Asthma Management Handbook

Investigating exercise-induced respiratory symptoms in people without a diagnosis of asthma

Recommendations

For adults or children with exercise-related respiratory symptoms who do not have a previous asthma diagnosis, investigate as for patients with suspected asthma: take a history, perform a physical examination and 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).

Do not rely on peak expiratory flow meters to investigate exercise-induced bronchoconstriction.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Weiler et al. 20101

In younger children unable to perform spirometry, investigate as for child with suspected asthma.

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 exercise-related symptoms, including:

  • poor cardiopulmonary fitness
  • upper airway dysfunction
  • exercise-induced dyspnoea
  • hyperventilation
  • psychological conditions (e.g. anxiety)
  • obesity
  • cardiac abnormalities
  • other lung conditions (including COPD, bronchiolitis, infection).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Benninger et al. 20112
  • British Thoracic Society, Scottish Intercollegiate Guidelines Network, 20083
  • Deckert and Deckert, 20104
  • Kenn and Balkissoon, 20115
  • Tilles, 20106
  • Towns and van Asperen, 20097
  • Weiler et al. 20101
  • Weinberger and Abu-Hasan, 20078

Consider exercise testing for cardiopulmonary function to rule out exercise-related dyspnoea due to poor cardiopulmonary fitness.

How this recommendation was developed

Consensus

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

In patients with exercise-related respiratory symptoms but without a clear diagnosis of asthma, do not initiate inhaled corticosteroid treatment before ruling out alternative diagnoses (e.g. upper airway dysfunction), because it is much more difficult to confirm the diagnosis after the person has begun inhaled corticosteroid treatment.

How this recommendation was developed

Consensus

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

In children, if symptoms only occur during exercise, consider specialist referral for investigation (e.g. paediatric respiratory physician).

How this recommendation was developed

Consensus

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

For adolescents, consider objective testing (e.g. referral to a accredited respiratory function laboratory for indirect challenge testing) or referral to a paediatric respiratory physician for assessment.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • British Thoracic Society, Scottish Intercollegiate Guidelines Network, 20083
  • Tilles, 20106
  • Towns and van Asperen, 20097
  • Weinberger and Abu-Hasan, 20078

If the post-bronchodilator spirometry reading demonstrates acute reversibility of airflow limitation, and other diagnoses have been excluded, make the diagnosis of asthma and manage according to the individual’s age, pattern of symptoms and risk factors.

How this recommendation was developed

Consensus

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

If history is consistent with exercise-induced bronchoconstriction but other investigations do not demonstrate variable airflow limitation (e.g. spirometry before and 10–15 minutes after bronchodilator shows no or little response), consider referral to a respiratory physician for investigation or referral to an accredited respiratory function laboratory for indirect challenge testing.

How this recommendation was developed

Consensus

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

If the history is consistent with exercise-induced bronchoconstriction and indirect challenge test is positive, this confirms the diagnosis of asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Parsons et al. 20139
  • Weiler et al. 20101

If initial indirect challenge test is negative, consider referring patient for a sports-specific field challenge test or refer to a respiratory physician.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Weiler et al. 20101

Challenge tests should be performed only in accredited respiratory function laboratories.

How this recommendation was developed

Consensus

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

If the person is involved in competitive sport, check whether specific tests are required to confirm the presence of exercise-induced bronchoconstriction before medicines are permitted.

Note: Testing rules differ between competitive sports – check with ASADA.

How this recommendation was developed

Consensus

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

More information

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.10, 1112

Symptoms typically peak at 5–10 mins after exercise13 – 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.1112

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,14, 1516 particularly in elite athletes and adolescents.3 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.8

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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.9

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.17

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

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Aetiology of exercise-induced bronchoconstriction

Both genetics and environment may contribute to exercise-induced bronchoconstriction.1

Exercise-induced bronchoconstriction occurs when a person’s ventilatory rate is high and their airways must heat and humidify a large volume of air in a short time. Dehydration of the airway leads to release of inflammatory mediators within the airway and contraction of airway smooth muscle.1 Dry air is one risk factor.1

Exercise-induced bronchoconstriction in athletes who do not have chronic asthma may have different pathogenesis and presentation than exercise-induced bronchoconstriction in people with asthma.1 Elite athletes often report onset of exercise-induced bronchoconstriction after age 20 years and after many years of high-level training.18

In elite athletes, exercise-induced bronchoconstriction is probably due to chronic injury to airway epithelium associated with long-term frequent prolonged high ventilation rates in the presence of environmental exposure to cold air, dry air, and airborne pollutants such as ozone, particulate matter:

