Challenges in the Management of Exercise-induced Asthma

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].

Data from [1-3].

Data from [1,3].

Authors and Disclosures

William Storms, MD

The William Storms Allergy Clinic, 1625 Medical Center Point, Suite 190, Colorado Springs, CO 80907, USA Tel.: +1 719 955 6006 Fax: 1 719 955 9595 sneezedoc@stormsallergy.com

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Key Issues

• Exercise-induced asthma (EIA) is a common problem affecting the general population of asthmatics, whereas the prevalence of exercise-induced bronchospasm (EIB) as a sole respiratory symptom in persons not otherwise diagnosed with asthma is reported to be high among some recreational and elite athletes.

• The diagnosis of EIA, and its differentiation from EIB, can be difficult due to reliance on symptoms for diagnosis. Confirmation of the diagnosis by an appropriate trial of medication and/or challenge test (the latter of which is preferred) is important.

• Respiratory symptoms indicative of EIB, such as breathlessness, cough, wheezing and chest tightness, which occur regularly upon exercising, are suggestive of asthma and should be regarded as a 'red flag.' Patients presenting with these symptoms should be carefully monitored for additional signs of underlying airway inflammation.

• Inhaled mannitol is a simple indirect challenge test that is under review by the US FDA. It does not require specialized equipment, can be performed quickly and safely and, when approved, should become a commonly used test to confirm the diagnosis of asthma and to screen athletes for EIA and EIB.

• Short-acting β₂-agonists are the most commonly used medications to treat EIA and EIB; however, a daily controller medication is recommended for all patients with persistent symptoms and to reduce the need for (and tolerance to) bronchodilators.

• The role of the small airways in EIA is a topic of current debate; however, medications that reach the peripheral airways may reduce damage associated with mechanical shear related to high minute ventilation.

• All patients with EIA and EIB should recognize and understand what causes their symptoms and what makes their symptoms worse. In addition to treating their condition with medications, patients should be informed about nonpharmacological methods to reduce their symptoms.