollutants, irritants, and allergens, which result in the generation of reactive oxygen species and a neutrophilic inflammatory response. [3] [2] [11]  Some research shows people genetically unable to counteract oxidative stress with glutathione may have an increased risk of EIB. [11]

Changes in mucus composition and decrease function of mucociliary clearance can lead to mucus plugging and bacterial growth. [9]  Intense physical training can independently lead to transient immune suppression with a shift to T2 lymphocyte response and has been linked to increased atopy and viral upper respiratory infection (URI). [2]

Long term exposure can lead to epithelial damage and shedding, with remodeling and inflammation resembling asthma. [3]  The process is partially reversible as studies have shown the lung damage and hyperresponsiveness improves over weeks to years when exposure and exercise are stopped. [3] [2]

The osmotic theory is supported by evidence that EIB severity is directly related to the rate of water loss in the airways, EIB can be prevented by inhaling fully humidified air at body temperature, and bronchoconstriction can also be induced by inhalation of hyperosmolar saline. [9]  Studies have shown an increased number of epithelial cells in sputum samples and elevated exhaled nitric oxide indicative of increased airway inflammation, damage, and shedding in those with EIB. [1]  Exposure to foreign substances as a contributor to EIB is supported by evidence that pollutants such as fossil fuels and ozone contribute to EIB in environments such as ice rinks or practice fields close to major roadways. Competitive swimmers have increased EIB likely due to the inhalation of trichloramine. [1] [2]  Exercising in areas with high pollen counts can also increase EIB. [1]

Interestingly, EIB has not been proven to affect exercise or athletic performance negatively. [3] [12]

• History and Physical

Symptoms of exercise-induced bronchoconstriction can include mild to moderate symptoms of chest tightness, wheezing, coughing, and dyspnea that occurs within 15 minutes after 5 to 8 minutes of high-intensity aerobic training. [1] [3] [2]  Reports of severe symptoms with respiratory failure and death occur rarely. Symptoms may occur more often in specific environments with cold, dry air or high concentration of respiratory irritants. Symptoms usually resolve spontaneously within 30 to 90 minutes and induce a refractory period of 1 to 3 hours, where continued exercise does not produce bronchoconstriction. [1]  Patients may also be asymptomatic, and therefore EIB may be underdiagnosed.

Risk factors include a personal or family history of asthma, a personal history of atopy or allergic rhinitis, exposure to cigarette smoke, participating in high-risk sports (see epidemiology), living and practicing in areas with high levels of pollution, and female gender. Some small studies suggest sugar-sweetened beverages may increase risk by increasing inflammation and adiposity. [13] [11]

Clinical diagnosis by symptoms has low sensitivity and specificity, and some patients are asymptomatic. Standardized testing for diagnosis includes direct and indirect methods and usually involves spirometry measurement of FEV1 changes from baseline expressed as a percent decrease. [14] [1] [3]

Direct stimulation of smooth muscle receptors by methacholine to induce bronchoconstriction is well established. Sensitivity at predicting EIB has been reported to be 58.6% to 91.1%. [14]

Indirect testing, which is more specific for EIB, can involve aerobic exercise in a controlled environment with cold, dry air as these conditions are known to precipitate EIB in susceptible individuals. Alternatives to exercise testing include eucapnic voluntary hyperpnea or hyperventilation of dry air, and airway provocation testing, including hyperosmolar 4.5% saline or dry powder mannitol, which act to dehydrate the respiratory epithelium to induce EIB. The sensitivity and specificity of the alternatives are not well established and may vary by the lab. [14] [1] [6]

Exercise Challenge Testing

The ATS recommends exercise challenge testing in a controlled dry environment. Exercise testing parameters outlined by the ATS include recommendations on ventilation level, heart rate, time at maximal capacity, and medications to hold before testing, including caffeine. The patient must avoid entering the refractory period before exercise testing. Serial measurements of spirometry, specifically FEV1, are recorded during exercise at 5,10,15, and 30 minutes. FEV1 has good repeatability and is recommended by ATS to diagnose EIB. [1]  A fall in FEV1 of greater than or equal to 10% is diagnostic for EIB, with mild at 10% to less than 25%, moderate at 25% to less than 50%, and severe at 50% or greater. [1] [3]  Some labs use 15% as the minimum reduction for diagnosis as it is more specific. Some patients may require multiple exercise sessions to confirm the diagnosis as the reproducibility is 76%. [1]

Pulmonary Function Testing

CHEST guidelines provide 2B recommendation for pulmonary function tests (PFT), exercise or bronchoprovocation studies as described above, and allergy testing for common airborne allergens to distinguish between the most common causes of exercise-induced cough. [4]

Fractional Excretion of Nitric Oxide (FENO) Testing

A few smaller studies suggest fractional excretion of nitric oxide (FENO) may replace FEV1 to diagnose and measure the severity of EIB instead of spirometry with FEV1 percent change. The FENO can be used with direct or indirect testing and can be easily performed by younger children. FENO measures the T helper cell type 2 (Th2) inflammatory response, versus airway hyperresponsiveness, and may be better suited to distinguish EIB from another etiology of symptoms. Cut off values of 27 to 46 ppb FENO have been suggested as diagnostic, with greater than 46 ppb being 100% specific. [15] [16] [17]

• Treatment / Management

Short-Acting Beta Agonists (SABA)

American Thoracic Society (ATS) guidelines from 2013 provide a strong recommendation with high-quality evidence for short-acting beta 2 agonists (SABA) use 5 to 20 minutes (optimally 15) minutes before exercise. [1]  The bronchodilation is of rapid onset and can last 2 to 4 hours. Tolerance can develop with frequent SABA use and is likely due to the downregulation of the beta 2 receptors. SABA's are the preferred first-line treatment and have limited side effects. [1] [18]  Mechanism of action is through relaxation of the airway smooth muscles and inhibition of mast cell degranulation. [19]

Inhaled Corticosteroids (ICS)

If symptoms are not well controlled with the SABA or patient is using SABA daily, additional medications can be added after medication adherence, and proper use has been confirmed. It is estimated that 15% to 20% of the patients will not respond to SABA treatment. ATS provides a strong recommendation with moderate-quality evidence for daily inhaled corticosteroids (ICS). [1] [18]  ICS may take 2 to 4 weeks for the maximal benefit. ICS appears to be more effective in patients with underlying asthma and are dose-dependent. ICS is not effective when used intermittently before exercise. [1]  ICS has multiple well-studied benefits in patients with asthma, including a reduction in mortality. [18]

Leukotriene Receptor Antagonists (LTRA)

ATS provides a strong recommendation with moderate-quality evidence for daily leukotriene receptor antagonist (LTRA) to address the inflammatory mediator release involved in EIB. [1] [18]  LTRAs may take 2-4 weeks for the maximal benefit. [1]  LTRAs, including montelukast, zafirlukast, and zileuton, provide longer-lasting bronchodilation and are not associated with tolerance. The effect on FEV1 reduction is less than with ICS or SABA. The choice between adding ICS of LTRA is patient-specific. [1]

Mast Cell Stabilizing Agents (MCSA)

ATS also makes strong recommendations with high-quality evidence for adding mast cell stabilizer (MCSA) before exercise. Mast cell degranulation plays a key role in EIB pathology. There is no additional benefit when MCSA is combined with SABA, and MCSAs are less effective than SABA. MCSA is not widely available in the U.S. [1]

Short-acting Muscarinic Antagonists (SAMA)

Inhaled anticholinergic agents are weakly recommended with low-quality evidence. Short-acting muscarinic antagonists (SAMA) are less effective than SABA; however, they can be used in combination when SABA tolerance develops. [1] [18]

Antihistamine

An antihistamine may be beneficial in patients with underlying allergies. [1]

Long-acting Beta Agonists (LABA)