  • The high prevalence of exercise-induced bronchoconstriction in ice-rink athletes has been linked to inhalation of cold dry air in combination with airborne pollutants from fossil-fuelled ice resurfacing machines
  • Exercise-induced bronchoconstriction in skiers and other winter athletes has been linked to injury of airway epithelium due to conditioning large volumes of cold dry air91920
  • The high prevalence of asthma and exercise-induced bronchoconstriction reported among competitive swimmers has been associated with exposure to chlorine in indoor swimming pools921, 22
  • The increased prevalence of exercise-induced bronchoconstriction among distance runners, compared with the general population, has been attributed to exposure to high levels of airborne allergens and ozone19
  • Certain airborne viruses inhaled during exercise may also contribute to exercise-induced bronchoconstriction.1
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Exercise-induced bronchoconstriction in people without a previous asthma diagnosis

Exercise-induced bronchoconstriction in people without a previous diagnosis of asthma can be associated with airway inflammation, but is not always.

Laboratory studies show that exercise-induced bronchoconstriction is likely to respond to inhaled corticosteroids if it is associated with airway inflammation and the presence of eosinophils.1 However, sputum testing is not necessary to make the diagnosis.

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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 asthma24 and is commonly misdiagnosed as asthma.823 It can cause severe acute episodes of dyspnoea that occur either unpredictably or due to exercise.8 Inspiratory stridor associated with vocal cord dysfunction is often described as ‘wheezing’,8 but symptoms do not respond to asthma treatment.45

Upper airway dysfunction can coexist with asthma.2 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.2

Upper airway dysfunction probably has multiple causes.2 In some people it is probably due to hyperresponsiveness of the larynx in response to intrinsic and extrinsic triggers.224 Triggers can include exercise, psychological conditions, airborne irritants, rhinosinusitis, gastro-esophageal reflux disease, and medicines.423

Upper airway dysfunction should be considered when spirometry shows normal FEV1/FVC ratio in a patient with suspected asthma23 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.8 Direct observation of the vocal cords is the best method to confirm the diagnosis of upper airway dysfunction.2

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Exercise-related symptoms in adolescents

In adolescents, exercise-related wheezing and breathlessness are poor predictors of exercise-induced bronchoconstriction. Only a minority of adolescents referred for assessment of exercise-induced respiratory symptoms show objective evidence of exercise-induced bronchoconstriction.3

For adolescents with exercise-related symptoms, common conditions that should be considered in the differential diagnosis include poor cardiopulmonary fitness, exercise-induced upper airway dysfunction and exercise-induced hyperventilation.76

In addition to spirometry, other objective tests (e.g. cardiopulmonary fitness testing, bronchial provocation tests) may be helpful to clarify the diagnosis and inform management.

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Challenge tests for exercise-induced bronchoconstriction

Role of challenge tests

Self-reported symptoms are not sensitive enough to detect exercise-induced bronchoconstriction reliably or specific enough to rule out other conditions, particularly in elite athletes.12516 Single office FEV1 readings or peak expiratory flow measurement are not adequate to demonstrate exercise-induced bronchoconstriction.9

Standardised, objective bronchial provocation (challenge) tests using spirometry are necessary for the investigation of suspected exercise-induced bronchoconstriction in elite athletes. These tests involve serial spirometry measurements after challenge with exercise (or exercise surrogates e.g. dry powder mannitol, eucapnic voluntary hyperpnoea or hyperventilation, or hyperosmolar aerosols such as 4.5% saline).19, 1826 Severity of exercise-induced bronchoconstriction is assessed by percentage fall in FEV1 after challenge.9

Challenge testing is mandated by sports governing bodies before the athlete is given permission to use some asthma medicines, and the required testing protocol varies between specific sports. The latest information is available from the Australian Sports Anti-Doping Authority (ASADA) and the World Anti-Doping Agency (WADA).

Challenge tests are also used in the investigation of exercise-related symptoms in recreational and non-athletes, when objective demonstration of exercise-induced bronchoconstriction is needed to guide management decisions.

Choice of challenge test

There is no single challenge test that will identify all individuals with exercise-induced bronchoconstriction.1 The most appropriate test or tests for an individual depend on clinical and individual factors:

  • The eucapnic voluntary hyperpnoea test can provoke a severe response.1 For safety reasons, the eucapnic voluntary hyperpnoea test should only be used in adults who regularly exercise at high intensity (e.g. elite athletes).1 It should not be used in children.
  • When an exercise challenge test is used, inhalation of dry air is recommended to diagnose or exclude exercise-induced bronchoconstriction because it increases the sensitivity of the test.1
  • Mannitol challenge can be used as an alternative to exercise provocation testing to investigate suspected exercise-induced bronchoconstriction, 1, 27, 28 including in children.29, 30
  • For safety reasons, exercise challenge in dry air should be avoided in patients with FEV1 <70% predicted1

Referral

If challenge testing is needed, consider referring to a respiratory physician for investigation, or discussing with a respiratory physician before selecting which test to order. Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment in the few weeks before challenge testing, because these could invalidate the result.

