New Exercise-Induced Bronchoconstriction Guidelines

Laurie Barclay, MD

May 01, 2013

New practice guidelines from the American Thoracic Society on exercise-induced bronchoconstriction (EIB), or acute airway narrowing resulting from exercise appear in the May 1 issue of the American Journal of Respiratory and Critical Care Medicine.

A multidisciplinary panel of stakeholders has reviewed the pathogenesis of EIB and developed the new evidence-based recommendations, which address diagnosis, management, environmental triggers, and special considerations in elite athletes.

"While a large proportion of asthma patients experience exercise-induced respiratory symptoms, EIB also occurs frequently in subjects without asthma," guidelines committee chair Jonathan Parsons, MD, associate professor of internal medicine and associate director of the Ohio State University Asthma Center in Columbus, said in a news release.

"Given the high prevalence of EIB, evidence-based guidelines for its management are of critical importance," he added.

Although the prevalence of EIB in patients with asthma is still unknown, estimated prevalence may reach 20% in those without diagnosed asthma. For Olympic and elite athletes, the prevalence estimates are even higher, between 30% and 70%.

Cold air, dry air, ambient ozone, and airborne particulate matter are known environmental triggers for EIB, which may help explain the increased prevalence of EIB among competitive ice skaters, skiers, swimmers, and distance runners.

The Grading of Recommendations, Assessment, Development, and Evaluation approach showed a variable quality of evidence for EIB.

  • Exercise-induced changes in lung function, and not symptoms, allow the diagnosis of EIB. Serial measurement of FEV1 after a specific exercise or hyperpnea challenge is preferable to measurement of peak expiratory flow rate. A fall in forced expiratory volume in 1 second of at least 10% defines EIB.

  • The guidelines strongly recommend that all patients with EIB use an inhaled short-acting beta-agonist about 15 minutes before exercise.

  • For those who still have symptoms or who use short-acting beta-agonist therapy daily or more frequently, the guidelines strongly recommend a daily inhaled corticosteroid, a daily leukotriene receptor antagonist, or a mast cell–stabilizing agent before exercise.

  • However, the guidelines note that beta-agonists and some other drugs used to treat EIB are considered performance-enhancing and are therefore banned or restricted in athletic competitions. Clinicians therefore should tailor treatment to the guidelines of the governing bodies of these sports.

  • It may take 2 to 4 weeks after starting daily inhaled corticosteroids to see maximal improvement. The guidelines strongly recommend against administering inhaled corticosteroids only before exercise.

  • Because of the potential for serious adverse effects, the guidelines strongly recommend against daily use of an inhaled long-acting beta-agonist as single therapy.

  • All patients with EIB should do interval or combination warm-up exercises before planned exercise.

"While EIB is common, there are effective treatments and preventive measures, both pharmacological and non-pharmacological," Dr. Parsons said in the news release. "The recommendations in these guidelines synthesize the latest clinical evidence and will help guide the management of EIB in patients with or without asthma and in athletes at all levels of competition."

The guidelines authors anticipate a future revision and update based on new clinical research data.

The guidelines authors do not report any financial disclosures.

Am J Respir Crit Care Med. 2013;187:1016-1027. Abstract