ATS strongly recommends against, with high-quality evidence, the daily use of long-acting beta 2 agonists (LABA) because the potential side effects do not outweigh the benefits. [1]

Non-pharmacologic Interventions

Nonpharmacologic treatment approaches are strongly recommended with moderate-quality evidence. [1]  The first is to induce a refractory period by performing 10 to 15 minutes of vigorous activity, decreasing EIB for the next 2 hours. However, high or low-intensity exercise does not induce the refractory period. [1] [20]  The refractory period is theorized to occur due to an increase in bronchodilating PGE2 and/or desensitization to bronchoconstriction mediators. [9] [20]

Secondly, masks to promote warming and humidification of the air with exercise are weakly recommended with low-quality evidence and may be as effective as using a SABA. [1] [20]  The severity of bronchoconstriction is related to the humidity of the air inhaled, and new heat and moisture exchanger masks may reduce the severity and SABA use. [20]

Thirdly, wearing a mechanical barrier mask and/or avoiding exercise in environments high in pollen, allergens, ozone, exhaust, and high levels of chlorine can reduce EIB. Alternatives for pool disinfection are available. [3] [20]  The patient can also choose a sport with a lower risk of EIB, where 5 to 8 minutes of sustained intense activity is less likely to occur. [2]

Increasing general exercise tolerance and endurance and decreasing bodyweight if the patient is obese are helpful, and a Cochrane review found exercise to improve EIB severity, pulmonary function, and reduce airway inflammation in people with asthma and EIB. [3] [2] [1] [21]  Exercise has been shown to independently reduce markers of airway inflammation and reduce the severity of EIB in some studies. [3]

Caffeine may offer protection against bronchoconstriction and decreased ventilatory dead space and decreases exercise-induced hypoxemia and respiratory muscle fatigue when used before exercise. [20]

Low salt diet and supplementation with fish oil and vitamin C may be beneficial in some patients. [1]  A Cochrane review of vitamins C and E to protect from oxidative damage found insufficient evidence to make a recommendation. [8]  ATS recommends against lycopene supplementation. [1]

Non-invasive positive pressure ventilation (NIPPV) 

Treatment with non-invasive positive pressure ventilation (NIPPV) support has been shown to decrease airway reactivity in children with asthma and was evaluated in combination with respiratory physical therapy in one study for EIB in asthmatics with positive results in a Brazilian study. The benefit of NIPPV was postulated to involve the stretch mechanism in airways and with the resulting induction of an inhibitory pathway that stopped the cycle of inflammation and promoted bronchodilation. Participants completed 10 1-hr sessions twice a week. The first 20 minutes were spent completing respiratory exercises while sitting and supine, followed by either continuous positive airway pressure (CPAP) at 8 cmH2O, inspiratory muscle training, or bilevel positive airway pressure (BiPAP) at 8/12 cm H2O. Results included exercise FEV1 measurements as outlined by ATS, FENO to measure airway inflammation, and a questionnaire for symptom measurement. PPV both bilevel and CPAP reduced EIB. Respiratory muscle training (RMT) was shown in the same study to reduce medication use and increase respiratory muscle strength. [10]  This recent study offers additional nonpharmacologic options for the treatment of EIB.

Treatment to reduce the perception of symptoms

Another treatment approach involves reducing the perception of symptoms. Breathing control, including yoga, or supervised breathing training, has been shown in some small studies to decrease symptoms, reduce medication use, decrease anxiety and depression associated with EIB, and increase the quality of life. Further research and adaptation for use during EIB events are needed. [20]  Respiratory muscle training involves first ensuring proper breathing technique and then using a device to increase inspiratory and expiratory muscle strength. A Cochrane review of a small number of studies reported no evidence for or against respiratory muscle training. It has shown promise with COPD, exercise-induced laryngeal obstruction (EILO), and stridor and offers an additional inexpensive treatment for EIB. [20] [21]

• Differential Diagnosis

Symptoms of chest tightness, wheezing, coughing, and dyspnea occurring with exercise can indicate pathology along the entire airway. [7]  Exercise-induced bronchoconstriction is not easily diagnosed by clinical symptoms, and objective data of a decrease in lung function with exercise is required. [1]

Nasal Airway

The differential includes diseases of the nasal airway, including exercise-induced rhinosinusitis, allergic rhinitis, upper airway cough syndrome, upper respiratory infection (URI), and anatomic abnormalities. The nasal airway participates in filtering, humidifying, and regulating airway resistance and, therefore, nasal airway conditions can be comorbid with EIB. [7] [22]  Treatment for upper airway diseases includes avoidance of triggers and irritants, MCSA, and LTRA’s, used for EIB in addition to intranasal corticosteroids, decongestants, and immunotherapy. [22] [1] [4] [2] [7]

Pharynx and Larynx

The differential also includes diseases of the pharynx and larynx, including EILO, previously called exercise-induced vocal cord dysfunction. Athletes with EILO present similarly to EIB; however, treatment is not, and differentiation is required with appropriate testing, including visualization of the larynx with exercise. [1] [4] [2] [7]

Lower Airways

Lastly, the differential included diseases of the airways, including asthma, respiratory tract infection (RTI), and gastroesophageal reflux disease (GERD). [1] [4] [2] [7]

Cardiac causes of exertional dyspnea should be investigated, especially in children. [6]

Gastrointestinal

CHEST guidelines recommend the evaluation of cough in adolescent athletes include asthma, EIB, respiratory tract infection, upper airway cough syndrome, and environmental exposures. [4]

Less common causes include exercise-induced pulmonary edema, mainly seen in water immersion sports or high-altitude winter sports, PE, saltwater aspiration syndrome, and smoking. No studies were identified by the authors of CHEST guidelines for exercise-induced cough caused by cardiac abnormalities. [4]

With appropriate treatment, athletes can perform at the same level as peers and compete and win a medal in the Olympics and other international competitions. [2]

• Complications

Complications involve sequela of poorly managed asthma, reduction in physical activity, and a sedentary lifestyle.

• Pearls and Other Issues

It is important to consider the anti-doping regulations present in many athletic programs. Some medications utilized for Exercise-induced bronchoconstriction may require a therapeutic use exemption (TUE). ICS, LTRA's, MCSA's, inhaled anticholinergics, SABA (including albuterol and formoterol), antibiotics, 1st generation antihistamines with or without oral decongestant, nasal ipratropium, dextromethorphan, nasal corticosteroids, topical decongestants, and proton pump inhibitors (PPIs) in appropriate doses do not enhance performance and therefore do not require a TUE. [1]  Oral steroids and terbutaline are banned and require TUE. [1] [4]

• Enhancing Healthcare Team Outcomes

Care coordination between primary care providers, pulmonologists, ENT, sports medicine practitioners, and coaches is required to ensure proper diagnosis and treatment of Exercise-induced bronchoconstriction. Sports coaches play an important role in identifying athletes who are experiencing symptoms during the practice or who express a desire to quit the sport due to poor fitness, as it can be a sign of EIB. The education of coaches is important to ensure adherence to face protection from cold, dry air, exposure to pollutants, particulate matter, and allergens during practice. Coaches can also work with school administration to ensure practice locations and pool chemicals are safe for practice. Primary care sports medicine practitioners may be the first contact for athletes with symptoms. Proper testing for diagnosis is required as clinical symptoms are not sensitive or specific, and some patients are asymptomatic. Differential diagnosis includes the entire airway, and each part may contribute to symptoms requiring referral to an otolaryngologist. Coordination with pulmonology for testing may be required. Pulmonology may already be involved in asthma management in hard to control patients. Communication and coordination will lead to an optimal diagnosis, treatment, treatment adherence, and control of bronchoconstriction, allowing patients to participate in an activity as they desire.

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Pathophysiology of Asthma. Figure A displays the location of the lungs and airways in the body. Figure B shows a cross section of a normal airway. Figure C illustrates a cross section of an airway during asthma symptoms National Institutes of Health

Disclosure: Marie Gerow declares no relevant financial relationships with ineligible companies.

