eMedicine Specialties > Sports Medicine > Introductory Topics in Sports Medicine
Exercise-Induced Asthma: Treatment & Medication
Updated: Jun 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Medical Issues/Complications
Although rare, as with any asthma attack, progression of EIA can result in status asthmaticus and even death. Treatment for this condition should be provided immediately and the situation taken seriously.
Consultations
On the playing field, consultation is rarely available and is not needed in the acute EIA attack; however, access to the emergency medical system should be readily available.
Other Treatment
Treatment of the athlete who is experiencing an acute attack of EIA is the same as in any asthma attack situation and includes the following:
- Immediately remove the patient from competition or play.
- Provide immediate administration of a rapid onset, short-acting β2 -agonist (eg, albuterol); this has the highest therapeutic yield. The usual dose is 2 puffs of albuterol via a metered dose inhaler (MDI).
- If the patient's response is not satisfactory, transportation to an emergency facility should be initiated because the EIA attack may escalate.
- If available, the use of a spacer device can help to transport the medication to the area of greatest need, especially when an athlete is distracted in the midst of competition or anxious from dyspnea and unable to concentrate.
- If the initial treatment fails or is unavailable, immediate transfer of the patient to an acute care facility should occur. Subcutaneous epinephrine can be administered in such life-threatening situations.
Recovery Phase
Medical Issues/Complications
If the initial response to treatment was adequate, patient observation and monitoring need to continue for several hours in case of a relapse.
Consultations
If patient relapse is immediate, transportation to an emergency facility should be initiated.
Other Treatment (Injection, manipulation, etc.)
If mild, residual symptoms persist in the patient after relief of the acute symptoms, a repeat administration of albuterol is advisable; the recommended dosing interval is 4 hours.
Maintenance Phase
Medical Issues/Complications
Long-term treatment of EIA is prevention of the condition (see Medication).1
Other Treatment
Nonpharmacologic measures can also be taken in the treatment of EIA.
- Sports selection – It can be helpful to guide an athlete toward the performance of sports in environments that are less likely to cause bronchospasm. If the athlete has a choice, he or she can choose a time or place to exercise where the air is warmer and the humidity is higher. Likewise, a flexible athlete can change sports to be more active in these sorts of environments (eg, changing from running to swimming automatically increases the humidity of the environment). As indicated earlier, focusing on sports with less prolonged aerobic demands (eg, sprinting, weight lifting, baseball, football) is better tolerated by affected athletes.
- Breathing and warm-up techniques:
- Altering breathing techniques – A change from predominant mouth breathing to nasal breathing can result in less bronchospasm with the performance of an activity because the inhaled air is both warmed and humidified.
- The coordination and timing of competition with medication use can also maximize exercise performance with regard to bronchospasm. To minimize the likelihood of bronchospasms, the athlete can time the warm-up so that the competition coincides with a refractory phase. This is most likely to occur by initiating a 15-30 minute warm-up followed by a 15-minute rest period, at which time the medication is administered. This entire period should be timed to result in commencement of the competition 15-30 minutes after medication administration.
Medication
The optimal treatment for EIA is to prevent the onset of symptoms. After controlling the patient's underlying and contributing factors (eg, respiratory infection, allergy, allergic asthma), a combination of drugs can be used to prevent EIA.1 The basis of treatment is with preexercise short-acting β2 -agonist administration.1 A role also exists for long-acting β2 -agonists and mast cell stabilizers. Antileukotriene drugs have been shown to be effective as well.12,13 Traditional asthma medications (eg, corticosteroids, theophylline) have less of a role in the treatment of pure EIA. There is ongoing investigation regarding other agents (eg, heparin, calcium-channel blockers, diuretics).
Beta2-agonists
These agents are used for prophylactic bronchodilation to prevent the onset of symptoms with exercise and have been shown to have a 90% efficacy.
Albuterol (Proventil, Ventolin)
DOC and first-line agent. β 2 -agonist for bronchospasm that is refractory to epinephrine. Relaxes bronchial smooth muscle by action on β 2 -receptors with little effect on cardiac muscle contractility.
