Asthma Management Handbook

Investigating exercise-induced bronchoconstriction in people with asthma

Recommendations

Before altering treatment to manage exercise-related symptoms, review asthma and rule out other causes. 

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For an adult or child with asthma who has new-onset or worsening symptoms that suggest exercise-induced bronchoconstriction, ask about:

  • the type of physical activity and environment that provokes symptoms
  • timing of symptom onset (symptoms of exercise-induced bronchoconstriction are typically worst 5–10 minutes after stopping exercise, not during exercise)
  • exposure to allergens or other triggers.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If the patient is already using a preventer medicine, check adherence and inhaler technique. 

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For adults and for children able to do the spirometry test reliably, perform or arrange spirometry before and after bronchodilator.

Notes

If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriate provider such as an accredited respiratory function laboratory.

Most children aged 6 years and older are able to perform spirometry reliably.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider the possibility of an alternative cause for new-onset exercise-related symptoms, including:

  • poor cardiopulmonary fitness
  • upper airway dysfunction (relatively common in young women)
  • hyperventilation
  • psychological conditions (e.g. anxiety)
  • obesity
  • cardiac abnormalities
  • other lung conditions (including COPD, infection). 
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider further investigations for cardiopulmonary function to rule out exercise-related dyspnoea due to poor cardiopulmonary fitness or left ventricular dysfunction.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider objective testing to confirm exercise-induced bronchoconstriction (e.g. referral to a accredited respiratory function laboratory for indirect challenge testing) if exercise-related symptoms do not respond to treatment, or if required for competitive sport or employment.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Exercise-induced bronchoconstriction and asthma

Exercise-induced bronchoconstriction is a manifestation of airway hyperresponsiveness.1

Exercise-induced bronchoconstriction is one of the first symptoms to appear when asthma control is suboptimal,1 and one of the last symptoms to resolve with treatment.

Asthma control measured by the Asthma Score does not correlate with the finding of exercise-induced bronchoconstriction.2345 Exercise-induced bronchoconstriction can occur despite well-controlled asthma.2

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Symptoms and signs of exercise-induced bronchoconstriction

Symptoms of exercise-induced bronchoconstriction include cough, wheeze, a feeling of tightness in the chest, breathlessness, excessive mucus production.1 Some children experience chest pain with exercise-induced bronchoconstriction.1 Young children recover from exercise-induced bronchoconstriction faster than older children and adults.6, 78

Symptoms typically peak at 5–10 mins after exercise9 – unlike physiological exercise-induced dyspnoea, which resolves rapidly when the person stops the strenuous activity. (Physiological exercise-induced dyspnoea is a normal response and does not require treatment.) Because exercise-induced bronchoconstriction usually occurs after exercise, it may not affect exercise performance.78

After an episode of exercise-induced bronchoconstriction, approximately 50% of people with this condition experience a refractory period of 2–3 hours, during which they do not develop bronchoconstriction even if they exercise.1 (Some athletes make use of this phenomenon to their advantage.)

Exercise-related wheezing and breathlessness are poor predictors of exercise-induced bronchoconstriction,2, 45 particularly in elite athletes and adolescents.10 Other diagnoses associated with consistent exercise-induced symptoms in adolescents include normal physiological exercise limitation, with and without poor cardiopulmonary fitness, upper airway dysfunction and hyperventilation.11

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Definition and prevalence of exercise-induced bronchoconstriction

Exercise-induced bronchoconstriction is transient narrowing of the lower airways, occurring after vigorous exercise.1

It may occur in people with asthma or in people who do not have a history of known asthma.1

It is defined as a reduction in FEV1 from the value measured before exercise of 10% or more in adults1 and 13% or more in children.

In people with asthma who experience exercise-induced bronchoconstriction, exercise does not cause asthma but is an asthma trigger.1

Recovery from exercise-induced bronchoconstriction is usually spontaneous. FEV1 usually returns to 95% baseline value within 30–90 minutes.12

Up to 90% of people with asthma and 50% of competitive athletes may experience exercise-induced bronchoconstriction.1

An estimated 18–26% of school children experience exercise-induced bronchoconstriction.13

Note: The term ‘exercise-induced asthma’ is no longer used.1

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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1415

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,16, 17, 18, 19, 20 even among regular users.21 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.22

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.16, 23, 21, 24, 25 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.21

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.26, 27

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:22

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:22

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.22 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.28, 16, 29, 30 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.29 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).14, 27

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.26, 16, 17 

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Spirometry in diagnosis and monitoring

Spirometry is the best lung function test for diagnosing asthma and for measuring lung function when assessing asthma control. Spirometry can:

  • detect airflow limitation
  • measure the degree of airflow limitation compared with predicted normal airflow (or with personal best)
  • demonstrate whether airflow limitation is reversible.

It should be performed by well-trained operators with well-maintained and calibrated equipment.31, 32

Before performing spirometry, check if the person has any contraindications (e.g. myocardial infarction, angina, aneurysm, recent surgery, suspected pulmonary embolism, suspected pneumothorax, fractured ribs). Advise them to stop if they become dizzy.

