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Exercise-induced bronchoconstriction

exercise-induced bronchoconstriction, exercise-induced bronchoconstriction (eib)
Exercise-induced asthma, or EIA, occurs when the airways narrow as a result of exercise The preferred term for this condition is exercise-induced bronchoconstriction EIB; exercise does not cause asthma, but is frequently an asthma trigger1


  • 1 Signs and symptoms
  • 2 Cause
  • 3 Diagnosis
    • 31 Spirometry
    • 32 Exercise testing
    • 33 Field-exercise challenge
      • 331 Eucapnic voluntary hyperventilation challenge
      • 332 Medication challenge
  • 4 Treatment
    • 41 Lifestyle
    • 42 Medication
  • 5 Prognosis
  • 6 References
  • 7 External links

Signs and symptomsedit

It might be expected that people with EIB would present with shortness of breath, and/or an elevated respiratory rate and wheezing, consistent with an asthma attack However, many will present with decreased stamina, or difficulty in recovering from exertion compared to team members, or paroxysmal coughing from an irritable airway2 Similarly, examination may reveal wheezing and prolonged expiratory phase, or may be quite normal Consequently, a potential for under-diagnosis exists Measurement of airflow, such as peak expiratory flow rates, which can be done inexpensively on the track or sideline, may prove helpful


While the potential triggering events for EIB are well recognized, the underlying pathogenesis is poorly understood3 It usually occurs after at least several minutes of vigorous, aerobic activity, which increases oxygen demand to the point where breathing through the nose nasal breathing must be supplemented by mouth breathing The resultant inhalation of air that has not been warmed and humidified by the nasal passages seems to generate increased blood flow to the linings of the bronchial tree, resulting in edema Constriction of these small airways then follows, worsening the degree of obstruction to airflow There is increasing evidence that the smooth muscle that lines the airways becomes progressively more sensitive to changes that occur as a result of injury to the airways from dehydration The chemical mediators that provoke the muscle spasm appear to arise from mast cells3


Exercise-induced bronchoconstriction can be difficult to diagnose clinically given the lack of specific symptoms2 and frequent misinterpretation as manifestations of vigorous exercise There are many mimics that present with similar symptoms, such as vocal cord dysfunction, cardiac arrhythmias, cardiomyopathies, and gastroesophageal reflux disease It is also important to distinguish those who have asthma with exercise worsening, and who consequently will have abnormal testing at rest, from true exercise-induced bronchoconstriction, where there will be normal baseline results Because of the wide differential diagnosis of exertional respiratory complaints, the diagnosis of exercise-induced bronchoconstriction based on history and self-reported symptoms alone has been shown to be inaccurate 45 and will result in an incorrect diagnosis more than 50% of the time6


Objective testing should begin with spirometry at rest In true exercise-induced bronchoconstriction, the results should be within normal limits Should resting values be abnormal, then asthma, or some other chronic lung condition, is present There is, of course, no reason why asthma and exercise-induced bronchoconstriction should not co-exist but the distinction is important because without successful treatment of underlying asthma, treatment of an exercise component will likely be unsuccessful If baseline testing is normal, some form of exercise or pharmacologic stress will be required, either on the sideline or practice venue, or in the laboratory7

Exercise testingedit

Treadmill or ergometer-based testing in lung function laboratories are effective methods for diagnosing exercise-induced bronchoconstriction, but may result in false negatives if the exercise stimulus is not intense enough

Field-exercise challengeedit

Field-exercise challenge tests that involve the athlete performing the sport in which they are normally involved and assessing FEV1 after exercise are helpful if abnormal but have been shown to be less sensitive than eucapnic voluntary hyperventilation8

Eucapnic voluntary hyperventilation challengeedit

The International Olympic Committee recommends the eucapnic voluntary hyperventilation EVH challenge as the test to document exercise-induced asthma in Olympic athletes9 In the EVH challenge, the patient voluntarily, without exercising, rapidly breathes dry air enriched with 5% CO2 for six minutes The presence of the enriched CO2 compensates for the CO2 losses in the expired air, not matched by metabolic production, that occurs during hyperventilation, and so maintains CO2 levels at normal10

Medication challengeedit

Medication challenge tests, such as the methacholine challenge test, have a lower sensitivity for detection of exercise-induced bronchoconstriction in athletes and are also not a recommended first-line approach in the evaluation of exercise-induced asthma11

Mannitol inhalation1213 has been recently approved for use in the United States

It should be noted, however, that a relatively recent review of the literature has concluded that there is currently insufficient available evidence to conclude that either mannitol inhalation or eucapnic voluntary hyperventilation are suitable alternatives to exercise challenge testing to detect exercise-induced bronchoconstriction and that additional research is required14


Further information: Asthma § Treatment


The best treatment is avoidance of conditions predisposing to attacks, when possible In athletes who wish to continue their sport or do so in adverse conditions, preventive measures include altered training techniques and medications

