Management Of Exercise-induced Bronchoconstriction Research Articles

Exercise-Induced Asthma: Managing Respiratory Issues in Athletes.

Asthma is a complex respiratory condition characterized by chronic airway inflammation and variable expiratory airflow limitation, affecting millions globally. Among athletes, particularly those competing at elite levels, the prevalence of respiratory conditions is notably heightened, varying between 20% and 70% across specific sports. Exercise-induced bronchoconstriction (EIB) is a common issue among athletes, impacting their performance and well-being. The prevalence rates vary based on the sport, training environment, and genetics. Exercise is a known trigger for asthma, but paradoxically, it can also improve pulmonary function and alleviate EIB severity. However, athletes' asthma phenotypes differ, leading to varied responses to medications and challenges in management. The unique aspects in athletes include heightened airway sensitivity, allergen, pollutant exposure, and temperature variations. This review addresses EIB in athletes, focusing on pathogenesis, diagnosis, and treatment. The pathogenesis of EIB involves complex interactions between physiological and environmental factors. Airway dehydration and cooling are key mechanisms, leading to osmotic and thermal theories. Airway inflammation and hyper-responsiveness are common factors. Elite athletes often exhibit distinct inflammatory responses and heightened airway sensitivity, influenced by sport type, training, and environment. Swimming and certain sports pose higher EIB risks, with chlorine exposure in pools being a notable factor. Immune responses, lung function changes, and individual variations contribute to EIB in athletes. Diagnosing EIB in athletes requires objective testing, as baseline lung function tests can yield normal results. Both EIB with asthma (EIBA) and without asthma (EIBwA) must be considered. Exercise and indirect bronchoprovocation tests provide reliable diagnoses. In athletes, exercise tests offer effectiveness in diagnosing EIB. Spirometry and bronchodilation tests are standard approaches, but the diagnostic emphasis is shifting toward provocation tests. Despite its challenges, achieving an optimal diagnosis of EIA constitutes the cornerstone for effective management, leading to improved performance, reduced risk of complications, and enhanced quality of life. The management of EIB in athletes aligns with the general principles for symptom control, prevention, and reducing complications. Non-pharmacological approaches, including trigger avoidance and warming up, are essential. Inhaled corticosteroids (ICS) are the cornerstone of asthma therapy in athletes. Short-acting beta agonists (SABA) are discouraged as sole treatments. Leukotriene receptor antagonists (LTRA) and mast cell stabilizing agents (MCSA) are potential options. Optimal management improves the athletes' quality of life and allows them to pursue competitive sports effectively.

Eucapnic voluntary hyperpnea challenge can support management of exercise‐induced bronchoconstriction in elite swimmers

Introduction: This study investigated the use of eucapnic voluntary hyperpnea (EVH) to monitor efficacy of pharmacological therapy in elite swimmers with exercise-induced bronchoconstriction (EIB). Secondly, it evaluated the long-term test-retest repeatability of EVH in this population. Methods: Twenty-seven elite international swimmers were included in this retrospective analysis of comprehensive respiratory assessments. Following an initial “withheld-therapy” assessment, athletes with EIB had been prescribed appropriate pharmacological therapy and returned twelve months later for a follow-up assessment to monitor EIB protection afforded by treatment. EIB-negative athletes had returned to confirm initial diagnosis, as were still reporting persistent respiratory symptoms. Athletes were retrospectively grouped into either “Therapy Adherent Group” (n = 12) or “Repeatability Group” (discontinued therapy at follow-up or EIB-negative, n = 15). Results: Greatest fall in forced expiratory volume in 1 second (ΔFEV1max) was significantly lower following therapy adherence (−11.8 ± 3.8%) compared to initial assessment (−24.0 ± 11.3%; P < .01). “Repeatability Group” ΔFEV1max did not differ significantly between initial assessment (−13.1 ± 4.5%) and follow-up (−12.3 ± 5.6%; P = .32), and showed good agreement (0.6%; −5.9%, 7.1%). Conclusion: A follow-up assessment utilizing EVH is useful in the management of EIB and shows good test-retest repeatability over twelve months in elite swimmers who discontinue treatment or are EIB-negative.

Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes

Exercise-induced bronchoconstriction, otherwise known as exercise-induced bronchoconstriction with asthma or without asthma, is an acute airway narrowing that occurs as a result of exercise and can occur in patients with asthma. A panel of members from the American Academy of Allergy, Asthma & Immunology Sports, Exercise, & Fitness Committee reviewed the diagnosis and management of exercise-induced bronchoconstriction in athletes of all skill levels including recreational athletes, high school and college athletes, and professional athletes. A special emphasis was placed on the recommendations and regulations set forth by professional athletic organizations after a detailed review of their collective bargaining agreements, substance abuse policies, antidoping program manuals, and the World Anti-Doping Agency antidoping code. The recommendations in this review are based on currently available evidence in addition to providing guidance for athletes of all skill levels as well as their treating physicians to better understand which pharmaceutical and nonpharmaceutical management options are appropriate as well as which medications are permitted or prohibited, and the proper documentation required to remain compliant.

Management of Exercise-Induced Bronchoconstriction in Athletes

Exercise-induced bronchoconstriction (EIB) is a phenomenon observed in asthma but is also seen in healthy individuals and frequently in athletes. High prevalence rates are observed in athletes engaged in endurance sports, winter sports, and swimming. The pathophysiology of EIB is thought to be related to hyperventilation, cold air, and epithelial damage caused by chlorine and fine particles in inspired air. Several diagnostic procedures can be used; however, the diagnosis of EIB based on self-reported symptoms is not reliable and requires an objective examination. The hyperosmolar inhalation test and eucapnic voluntary hyperpnea test, which involve indirect stimulation of the airway, are useful for the diagnosis of EIB. A short-acting β-agonist is the first choice for prevention of EIB, and an inhaled corticosteroid is essential for patients with asthma. Furthermore, treatment should accommodate antidoping requirements in elite athletes. Tailoring of the therapeutic strategy to the individual case and the prognosis after cessation of athletic activity are issues that should be clarified in the future.

Management of Exercise-Induced Bronchoconstriction in Athletes

Management of Exercise-Induced Bronchoconstriction in Athletes

Dyspneic athlete.

Breathing concerns in athletes are common and can be due to a wide variety of pathology. The most common etiologies are exercise-induced bronchoconstriction (EIB) and paradoxic vocal fold movement disorder (PVFMD). Although some patients may have both, PVFMD is often misdiagnosed as EIB, which can lead to unnecessary treatment. The history and physical exam are important to rule out life threatening pulmonary and cardiac causes as well as common conditions such as gastroesophageal reflux disease, sinusitis, and allergic etiologies. The history and physical exam have been shown to be not as vital in diagnosing EIB and PVFMD. Improvement in diagnostic testing with office base spirometry, bronchoprovocation testing, eucapnic voluntary hyperpnea (EVH) and video laryngoscopy are essential in properly diagnosing these conditions. Accurate diagnosis leads to proper management, which is essential to avoid unnecessary testing and save healthcare costs. Also important to the physician treating dyspnea in athletes is knowing regulations on medications, drug testing, and proper documentation needed for certain organizations. The differential diagnosis of dyspnea is broad and is not limited to EIB and PVFMD. Ruling out life threatening cardiac and pulmonary causes with a proper history, physical, and appropriate testing is essential. The purpose of this review is to highlight recent literature on the diagnosis and management of EIB and PVFMD as well as discuss other potential causes for dyspnea in the athlete.

Exercise-induced bronchoconstriction update: Therapeutic management

Management of exercise-induced bronchoconstriction (EIB) should include both prevention and treatment directed toward the underlying asthma and bronchial hyperresponsiveness. Both nonpharmacologic and pharmacologic approaches should be followed. Preexercise warm-up, to take advantage of the refractory period that follows EIB, is an important preventive technique. Dietary interventions such as fish oil, vitamin D, and ascorbic acid have shown promising results. Beta 2-agonists are considered the most effective agents for EIB at this time but intermittent use is recommended to avoid tolerance or decreased effectiveness with daily regular use. Leukotriene inhibitors and mast cell stabilizing agents can be useful in EIB but are less effective than beta 2-agonists. Tolerance to beta 2-agonists is not prevented by concomitant use of inhaled corticosteroid but it is not known whether use of leukotriene inhibitors can affect tolerance. EIB in elite athletes with no underlying asthma may have a different pathogenesis.

Exercise-Induced Lung Disease: Too Much of a Good Thing?

