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 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

Last reviewed version 2.0

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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

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,14, 15,1616, 17 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.14, 15, 18, 19, 20, 21

Poor asthma symptom control is often due to incorrect inhaler technique.22, 23

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

Last reviewed version 2.0

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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.24, 25

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: 26

  • 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.26

Repeatability criteria

Repeatability criteria for a set of acceptable tests are met if both of the following apply:24

  • 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.26

Testing bronchodilator response (reversibility of airflow limitation)

Repeat spirometry 10-15 minutes after giving 4 separate puffs of salbutamol (100 microg/actuation) via a pressurised metered-dose inhaler and spacer.26 (For patients who have reported unacceptable side-effects with 400 microg, 2 puffs can be used.)

For adults and adolescents, record a clinically important bronchodilator response if FEV1 increases by ≥ 200 mL and ≥ 12%.26

For children, record a clinically important bronchodilator response if FEV1 increases by
≥ 12%.26

Last reviewed version 2.0

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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 asthma2728 and is commonly misdiagnosed as asthma.1129 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.2830

Upper airway dysfunction can coexist with asthma.27 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.27

Upper airway dysfunction probably has multiple causes.27 In some people it is probably due to hyperresponsiveness of the larynx in response to intrinsic and extrinsic triggers.2731 Triggers can include exercise, psychological conditions, airborne irritants, rhinosinusitis, gastro-esophageal reflux disease, and medicines.2829

Upper airway dysfunction should be considered when spirometry shows normal FEV1/FVC ratio in a patient with suspected asthma29 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.27

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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. 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
  8. 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
  9. 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
  10. Schuh, S, Willan, AR, Stephens, D, et al. Can montelukast shorten prednisolone therapy in children with mild to moderate acute asthma? A randomized controlled trial. J Pediatr. 2009; 155: 795-800. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19656525
  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
  12. 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
  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. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  15. 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
  16. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. 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
  17. 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
  18. 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
  19. Levy ML, Dekhuijzen PN, Barnes PJ, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med. 2016; 26: 16017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27098045
  20. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  21. 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
  22. Harnett, C. M., Hunt, E. B., Bowen, B. R., et al. A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic. J Asthma. 2014; 51: 440-5.
  23. Hardwell, A., Barber, V., Hargadon, T., et al. Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Prim Care Respir J. 2011; 20: 92-6. Available from: http://www.nature.com/articles/pcrj201088
  24. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26: 319-338. Available from: http://erj.ersjournals.com/content/26/2/319
  25. Levy ML, Quanjer PH, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J. 2009; 18: 130-147. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684995
  26. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
  27. 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
  28. 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
  29. Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010; 138: 1213-23. Available from: https://journal.chestnet.org/article/S0012-3692(10)60600-9/fulltext
  30. 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
  31. 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