Adult
2 puffs via metered dose inhaler 15-30 min preexercise
Pediatric
1-2 puffs via metered dose inhaler 15-30 min preexercise
Caution with other sympathomimetics, MAOIs, tricyclic antidepressants, other agents that decrease potassium
Documented hypersensitivity; tachyarrhythmias; hypokalemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause jitteriness and tachycardia; caution with hypokalemia from repetitive and frequent use
Salmeterol (Serevent)
By relaxing the smooth muscles of the bronchioles in conditions that are associated with bronchitis, emphysema, asthma, or bronchiectasis, salmeterol can relieve bronchospasms. Effect may also facilitate expectoration.
Adverse effects are more likely to occur when this agent is administered at high or more frequent doses than recommended; the incidence of side effects is then higher.
Adult
2 puffs via metered dose inhaler 30-45 min preexercise or bid
Pediatric
1-2 puffs via metered dose inhaler 30-45 min preexercise or bid
Caution with other sympathomimetics, MAOIs, tricyclic antidepressants
Documented hypersensitivity; tachyarrhythmias; hypokalemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm; long-acting β 2 -agonists may cause more tachyphylaxis than short-acting agents.
Mast cell stabilizers
These agents are 70-80% effective in preventing bronchospasm during exercise. An additive effect is noted when used in combination with albuterol.
Cromolyn sodium (Intal, Nasalcrom)
First- or second-line agent in the prevention of EIA.
Adult
2 puffs via metered dose inhaler 30-45 min preexercise
Pediatric
1-2 puffs via metered dose inhaler 30-45 min preexercise
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm; avoid use with isoproterenol during pregnancy.
Inhaled corticosteroids
These agents provide no bronchodilatory effect but are useful in controlling the underlying inflammation of allergic asthma.
Flunisolide (AeroBid Oral Aerosol Inhaler, Nasalide Nasal Aerosol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Does not depress the hypothalamus. Considered a third-line agent.
Adult
2-4 inhalations qd/qid; varies with preparation
Pediatric
<6 years: Some preparations are contraindicated
>6 years: 1-4 inhalations qd/qid; varies with preparations
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm.
Triamcinolone acetonide (Azmacort)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Considered a third-line agent.
Adult
2-4 inhalations qd/qid; varies with preparation
Pediatric
<6 years: Some preparations are contraindicated
>6 years: 1-4 inhalations qd/bid/tid/qid; varies with preparations
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm; do not exceed recommended doses.
Beclomethasone dipropionate (Beclovent, Beconase, Vancenase, Vanceril)
Inhibits bronchoconstriction mechanisms; produces direct smooth muscle relaxation; may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. Considered a third-line agent.
Adult
2-4 inhalations qd/qid; varies with preparation
Pediatric
<6 years: Some preparations are contraindicated
>6 years: 1-4 inhalations qd/qid; varies with preparations
Coadministration with ketoconazole may increase plasma levels but do not appear to be clinically significant
Documented hypersensitivity, bronchospasm, status asthmaticus, other types of acute episodes of asthma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm.
Xanthine derivatives
Xanthine derivatives have been used in allergic asthma for their bronchodilatory and anti-inflammatory properties; however, these agents have multiple side effects. Therefore, monitoring for nontoxic levels is necessary.
Theophylline (Aminophylline, Theo-24, Theolair)
Potentiates exogenous catecholamines, stimulates endogenous catecholamine release and diaphragmatic muscular relaxation, which in turn stimulates bronchodilation.
For bronchodilation, near-toxic (>20 mg/dL) levels are usually required.
Adult
5.6 mg/kg loading dose (based on aminophylline) IV over 20 min, followed by maintenance infusion of 0.1-1.1 mg/kg/h
Pediatric
6 weeks to 6 months: 0.5 mg/kg/h loading dose IV in first 12 h (based on aminophylline), followed thereafter by maintenance infusion of 12 mg/kg/d; may administer continuous infusion by dividing total daily dose by 24 h
6 months to 1 year of age: 0.6-0.7 mg/kg/h, loading dose IV in first 12 h, followed by maintenance infusion of 15 mg/kg/d; may administer as continuous infusion, as above
>1 year: Administer as in adults
Aminoglutethimide, barbiturates, carbamazepine, ketoconazole, loop diuretics, charcoal, hydantoins, phenobarbital, phenytoin, rifampin, isoniazid, and sympathomimetics may decrease effects of theophylline; theophylline effects may increase with allopurinol, β -blockers, ciprofloxacin, corticosteroids, disulfiram, quinolones, thyroid hormones, ephedrine, carbamazepine, cimetidine, erythromycin, macrolides, propranolol, and interferon.
