Treatment Of Exercise-induced Asthma Research Articles

Mechanisms and Management of Exercise-Induced Asthma in Elite Athletes

Objective and methods. Asthma is often reported by elite athletes, especially endurance athletes. The aim of this article is to review current knowledge of mechanisms and management of exercise-induced asthma (EIA) in adult elite athletes. Results. The mechanisms underlying EIA is incompletely understood, but the two prevailing hypotheses are the hyper-osmolarity and the thermal hypothesis. Both hypotheses consider inflammation and activation of mast cells as being crucial for the development of EIA, although the assumed mechanisms triggering the inflammatory response differ. Objective testing is of utmost importance in the diagnosis of EIA in elite athletes. Management of EIA can be divided into pharmacologic and non-pharmacologic treatment. The basic principles for the treatment of EIA in elite athletes should be as for any asthmatic individual, including use of inhaled corticosteroids (ICS), β2-agonists, and leukotriene antagonists. However, evidence suggests that daily use of β2-agonists might lead to the development of tolerance. ICS therapy is, due to its anti-inflammatory effects, the recommended primary therapy for EIA also in elite athletes. All doctors treating individuals with asthma, especially elite athletes, should remain updated on doping aspects of asthma therapy. Non-pharmacologic management of EIA in elite athletes includes physical warm-up, which takes advantage of the refractory period following an attack of EIA, whereas high intake of antioxidants may reduce airway inflammation. Wearing heat masks, specially designed for outdoor winter athletes, might protect against bronchoconstriction triggered by inhalation of cold and dry air. Conclusion. EIA in elite athletes should be managed as in any individual with asthma, but the risk of developing tolerance to bronchodilators as well as doping aspects should always be taken into account.

Asthma in elite athletes

Asthma is frequently found among elite athletes performing endurance sports such as swimming, rowing and cross-country skiing. Although these athletes often report symptoms while exercising, they seldom have symptoms at rest. Moreover, compared with nonathletic asthmatic individuals, elite athletes have been shown to have a different distribution of airway inflammation and unequal response to bronchial provocative test. Elite athletes display signs of exercise-induced symptoms, for example, nonasthmatic inspiratory wheeze, vocal cord dysfunction and cardiac arrhythmias, which could limit their physical capacity. Elite athletes should undergo comprehensive assessment to confirm an asthma diagnosis and determine its degree of severity. Treatment should be as for any other asthmatic individual, including the use of β2-agonist, inhaled steroid as well as leukotriene-antagonist. It should, however, be noted that daily use of β-agonists could expose elite athletes to the risk of developing tolerance towards these drugs. Use of β2-agonist should be replaced with daily inhaled corticosteroid treatment, the most important treatment of exercise-induced asthma. All physicians treating asthma should be aware of the doping aspects. Systemic β2-agonist intake is strictly prohibited, whereas inhaled treatment is allowed in therapeutic doses when asthma is documented and dispensation has been granted when needed.

Exercise-induced asthma in children

Exercise-induced bronchoconstriction affects 40–90% of people with asthma, compared with 3–15% of the general population. Exercise-induced asthma (EIA) is diagnosed on the basis of subjective symptoms of airflow obstruction during and after exercise, objective measures of airflow obstruction and the exclusion of alternative diagnoses. Although the pathogenesis of EIA has not been fully elucidated, two major theories have been proposed: the airway rewarming theory and the hyperosmolarity theory. Increasing evidence suggests that airway inflammation plays a major role in the pathogenesis of EIA. In this article, we review the prevalence, pathogenesis, methods for diagnosis and treatment of EIA, as well as the responsiveness of children and adolescents to EIA therapies.

