Exercise induced asthma &bronchospasm

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  • Symptoms may begin during exercise and will usually worsen 5-20 minutes after your student stops the activity. Some individuals may experience a “late-phase reaction” 4-12 hours after exercising. These symptoms are usually less severe, but may last up to 24 hours. Students who are experiencing minor symptoms or are recovering from a recent asthma attack or episode/ illness may require exercise/activity modification. You may need to be creative to include these students, but participating at any level is better than being left out.


  • 1. Fawzia abo aliProf.of allergy &clinical immunology Faculty of medicine Ain shams university
  • 2. Exercise-induced asthma & bronchospasm• Definition: Airway obstruction, and hyper responsiveness, triggered by exercise - EIA: exercise induces symptoms of asthma in patients who have asthma (90% of patients) - EIB: exercise induces bronchospasm in patients without chronic asthma, for example, an elite athlete.
  • 3.  physical activity is the second leading cause of airway constriction after upper respiratory tract infections. EIA: symptoms start after exercise, peak 8 to 15 minutes after exercise and spontaneously resolve in 60 minutes. EIA is diagnosed by a 15% decrease in FEV1. EIA is most frequently seen in children and young adults because of their high levels of physical activity.
  • 4. Epidemiology EIA affects: 90% of asthmatics 40-50% of patients with allergic rhinitis 3-13% of the general population 10-20% of athletes
  • 5. Asthmogenic exercise: The type of exercise performed directly affects the intensity and duration of an EIA episode. Asthmogenic sports are characterized by sustained hyperpnea (deep, rapid breathing during intense, prolonged aerobic activity) - basketball - cycling - running - hockey
  • 6. Less asthmogenic sports:sport that produces intermittent bursts of hyperpnea, such as baseball, weight lifting or tennis. In addition, activities such as bike-riding and swimming are less likely to induce EIA than running.Swimming appears to be the least asthmogenic sport, which may in part be related to the inhalation of humidified air.
  • 7. The sequence of events in EIA is characteristic: 1. Airways dilate during exercise (FEV1 increases by 5% in normal people). 2. When the exercise is over, airway obstruction begins and progresses until it reaches a peak in 5-10 minutes 3. Spontaneous resolution occurs in 30 minutes. The tendency toward spontaneous remission is a hallmark of EIA: one needs only to reverse the acute event and the patient will then remain free of symptoms.
  • 8. Pathogenesis There are 2 theories for EIA pathogenesis: thermal osmoticThermal hypothesis, there is no role for biochemical mediators. Osmotic theory has been gaining a wider acceptance in recent years.
  • 9. histamine, leukotrienes, prostaglandins
  • 10.  Several studies have noted an increase in the concentration of cysteinyl leukotrienes (CysLTs) in the airways of patients with EIB. a recent study found that the fraction of exhaled nitric oxide (FENO) is elevated in asthmatic patients with EIB, Angiopoetin 2, a mediator that enhances microvascular permeability, is increased in the airways in EIB Mast cell infiltration of the airways has also been implicated in EIB.
  • 11. Duration of EIA Symptoms• Symptoms begin during or after exercise and usually worsen 5-20 minutes after stopping activity• Some people experience a “late-phase reaction” 4- 12 hours after exercising. Symptoms usually less severe.
  • 12. Diagnosis Exercise-induced asthma can be diagnosed by history only and formal testing is usually required only in competitive athletes. Points in the patient history: - Onset during or after exercise - EIB not affect first 5 minutes of exercise - Symptoms duration longer than 5 minutes
  • 13. Testing for EIA - FRAST: free running asthma screening test - Treadmill exercise test - Cycling FRAST A simple screening test in children: 1. Establish a baseline PEF. 2. Have the child run continuously for 7 minutes (same duration as treadmill exercise test), OR have the child run until he/she has symptoms. 3. Check PEF, more than 15% decrease in PEF is diagnostic of EIA.
  • 14. Exercise Challenge TestDiagnosis: 10 - 15% reduction of PEFR or FEV1 after 6 minutes treadmill exercise at 85- 90% maximal heart rate
  • 15. Bronchial provocation tests used to diagnose asthma in athletes• Methacholine challenge• Exercise challenge• Mannitol inhalation• Eucapnic voluntary hyperpnea• Hypertonic saline challenge
  • 16. Management Non-pharmacological treatment: - Ensure patient has taken asthma medicine• Warm-up and Cool down periods• Hydrate before, during and after exercise• Check pollen and air quality• Cold Weather• - breath through the nose
  • 17. Pharmacological treatment Mnemonic for drugs used for treatment of EIB - CLIMB: Cromolyn Leukotriene receptor antagonist (LTRA), montelukast Inhaled steroids (ICS) Mast cell stabilizers other than cromolyn Beta-2 agonists, albuterol
  • 18. In conclusion• EIA is common affecting10-20% of the general population, and up to 90% of unselected asthmatics• It is easily managed with warm-up and cool- down, nasal breathing and pre-medication.• Cough post exercise best predictor for positive exercise challenge test• 90% can be successfully treated with pre exercise MDI• Return to play usually safe• Control of Exercise-induced asthma affords a healthy lifestyle in which exercise is performed without restrictions.
  • 19. Resources• American College of Allergy, Asthma, and Immunology – http://www.acaai.org• American College of Chest Physicians – http://www.chestnet.org• American Thoracic Society – http://www.thoracic.org• The Centers for Disease Control and Prevention – http://www.cdc.gov/asthma• National Asthma Education and Prevention Program – http://www.nhlbi.nih.gov/about/naepp/• Asthma and Allergy Foundation of America – http://www.aafa.org• American Lung Association – http://www.lungusa.org• American Academy of Allergy, Asthma, and Immunology – http://www.aaaai.org• Allergy and Asthma Network/Mothers of Asthmatics, Inc. – http://www.aanma.org