Get Exercise-Induced Asthma Under Control Get Exercise-Induced Asthma Under Control
American Academy of Allergy, Asthma and Immunology

This Topic of the Month answers the following questions:

What are symptoms of EIA?
Why does this happen to people with EIA?
How is a diagnosis made?
Is exercise bad for people with EIA?
What are recommended activities for people with EIA?
What are treatments for EIA?
When should someone see an allergy/asthma specialist?

People with exercise-induced asthma (EIA) may find it difficult to participate in strenuous physical activity and should see an allergist/immunologist for proper treatment.

Approximately 7% of the population, or about 20 million Americans, are reported to suffer from asthma, according to the American Lung Association. With strenuous physical exercise, most of these individuals experience asthma symptoms. In addition, many non-asthmatic patients-up to 13% of the population, up to 40% of patients with allergic rhinitis and often people who have a family history of allergy-experience asthma associated with exercise.

What are symptoms of EIA?
People with exercise-induced asthma, may experience breathing difficulty within 5-20 minutes after exercise. Symptoms may include wheezing, chest tightness, coughing and chest pain. Other EIA symptoms include prolonged shortness of breath, often beginning 5-10 minutes after brief exercise.

Why does this happen to people with EIA?
Patients with EIA have airways that are overly sensitive to sudden changes in temperature and humidity, especially when breathing colder, drier air. During strenuous activity, people tend to breathe through their mouths, allowing the cold, dry air to reach the lower airways without passing through the warming, humidifying effect of the nose. With mouth breathing-also common in patients with colds, sinusitis and allergic rhinitis (hay fever)-air is moistened to only 60-70% relative humidity, while nose-breathing warms and saturates air to about 80 to 90% humidity before it reaches the lungs.

In addition to mouth-breathing, air pollutants, high pollen counts, and viral respiratory tract infections can also increase the severity of wheezing with exercise.

How is a diagnosis made?
To confirm a diagnosis of EIA, a physician will obtain the patients history, perform a breathing test when the patient is at rest to ensure that the patient does not have chronic asthma and often may perform a breathing test after exercise.

Measurement can be done in a medical facility or “on the field.” In the office setting, a patient exercises for six to eight minutes using a treadmill or cycle to create enough exertion to maintain a heart rate at 80-90% of the age-related maximal predicted value. The patient breathes into a breathing machine called a spirometer, which processes the patient’s ability to breathe out, or expire air. This test is performed before exercise and at various intervals from two to 30 minutes after exercise stops. A decrease of at least 12-15% in the volume of air blown out (as compared to the starting value) by the patient in one second (termed the forced expiratory value in one second , or FEV 1) indicates possible EIA.

On the field, expiratory airflow can be evaluated before and after a six- to eight-minute “free run” or after participation in a sport or activity that usually induces respiratory symptoms. Airflow is again measured for 30 minutes after exercise ends. Although a portable spirometer can be used, physicians often recommend a small, relatively inexpensive peak flow meter to demonstrate the characteristic post-exercise decrease in expiratory airflow. In this case a 15-20% decrease is required for the test to be considered positive for EIA.

EIA Treatment Checklist:

Use a short-acting beta2-agonist inhaler, 15 minutes prior to exercise. This will help ease asthma exacerbations and lasts between four to six hours.
Warm-up for six to ten minutes before beginning a full exercise program.
Drink plenty of fluids.
Stop exercising if symptoms arise.
Cool down at the end of your exercise.
Check out Tips to Remember: Exercise-Induced Asthma for more on prevention.

Is exercise bad for people with EIA?
People with EIA should not stop exercising. Exercise is good for all people, including those with asthma. If you have been diagnosed with EIA, talk with your allergist/immunologist about a personalized management plan for your EIA and begin exercising again. Many asthmatics have found that with proper training and medical treatment, they are able to reduce the symptoms of EIA.

What are recommended activities for people with EIA?
Although the type and duration of recommended activity varies with each individual, some activities are better for people with EIA.

Swimming is often considered the sport of choice for asthmatics and those with a tendency toward bronchospasm because of its many positive factors: a warm, humid atmosphere, year-round availability, toning of upper body muscles, and the way the horizontal position may help mobilize mucus from the bottom of the lungs. Walking, leisure biking, hiking and free downhill skiing are also activities less likely to trigger EIA. In cold weather, wearing a scarf or surgical mask over the mouth and nose can decrease symptoms by warming inhaled air.

Team sports that require short bursts of energy, such as baseball, football, wrestling, golfing, gymnastics, short-term track and field events or surfing are less likely to trigger asthma than sports requiring continuous activity such as soccer, basketball, field hockey or long-distance running. Cold weather activities such as cross-country skiing and ice hockey are also more likely to aggravate airways. However, many asthmatics have found that with proper training and medical treatment, they are able to excel as runners or even basketball players.

What are treatments for EIA?
Inhaled medications taken prior to exercise are helpful in controlling and preventing exercise-induced bronchospasm. The medication of choice in preventing EIA symptoms is a short-acting beta 2 agonist bronchodilator spray used 15 minutes before exercise. These medications, which include albuterol, levalbuterol, formoterol and pirbuterol, are effective in 80 to 90 percent of patients, have a rapid onset of action, and last for up to four to 12 hours. These drugs can also be used to relieve symptoms associated with EIA after they occur.

In the school setting, these medications may be administered to children by school nurses. A long-acting bronchodilator spray that lasts up to 12 hours is also available. By using this before school, many children are able to participate in physical education class and other sports throughout the day without needing short-acting sprays.

If symptoms are not readily controlled by medications, patients should talk to their physician about using daily medication that treats the underlying asthma-the inflammatory process that is causing increased “twitchiness” or sensitivity of the airways.

In addition to medications, a warm-up period of activity before exercise may lessen the chest tightness that occurs after exertion. A warm-down period, including stretching and jogging after strenuous activity, may prevent air in the lungs from changing rapidly from cold to warm, and may prevent EIA symptoms that occur after exercise.

Athletes should restrict exercising when they have viral infections, when temperatures are extremely low, or-if they are allergic-when pollen and air pollution levels are high. Pursed (narrowed) lip breathing may also help reduce airway obstruction.

When should someone see an allergy/asthma specialist?
The AAAAI’s How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence provide information to assist patients and health care professionals in determining when a patient may need consultation or ongoing specialty care by the allergist/immunologist. Patients should see an allergist/immunologist if they:

Have exercise-induced symptoms that are unusual or do not respond well to pre-treatment with albuterol, nedocromil, or cromolyn.
Have had exercise-induced anaphylaxis or food-dependent exercise-induced anaphylaxis.
Want to SCUBA dive and have a history of asthma.