Challenge of exercise-induced asthma and exercise-induced bronchoconstriction

Exertional dyspnea is a common clinical problem seen with different etiologies in different clinical situations and may even be found in healthy individuals. Approximately 90% of asthmatic patients suffer from shortness of breath in the context of exercise. Dyspnea, occurring during or after exercise, can be the only clinical manifestation of asthma. On the other hand, bronchoconstriction may occur in the absence of asthma – so-called exercise-induced bronchoconstriction. In elite athletes and persons performing sports with high ventilatory demand, bronchospasm in the context of exercise may appear without the presence of asthma. In these circumstances, bronchoconstriction is characterized by neutrophilic inflammation in the bronchial epithelium. Exercise-induced bronchoconstriction in the absence of asthma is difficult to diagnose and to treat. Diagnostic tests are often complex to handle, infrequently performed and the majority miss well-defined cut-off points. Diagnosis is confirmed either by performing direct or indirect bronchial challenge tests for classical asthma or through indirect tests for exercise-induced bronchoconstriction. Therapy for both diseases is based on short-acting β-agonists used 15 min before exercise. Daily basic therapy is different for asthmatics and nonasthmatics – where basic therapy consists of inhaled corticosteroids in asthmatics, leukotriene antagonists play a more important role in exercise-induced bronchoconstriction. In general, treatment of exercise-induced asthma follows the Global Initiative of Asthma guidelines.

Treatment of exercise‐induced asthma, respiratory and allergic disorders in sports and the relationship to doping: Part II of the report from the Joint Task Force of European Respiratory Society (ERS) and European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN*

The aims of part II is to review the current recommended treatment of exercise-induced asthma (EIA), respiratory and allergic disorders in sports, to review the evidence on possible improvement of performance in sports by asthma drugs and to make recommendations for their treatment. The literature cited with respect to the treatment of exercise induced asthma in athletes (and in asthma patients) is mainly based upon the systematic review given by Larsson et al. (Larsson K, Carlsen KH, Bonini S. Anti-asthmatic drugs: treatment of athletes and exercise-induced bronchoconstriction. In: Carlsen KH, Delgado L, Del Giacco S, editors. Diagnosis, prevention and treatment of exercise-related asthma, respiratory and allergic disorders in sports. Sheffield, UK: European Respiratory Journals Ltd, 2005:73-88) during the work of the Task Force. To assess the evidence of the literature regarding use of beta(2)-agonists related to athletic performance, the Task Force searched Medline for relevant papers up to November 2006 using the present search words: asthma, bronchial responsiveness, exercise-induced bronchoconstriction, athletes, sports, performance and beta(2)-agonists. Evidence level and grades of recommendation were assessed according to Sign criteria. Treatment recommendations for EIA and bronchial hyper-responsiveness in athletes are set forth with special reference to controller and reliever medications. Evidence for lack of improvement of exercise performance by inhaled beta(2)-agonists in healthy athletes serves as a basis for permitting their use. There is a lack of evidence of treatment effects of asthma drugs on EIA and bronchial hyper-responsiveness in athletes whereas extensive documentation exists in treatment of EIA in patients with asthma. The documentation on lack of improvement on performance by common asthma drugs as inhaled beta(2)-agonists with relationship to sports in healthy individuals is of high evidence, level (1+). Exercise induced asthma should be treated in athletes along same principles as in ordinary asthma patients with relevance to controller and reliever treatment after careful diagnosis. There is very high level of evidence for the lack of improvement in athletic performance by inhaled beta2-agonists.

Pharmaceutical treatment strategies for childhood asthma

Although great improvement has been obtained in quality of life and mastering of illness by asthmatic children over recent decades, controversies still exist related to asthma treatment. The objective of the present article is to discuss such controversies. Results from recent publications related to childhood asthma treatment question existing dogmas. Important for prescribing correct treatment to children is correct diagnosis. Phenotypes of childhood asthma related to treatment decisions are discussed. Early use of inhaled steroids in young children is still debated as well as the preference of inhaled long-acting beta2-agonists versus leukotriene receptor antagonists as add on to inhaled steroids. When present, both allergic rhinitis and asthma should be treated to obtain improved control. Also as regards the treatment of exercise-induced asthma in children, new results concerning use of leukotriene receptor antagonists is discussed as well as the acute treatment in infants with bronchial obstruction. There are still several controversies regarding treatment of the asthmatic child. New studies designed specifically for children are needed to solve these questions. One cannot rely on studies performed in adults for treatment in children. New studies designed for childhood asthma are needed to solve these controversies.