A list of accredited respiratory function laboratories is available from the Australian and New Zealand Society of Respiratory Science.

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Anti-doping agencies

Australian Sports Anti-Doping Authority

The Australian Sports Anti-Doping Authority (ASADA) is the Australian federal government statutory authority with a mission to protect Australia's sporting integrity through the elimination of doping. 

World Anti-Doping Agency

The World Anti-Doping Agency (WADA) is the international independent anti-doping agency composed of representatives from the Olympic movement and public authorities from around the world. Its mission is to lead a collaborative worldwide campaign for doping-free sport.

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References

  1. Weiler JM, Anderson SD, Randolph C, et al. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol. 2010; 105: S1-47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21167465
  2. 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
  3. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  4. 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
  5. Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know?. Eur Respir J. 2011; 37: 194-200. Available from: http://erj.ersjournals.com/content/37/1/194.long
  6. Tilles SA. Exercise-induced respiratory symptoms: an epidemic among adolescents. Ann Allergy Asthma Immunol. 2010; 104: 361-7; 368-70, 412. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20486325
  7. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20298380
  8. 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
  9. Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013; 187: 1016-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23634861
  10. 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
  11. 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
  12. van Leeuwen JC, Driessen JM, de Jongh FH, et al. Monitoring pulmonary function during exercise in children with asthma. Arch Dis Child. 2011; 96: 664-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21460404
  13. Brudno DS, Wagner JM, Rupp NT. Length of postexercise assessment in the determination of exercise-induced bronchospasm. Ann Allergy. 1994; 73: 227-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8092556
  14. 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
  15. 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/
  16. 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
  17. 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
  18. Fitch KD, Sue-Chu M, Anderson SD, et al. Asthma and the elite athlete: Summary of the International Olympic Committee's Consensus Conference, Lausanne, Switzerland, January 22-24, 2008. J Allergy Clin Immunol. 2008; 122: 254-260. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18678340
  19. Anderson SD, Kippelen P. Airway injury as a mechanism for exercise-induced bronchoconstriction in elite athletes. J Allergy Clin Immunol. 2008; 122: 225-235. Available from: http://www.jacionline.org/article/S0091-6749(08)00785-9/fulltext
  20. Sue-Chu M, Brannan JD, Anderson SD, et al. Airway hyperresponsiveness to methacholine, adenosine5-monophosphate, mannitol, eucapnic voluntary hyperpnoea and field exercise challenge in elite cross country skiers. Brit J Sports Med. 2010; 44: 827-832. Available from: http://bjsm.bmj.com/content/44/11/827.long
  21. Bougault V, Boulet LP, Turmel J. Bronchial challenges and respiratory symptoms in elite swimmers and winter sport athletes. Chest. 2010; 138: 31S-37S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086631
  22. Bougault V, Turmel J, St-Laurent J, et al. Asthma, airway inflammation and epithelial damage in swimmers and cold-air athletes. Eur Respir J. 2009; 33: 740-746. Available from: http://erj.ersjournals.com/content/33/4/740.long
  23. Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010; 138: 1213-23. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1045155
  24. 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
  25. 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
  26. Anderson SD, Kippelen P. Assessment and prevention of exercise-induced bronchoconstriction. Br J Sports Med. 2012; 46: 391-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22247297
  27. Brannan JD, Koskela H, Anderson SD, Chew N. Responsiveness to mannitol in asthmatic subjects with exercise- and hyperventilation-induced asthma. Am J Respir Crit Care Med. 1998; 158: 1120-6. Available from: http://www.atsjournals.org/doi/full/10.1164/ajrccm.158.4.9802087
  28. Holzer K, Anderson SD, Chan HK, Douglass J. Mannitol as a challenge test to identify exercise-induced bronchoconstriction in elite athletes. Am J Respir Crit Care Med. 2003; 167: 534-7. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200208-916OC
  29. Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children. Pediatr Pulmonol. 2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571
  30. Barben J, Kuehni CE, Strippoli MP, et al. Mannitol dry powder challenge in comparison with exercise testing in children. Pediatr Pulmonol. 2011; 46: 842-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21465681