Challenges in the Management of Exercise-induced Asthma

William Storms, MD


Expert Rev Clin Immunol. 2009;5(3) 

In This Article

What about the Elite Athlete?

Exercise-induced asthma is not uncommon in elite athletes who do not otherwise have asthma symptoms, and presentation, pathology and evaluation of elite athletes may be different from asthma patients who have symptoms with normal exercise.[6,7]

Exercise-induced asthma in elite athletes may be associated with a mixed neutrophil–eosinophil-type airway inflammation versus the eosinophil-dominant inflammatory cascade reported with asthma and with EIA in recreational athletes. The underlying airway inflammation in elite athletes may be exacerbated by the high intensity of physical training and high minute ventilation, which can damage the bronchial epithelium.[7] The high minute ventilation may also aggravate the effects of environmental exposures during physical activity, permitting airborne allergens and irritants (e.g., chlorine derivatives in swimming pools, particulate matter from combustion as seen in the 2008 Summer Olympic Games and fumes related to machines used to groom ice rinks) to be drawn deeper into the lungs. Indeed, differences between the capacities of various sports to cause EIA may result in part from environmental irritants reaching the smaller airways, including exposure to seasonal and perennial allergens in sensitized individuals, as well as cold and dry air and pollutants.[6,7]

Diagnosing EIA in elite athletes may be complicated by their seemingly excellent physical condition. Many elite athletes do not present with daily asthma symptoms, and baseline pulmonary function tests may not indicate EIA in these individuals. In fact, many athletes have 'super-normal' pulmonary function tests, which may be misleading. Challenge testing by EVH is recommended by the IOC Medical Commission, and it is now accepted that mannitol testing has comparable sensitivity to EVH.[6,7,14]

The management of EIA in elite athletes is similar to that for recreational athletes, and should include reducing relevant environmental exposures as much as possible, treating associated comorbid conditions, appropriate pharmacotherapy for control, prophylaxis and rescue, and patient education.[6] Controller pharmacotherapy is recommended using ICS and, if EIA is not controlled despite appropriate technique and adherence to therapy, treatment can be stepped up by increasing the dose or by adding other medications.[2,6] However, asthma symptoms in elite athletes have been reported to be less responsive to ICS, perhaps reflecting the mixed airway inflammation.[6]

Ideally, elite athletes should only use β-agonists infrequently owing to the potential for tolerance described previously.[6,16] A lack of appropriate response to therapy requires additional evaluation of the athlete.


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