Disclosure: Paul Bruner declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Gerow M, Bruner PJ. Exercise-Induced Asthma. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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EXERCISE-INDUCED ASTHMA OVERVIEW

Exercise-induced asthma occurs when the airways narrow as a result of exercise. The preferred term for this condition is exercise-induced bronchoconstriction (EIB); exercise does not cause asthma, but is frequently an asthma trigger.

A person may have asthma symptoms that become worse with exercise (more common) or may have only exercise-induced bronchoconstriction, without symptoms at other times. If a person's asthma is triggered only during vigorous exercise (exercise-induced bronchoconstriction), they are considered to have mild intermittent asthma. Separate topic reviews discuss asthma in children and adults. (See "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" .)

EXERCISE-INDUCED ASTHMA SYMPTOMS

Typical symptoms are shortness of breath, chest tightness, and cough. Exercise-triggered symptoms typically develop 10 to 15 minutes after a brief episode of exercise or about 15 minutes into prolonged exercise. Symptoms typically resolve with rest over 30 to 60 minutes. Exercise-induced symptoms occur more commonly and are more intense when the inhaled air is cold, probably due to changes in the airways that are triggered by the large amounts of relatively cool, dry air inhaled during vigorous activity. (See "Patient education: Trigger avoidance in asthma (Beyond the Basics)" .)

EIB is different than simple shortness of breath related to exercise, which generally resolves within five minutes of stopping exercise.

EXERCISE-INDUCED ASTHMA PREVENTION

Exercise is important for your health, even if you have asthma, so it is important to develop a routine that allows exercise. Some patients can often prevent or reduce exercise-induced asthma symptoms by improving their day-to-day asthma control and improving their fitness level with regular exercise.

Nonmedical preventive methods  —  Breathing cold, dry air during exercise can provoke asthma symptoms. Wearing a loosely fitting scarf or mask when exercising in cold, dry air or exercising where the air is warmer and more humid can help prevent exercise-induced asthma symptoms. Some patients find that warm-up routines before intense exertion can help reduce asthma symptoms.

For people who exercise once a day or less  —  Preventing exercise-induced bronchoconstriction usually includes use of an inhaled medication prior to exercise.

Rapid-acting bronchodilators  —  Inhalation of a rapid-acting bronchodilator (eg, two puffs of albuterol) may be taken 5 to 20 minutes before exercise. This inhaler can also be used to relieve symptoms caused by exercise. (See "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" .)

An alternative is to use a combination inhaler that includes formoterol and an inhaled corticosteroid. Formoterol works as quickly as albuterol and lasts for 12 hours, so it is both a rapid-acting and a long-acting bronchodilator. For prevention of exercise-induced asthma one of the combination inhalers, such as budesonide-formoterol (brand names: Breyna, Symbicort) or mometasone-formoterol (brand name: Dulera), can be used one inhalation, at least five minutes prior to exertion. Like albuterol, these medications can also be used to relieve asthma symptoms.

For exertion throughout the day  —  Some adults and most children exercise intermittently throughout the day, making it hard to use a preventive treatment before each episode of activity. In this case, a long-acting inhaled bronchodilator (eg, salmeterol or formoterol) or a leukotriene modifier (eg, montelukast or zafirlukast) may be recommended to provide day-long protection (see 'Leukotriene modifiers' below).

Long-acting bronchodilators  —  Long-acting bronchodilators (LABAs), such as salmeterol and formoterol, work for a longer period than rapid-acting bronchodilators. LABAs should always be used in combination with an inhaled glucocorticoid. While formoterol is a LABA, it works as quickly as albuterol. Combination inhalers containing formoterol can be used shortly before exercise (at least five minutes) and can also be used to relieve asthma symptoms that occur despite pretreatment.

Some patients prefer to take their inhaler on a once or twice a day schedule. In this case, inhalers that contain the LABA, salmeterol, and an inhaled corticosteroid (eg, Advair or Seretide in Europe) can be used. These medications are usually taken twice daily and 30 minutes after the morning dose help prevent exercise-induced asthma symptoms for the next 12 hours.

Leukotriene modifiers  —  Leukotriene modifiers work by decreasing airway narrowing, inflammation, and mucus production. Examples of leukotriene modifiers include montelukast (brand name: Singulair) and zafirlukast (brand name: Accolate). These are taken in pill form by mouth once daily (montelukast) or twice daily (zafirlukast) and have few side effects. Taken regularly, either of these medications is useful in preventing exercise-induced bronchospasm.

Leukotriene modifiers may be used as an alternative to rapid-acting bronchodilators to prevent exercise-induced bronchoconstriction for patients who prefer or need all-day protection or have difficulty using inhalers.

Montelukast is approved for use as needed before exercise for patients who do not require daily medication. If not taken on a daily basis, montelukast should be taken at least two hours before the start of exercise. If the medication is taken daily, there is no need to take an additional dose prior to exercise.

Leukotriene modifiers are used for prevention of symptoms, NOT for relief of symptoms once they have developed. If asthma symptoms develop despite pretreatment with a leukotriene modifier, a rapid-acting bronchodilator (eg, albuterol, levalbuterol, or budesonide-formoterol) should be used.

ASTHMA ATTACK TREATMENT

The term "asthma attack" is somewhat confusing because it does not distinguish between a mild increase in symptoms and a life-threatening episode. Asthma symptoms may develop during exercise despite pretreatment and may sometimes be more severe than expected. Exercise induced asthma symptoms may be aggravated by changes in air quality, common colds, exposure to allergens, or changes in the weather. These triggers can cause mild, moderate, or severe symptoms to develop. Any of these changes could be considered an asthma "attack."

Some people have periodic, mild attacks that never require emergency care, while others have severe and sudden attacks that require a call for emergency medical services.

Emergency care plan  —  A patient or parent/caregiver should work with a healthcare provider to formulate an emergency care plan (also called an asthma action plan) that explains specifically what to do if asthma symptoms worsen.

● Mild attacks – Take your rescue medication: most people take two puffs of albuterol or levalbuterol, or one puff of formoterol-budesonide. This may be repeated twenty minutes later, and then periodically (every two to four hours) until symptoms are improved. People who take controller medications, such as inhaled glucocorticoids, may need to increase the dose and should contact their provider for further instruction.

● Severe attack – Take two to six puffs of a rescue medication, depending upon how much the individual can tolerate at once without becoming too jittery. For patients with home nebulizer machines, two treatments can be given, 20 minutes apart.

For severe symptoms or symptoms that worsen or do not improve after initial use of a rescue medication, someone should immediately call for emergency medical assistance. Severe asthma attacks can be fatal if not treated promptly.

In most areas of the United States, emergency medical assistance is available by calling 911. Patients should not attempt to drive to the hospital and should not ask someone else to drive. Calling 911 is safer than driving for two reasons:

● From the moment EMS personnel arrive, they can begin evaluating and treating asthma. When driving in a car, treatment cannot begin until the person arrives in the emergency department.

● If a dangerous complication of asthma occurs on the way to the hospital, EMS personnel may be able to treat the problem immediately.

Following a severe asthma attack, the patient is usually given a three to ten day course of an oral glucocorticoid medication (eg, prednisone, prednisolone). This treatment helps to reduce the risk of a second asthma attack.

Wear medical identification  —  Many people with medical conditions wear a bracelet, necklace, or similar alert tag at all times. If an accident occurs and the person cannot explain their condition, this will help responders provide appropriate care.

The alert tag should include a list of major medical conditions and allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert ( www.medicalert.org ), provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site ( www.uptodate.com/patients ). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information  —  UpToDate offers two types of patient education materials.