Clearly explain and physically demonstrate correct spirometry technique: 33

  • Sit upright with legs uncrossed and feet flat on the floor and do not lean forward.
  • Breathe in rapidly until lungs feel absolutely full. (Coaching is essential to do this properly.)
  • Do not pause for more than 1 second.
  • Place mouthpiece in mouth and close lips to form a tight seal.
  • Blast air out as hard and fast as possible and for as long as possible, until the lungs are completely empty or you are unable to blow out any longer.
  • Remove mouthpiece.

Repeat the test until you obtain three acceptable tests and these meet repeatability criteria.

Acceptability of test

A test is acceptable if all the following apply:

  • forced expiration started immediately after full inspiration
  • expiration started rapidly
  • maximal expiratory effort was maintained throughout the test, with no stops
  • the patient did not cough during the test
  • the patient did not stop early (before 6 seconds for adults and children over 10 years, or before 3 seconds for children under 10 years).

Record the highest FEV1 and FVC result from the three acceptable tests, even if they come from separate blows.33

Repeatability criteria

Repeatability criteria for a set of acceptable tests are met if both of the following apply:31

  • the difference between the highest and second-highest values for FEV1 is less than 150 mL
  • the difference between the highest and second-highest values for FVC is less than 150 mL.

For most people, it is not practical to make more than eight attempts to meet acceptability and repeatability criteria.33

Testing bronchodilator response (reversibility of airflow limitation)

Repeat spirometry 10-15 minutes after giving 4 separate puffs of salbutamol (100 mcg/actuation) via a pressurised metered-dose inhaler and spacer.33 (For patients who have reported unacceptable side-effects with 400 mcg, 2 puffs can be used.)

For adults and adolescents, record a clinically important bronchodilator response if FEV1 increases by ≥ 200 mL and ≥ 12%.33

For children, record a clinically important bronchodilator response if FEV1 increases by
≥ 12%.33

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Upper airway dysfunction

Upper airway dysfunction is intermittent, abnormal adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. It often mimics asthma3435 and is commonly misdiagnosed as asthma.1136 It can cause severe acute episodes of dyspnoea that occur either unpredictably or due to exercise.11 Inspiratory stridor associated with vocal cord dysfunction is often described as ‘wheezing’,11 but symptoms do not respond to asthma treatment.3537

Upper airway dysfunction can coexist with asthma.34 People with asthma who also have upper airway dysfunction experience more symptoms than those with asthma alone and this can result in over-treatment if vocal cord dysfunction is not identified and managed appropriately.34

Upper airway dysfunction probably has multiple causes.34 In some people it is probably due to hyperresponsiveness of the larynx in response to intrinsic and extrinsic triggers.3438 Triggers can include exercise, psychological conditions, airborne irritants, rhinosinusitis, gastro-esophageal reflux disease, and medicines.3536

Upper airway dysfunction should be considered when spirometry shows normal FEV1/FVC ratio in a patient with suspected asthma36 or symptoms do not respond to short-acting beta2 agonist reliever. The shape of the maximal respiratory flow loop obtained by spirometry may suggest the diagnosis.11 Direct observation of the vocal cords is the best method to confirm the diagnosis of upper airway dysfunction.34

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References

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  2. Madhuban AA, Driessen JM, Brusse-Keizer MG, et al. Association of the asthma control questionnaire with exercise-induced bronchoconstriction. J Asthma. 2011; 48: 275-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21348805
  3. Rundell KW, Im J, Mayers LB, et al. Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc. 2001; 33: 208-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11224807
  4. Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma. Respir Res. 2010; Sept 1: 120. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/
  5. Holzer K, Anderson SD, Douglass J. Exercise in elite summer athletes: Challenges for diagnosis. J Allergy Clin Immunol. 2002; 110: 374-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12209082
  6. Hofstra WB, Sterk PJ, Neijens HJ, et al. Prolonged recovery from exercise-induced asthma with increasing age in childhood. Pediatr Pulmonol. 1995; 20: 177-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8545170
  7. van Leeuwen JC, Driessen JM, de Jongh FH, et al. Measuring breakthrough exercise-induced bronchoconstriction in young asthmatic children using a jumping castle. J Allergy Clin Immunol. 2013; 131: 1427-1429.e5. Available from: http://www.jacionline.org/article/S0091-6749(12)01658-2/fulltext
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  11. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007; 120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
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  13. Haby MM, Peat JK, Mellis CM, et al. An exercise challenge for epidemiological studies of childhood asthma: validity and repeatability. Eur Respir J. 1995; 8: 729-736. Available from: http://erj.ersjournals.com/content/8/5/729.long
  14. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  15. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  16. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
  17. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  18. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
  19. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
  20. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
  21. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  22. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  23. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
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  25. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
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  33. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
  34. Benninger C, Parsons JP, Mastronarde JG. Vocal cord dysfunction and asthma. Curr Opin Pulm Med. 2011; 17: 45-49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21330824
  35. Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. 2010; 81: 156-159. Available from: http://www.aafp.org/afp/2010/0115/p156.html
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  38. Gimenez LM, Zafra H. Vocal cord dysfunction: an update. Ann Allergy Asthma Immunol. 2011; 106: 267-274. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21457874