Exercise in children has important health benefits. However, in elite endurance athletes, there is an increased prevalence of exercise-induced bronchoconstriction and airway inflammation. Particularly at risk are those who practice in cold weather, ice rinks, swimming pools, and air pollution. The inflammation is caused by repetitive episodes of hyperventilation of cold, dry air, allergens, or toxins such as chlorine or air pollution. Children may be particularly at risk for lung injury under these conditions because of the immaturity and ongoing development of their lung. However, studies in pediatric athletes and exercising young children are sparse. Epithelial injury associated with hyperventilation of cold, dry air has not been described in children. However, exercise in the presence of air pollution and chlorine is associated with airway injury and the development of asthma in children; the effect appears to be modulated by both atopy and genetic polymorphisms. While management of exercise-induced bronchoconstriction and asthma is well established, there is little data to guide treatment or prevention of remodeling in athletes or inhalational lung injury in children. Studies underscore the need to maintain high levels of air quality. More investigations should be undertaken to better define the natural history, pathophysiology, and treatment of exercise-induced pulmonary inflammation in both elite athletes and exercising children.

An update on exercise-induced bronchoconstriction with and without asthma

Exercise-induced bronchoconstriction (EIB) is defined as transient, reversible bronchoconstriction that develops after strenuous exercise. It is a heterogeneous syndrome made up of a spectrum of phenotypes ranging from the asymptomatic military recruit whose condition is detected by diagnostic exercise challenge to the athlete with known asthma to the elite athlete for whom EIB represents an overuse or injury syndrome. If exercise is the only identified trigger for bronchoconstriction, it is called EIB. However, when it is associated with known asthma, then it is defined as EIB with asthma. This review discusses the pathogenesis, presentation, diagnosis, and management of EIB and EIB with asthma.

Exercise-Induced Bronchoconstriction in Asthmatic Children

The aim of this article is to critically review the efficacy and safety data from randomized controlled trials (RCTs) using inhaled corticosteroids (ICSs), long- or short-acting beta(2)-adrenoceptor agonists (LABAs, SABAs), parasympatholytics and oral leukotriene receptor antagonists in the management of exercise-induced bronchoconstriction (EIB) in children with persistent asthma (EIA). The studies with sufficient information on patient characteristics and outcomes were chosen using a MEDLINE search. Results from the individual searches were combined and repeated. Studies were also found by reviewing the reference lists of the articles not included in this review. Studies focusing solely on individuals with asthma and other allergic co-morbidities (i.e. a degree of bronchial reversibility) were considered in this review. To make the paper evidence-based, the design and the quality of different studies were assessed employing the Sign criteria (evidence level [EL] and grades of recommendation [GR]). No additional statistical analyses were performed. Most of studies included paediatric patients with underlying EIA. We need to distinguish children with recurrent asthma symptoms in whom EIB is also present (patients with EIA) from asthmatic subjects whose symptoms appear only as a result of exercise (patients with EIB). Further controller treatment is indicated in patients with EIA and further reliever treatment in patients with EIB. ICSs are the first-choice controller drugs for EIA in children with persistent asthma (Sign grade of recommendation [GR]:A). In children with EIA without complete control with ICSs, SABAs (GR:A), leukotriene receptor antagonists (LTRAs) [GR:A] or LABAs (GR:A) may be added to gain control. Treatment with relievers such as SABAs (GR:A), parasympatholytics (GR:B) or, eventually, LABAs (GR:A), administered 10-15 minutes before exercise is the most preferable method of preventing EIB symptoms in children; however, not as monotherapy in children with EIA. The disadvantages and controversy relating to inhaled beta(2)-adrenoceptor agonist use lie in the development of tolerance to their effect when they are used on a regular basis, and the possibility of a resulting underuse of ICSs in patients with EIA. Researchers and guidelines recommend that if any patient requires treatment with a beta(2)-adrenoceptor agonist more than twice weekly, a low dose of ICSs should be administered. Inhaled parasympatholytics may be effective as preventive relievers in some children with EIB or EIA, especially among those with increased vagal activity. LTRAs have a well balanced efficacy-safety profile in preventing the occurrence of EIB symptoms in children. Compared with LABAs, LTRAs produce persistent attenuation of EIB and possess an additional effect with rescue SABA therapy in persistent asthmatic patients with EIA. A disadvantage of LTRAs is a non-response phenomenon. There are still insufficient data on the efficacy-safety profiles of ICS/LABA combination drugs in the treatment of EIA in children to recommend this treatment without caution. Safety profiles of inhaled SABAs, anticholinergics and montelukast in approved dosages seem sufficient enough to recommend use of these drugs in the prevention of EIB symptoms in children. Many researchers agree that treatment of EIA in children should always be individualized.

