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exercise-induced asthma

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 - no wheezing except with exercise Special laboratory: - 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] - 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

General

asthma

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
  2. Parsons JP, Mastronarde JG. Exercise-induced asthma. Curr Opin Pulm Med. 2009 Jan;15(1):25-8 PMID: 19077702
  3. 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 PMID: 23634861 http://www.atsjournals.org/doi/abs/10.1164/rccm.201303-0437ST
  4. Boulet LP, O'Byrne PM. Asthma and exercise-induced bronchoconstriction in athletes. N Engl J Med. 2015 Feb 12;372(7):641-8 PMID: 25671256 http://www.nejm.org/doi/full/10.1056/NEJMra1407552
  5. NEJM Knowledge+ Question of the Week. Feb 28, 2017 http://knowledgeplus.nejm.org/question-of-week/4093/
  6. 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: 23925985
  7. NEJM Knowledge+ Question of the Week. Jan 17, 2023 http://knowledgeplus.nejm.org/question-of-week/1951/ - NEJM Knowledge+ Allergy/Immunology
  8. 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: 21167465
  9. Del Giacco SR et al. Exercise and asthma: an overview. Eur Clin Respir J 2015; 2:27984. PMID: 26672959 PMCID: PMC4653278 Free PMC article
  10. NEJM Knowledge+ - Global Strategy for Asthma Management and Prevention. July 10, 2023 https://ginasthma.org/reports/