Challenges in the Management of Exercise-induced Asthma

William Storms, MD

Expert Rev Clin Immunol. 2009;5(3)

Abstract and Introduction

Abstract

Exercise and physical activity are common triggers of symptoms in patients with asthma, although some individuals – especially athletes – may have symptoms with exercise alone. Exercise-induced bronchospasm (EIB) describes airway hyper-reactivity that is observed following exercise in a patient who is not otherwise diagnosed with asthma; exercise-induced asthma (EIA) describes airway hyper-reactivity associated with exercise in a patient who has persistent asthma. Specific challenges affecting both the diagnosis and treatment of these conditions are discussed in this review. The past decade has seen substantial advances in our understanding of EIA and EIB, including new guidelines on their management. With appropriate therapy, all patients with exercise-related symptoms should be able to reach their desired level of performance.

Introduction

Exercise and physical activity are common triggers of symptoms in patients with asthma, and the term exercise-induced asthma (EIA) has been used for almost 50 years to describe the characteristic bronchial hyper-reactivity (BHR) observed in response to exercise or physical activity.^[1] EIA is not a unique form of asthma, nor is it a subtype or phenotype of the disease and, while more than 90% of asthma patients develop respiratory symptoms following an appropriate exercise challenge, others respond to normal activities of daily life with symptoms requiring treatment.^[1,2]

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Table 1. Challenge tests for exercise-induced asthma and exercise-induced bronchospasm.
Indirect	Direct
Adenosine monophosphate^*	Carbachol^*
Eucapnic voluntary hyperventilation	Histamine^*
Mannitol^‡	Methacholine
Hypertonic saline

^*Not accepted by the International Olympic Commitee Medical Commission.
^‡Currently in review by the US FDA, although not yet approved.
Data from [1,6,7,13].

Box 1. Exercise-induced asthma or exercise-induced bronchospasm?
Exercise-induced bronchospasm is bronchospasm that occurs with exercise in a patient who has no evidence of asthma, based on current asthma management guidelines: Normal pulmonary function tests at rest No symptoms with normal activities of daily living No need to use β₂-agonists (other than with exercise) Good Asthma Control Test score (or other questionnaire)
Exercise-induced asthma is bronchospasm that occurs in a patient who has documented persistent asthma, when they exercise

Data from [1-3].

Box 2. Some atypical symptoms of exercise-induced asthma (and exercise-induced bronchospasm).
Complaints of chest pain not associated with cardiac disease 'Locker room cough' or a dry cough lasting up to a day following exercise Difficulty sleeping related to nocturnal asthma symptoms that may be a manifestation of late-phase responses to exercise or physical activity Complaints of 'heavy legs' or 'feeling out of shape' Fatigue Abdominal pain Headaches or dizziness Muscle cramps Seasonal fluctuations of symptoms following exercise related to changes in humidity and levels of airborne allergens and pollutants Avoidance of activities, exercise and/or sports; children may not want to participate in 'sleepovers' or go to 'camp' Inability to keep up with peers Symptoms in children while playing (especially in relation to other triggers, such as animal dander, house dust mites, mold, tobacco and other smoke, and cold air)

Data from [1,3].

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