The Basics  —  The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Exercise-induced asthma (The Basics) Patient education: Asthma in adults (The Basics) Patient education: Asthma in children (The Basics)

Beyond the Basics  —  Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Asthma treatment in adolescents and adults (Beyond the Basics) Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics) Patient education: Trigger avoidance in asthma (Beyond the Basics) Patient education: Asthma inhaler techniques in children (Beyond the Basics) Patient education: Inhaler techniques in adults (Beyond the Basics)

Professional level information  —  Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Antileukotriene agents in the management of asthma An overview of asthma management in children and adults Beta agonists in asthma: Acute administration and prophylactic use Exercise-induced bronchoconstriction Trigger control to enhance asthma management Asthma education and self-management

The following organizations also provide reliable health information.

● The National Library of Medicine

     ( www.nlm.nih.gov/medlineplus/healthtopics.html )

● National Heart, Lung, and Blood Institute

     ( www.nhlbi.nih.gov/ )

● American Lung Association

     ( https://www.lung.org/ )

● The Asthma and Allergy Foundation of America

     ( www.aafa.org )

● American Academy of Allergy, Asthma, and Immunology

     ( www.aaaai.org/patients.stm )

● American College of Allergy, Asthma, and Immunology

     ( https://acaai.org/asthma/types-of-asthma/exercise-induced-bronchoconstriction-eib/ )

• Global Initiative for Asthma. The Global Strategy for Asthma Management and Prevention. https://ginasthma.org/ (Accessed on June 29, 2021).
• Weiler JM, Brannan JD, Randolph CC, et al. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol 2016; 138:1292.
• Philip G, Villarán C, Pearlman DS, et al. Protection against exercise-induced bronchoconstriction two hours after a single oral dose of montelukast. J Asthma 2007; 44:213.
• 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.
• Boulet LP, O'Byrne PM. Asthma and exercise-induced bronchoconstriction in athletes. N Engl J Med 2015; 372:641.
• Lazarinis N, Jørgensen L, Ekström T, et al. Combination of budesonide/formoterol on demand improves asthma control by reducing exercise-induced bronchoconstriction. Thorax 2014; 69:130.

Exercise-induced asthma

On this page, alternative medicine, preparing for your appointment.

To diagnose exercise-induced bronchoconstriction, your health care provider first takes a medical history and does a physical exam. You may have tests to check your lung function and rule out other conditions.

Test of current lung function

Your provider will likely perform a spirometry (spy-ROM-uh-tree) test. This exam shows how well your lungs function when you aren't exercising. A spirometer measures how much air you inhale, how much you exhale and how quickly you exhale.

Your provider might have you repeat the test after you take an inhaled medicine to open your lungs. This medicine is known as a bronchodilator. Your provider compares the results of the two measurements to see whether the bronchodilator improved your airflow. This initial lung function test is important for ruling out chronic asthma as the cause of symptoms.

A spirometer is a diagnostic device that measures the amount of air you're able to breathe in and out. It also tracks the time it takes you to exhale completely after you take a deep breath.

Exercise challenge tests

During an exercise challenge test, you run on a treadmill or use other stationary exercise equipment to increase your breathing rate.

The exercise needs to be intense enough to trigger your symptoms. If needed, you might be asked to perform a real-life exercise challenge, such as climbing stairs. Spirometry tests before and after the challenge can provide evidence of exercise-induced bronchoconstriction.

Methacholine challenge breathing test

This test involves inhaling an agent, often methacholine, that narrows the airways in some people with exercise-induced bronchoconstriction. Afterward, a spirometry test checks lung function. This test mimics the conditions likely to trigger exercise-induced bronchoconstriction.

Your health care provider might prescribe medicines to take shortly before exercise or to take daily for long-term control.

Preexercise medicines

If your provider prescribes a medicine to take before exercising, ask how much time you need between taking the medicine and starting the activity.

• Short-acting beta agonists (SABAs) are the most commonly prescribed medicines to take before exercising. These medicines include albuterol (ProAir HFA, Proventil-HFA, Ventolin HFA) and levalbuterol (Xopenex HFA). short-acting beta2 agonists (SABAs) are inhaled medicines that help open airways. Do not use these medicines every day because it can make them less effective.
• Ipratropium (Atrovent HFA) is an inhaled medicine that relaxes the airways and may be effective for some people. A generic version of ipratropium also can be taken with a device called a nebulizer.

Long-term control medicines

Your provider may prescribe a long-term control medicine to manage underlying asthma or to control symptoms when preexercise treatment alone doesn't work. These medicines are usually taken daily. They include:

• Inhaled corticosteroids, which help calm inflammation in your airways. You take these medicines by breathing them in. You might need to use this treatment for up to four weeks before it will have maximum benefit.
• Combination inhalers, which contain a corticosteroid and a long-acting beta agonist (LABA), a medicine that relaxes airways. These inhalers are prescribed for long-term control, but your provider may recommend using it before you exercise.

Leukotriene modifiers, which are medicines that block inflammatory activity for some people. These medicines are taken by mouth. They can be used daily or before exercise if taken at least two hours in advance.

Possible side effects of leukotriene modifiers include behavior and mood changes and suicidal thoughts. Talk to your provider if you have these symptoms.

Don't rely only on quick-relief medicines

You also can use preexercise medicines as a quick-relief treatment for symptoms. However, you shouldn't need to use your preexercise inhaler more often than recommended.

Keep a record of:

• How many puffs you use each week.
• How often you use your preexercise inhaler for prevention.
• How often you use it to treat symptoms.

If you use your inhaler daily or you frequently use it for symptom relief, your provider might adjust your long-term control medication.

Exercise is an important part of a healthy lifestyle for everyone, including most people with exercise-induced bronchoconstriction. Besides taking your medicine, you can take these steps to prevent or reduce symptoms:

• Do about 15 minutes of warmup that varies in intensity before you begin regular exercise.
• Breathe through your nose to warm and humidify air before it enters your lungs.
• Wear a face mask or scarf when exercising, especially in cold, dry weather.
• If you have allergies, avoid triggers. For example, don't exercise outside when pollen counts are high.
• Try to avoid areas with high levels of air pollution, such as roads with heavy traffic.

If your child has exercise-induced bronchoconstriction, talk to your health care provider about providing an action plan. This document provides step-by-step instructions for teachers, nurses and coaches that explain:

• What treatments your child needs.
• When treatments should be given.
• What to do if your child has symptoms.

There is limited clinical evidence that any alternative treatments benefit people with exercise-induced bronchoconstriction. For example, it's been suggested that fish oil, vitamin C or vitamin C supplements can help prevent exercise-induced bronchoconstriction, but there isn't enough evidence to show if they're useful.

You're likely to start by seeing your primary health care provider. Your provider may refer you to someone who specializes in asthma, such as an allergist-immunologist or a pulmonologist.

Be prepared to answer the following questions:

• What symptoms have you had?
• Do they start immediately when you start exercising, sometime during a workout or after?
• How long do the symptoms last?
• Do you have breathing difficulties when you're not exercising?
• What are your typical workouts or recreational activities?
• Have you recently made changes to your exercise routine?
• Do the symptoms occur every time you exercise or only in certain environments?
• Have you been diagnosed with allergies or asthma?
• What other medical conditions do you have?
• What medications do you take? What is the dosage of each medication?
• What dietary supplements or herbal medications do you take?