Some take advantage of the refractory period by precipitating an attack by "warming up," and then timing competition such that it occurs during the refractory period Step-wise training works in a similar fashion Warm up occurs in stages of increasing intensity, using the refractory period generated by each stage to reach a full workload15


The treatment of EIB has been extensively studied in asthmatic subjects over the last 30 years, but not so in EIBclarification needed Thus, it is not known whether athletes with EIB or ‘sports asthma’ respond similarly to subjects with classical allergic or nonallergic asthma However, there is no evidence supporting different treatment for EIB in asthmatic athletes and nonathletes16

The most common medication used is a beta agonist taken about 20 minutes before exercise16 Some physicians prescribe inhaled anti-inflammatory mists such as corticosteroids or leukotriene antagonists, and mast cell stabilizers have also proven effective16 A randomized crossover study compared oral montelukast with inhaled salmeterol, both given two hours before exercise Both drugs had similar benefit but montelukast lasted 24 hours17

Three randomized double-blind cross-over trials have examined the effect of vitamin C on EIB18 Pooling the results of the three vitamin C trials indicates an average 48% reduction in the FEV1 decline caused by exericise Figure The systematic review concluded that "given the safety and low cost of vitamin C, and the positive findings for vitamin C administration in the three EIB studies, it seems reasonable for physically active people to test vitamin C when they have respiratory symptoms such as cough associated with exercise"18 It should be acknowledged that the total number of subjects involved in all three trials was only 40

Figure: This forest plot shows the effect of vitamin C 05–2 g/day on post-exercise decline in FEV1 in three studies with asthmatic participants Constructed from data in Fig 4 of Hemilä 201318 The three horizontal lines indicate the three studies, and the diamond shape at the bottom indicates the pooled effect of vitamin C: decrease in the post-exercise decline in FEV1 by 48% 95%CI: 33 to 64%

In May 2013, the American Thoracic Society issued the first treatment guidelines for EIB19


As evidenced by many professional athletes who have overcome EIB using some combination of accepted treatments, the prognosis is usually very gooddubious – discuss Olympic swimmers Tom Dolan, Amy Van Dyken, and Nancy Hogshead, Olympic track star Jackie Joyner-Kersee, baseball Hall of Famer Catfish Hunter, and American football player Jerome Bettis are among the many who have done so Tour de France winner Chris Froome admitted to suffer from the condition after being spotted using a nasal inhaler during race20 Other sportspeople with EIB include racing cyclist Simon Yates, distance runner Paula Radcliffe21 and cross-country skier Marit Bjørgen22 Research by sports scientist John Dickinson found that 70 percent of UK-based members of the British swimming team had some form of asthma, as did a third of Team Sky cyclists, compared to a national asthma rate of eight to ten percent,21 whilst a study by the United States Olympic Committee in 2000 found that half of cross-country skiers had EIB22

School children are also one of the major groups impacted by EIB as exercise programs and sports activities form a big part of most schools Proactive schools usually set special EIB friendly guidelines for students with EIB so that they can be included in mainstream student exercise programs23


