Medscape: How should clinicians advise patients about engaging in exercise if they are still having symptoms with EIB? Should they wear identification, or carry inhalers?
Dr. Parsons: Deaths have been associated with EIB, but they are rare. The goal of managing these patients is to get them to be able to exercise at whatever level they want to without symptoms. If the athlete is still having symptoms during exercise that by our criteria, by our goals of care, are inadequately controlled, then that regimen should be augmented.
I don't want any of my patients running around exercising with symptoms at all. They should be able to do whatever they want to, limit-free. That being said, when they are running competitive races, and they sign up for a half-marathon or a 10K, they are asked whether they have asthma, and it would be a good idea to indicate on their registration form that they do have asthma, so that if something were to happen the EMS personnel would know exactly what to do, to look for, or to attend to.
I tell my patients who are athletes to always have immediate access to their albuterol inhalers. If they are cycling or swimming, that doesn't necessarily make it very convenient, but maybe on their bike they can have it available somewhere for a long cycling route or a long run.
An albuterol inhaler, if used properly before exercise, should provide 3-4 hours of protection. That is going to cover most competitive events that athletes will ever be competing in, unless they are doing one of these ultramarathons or triathlons.
We don't tolerate symptoms in patients who have documented EIB. They should be able to exercise without symptoms, and they need to have access to their albuterol inhalers -- if not immediate, then very easy access to it. There are forms of identification that can be worn, but I don't necessarily recommend that in most cases.
Medscape: What are your bottom-line messages about EIB to primary care providers?
Dr. Parsons: I would say a couple of things. Most important, the symptoms of EIB are very nonspecific. Making a diagnosis on the basis of symptoms alone is setting a clinician up to make the wrong diagnosis in a significant percentage of cases. For that reason, it is clinically important to objectively document that you are making the proper diagnosis, and once you make the proper diagnosis, that you are documenting the severity of EIB in this particular patient.
The next point I would make is that albuterol is very effective in controlling EIB in the vast majority of patients. If you have an athlete or a patient who is still symptomatic despite adequate treatment with albuterol, then I would start to look for alternative diagnoses or start to consider augmenting pharmacologic therapy at that point.
Medscape: What is the most common alternative diagnosis?
Dr. Parsons: In our practice, the most common alternative diagnosis is vocal cord dysfunction, which is something that is not commonly considered by a primary care doctor but is a very common diagnosis in patients with exercise-induced respiratory symptoms. These patients have an irritable larynx syndrome where the upper airway becomes irritated in a similar fashion to EIB, but they don't respond to inhalers, and they continue to have symptoms despite a significant regimen of asthma medicines because they don't have asthma or EIB.
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Cite this: Exercise-Induced Bronchoconstriction: The New Guidelines - Medscape - Feb 03, 2014.