Asthma Management Handbook

Asthma and exercise-induced bronchoconstriction in elite athletes

Recommendations

If possible, refer elite athletes to a sports medicine expert or specialist with expertise in the investigation and management of exercise-induced bronchoconstriction in competitive athletes, to ensure that all investigations and treatments comply with requirements of sports governing bodies.

How this recommendation was developed

Consensus

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

Do not rely on history alone to diagnose or exclude 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):

  • Parsons et al. 20131
  • Weiler et al. 20102

Advise athletes that some sports stipulate a specific testing protocol to demonstrate asthma and allow the person to use medicines (refer to sports governing bodies).

How this recommendation was developed

Consensus

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

If baseline (pre-bronchodilator) FEV1 is ≥ 70% predicted, consider indirect challenge testing such as exercise challenge with dry air, or mannitol challenge test. Refer or discuss with a respiratory physician before ordering these tests.

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. 20131
  • Weiler et al. 20102

For elite athletes who also have chronic asthma, manage exercise-induced bronchoconstriction as for other patients with asthma.

How this recommendation was developed

Consensus

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

Before prescribing any medicine for an elite athlete, check whether it is permitted in sport via the Australian Sports Anti-Doping Authority or the World Anti-Doping Agency.

How this recommendation was developed

Consensus

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

More information

Aetiology of exercise-induced bronchoconstriction

Both genetics and environment may contribute to exercise-induced bronchoconstriction.2

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.2 Dry air is one risk factor.2

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.2 Elite athletes often report onset of exercise-induced bronchoconstriction after age 20 years and after many years of high-level training.3

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 air145
  • The high prevalence of asthma and exercise-induced bronchoconstriction reported among competitive swimmers has been associated with exposure to chlorine in indoor swimming pools16, 7
  • 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 ozone21
  • Certain airborne viruses inhaled during exercise may also contribute to exercise-induced bronchoconstriction.2
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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.289 Single office FEV1 readings or peak expiratory flow measurement are not adequate to demonstrate exercise-induced bronchoconstriction.1

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).21, 310 Severity of exercise-induced bronchoconstriction is assessed by percentage fall in FEV1 after challenge.1

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.2 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.2 For safety reasons, the eucapnic voluntary hyperpnoea test should only be used in adults who regularly exercise at high intensity (e.g. elite athletes).2 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.2
  • Mannitol challenge can be used as an alternative to exercise provocation testing to investigate suspected exercise-induced bronchoconstriction, 2, 11, 12 including in children.13, 14
  • For safety reasons, exercise challenge in dry air should be avoided in patients with FEV1 <70% predicted2

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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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.2 However, sputum testing is not necessary to make the diagnosis.

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Use of medicines in sport

Many sporting bodies require athletes to provide objective evidence of exercise-induced bronchoconstriction before they are permitted to use asthma medicines during competition.

The Australian Sports Anti-Doping Authority provides information about Therapeutic Use Exemptions for athletes who require treatment with prohibited substances.

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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. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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