Treatment of exercise-induced asthma with beclomethasone dipropionate in children with asthma

A new hydrofluoroalkane-beclomethasone dipropionate (HFA-BDP) aerosol markedly increases drug delivery to the airways. Therefore, even low doses of HFA-BDP should be effective, and the present study assesses this. A randomised, double-blind, crossover study was used to compare the effect of placebo, HFA-BDP 50 microg or 100 microg given q.d. (QVAR(TM) Autohaler(TM); 3M Pharmaceuticals, St. Paul, MN, USA) on exercise-induced bronchoconstriction and exhaled nitric oxide (eNO). After a 14-day run-in, 25 children (5-14 yrs old) entered three 4-week treatment periods, separated by a 1-week washout. After each period, the fall in forced expiratory volume in one second (FEV1), after an exercise test, and eNO were measured. Significant treatment effects with no carry-over or period effects were seen for both eNO and maximum fall in FEV1 after exercise. Differences were seen between placebo (fall in FEV1=27.9%; eNO=14.4 parts per billion (ppb)) and either dose of HFA-BDP, but not between the two active doses (50 microg: fall in FEV1=20.8%, eNO=9.3 ppb; 100 microg: fall in FEV1=20.9%, eNO=8.9 ppb). In conclusion, low q.d. doses of hydrofluoroalkane-beclomethasone dipropionate reduced exhaled nitric oxide and exercise-induced bronchoconstriction. Further studies are needed to assess whether q.d. administration of beclomethasone dipropionate is as effective as b.i.d. administration.

Progressive exercise-induced asthma in a 38-year-old man

HISTORY OF PRESENT ILLNESS A previously healthy, 38-year-old male, security guard presents with a 4-month history of shortness of breath with exercise such as running and swimming. He denied symptoms of orthopnea, paroxysmal nocturnal dyspnea, cough, wheeze, and ankle edema. He was prescribed albuterol by inhalation to be taken before exercise and triamcinolone inhaler by his primary care physician with partial improvement. He was referred to us for further treatment for exerciseinduced asthma. Two weeks before his evaluation, he presented to the emergency department complaining of severe dyspnea on exertion. An electrocardiogram (EKG) and chest x-ray examination were normal. Laboratory studies including a complete blood cell count and thyroid function tests were normal. He had discontinued the triamcinolone inhaler.

Dietary components with demonstrated effectiveness in decreasing the severity of exercise-induced asthma.

Exercise-induced asthma (EIA) occurs in up to 90% of individuals with asthma and approximately 10% of the general population without asthma. EIA describes a condition in which vigorous physical activity triggers acute airway narrowing with heightened airway reactivity resulting in reductions in forced expiratory volume in 1 second of greater than 10% compared with pre-exercise values. Treatment of EIA almost exclusively involves the use of pharmacological medications. However, there is accumulating evidence that a dietary excess of salt and omega-6 fatty acids, and a dietary deficiency of antioxidant vitamins and omega-3 fatty acids, can modify the severity of EIA. The modification of these dietary factors has the potential to reduce the incidence and prevalence of this disease. The dietary component most studied to date is dietary salt. Recent studies have supported a role for dietary salt as a modifier of the severity of EIA, suggesting that salt-restrictive diets can reduce the severity of EIA. Since EIA is part of the asthmatic diathesis, it is possible that EIA may serve as a useful model for investigation of potential dietary interventions for reducing airway hyperresponsiveness.

Preventing and managing exercise-induced asthma.