Dec 07, 2022

• Exercise-induced bronchoconstriction (EIB). American College of Allergy, Asthma & Immunology. https://acaai.org/asthma/types-of-asthma/exercise-induced-bronchoconstriction-eib/. Accessed Oct. 21, 2022.
• Klain A, et al. Exercise-induced bronchoconstriction in children. Frontiers in Medicine. 2022; doi:10.3389/fmed..
• Malewska-Kaczmarek K, et al. Adolescent athletes at risk of exercise-induced bronchoconstriction: A result of training or pre-existing asthma? International Journal of Environmental Research and Public Health. 2022; doi:10.3390/ijerph19159119.
• Pigakis KM, et al. Exercise-induced bronchospasm in elite athletes. Cureus. 2022; doi:10.7759/cureus.20898.
• Asthma and physical activity in the school. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/resources/asthma-and-physical-activity-school. Accessed Oct. 27, 2022.
• Broaddus VC, et al., eds. Exercise testing. In: Murray and Nadel's Textbook of Respiratory Medicine. 7th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Oct. 27, 2022.
• Burks AW, et al. Asthma pathogenesis. In: Middleton's Allergy: Principles and Practice. 9th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Oct. 27, 2022.
• O'Byrne PM. Exercise induced bronchoconstriction. https://www.uptodate.com/contents/search. Accessed Oct. 27, 2022.
• FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. Food & Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-boxed-warning-about-serious-mental-health-side-effects-asthma-and-allergy-drug. Accessed Oct. 27, 2022.
• Li JT (expert opinion). Mayo Clinic. Oct. 31, 2022.
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• 20 Running Tips For Every Runner to Know
• Each of us is an expert in the self—1989
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Exercise-Induced Asthma

• Dial "C" for Comfortable — 1991
• A Letter from the Sheehan Family
• Sheehan Classic Race

​“You should not even have to settle for diminished performance. The asthmatics who won medals in the last Olympics are testimony to that.”

About two years ago, I was just past the mile mark in a 10k when I felt a tightness in my windpipe. I had some difficulty getting air in and out. I tried couching to get rid of the feeling, but it persisted. I continued running, coughing intermittently, and after a few minutes the tightness went away. I finished the race with no further difficulty.

From then on, this sensation of my throat closing down became a regular occurrence in my races. It always came on early and always cleared before the finish. Eventually, I realized that I had exercise-induced asthma, or EIA.

My experience in developing exercise-induced asthma is increasingly common. One of the surprises in sports medicine has been the prevalence of this condition in athletes. Surveys indicate that 10 percent of athletes have EIA. Given its atypical manifestations and the lack of suspicion on the part of physicians, this may represent a low estimate. It is likely, for instance, that the 20 percent of our population with hay fever contains prime candidates for exercised induced asthma.

Undoubtedly there are many runners and athletes who never suspect that their cough or “hyperventilation” or “stitch” is due to EIA. In some runners the only symptom may be "inability to improve." Even should they consider the possibility, by the time they are seen in the physician’s office, their physical findings and pulmonary function tests will be normal.

Asthma is due to a transient bronchoconstriction. Between attacks there will be no evidence of the condition. Therefore, establishing the diagnosis requires a procedure that will precipitate the bronchoconstriction. Six minutes at race pace should, and usually does, result in diagnostic changes in pulmonary tests. This six minutes can be done on a treadmill or by simple running outside the doctor’s office.

Progress in understanding EIA has been rapid. Cold, dry air is especially likely to cause attacks. Sufferers must take steps in cold weather to heat and, if possible, to moisten the air. A ski mask without a mouth opening will achieve this purpose. It is also necessary to keep the face warm. Cold air striking the face and not inhaled can also cause symptoms.

I wear the mask as soon as the weather turns cold. I look on cold as relative. It need not be freezing to cause bronchoconstriction. I also take a prolonged warm-up before my races with a few flat-out sprints. I hope thereby to desensitize myself to asthma. I have the idea that a brisk 440 would do the trick, but I hate to do that before a race.

But mainly I rely on my medication, a beta-agonist inhalant (please check with your doctor). I position the inhaler several inches from my open mouth, exhale normally, then use the inhalant with a deep inhalation I hold for 10 seconds. I wait a few minutes and take a second puff. I do this two hours prior to a race, repeat it one hour later and then a final time 15 minutes before I go to the line.

If I follow this routine, I have no asthma during the race. The times I've failed to adhere to this schedule, the difficulty in breathing has recurred. I know I am lucky to find my simple measures that effective. I have met other runners with asthma who have to do much more. At times a persistent sinusitis makes the asthma extremely difficult to treat. Food, air pollution and inhalant allergens can be important factors. The help of an allergist with considerable experience treating EIA in athletes is almost always necessary. This is especially true if cortisone is required to restore normal running.

Be assured that in almost 100 percent of cases, exercised-induced asthma can be controlled. There should be no need to stop your sport. You should not even have to settle for diminished performance. The asthmatics who won medals in the last Olympics are testimony to that.

The most difficult step in treating this condition is making the diagnosis. After that, the athlete should be home free. Effective therapy is available. All you need is a physician who knows how to use it. (1986)

The Asthma and Allergy Foundation of America (AAFA), a not-for-profit organization founded in 1953, is the leading patient organization for people with asthma and allergies, and the oldest asthma and allergy patient group in the world.

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AAFA offers a variety of educational programs, resources and tools for patients, caregivers, and health professionals. AAFA launches educational awareness campaigns throughout the year. We teach the general public about asthma and allergic diseases.

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Research is an important part of our pursuit of better health. Through research, we gain better understanding of illnesses and diseases, new medicines, ways to improve quality of life and cures. The Asthma and Allergy Foundation of America (AAFA) conducts and promotes research for asthma and allergic diseases.

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Exercise-Induced Bronchoconstriction (Asthma)

Everyone needs to exercise, even people with asthma ! A strong, healthy body is one of your best defenses against disease. But some people have asthma episodes during exercise. By taking steps to control your asthma, you should be able to exercise free of symptoms.

What Is Exercise-Induced Asthma?

If you have asthma symptoms during exercise or physical activity, you may have exercise-induced bronchoconstriction [BRAHN-koh-kahn-STRIK-shun]. In the past, it was called exercise-induced asthma. But that name wrongly suggests that exercise causes asthma.

Exercise can cause shortness of breath in anyone. If you have exercise-induced bronchoconstriction (EIB), your airways become tight and inflamed during physical activity. As many as 90% of all people who have asthma also have EIB. 1 You can also have EIB even if you do not have asthma.

What Are the Symptoms of Exercise-Induced Bronchoconstriction EIB (Exercise-Induced Asthma)?

Symptoms of EIB include:

• Shortness of breath
• Wheeze (a whistling sound when you breathe)
• Chest tightness or pain

Coughing is the most common symptom of EIB and may be the only symptom you have. Symptoms can range from mild to severe.

The typical timeline for EIB symptoms:

• Start within three minutes of starting exercise
• Peak within 10 to 15 minutes
• Resolve by one hour after stopping exercise

Some people will have a second wave (“late-phase”) of symptoms four to 12 hours after stopping exercise. Late-phase symptoms are often less severe and can take up to 24 hours to resolve.

What Causes EIB (Exercise-Induced Asthma)?

When you exercise, your body demands more oxygen so you breathe faster and deeper. You usually breathe in through your mouth during exercise. Air that you breathe in from your mouth is dryer and cooler than when you breathe through your nose.

The dry and/or cold air is the main asthma trigger for airway narrowing (bronchoconstriction) and inflammation seen in EIB. Exercise that exposes you to cold, dry air is more likely to cause asthma symptoms than exercise involving warm and humid air.

Other triggers that can make EIB symptoms worse include:

• Air pollution
• High pollen counts
• Exposure to other irritants, such as smoke and strong fumes
• A recent cold or asthma episode

How Do Doctors Diagnose EIB (Exercise-Induced Asthma)?

It is important to know the difference between being out of shape and having EIB. Your doctor will ask you about your medical history and may perform a series of tests to diagnose EIB. Your doctor may measure your breathing before, during, and after exercise to test your lung functions. If you have EIB, your doctor will help you create a plan so you can take steps to prevent asthma symptoms during exercise. Your doctor will also tell you what to do if you have an asthma flare-up or attack.