Documented hypersensitivity; patients with uncontrolled arrhythmias, peptic ulcers, hyperthyroidism, and uncontrolled seizure disorders
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with peptic ulcer disease, hypertension, tachyarrhythmias, hyperthyroidism, and compromised cardiac function; do not inject IV solution >25 mg/min; patients with pulmonary edema or liver dysfunction are at greater risk of toxicity because of reduced drug clearance.
Leukotriene receptor antagonists
Leukotriene receptor antagonists can be used as adjuncts in cases of incompletely controlled EIA with the use of other agents; however, leukotriene receptor antagonists should be reserved for more frequent and persistent cases of EIA rather than for intermittent cases. Leukotriene receptor antagonists should not to be used alone for the treatment of EIA.
Zafirlukast (Accolate)
Inhibits effects by the leukotriene receptor, which has been associated with asthma, including airway edema, smooth muscle contraction, and cellular activity associated with the symptoms. Third-line agent and used as adjunct only.
Adult
20 mg PO bid
Pediatric
10 mg PO bid
Erythromycin and theophylline decrease serum levels; aspirin increases levels of zafirlukast; zafirlukast increases toxicity of warfarin.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm; may cause liver inflammation; not for use as monotherapy in the management of EIB
Neuropsychiatric events have been reported, and following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor
Montelukast (Singulair)
Inhibits the leukotriene receptor effects associated with asthma, including airway edema, smooth muscle contraction, and cellular activity associated with the symptoms. Third-line agent and used as an adjunct only. European studies have suggested an improvement in gas exchange versus β 2 -agonist medication.
Adult
10 mg PO at least 2 h before exercise; do not repeat dose within 24 h
Pediatric
<15 years: Not established; some pediatric subspecialists recommend 5 mg PO qd
> 15 years: Administer as in adults
Phenobarbital and rifampin reduce effects.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not indicated to reverse acute asthma attacks; not for use as monotherapy in the management of EIB; use appropriate short-acting, inhaled β 2 -agonist for exacerbations; if already taking montelukast daily (eg, chronic asthma, allergic rhinitis), do not take an additional dose to prevent EIB; administration for chronic asthma has not been established to prevent acute EIB; chewable tab contains phenylalanine: caution in patients with phenylketonuria
Neuropsychiatric events have been reported, and following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor
Zileuton (Zyflo)
Inhibits leukotriene formation, which in turn decreases neutrophil and eosinophil migration, neutrophil and monocyte aggregation, leukocyte adhesion, capillary permeability, and smooth muscle contractions. Third-line therapy and used as an adjunct only.
Adult
600 mg PO qid
Pediatric
Not established
Monitor drugs that are metabolized by cytochrome p3A4; potentiates theophylline, warfarin, and propranolol
Documented hypersensitivity; patients with active liver disease or transaminase elevation greater than or equal to 3 times the upper limit of the normal value
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm; monitor liver enzymes; neuropsychiatric events have been reported, and following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor
Adrenergic agonists
Adrenergic agonists are used in the emergency treatment of life-threatening situations, when β-agonists are unavailable or treatment with β-agonists has failed.
Epinephrine (Adrenalin, Bronitin, EpiPen, Primatene Mist)
Has α -agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. β -agonist effects of epinephrine include bronchodilation, chronotropic cardiac activity, and positive inotropic effects. Indicated in the emergency treatment of bronchospasm.
Adult
0.2-1 mg SC q4h prn
Pediatric
0.01 mg/kg SC q4h prn; not to exceed 0.5 mg
May potentiate the pressor effects of tricyclic antidepressants, furazolidone, antihistamines, levothyroxine, β- blockers, and guanethidine; epinephrine may be antagonized by nitrites and α-b lockers; should avoid digitalis and other arrhythmia-producing agents
Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma; local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; during labor (may delay second stage of labor)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients and in patients with prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
More on Exercise-Induced Asthma |
| Overview: Exercise-Induced Asthma |
| Differential Diagnoses & Workup: Exercise-Induced Asthma |
 Treatment & Medication: Exercise-Induced Asthma |
| Follow-up: Exercise-Induced Asthma |
| References |
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References
National Heart, Lung,and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 3:Guidelines for the Diagnosis and Management of Asthma: Full Report 2007. Bethesda, Md: NHLBI; August 2007. Publication no. 07-4051. [Full Text].