Managing exercise-induced asthma is a challenge for the patient and the clinician. As the incidence of exercise-induced asthma increases, health care providers need effective protocols to diagnose and treat these patients in outpatient settings. This article discusses the incidence, risk factors, pathophysiology, diagnosis, and treatment of exercise-induced asthma. Both traditional and new methods of disease diagnosis and treatment in the outpatient setting are explored.

Nedocromil sodium in the treatment of exercise-induced asthma: a meta-analysis.

Exercise-induced asthma (or bronchoconstriction) afflicts millions of people worldwide. While generally self-limiting, it can hinder performance and reduce activity levels, thus it is an important condition to diagnose and treat. The objective of this review was to assess the prophylactic effect of a single dose of nedocromil sodium on exercise-induced asthma. The Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, reference lists of relevant articles, review articles and textbooks were searched for randomized trials comparing a single dose of nedocromil to placebo to prevent exercise-induced asthma in people >6 yrs of age. Authors and the drug manufacturer were contacted for additional trials. Trial quality assessments and data extraction were conducted independently by two reviewers. Authors were contacted when possible. Twenty trials were included. All were rated as having good methodological quality. Nedocromil inhibited bronchoconstriction in all age groups. The pooled weighted mean difference for the maximum percentage fall in forced expiratory volume in one second was 15.6%, (95% confidence interval (95% CI): 13.2-18.1) and for the peak expiratory flow was 15.0% (95% CI: 8.3-21.6). These differences are both statistically and clinically significant. After nedocromil the time to recover normal lung function was <10 min compared to >30 min with placebo. Nedocromil had a greater effect on people with a fall in lung function of >30% from baseline. There were no significant adverse effects reported with this short-term use. In conclusion, Nedocromil taken before exercise appears to reduce the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced as severity increases.

Comparative efficacy of inhaled furosemide and disodium cromoglycate in the treatment of exercise-induced asthma in children

Background: Inhaled furosemide has been shown, in patients with asthma, to have prophylactic properties similar to those of disodium cromoglycate. Objective: The aim of this study was to evaluate the protective effect of these drugs in the treatment of exercise-induced asthma. Methods: Fifteen children with exercise-induced asthma (mean age, 10.8 years) underwent exercise challenge after a single dose of nebulized placebo, furosemide (20 mg/m 2 body area), or disodium cromoglycate (20 mg), 2 days apart, in a single-blind crossover trial. Results: Both furosemide and disodium cromoglycate exerted significant protection against the bronchial response to exercise challenge, with a mean maximum percentage falls in FEV 1 of 4.66% and 7.22%, respectively ( p < 0.05). On the placebo day, the mean maximum percentage fall in FEV 1 was 34.50% ( p< 0.05). Conclusion: The results of this study suggest that furosemide and disodium cromoglycate provide comparable efficacy in preventing exercise-induced asthma in children, with no side effects. (J Allergy Clin Immunol 1997;99:204-9.)

Special problems of the asthmatic patient

Environmental factors and physical activity present special problems for the asthmatic patient. Bronchoconstriction due to workplace exposure is one of the most common forms of occupational lung disease and has similar pathogenic mechanisms to nonoccupational asthma. Diagnosing occupational asthma may be difficult because the association between symptoms during or after work and a causative agent may be obscure. Nevertheless, it is important to recognize occupational asthma because even trace amounts of the causative agent may trigger bronchoconstriction, and the affected employee must almost always avoid exposure. Bronchoconstriction induced by exercise has affected the lifestyles of many asthmatic patients and has created special problems for numerous accomplished athletes. Although exercise-induced asthma (EIA) characteristically occurs immediately after cessation of exertion, a recent study suggests that it may sometimes begin during sustained exertion. Asthmatic patients who participate in winter sports are particularly susceptible to EIA. Vocal cord dysfunction in athletes who participate in intense competition can mimic EIA. In addition to beta-agonists used immediately before exercise, newer drugs that show promise in the treatment of EIA include the leukotriene inhibitors and furosemide. Asthmatic patients are susceptible to extremes in atmospheric pressure and have increased risk of barotrauma and arterial gas embolism during scuba diving. During longer stays at high altitude, however, asthmatic patients appear to have attenuated bronchial responsiveness.