Other conditions your doctor will need to rule out:

• Vocal cord dysfunction
• Abnormal airways
• Exercise-induced anaphylaxis
• Poor cardiovascular conditioning
• Other underlying lung diseases

With a diagnosis and treatment plan, you can enjoy all types of physical activity.

What Types of Medicines Treat or Prevent EIB?

Good general health and medical treatment can prevent EIB in most people. If  you have EIB, your doctor will prescribe asthma medicine for you to take to help you manage your symptoms. Your doctor may prescribe a quick-relief medicine (usually in inhaler form). You would take it 15 to 20 minutes before activity including significant exercise.  An example of a quick-relief medicine is albuterol. It works by relaxing the small muscles that squeeze the airways. (These medicines “relieve the squeeze.”)

Your doctor may also prescribe a controller medicine, as well as other asthma medicines , which aim to control and prevent symptoms.

Together, you can find the best asthma treatment for you based on your medical history and the type of activity you do.

If you continue to have frequent symptoms with usual activity or exercise, talk with your doctor. Your doctor may adjust your asthma treatment plan to help your symptoms.  The major goal is to continue exercise and not avoid it.

Remember, you should be able to take part in activities, sports, and exercise without experiencing symptoms! Do not let EIB keep you from leading an active life or from achieving your athletic dreams.

What Types of Sports Are Best for People with EIB?

Activities most likely to trigger EIB:

• Sports or activities in cold/dry weather (ice hockey, skiing, ice skating, snowboarding)
• Sports or activities that need constant activity (long distance running, soccer)

Activities least likely to trigger EIB:

• Sports or activities that use short bursts of exercise (volleyball, baseball, gymnastics)
• Walking or leisure biking
• Swimming in a warm, humid environment

It is important to consult with your health care provider before beginning any exercise program. Pace yourself. With effective management, people with EIB can perform and excel in a variety of sports. Many Olympic athletes and professional athletes with EIB excel in their sports.

Can Exercise Help Asthma?

Exercise benefits your entire body. Exercise cannot cure asthma, but some of its health benefits can help you keep your asthma well-controlled.

Some health benefits of exercise that can help your asthma include:

• Improved lung function
• Weight loss/maintenance – Weight can affect lung volume, blood flow to the airways, and how you respond to medicine
• Stress reduction – Stress and emotions can trigger asthma symptoms

Medical Review : June 2022 by John James, MD

1. Exercise-Induced Bronchoconstriction (EIB) . (n.d.). American College of Allergy, Asthma & Immunology. Retrieved June 9, 2022, from https://acaai.org/asthma/types-of-asthma/exercise-induced-bronchoconstriction-eib/

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Exercise-Induced Asthma in Children Coursework

Introduction, pathogenesis of exercise-induced asthma, diagnosis of exercise-induced asthma, treatment and control of exercise-induced asthma.

Exercise-Induced Asthma (EIA), also known as Exercise-Induced bronchoconstriction (EIB) is a respiratory condition that causes patients to experience shortness of breath, coughing or wheezing immediately after physical exercise (Spooner, Spooner & Rowe, 2009). The condition is common among children, and is often associated with other forms of childhood asthma (Kersten et al, 2012). With such a profound impact, EIA has received a lot of attention from the medical fraternity, with numerous studies being done on it. This paper reviews these studies and other study reviews on EIA and outlines the pathogenesis of the condition, its diagnosis, treatment and management.

The onset of an EIA attack follows a constriction of the airways of the patient after physical exercise. The constriction is caused by loss of water vapor in the bronchi of a patient. This is followed by an increase in osmolarity of the liquid on the surface of the airway leading to an asthma attack. When water shifts from the cells of the epithelium to the airway surface, it causes a release of mediators from the inflammatory cells that cause constriction of the bronchi. Exercising in cold or dry air can lead to an increase in the severity of EIA (Kersten et al, 2012). The attack is also caused by inflammation of the bronchi and a dysfunction of the smooth muscles (Backer & Rasmussen, 2009).

The greatest constriction of the bronchi occurs between 3 and 15 minutes after the patient has rested from the exercise. This phase takes between 20 and 60 minutes to subside. Some patients may experience a refractory period extending to 3 hours, during which more exercise causes less constriction. Factors that influence the severity of the reaction include the severity of asthma, duration and intensity of the exercise or activity, environmental conditions, and the interval of time since the previous exercise (Spooner, Spooner, & Rowe, 2009).

EIA occurs when continuous exercise causes the narrowing of the airway resulting in symptoms such as coughing, wheezing, tightness of the chest, premature fatigue and reduced stamina (Spooner, Spooner, & Rowe, 2009). These symptoms are the first indicators of the presence of EIA (hull et al, 2009). The symptoms are also seen to vary from patient to patient (Backer & Rasmussen, 2009). However, for a proper treatment to be given, a proper diagnosis must be done since the symptoms are not conclusive evidence of the presence of EIA. Medical practitioners use bronchoprovocation testing as a method of diagnosing for EIA. The most commom method used is the use of laboratory-based exercise tests (Hull et al, 2009). Other methods used include the trial of an inhaled beta-agonist during exercise, monitoring of the serial peak flow, reversibility testing, electrocardiogram, chest radiograph and use of a full blood count (Hull et al, 2009).

Traditionally, EIA has been controlled using nebulized short-acting beta-agonists, an example being salbutamol, which serve the purpose of relieving acute asthma attacks. These medications have, however, been linked to the spread of air borne infections such as H1N1. An alternative to this medication was therefore developed, which is the use of budesonide (formoterol) under the brand name Symbicort, a long- acting beta-agonist. It is in form of an inhaler. A study conducted on its effectiveness showed no significant variation between its effectiveness and the effectiveness of salbutamol, which makes it a better alternative since it carries no risk of infection spread (Chew, Kamarudin, & Hashim, 2012). Spooner, Spooner & Rowe (2009) also propose the use of b-agonosts, stating that they are more effective than anticholigenic medication in inducing bronchial dilation which reverses the constriction effect.

Backer & Rasmussen (2009) propose different treatments and control of EIA, based on the cause of the constriction of the brinchi. For constriction caused by inflammation, he proposes the use of corticosteroids while constriction caused by a dysfunction of the smooth muscles should be treated using a beta-agonist inhaler.

Treatment of EIA is important for active people. It has been seen to enable athletes to participate in any physical activity, allowing them to perform at normal or even above normal levels without the symptoms of the condition hindering their activity. Treatment of the condition also improves the self esteem of the patient (Spooner, Spooner, & Rowe, 2009). This means that even children, who are continuously active, can engage in play and lead normal lives if the condition is controlled through use of the right medication.

Backer, V., & Rasmussen, L. (2009). Exercise-Induced Asthma Symptoms and Nighttime Asthma: Are They Similar to AHR? Journal of Allergy , Article ID 378245, Web.

Chew, K. S., Kamarudin, H., & Hashim, C. W. (2012). A randomized open-label trial on the use of budesonide/formoterol (Symbicort®) as an alternative reliever medication for mild to moderate asthmatic attacks. International Journal of Emergency Medicine , 5:16, Web.

Hull, J. H., Hull, P. J., Parsons, J. P., Dickinson, J. W., & Ansley, L. (2009). Approach to the diagnosis and management of suspected exercise-induced bronchoconstriction by primary care physicians. BMC Pulmonary Medicine , 9:29, Web.

Kersten, Elin T.G.; Leeuwen, Janneke C. van; Brand, Paul L.P.; Duiverman, Eric J.; Jongh, Frans H.C. de; Thio, Bernard J.; Driessen, Jean M.M. (2012). Effect of an Intranasal Corticosteroid on Exercise Induced Bronchoconstriction in Asthmatic Children. Pediatric Pulmonology , 47, 27–35, Web.

Spooner, C., Spooner, G., & Rowe, B. (2009). Mast-cell stabilising agents to prevent exercise-induced bronchoconstriction (Review). The Cochrane Library . Web.

