exercise-induced asthma
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Etiology
- exercise
- cold air
Pathology
- key stimulus is probably airway dehydration as a result of increased ventilation, resulting in increased osmolarity of fluid lining the airways
- this triggers release of inflammatory mediators (histamine, leukotrienes, prostaglandins) resulting in airway smooth-muscle contraction & airway edema[4]
Clinical manifestations
- bronchospasm with exercise or exposure to cold air
- no nighttime symptoms
- symptoms occur immediately after cessation of exercise
- bronchoconstriction peaks 5-10 minutes after cessation of exercise & resolves within 30 minutes[1]
- physical examination is normal
Diagnostic procedures
- pulmonary function testing
- provocation inhalation challenge test[4]
- pre- & post-exercise spirometry is the gold standard for diagnosis
- not necessary with a classic history & physical examination
- indicated for failure of empiric bronchodilator treatment or if features of another pulmonary disease[5]
Management
- avoid exercising while exposed to large amounts of allergens or air pollutants[4]
- avoid exercising in very low temperatures[4]
- inhaled glucocorticoid/formoterol before exercise is treatment of choice[10]
- preferred initial treatment, not alternative treatment[10]
- other recommendations[10]
- trial of albuterol inhaler before exercise
- before pre & postexercise spirometry
- preferred initial treatment*[7]
- daily inhaled glucocorticoid + beta-2 adrenergic agonist inhaler (albuterol) 15 minutes prior to exercise[1] (avoid overuse[4]) *NEJM*[10]
- provides bronchodilation for 2-4 hours[1]
- inhaled glucocorticoid/formoterol is alternative[1]
- preferred initial treatment*[7]
- trial of albuterol inhaler before exercise
- for patients who continue to have symptoms despite use of a short-acting glucocorticoid/beta-2 adrenergic agonist before exercise
- a daily inhaled corticosteroid
- a daily leukotriene receptor antagonist
- mast cell stabilizing agent (cromolyn) before exercise[3]
- symptoms can be controlled in majority of patients
* either albuterol or inhaled glucocorticoid/formoterol preferred initial treatment
Notes
- preparticipation history & physical examination
- evaluate for exertional symptoms
- family history of sudden death
- evaluate for cardiac murmur
More general terms
References
- ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
- ↑ Parsons JP, Mastronarde JG. Exercise-induced asthma. Curr Opin Pulm Med. 2009 Jan;15(1):25-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19077702
- ↑ Jump up to: 3.0 3.1 Parsons JP et al An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction. American Journal of Respiratory and Critical Care Medicine, Vol. 187, No. 9 (2013), pp. 1016-1027 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23634861 <Internet> http://www.atsjournals.org/doi/abs/10.1164/rccm.201303-0437ST
- ↑ Jump up to: 4.0 4.1 4.2 4.3 4.4 4.5 Boulet LP, O'Byrne PM. Asthma and exercise-induced bronchoconstriction in athletes. N Engl J Med. 2015 Feb 12;372(7):641-8 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25671256 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMra1407552
- ↑ Jump up to: 5.0 5.1 NEJM Knowledge+ Question of the Week. Feb 28, 2017 http://knowledgeplus.nejm.org/question-of-week/4093/
- ↑ Randolph C. Pediatric exercise-induced bronchoconstriction: contemporary developments in epidemiology, pathogenesis, presentation, diagnosis, and therapy. Curr Allergy Asthma Rep. 2013 Dec;13(6):662-71. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23925985
- ↑ Jump up to: 7.0 7.1 7.2 NEJM Knowledge+ Question of the Week. Jan 17, 2023 http://knowledgeplus.nejm.org/question-of-week/1951/
NEJM Knowledge+ Allergy/Immunology - ↑ Weiler JM et al. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol 2010 Dec; 105:S1-47. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21167465
- ↑ Del Giacco SR et al. Exercise and asthma: an overview. Eur Clin Respir J 2015; 2:27984. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26672959 PMCID: PMC4653278 Free PMC article
- ↑ Jump up to: 10.0 10.1 10.2 10.3 10.4 NEJM Knowledge+
Global Strategy for Asthma Management and Prevention. July 10, 2023 https://ginasthma.org/reports/