Comparison of the protective effects of cromolyn sodium and nedocromil sodium in the treatment of exercise-induced asthma in children

Seventeen children with asthma were studied in a double-blind, crossover, placebo-controlled study designed to compare the efficacy of cromolyn sodium with that of nedocromil sodium in preventing exercise-induced asthma. All drugs were delivered through a metered-dose inhaler (cromolyn sodium, 10 mg; nedocromil sodium, 4 mg; placebo, two puffs). Nedocromil sodium and cromolyn sodium provided significant, comparable protection from exercise-induced asthma, and both drugs were better than placebo. We conclude that nedocromil sodium and cromolyn sodium administered by a pressurized aerosol provide equal protection against exercise-induced asthma in children.

Exercise-Induced Asthma in Children

One of the goals in treating asthmatic children is to give them the opportunity to have a normal lifestyle. Exercise-induced asthma (EIA) often prevents these children from participating in activities that are important for growth, physical fitness, and self-esteem. Although our treatment of EIA has improved grealy in the last 20 years, some questions concerning the pathogenesis of this disorder remain unanswered. Specific guidelines for exercise-challenge have improved our ability to diagnose this disorder, especially in those with no known history of asthma. Prevention remains the key to management of this condition and pharmacologic and nonpharmacologic methods are useful in achieving this. Finally, special attention needs to be paid to the child's school environment. Controlling EIA gives children the opportunity to participate in the healthy activities that lead to proper growth and development, and thus improves their quality of life.

Sports and Allergy

Allergic and asthmatic individuals may have exercise-induced respiratory problems and sports may induce, in some cases, allergic problems. Exercise-induced asthma (EIA) differs from common asthma only in its causative factor. It is a typical asthmatic attack following physical exercise, lasting 5-10 min, most often in cold and dry weather. The prevalence in asthmatic children is high, in adolescents not yet firmly established. Cold air and/or hypertonic bronchial challenges during exercise are discussed as pathophysiological mechanisms. Nonpharmacological and drug treatment of EIA must preferentially be preventive. Exercise-induced anaphylaxis (urticaria, pruritus, edema) occurs mainly in children, triggered by exercise alone or by the combination of sensitizing food and exercise. Antihistamines before exercise are recommended. The use of sport equipment can induce contact dermatitis in rare cases.

Bricanyl® Turbuhaler® and Ventolin® Rotahaler® in exercise‐induced asthma in children

Bricanyl Turbuhaler (0.5 mg terbutaline sulphate) and Ventolin Rotahaler (0.4 mg salbutamol) were compared in a randomized double-blind placebo controlled study on exercise-induced asthma in 19 children (14 boys) aged 7-14 years. The study was carried out on 3 separate days. Asthmatic attacks were provoked by free range running. Peak expiratory flow (PEF) was measured before and after exercise. If PEF decreased by greater than 20%, one inhalation from each of the inhalers was given under supervision of the investigator. Only one of the inhalers (none on the placebo day) delivered active drug. PEF was measured again 5 and 10 min after treatment. Already 5 min after treatment PEF had returned to baseline after active treatment. There was no statistically significant difference between the two active treatments. After placebo treatment, PEF did not return to baseline even at the 10 min post-exercise measurement. Ten children needed extra medication after the last PEF measurement on the placebo day, whereas no child needed extra medication after any of the active treatments. No adverse events were reported in this study. In conclusion, Bricanyl Turbuhaler (0.5 mg) and Ventolin Rotahaler (0.4 mg) were equally efficacious in the treatment of exercise-induced asthma in children.