What Is New in the Prevention of Exercise-Induced Bronchospasm (EIB) in Children?

Pediatric Asthma, Allergy & ImmunologyVol. 21, No. 1 PHARMACOTHERAPY UPDATEWhat Is New in the Prevention of Exercise-Induced Bronchospasm (EIB) in Children?H. William KellyH. William KellySearch for more papers by this authorPublished Online:1 May 2008https://doi.org/10.1089/pai.2007.8746.PHARMAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byPathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameterAnnals of Allergy, Asthma & Immunology, Vol. 105, No. 6 Volume 21Issue 1Mar 2008 Information© 2008 Mary Ann Liebert, Inc.To cite this article:H. William Kelly.What Is New in the Prevention of Exercise-Induced Bronchospasm (EIB) in Children?.Pediatric Asthma, Allergy & Immunology.Mar 2008.40-43.http://doi.org/10.1089/pai.2007.8746.PHARMPublished in Volume: 21 Issue 1: May 1, 2008PDF download

The Role of Leukotriene Modifiers in the Management of Exercise-Induced Bronchoconstriction

ObjectiveTo review the use of leukotriene modifiers in exercise-induced bronchoconstriction (EIB).Data SourceA MEDLINE search (1966–March 2001) identified pertinent English-language publications on EIB in humans.Study SelectionSelection of prospective clinical studies was limited to those that focused on prevention of EIB with leukotriene modifiers, including both leukotriene receptor antagonists and 5-lipoxygenase inhibitors.Data SynthesisLeukotriene modifiers have been shown to attenuate EIB in patients with mild to intermittent, stable asthma from exacerbations after exercise, especially those with a predicted forced expiratory volume in 1 second (FEV1) &gt;80% and who did not require corticosteroids. Extrapolation to patients with more severe forms of asthma cannot be made because of the lack of currently available data in these types of patients. Children may benefit from the oral dosage forms of leukotriene modifiers if they have difficulty using a metered-dose inhaler. The current literature supports a lack of a tolerance effect with leukotriene modifiers, as opposed to tachyphylaxis seen with beta2-adrenergic drugs after repeated dosing. As many as 25% of EIB patients will not respond to therapy with leukotriene modifiers. Montelukast has the greatest volume of data and the most positive benefits of the available leukotriene modifiers.ConclusionsEvidence supports the use of leukotriene modifiers for protection of EIB in patients with stable, mild to intermittent asthma with a predicted FEV1≥80% if beta-agonists are intolerable or ineffective. Potential benefits include the lack of a tolerance effect, the long duration of action exhibited by some leukotriene modifiers, and the availability of a tablet form. Beta2-adrenergic drugs should remain the first-line therapy for EIB; however, leukotriene modifiers may provide a valuable alternative in those few who cannot use short-acting beta-agonists. Long-term safety studies of leukotriene modifiers in children and the elderly with EIB are necessary before widespread use can be advocated in the pediatric and geriatric populations.

Management of exercise-induced bronchoconstriction.

Exercise-induced bronchoconstriction (EIB) is a common clinical manifestation of asthma, occurring in 70% to 80% of asthmatics. Evidence suggests that exercise and the ensuing bronchoconstriction do not contribute to a worsening of asthmatic inflammation. Asthmatics should not be discouraged from exercising, and, with adequate management, most patients should be able to exercise regularly with only minor symptoms. The first step in the management of patients with EIB should be to obtain optimum control of the underlying asthma, often requiring regular treatment with inhaled steroids. Regular treatment with inhaled corticosteroids usually reduces the extent of EIB by 50% or more. Frequently, despite optimal management of the underlying asthma, patients develop EIB symptoms requiring additional treatment. Short and long acting inhaled beta2-agonists are highly effective at reducing the magnitude of EIB, although there are concerns that the extent of protection diminishes during periods of regular use of these agents. Inhaled cromolyn and nedocromyl are effective at reducing the extent of EIB in some patients, although this protection does not extend beyond 2 to 3 h after treatment. The recently developed leukotriene receptor antagonists are effective at reducing the extent of EIB by 40% to 70%, and have the advantage that this protection lasts throughout the day and does not appear to diminish with regular use. Other agents, including anticholinergics and antihistamines, have been shown to offer partial protection against EIB, suggesting the possibility of using a combination treatment to manage some patients' symptoms. Finally, there is encouraging evidence suggesting that modifications of the pattern of exercise can markedly reduce the extent of EIB.