Exercise-induced Bronchoconstriction

Publication Date: May 1, 2016
Last Updated: December 16, 2022

Diagnosis

Summary Statement (SS)1: In asthmatic patients EIB can indicate lack of control of the underlying asthma. Therefore treat the uncontrolled asthma to get control of EIB. ( S , D )
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SS2: A diagnosis of EIB should be confirmed by demonstration of airways reversibility or challenge in association with a history consistent with EIB because self-reported symptoms are not adequate. ( S , B)
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SS3: Evaluate EIB in elite athletes by using objective testing. ( S , B)
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SS4: Perform a standardized bronchoprovocation (exercise or a surrogate) challenge to diagnose EIB because the prevalence of EIB will vary with the type of challenge and the conditions under which the challenge is performed. ( S , A)
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SS5: In subjects with no current clinical history of asthma, use an indirect ungraded challenge (eg, exercise challenge or surrogate testing, such as with EVH) for assessing EIB in the recreational or elite athlete who has normal lung function. ( S , D )
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SS6: Use an indirect graded challenge (eg, mannitol, if available) for assessing EIB in recreational or elite athletes who have normal to near-normal lung function and who might currently require treatment for the prevention of EIB or asthma. ( S , D )
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SS7: Perform an indirect challenge (eg, exercise challenge or surrogate testing, such as with eucapnic voluntary hyperpnea [EVH] or mannitol, where available) instead of a direct challenge (eg, methacholine) for assessing EIB, recognizing that an indirect challenge is more sensitive for detection of EIB than a direct (eg, methacholine) challenge. ( S , B)
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SS8: Ensure the ventilation reached and sustained during exercise challenge testing is at least 60% of the maximum voluntary ventilation by using dry medical grade air to achieve an adequate challenge. If ventilation cannot be measured, ensure the heart rate as a percentage of maximum heart rate (HRmax) that is reached and sustained is ≥85% in adults and ≥95% in children and elite athletes. ( S , B)
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SS9: Perform EVH as the preferred surrogate challenge for the athlete without a current history of asthma participating in competitive sports in whom the diagnosis of EIB is suspected. ( S , D )
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SS10: If an indirect graded challenge (eg, mannitol) result is negative and EIB is still suspected, an ungraded challenge should be considered. ( W , B)
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SS11: To differentiate between EIB and exercise-induced laryngeal dysfunction (EILD), perform appropriate challenge tests (eg, exercise, EVH, and mannitol for EIB) and potentially flexible laryngoscopy during exercise for diagnosis of EILD. ( S , B)
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SS12: To determine whether exercise-induced dyspnea and hyperventilation are masquerading as asthma, especially in children and adolescents, perform cardiopulmonary exercise testing. ( M , C)
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SS13: Perform spirometry, as well as detailed pulmonary examination, to determine whether shortness of breath with exercise is associated with underlying conditions, such as COPD, or restrictive lung conditions, such as obesity, skeletal defects (eg, pectus excavatum), diaphragmatic paralysis, or interstitial fibrosis, rather than EIB. ( M , C)
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SS14: Consider a diagnosis of exercise-induced anaphylaxis (EIAna) instead of EIB based on a history of shortness of breath or other respiratory tract symptoms accompanied by systemic symptoms (eg, pruritis, urticaria, and hypotension). ( M , C)
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Treatment

SS15: Refer to appropriate specialists (eg, cardiologist or pulmonologist) to perform cardiopulmonary testing when breathlessness with exercise, with or without chest pain, might be caused by heart disease or other conditions in the absence of EIB. ( M , C)
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SS16: Refer patients for psychological evaluation when the symptoms (eg, hyperventilation and anxiety disorders) are in the differential diagnosis of EIB. ( W , D )
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SS17: Schedule regular office visits with patients because medications can differ in effectiveness over time because of variability of asthma, environmental conditions, intensity of the exercise stimulus, and tachyphylaxis. ( S , A)
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β2-Adrenergic Receptor Agonists

SS18: Prescribe inhaled short-acting β2-adrenergic receptor agonists for protection against EIB and for accelerating recovery of pulmonary function when given after a decrease in pulmonary function after exercise. ( S , A)
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SS19: Prescribe a single dose of SABA, LABA, or both on an intermittent basis (ie, <4 times per week) before exercise because this might protect against or attenuate EIB. ( S , A)
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SS20: Be cautious in daily use of β2-adrenergic agents alone or in combination with ICSs because this can lead to tolerance manifested as a reduction in duration, magnitude, or both of protection against EIB and a prolongation of recovery in response to SABAs after exercise. ( S , A)
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Leukotriene Inhibitors

SS21: Consider prescribing daily therapy with leukotriene inhibitors because this does not lead to tolerance and has been shown to attenuate EIB in 50% of patients. It can also be used for intermittent or maintenance prophylaxis. However, it provides incomplete protection and is not effective for reversing airway obstruction. ( S , A)
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Mast Cell Stabilizers

SS22: Consider prescribing inhaled cromolyn sodium and nedocromil sodium (currently not available in the United States as a metered-dose inhaler or dry powder inhaler) shortly before exercise; this attenuates EIB but can have a short duration of action. There is no bronchodilator activity. They might be effective alone or as added therapy with other drugs for EIB. ( S , )
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ICSs

SS23: Consider prescribing ICSs in combination with other therapies because ICSs can decrease the frequency and severity of EIB but not necessarily eliminate it. ( S , )
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SS24: Do NOT prescribe daily LABAs with ICS therapy to treat EIB unless needed to treat moderate-to- severe persistent asthma. The ICS might not prevent the occurrence of tolerance from daily β2-agonist use. ( S , A)
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Anticholinergic Agents

SS25: Consider prescribing inhaled ipratropium bromide for patients who have not responded to other agents. However, its ability to attenuate EIB is inconsistent. ( W , )
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Nonpharmacologic Therapy

SS26: Prescribe pre-exercise warm-up for EIB because it can be helpful in reducing the severity of EIB. ( S , A)
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SS27: Consider with caution the recommendation of reduction of sodium intake and ingestion of fish oil and ascorbic acid supplementation. Results are questionable in reducing the severity of EIB. ( W , B)
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Competitive and Elite Athletes

SS28: Treat athletes with EIB alone in a similar manner to those with EIB and asthma by using the recommended general treatments for asthma. This might require additional consideration in athletes in whom some governing bodies might have requirements for obtaining permission to receive pharmaceutical agents for competition. ( S , A)
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Recommendation Grading

Overview

Title

Exercise-induced Bronchoconstriction

Authoring Organizations

Publication Month/Year

May 1, 2016

Last Updated Month/Year

March 26, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, School

Intended Users

Athletics coaching, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D001250 - Asthma, Exercise-Induced, D001249 - Asthma, D016084 - Bronchoconstriction

Keywords

exercise-induced bronchoconstriction, exercise-induced bronchospasm, exercise-induced asthma, sports-related asthma