  1. ^ Khan, DA Jan–Feb 2012 "Exercise-induced bronchoconstriction: burden and prevalence" Allergy and Asthma Proceedings 33 1: 1–6 PMID 22370526 doi:102500/aap2012333507 
  2. ^ a b Parsons JP, Cosmar D, Phillips G, Kaeding C, Best TM, Mastronarde JG March 2012 "Screening for exercise-induced bronchoconstriction in college athletes" J Asthma 49 2: 153–7 PMID 22276571 doi:103109/027709032011652329 
  3. ^ a b Anderson SD, Kippelen P March 2005 "Exercise-induced bronchoconstriction: Pathogenesis" Current Allergy and Asthma Reports 5 2: 116–22 PMID 15683611 doi:101007/s11882-005-0084-y 
  4. ^ Hallstrand TS, Curtis JR, Koepsell TD, et al September 2002 "Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction" J Pediatr 141 3: 343–8 PMID 12219053 doi:101067/mpd2002125729 
  5. ^ Rundell KW, Im J, Mayers LB, Wilber RL, Szmedra L, Schmitz HR February 2001 "Self-reported symptoms and exercise-induced asthma in the elite athlete" Med Sci Sports Exerc 33 2: 208–13 PMID 11224807 doi:101097/00005768-200102000-00006 
  6. ^ Parsons JP, Kaeding C, Phillips G, Jarjoura D, Wadley G, Mastronarde JG September 2007 "Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes" Med Sci Sports Exerc 39 9: 1487–92 PMID 17805078 doi:101249/mss0b013e3180986e45 
  7. ^ Carlsen KH, Anderson SD, Bjermer L, et al April 2008 "Exercise-induced asthma, respiratory and allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: Part I of the report from the Joint Task Force of the European Respiratory Society ERS and the European Academy of Allergy and Clinical Immunology EAACI in cooperation with GA2LEN" Allergy 63 4: 387–403 PMID 18315727 doi:101111/j1398-9995200801662x 
  8. ^ Mannix ET, Manfredi F, Farber MO 1999 "A comparison of two challenge tests for identifying exercise-induced bronchospasm in figure skaters" Chest 115 3: 649–53 PMID 10084470 doi:101378/chest1153649 
  9. ^ Douglas B McKeag; James L Moeller; American College of Sports Medicine 3 July 2007 ACSM's Primary Care Sports Medicine Lippincott Williams & Wilkins p 167 ISBN 978-0-7817-7028-6 Retrieved 21 April 2012 
  10. ^ Rosenthal, Richard "Eucapnic Voluntary Hyperventilation EVH A Test for the Presence of Asthma" Retrieved 2014-05-30 
  11. ^ Weiler JM, Bonini S, Coifman R, Craig T, Delgado L, Capão-Filipe M, et al 2007 "American Academy of Allergy, Asthma & Immunology Work Group report: exercise-induced asthma" J Allergy Clin Immunol 119 6: 1349–58 PMID 17433829 doi:101016/jjaci200702041 
  12. ^ Brannan JD, Koskela H, Anderson SD, Chew N 1998 "Responsiveness to mannitol in asthmatic subjects with exercise- and hyperventilation-induced asthma" Am J Respir Crit Care Med 158 4: 1120–6 PMID 9769270 doi:101164/ajrccm15849802087 
  13. ^ Muñoz PA, Gómez FP, Manrique HA, Roca J, Barberà JA, Young IH, et al 2008 "Pulmonary gas exchange response to exercise- and mannitol-induced bronchoconstriction in mild asthma" J Appl Physiol 105 5: 1477–85 PMID 18756011 doi:101152/japplphysiol001082008 
  14. ^ Stickland MK, Rowe BH, Spooner CH, Vandermeer B, Dryden DM September 2011 "Accuracy of eucapnic hyperpnea or mannitol to diagnose exercise-induced bronchoconstriction: a systematic review" Ann Allergy Asthma Immunol 107 3: 229–34 PMID 21875541 doi:101016/janai201106013 
  15. ^ Stickland MK, Rowe BH, Spooner CH, Vandermeer B, Dryden DM March 2012 "Effect of warm-up exercise on exercise-induced bronchoconstriction" Med Sci Sports Exerc 44 3: 383–91 PMID 21811185 doi:101249/MSS0b013e31822fb73a 
  16. ^ a b c Carlsen KH, Anderson SD, Bjermer L, et al April 2008 "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" Allergy 63 4: 492–505 PMID 18394123 doi:101111/j1398-9995200801663x 
  17. ^ Philip G, Pearlman DS, Villarán C, et al 2007 "Single-dose montelukast or salmeterol as protection against exercise-induced bronchoconstriction" Chest 132 3: 875–83 PMID 17573489 doi:101378/chest07-0550 
  18. ^ a b c Hemilä, H 7 June 2013 "Vitamin C may alleviate exercise-induced bronchoconstriction: a meta-analysis" BMJ Open 3 6: e002416 PMC 3686214  PMID 23794586 doi:101136/bmjopen-2012-002416 
  19. ^ Parsons JP, Hallstrand TS, Mastronarde JG, et al May 2013 "An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction" Am J Respir Crit Care Med 187 9: 1016–27 PMID 23634861 doi:101164/rccm201303-0437ST 
  20. ^ "Froome surprised at controversy over in-race inhaler use" 
  21. ^ a b Walker, Peter 29 April 2016 "Why do so many elite athletes have asthma" theguardiancom Retrieved 29 April 2016 
  22. ^ a b Gardner, Amanda 17 February 2010 "For Olympians and weekend warriors, winter sports can trigger asthma" cnncom Retrieved 29 April 2016 
  23. ^ "Tips for Exercise Induced Asthma EIA affected children to help them lead normal school lives" 

External linksedit

  • "Tips to Remember: Exercise-induced asthma" American Academy of Allergy, Asthma, and Immunology Retrieved 2007-04-12 
  • "Exercise-Induced Asthma" National Jewish Medical and Research Center July 2002 Retrieved 2010-04-11 
  • Reynolds, Gretchen January 13, 2010 "Why Do So Many Winter Olympians Have Asthma" The New York Times Retrieved 2009-02-13 
  • What is Exercise-Induced Asthma
  • Fact sheet: Exercise-induced asthma

exercise-induced bronchoconstriction, exercise-induced bronchoconstriction (eib), exercise-induced bronchoconstriction in athletes, exercise-induced bronchoconstriction treatment, exercise-induced bronchoconstriction: diagnosis and management

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