Anderson SD. How does exercise cause asthma attacks?. Curr Opin Allergy Clin Immunol. Feb 2006;6(1):37-42. [Medline].
Hough DO, Dec KL. Exercise-induced asthma and anaphylaxis. Sports Med. Sep 1994;18(3):162-72. [Medline].
Beaudouin E, Renaudin JM, Morisset M, et al. Food-dependent exercise-induced anaphylaxis--update and current data. Allerg Immunol (Paris). Feb 2006;38(2):45-51. [Medline].
Stensrud T, Berntsen S, Carlsen KH. Exercise capacity and exercise-induced bronchoconstriction (EIB) in a cold environment. Respir Med. Jul 2007;101(7):1529-36. [Medline].
Butcher JD. Exercise-induced asthma in the competitive cold weather athlete. Curr Sports Med Rep. Dec 2006;5(6):284-8. [Medline].
Dickinson JW, Whyte GP, McConnell AK, Harries MG. Screening elite winter athletes for exercise induced asthma: a comparison of three challenge methods. Br J Sports Med. Feb 2006;40(2):179-82; discussion 179-82. [Medline].
Wilson JJ, Wilson EM. Practical management: vocal cord dysfunction in athletes. Clin J Sport Med. Jul 2006;16(4):357-60. [Medline].
Kenn K. [Vocal Cord Dysfunction--what do we really know? A review] [German]. Pneumologie. Jul 2007;61(7):431-9. [Medline].
Kaplan TA. Exercise challenge for exercise-induced bronchospasm: confirming presence, evaluating control. Phys Sports Med. 1995;23(8):47-57.
Rundell KW, Anderson SD, Spiering BA, Judelson DA. Field exercise vs laboratory eucapnic voluntary hyperventilation to identify airway hyperresponsiveness in elite cold weather athletes. Chest. Mar 2004;125(3):909-15. [Medline]. [Full Text].
Storms W. Update on montelukast and its role in the treatment of asthma, allergic rhinitis and exercise-induced bronchoconstriction. Expert Opin Pharmacother. Sep 2007;8(13):2173-87. [Medline].
Steinshamn S, Sandsund M, Sue-Chu M, Bjermer L. Effects of montelukast and salmeterol on physical performance and exercise economy in adult asthmatics with exercise-induced bronchoconstriction. Chest. Oct 2004;126(4):1154-60. [Medline]. [Full Text].
Beuther DA, Martin RJ. Efficacy of a heat exchanger mask in cold exercise-induced asthma. Chest. May 2006;129(5):1188-93. [Medline]. [Full Text].
Knöpfli BH, Luke-Zeitoun M, von Duvillard SP, et al. High incidence of exercise-induced bronchoconstriction in triathletes of the Swiss national team. Br J Sports Med. Aug 2007;41(8):486-91; discussion 491. [Medline].
[Best Evidence] Koh MS, Tee A, Lasserson TJ, Irving LB. Inhaled corticosteroids compared to placebo for prevention of exercise induced bronchoconstriction. Cochrane Database Syst Rev. 2007;3:CD002739. [Medline].
Lacroix VJ. Exercise-induced asthma. Phys Sports Med. 1999;27(12):75-92.
McFadden ER Jr, Gilbert IA. Exercise-induced asthma. N Engl J Med. May 12 1994;330(19):1362-7. [Medline].
National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics 2002. Bethesda, Md: National Institutes of Health and National Heart, Lung, and Blood Institute; June 2003. NIH publication no. 02-5074. [Full Text].
Parsons JP, Kaeding C, Phillips G, ET AL. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc. Sep 2007;39(9):1487-92. [Medline].
Smith BW, MacKnight JM. Pulmonary. In: Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Vol 1. Philadelphia, Pa: Lippincott-Raven; 1998:244-9.
Storms WW. Asthma associated with exercise. Immunol Allergy Clin North Am. Feb 2005;25(1):31-43. [Medline].
Further Reading
Keywords
EIA, exertional asthma, exercise-induced bronchospasm, EIB, asthma, exercise-induced urticaria, allergic rhinitis, bronchoconstriction, exercise-related respiratory symptoms, wheezing, chest tightness, shortness of breath, dyspnea, difficulty breathing, aerobic exercise, environmental factors, allergic asthma, asthmogenic agents