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Up to 70 Percent of People With Asthma and C.O.P.D. Go Undiagnosed

Here’s how to tell if you’re one of them.

By Knvul Sheikh

In spring 2020, Jazzminn Hein received an automated phone call from The Ottawa Hospital in Canada, asking if she or anyone in her household had experienced wheezing, shortness of breath or other breathing problems in recent months. The question caught her attention: Just a week earlier, Ms. Hein, then 24, had gone on a stroll with her mother-in-law and newborn only to end up feeling like her chest was burning.

“I realized that I had had breathing issues from a very young age,” Ms. Hein said. As a child, she often had to catch her breath on the sidelines during gym class. As an adult, she frequently had to pause after carrying laundry up the stairs. So Ms. Hein pressed “1” to receive a follow-up call from a nurse.

A few months later, as part of a study conducted by researchers at the University of Ottawa, a doctor diagnosed Ms. Hein with asthma.

Estimates suggest that 20 to 70 percent of people with asthma or another group of conditions called chronic obstructive pulmonary disease that causes similar symptoms, go undiagnosed.

To look for patients with those diseases, researchers placed automated calls to more than a million households across Canada asking about breathing issues. Many people hung up. But the research team talked to more than 38,000 people experiencing such symptoms, and ultimately found more than 500 patients, including Ms. Hein, with either undiagnosed asthma or C.O.P.D. who could participate in their clinical trial.

Roughly half were told to follow up with their primary care provider and received standard care, such as a short-acting inhaler to be used as needed. The other half saw pulmonologists who frequently prescribed better, long-acting medication and worked with an educator who taught patients how to properly use an inhaler and avoid allergens, provided support to quit smoking, gave exercise and weight counseling, and more. These measures could help reduce symptoms, said Dr. Shawn Aaron, a lung specialist at The Ottawa Hospital and a professor at the University of Ottawa who led the research.

The results of the study, published this week in the New England Journal of Medicine , show that finding people with airway diseases and getting them care can pay off. People who “got the Cadillac treatment had much better outcomes than the group that just got usual care by the family doctor,” including fewer emergency visits for flare-ups in the year after diagnosis, Dr. Aaron said. But both groups saw improvement in breathing and quality of life — suggesting that diagnosis and even minimal treatment could make a difference.

How can you tell if you have asthma or C.O.P.D.?

The diseases can look different from one person to the next, said Dr. Sonali Bose, a pulmonologist at the Mount Sinai-National Jewish Health Respiratory Institute.

People with asthma can go without symptoms for months until they are in a “perfect storm situation,” Dr. Bose said, such as when allergens like tree pollen or airway inflammation after a common cold cause a flare-up. Others may feel chest tightness after exercise, or experience coughing or wheezing every evening.

C.O.P.D., on the other hand, emerges over time as lungs are progressively injured by exposure to irritants. Smoking and air pollution are the most common causes . The symptoms are similar to those caused by asthma, but can also vary over the course of a day, a week or by season.

This makes the diseases hard to recognize: Many patients may not focus on respiratory complaints that rise only occasionally, and doctors may misattribute symptoms to other causes, like allergies. It can take years to pinpoint what’s causing symptoms, said Dr. Robert Burkes, a pulmonologist at UC Health in Cincinnati .

If symptoms start interfering with your everyday life, it’s important to tell a doctor. Mention if you have a family history of asthma, allergies or eczema, or have allergies or eczema yourself; these factors are linked to a greater risk of airway disease.

How are these diseases diagnosed and treated?

A provider will listen for abnormal sounds in your lungs, and may order a spirometry test to measure the amount of air you breathe in and out, and how quickly you can do it. Primary care offices often can’t do this testing. The need to go to a special testing lab may be one reason patients go undiagnosed, Dr. Aaron said.

But people who remain undiagnosed risk progressive damage to their lungs, which can make exercise or everyday activities even harder, Dr. Burkes said. Chronic respiratory conditions like C.O.P.D. are the sixth leading cause of death in the United States and the third leading cause of death worldwide.

Doctors now have more tools than ever to help people manage asthma and C.O.P.D., Dr. Aaron said. There are long-acting inhalers, as well as injectable drugs for specific types of asthma. And more options for the two diseases may be on the way.

But, as the study found, patients can’t get those treatments if they don’t have a diagnosis.

“The important thing is finding the undiagnosed disease, making the diagnosis and then getting treatment,” he said. “If you do that, you will benefit.”

Knvul Sheikh is a Times reporter covering chronic and infectious diseases and other aspects of personal health. More about Knvul Sheikh

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Eosinophilic Asthma

Lindsay Curtis is a freelance health & medical writer in South Florida. Prior to becoming a freelancer, she worked as a communications professional for health nonprofits and the University of Toronto’s Faculty of Medicine and Faculty of Nursing.

Daniel More, MD, FAAAAI, FACAAI, FACP, is a board-certified allergist and former clinical immunologist at Allergy Partners of the Central California Coast.

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Eosinophilic asthma (also known as e-asthma or eos asthma) is a severe form of asthma that causes high levels of eosinophils in the lung tissue, blood, and mucus. Eosinophils are a type of immune system cell that typically help your body fight infections. Too many of these cells can cause inflammation in your airways and worsen asthma symptoms.

Eos asthma typically develops in adulthood, though it can also affect children. While the exact cause of eos asthma remains under investigation, genetic and environmental factors likely play a role in its development.

This type of asthma doesn't respond to traditional treatments, so other management techniques are necessary. Targeted therapies, such as biologics, are essential for managing symptoms and preventing asthma attacks and other complications of eos asthma.

Eosinophilic Asthma Symptoms 

People with eosinophilic asthma experience classic asthma symptoms , though they tend to be more persistent and severe than other asthma types. However, this type of asthma also causes inflammation that can narrow the airways and decrease your lung function—meaning, your lungs can't hold as much oxygen as they normally would. That said, common symptoms associated with this type of asthma include:

• Wheezing :  A high-pitched whistling sound when breathing
• Coughing :  A persistent, dry cough that may worsen at night or with exercise
• Shortness of breath :  Difficulty catching your breath
• Chest pain :  A feeling of tightness or pressure in the chest, making breathing uncomfortable
• Chronic rhinosinusitis :  Chronic inflammation and swelling of the sinuses, which can cause nasal drainage, nasal blockage, facial pressure or pain, and a decreased sense of smell
• Nasal polyps:  Soft growths that develop on the lining of the sinuses or nose, causing stuffiness, runny nose, loss of smell or taste, sneezing, and snoring
• Difficulty sleeping:  Worsening symptoms at night, leading to difficulty falling or staying asleep
• Fatigue :  Feeling tired or lethargic in the daytime due to disrupted sleep or difficulty breathing
• Exercise intolerance:  Difficulty engaging in physical activity due to experiencing asthma symptoms during exercise
• Frequent respiratory infections:  Impaired lung function can increase the risk of developing respiratory infections (like the common cold )

Because high levels of eosinophils cause chronic airway inflammation , people with eos asthma are at a higher risk of experiencing asthma attacks—which are periods when asthma symptoms worsen. If you develop an asthma attack, common symptoms include:

• Increased wheezing
• Chest pain or feeling as though a heavy weight is sitting on your chest 
• Difficulty catching your breath, as if you are sucking air through a straw 
• Gasping for air 
• Retractions, which occur when your ribs pull in with each breath
• Neck pain as a result of your muscles tightening if you're having trouble breathing strain to breathe

Eosinophilic asthma develops when abnormally high levels of eosinophils cause inflammation in the entire respiratory tract, from the sinuses to the small airways in the lungs.  Eosinophils are white blood cells that play an important role in the immune system, helping your body release inflammatory chemicals that fight infections.

An overactive immune response can increase eosinophil production, causing inflammation that narrows the airways, increases mucus production, and leads to hallmark asthma symptoms. Over time, inflammation can damage the airways and lung tissue, worsening asthma symptoms.

Researchers don’t know exactly what causes high levels of eosinophils and eosinophilic asthma, but genetic and environmental factors likely play a role. 

Studies about how genetics may be associated with eosinophilic asthma are ongoing. However, researchers have discovered some inherited gene mutations (changes) that may increase your risk of developing this condition.

Changes in genes that regulate the production and function of eosinophils may increase eosinophil counts in the blood and promote the buildup and activation of eosinophils in the airways. This can lead to inflammation and an increased risk of eosinophilic asthma.

Environmental Triggers 

Some people with eosinophilic asthma also have allergic conditions, such as hay fever, eczema , or food allergies. This doesn't apply to everyone who has asthma. However, if you do experience allergies, the following environmental factors can trigger or worsen eos asthma symptoms:

• Mold spores
• Lung irritants, like smoke or cleaning chemicals
• Strenuous exercise 
• Respiratory illnesses (e.g., the common cold, influenza )
• Extreme weather 

Risk Factors 

While genetics and environmental factors can play a role in the development of eos asthma, other factors can also increase your risk of this condition. Consider the following:

• Being 35-50 years old
• Having a personal or family history of asthma or other allergic conditions
• Smoking tobacco

If you have severe asthma or your asthma symptoms do not improve with standard treatments, your healthcare provider may order tests to determine whether you have eosinophilic asthma. During your appointment, your provider will consider your symptoms, medical history, and test results to provide an accurate diagnosis. They can also order additional tests to confirm a diagnosis, including:

• Blood test:  Blood tests measure your eosinophil count—the amount of eosinophils circulating in your blood. People with eosinophilic asthma have an eosinophil count of 150 cells or more per microliter of blood (cells/μl). Other types of asthma can also cause elevated eosinophil counts, so your healthcare provider will consider your symptoms and other test results.
• Sputum test: The provider collects a sample of coughed-up mucus (sputum) and examines it under a microscope to measure eosinophil cells in the sample. If you cannot bring up mucus when coughing, your provider may ask you to breathe in a saline solution through a nebulizer. In people with eosinophilic asthma, more than 2% of the cells within sputum will be eosinophils. 
• Bronchial biopsy:  A pulmonologist (a doctor specializing in lung diseases) will insert a thin tube called a bronchoscope into your nose or mouth to access your lungs. They will collect a sample of tissue or fluid and view it under the microscope to look for eosinophils and signs of inflammation. 

Eosinophilic Asthma Treatment 

If you receive a diagnosis for eos asthma, your healthcare provider will help you develop a treatment plan that meets your needs. The goal of treatment is to reduce eosinophils in the airways, control inflammation, improve asthma symptoms, and reduce the frequency and severity of asthma attacks.

Most people with eosinophilic asthma respond well to traditional asthma treatments but require some biologic medications directed against eosinophils or cytokines that regulate eosinophil growth and development.

Standard Asthma Treatments

First-line treatments for eos asthma are the same medications healthcare providers use to treat other types of asthma. These include:

• Bronchodilators:  Inhaled medicines that relax the muscles around the airways to open them and relieve symptoms like coughing, chest tightness , and wheezing. For example, short-acting beta-2 agonists (SABAs) provide quick relief when symptoms worsen, while long-acting beta-2 agonists (LABAs) help keep airways open for longer periods.  Muscarinic antagonists are other bronchodilators that can be short-acting (SAMAs) or long-acting (LAMAs).
• Corticosteroids:  Powerful anti-inflammatory drugs that help reduce airway inflammation. 
• Leukotriene modifiers: Oral medications that block the action of leukotrienes—inflammatory immune chemicals that are involved in your body’s immune response to allergens. These medicines help reduce airway swelling in people with eos asthma and allergies . 

Healthcare providers prescribe biologic medications for people with eos asthma when traditional asthma treatments are ineffective. Your healthcare provider may prescribe biologic drugs via subcutaneous injections (under the skin) or intravenous administration (through a vein in your arm).  

In most cases, your healthcare provider will likely recommend that you continue taking traditional asthma medications alongside biologics . There are four FDA-approved biologic therapies for treating eos asthma, including:

• Fasenra (benralizumab):  Prevents inflammatory cytokine interleukin -5 from activating eosinophils to reduce eosinophil counts and airway inflammation
• Nucala (mepolizumab):  Binds to interleukin-5 to decrease eosinophil counts in your blood and reduce airway inflammation
• Cinqair (reslizumab):  Lowers eosinophil counts in the blood and reduces airway inflammation by binding to interleukin-5 to control eosinophil production
• Dupixent (dupilumab):  Binds to inflammatory cytokine interleukin-4 receptors to reduce airway inflammation

How To Prevent Eosinophilic Asthma

While there is no known way to prevent eosinophilic asthma from developing, several strategies can help reduce the frequency and severity of symptoms and asthma attacks. These include the following:

• Avoid triggers:  Identify and avoid triggers that worsen your asthma symptoms. It may help to keep a symptom journal and write down your activities, foods you eat, and other potential environmental triggers. Common triggers include dust mites, pollen, cigarette smoke, strenuous exercise , and emotional stress. 
• Follow your treatment plan:  Take your asthma medications as prescribed and maintain regular follow-up appointments with your healthcare provider to ensure your medications are working and your eos asthma is well-controlled. 
• Track your asthma:  Use a peak flow monitor (a tool that measures how well air moves in and out of your lungs) to identify changes in your breathing before asthma symptoms appear. Using a peak flow monitor daily can help monitor treatment effectiveness, track changes in your breathing over time, and prevent asthma attacks.

People with eosinophilic asthma often have other conditions that develop in response to overactive immune responses or high eosinophil counts. These include:

• Chronic rhinosinusitis with nasal polyps:  Up to 60% of people with eos asthma have chronic rhinosinusitis with nasal polyps . Chronic sinus inflammation and polyps (soft growths) in the nasal passages cause a stuffy or runny nose, decreased sense of smell, facial pressure or pain, headaches , pain in the upper teeth, and snoring.  
• Allergic rhinitis:  Also known as hay fever, allergic rhinitis is inflammation of the nasal passages in response to allergen exposure. Many people with eos asthma also have allergic rhinitis, as both conditions involve an overactive immune response and airway inflammation.
• Eosinophilic esophagitis :  A chronic inflammatory condition that develops when eosinophils inflame and irritate the esophagus, leading to symptoms like difficulty swallowing, heartburn , acid reflux, and chest pain.

Living With Eosinophilic Asthma

It can be challenging to live with eosinophilic asthma. When your symptoms are poorly controlled, you may have trouble participating in your daily activities, including work, school, and hobbies. Fortunately, leading a fulfilling, active life with the right treatments and support is possible with eos asthma. 

Adhering to your treatment plan and close communication with your healthcare provider is the best way to keep your asthma well-controlled. Seeking support from healthcare providers, support groups, and loved ones can also provide valuable emotional and practical support.

Frequently Asked Questions

Research shows that a diet high in fruits, vegetables, whole grains, and healthy fats can reduce eosinophilic airway inflammation and help prevent worsening symptoms. A high-fat, low-fiber diet may increase eosinophilic inflammation in the airways.

Eosinophilic asthma is a subtype of asthma in which high amounts of eosinophils (inflammatory white blood cells) cause airway inflammation. In other types of asthma, different inflammatory cells trigger airway inflammation.

Eosinophilic asthma is a more severe subtype of asthma that does not always respond to traditional asthma medications and requires more targeted therapies to reduce eosinophil counts and airway inflammation.

Approximately 25 million people in the United States live with asthma, and about 2.5 million live with severe asthma. According to the Global Initiative for Asthma (GINA), approximately 50% of people with severe asthma have eosinophilic asthma.

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