Clinical Cases

A Case of Dyspnea in a College Athlete

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Lana Alghothani, MD

Clinical Instructor and Pulmonary/Critical Care Fellow

Department of Internal Medicine

The Ohio State University Wexner Medical Center

Columbus, Ohio

Jonathan P. Parsons, MD

Professor of Internal Medicine

Department of Internal Medicine

The Ohio State University Wexner Medical Center

Columbus, Ohio

Submit your comments to the author(s).


A 21 year old male presents with chest tightness and shortness of breath with exercise.  He is a college track athlete. His symptoms have been ongoing for several years and occur frequently after strenuous exercise sessions.  Specifically, his dyspnea occurs after several minutes of exercise and is associated with wheezing and a non-productive cough.  His review of systems is otherwise negative.  He has not noticed these symptoms outside of exercise.  He is concerned that his symptoms are negatively impacting his athletic performance.

He has no other significant past medical history.  He denies a history of known asthma or perennial allergies.  His family history is unremarkable.  He takes a daily multivitamin and denies any known drug allergies.  He is currently a junior in college and does not smoke cigarettes, though he mentions infrequent marijuana and moderate alcohol use.

Physical Exam

On physical exam, he is a healthy male in no acute distress. His head and neck exam is benign without stridor. Lung exam reveals normal breath sounds without wheezing. Heart exam reveals a regular rhythm with no murmurs, gallops, or rubs. Abdominal exam is benign. No cyanosis, clubbing or edema of the extremities is noted. A neurologic exam is non-focal.


Electrocardiogram:  Normal sinus rhythm, normal intervals, and no ST-segment changes.

Chest Xray: unremarkable.

Spirometry:  FVC is 4.77L or 97% of predicted, FEV1 is 3.86L or 92% of predicted, normal FEV1/FVC ratio, and normal flow-volume loops.

Eucapnic voluntary hyperventilation testing: maximal decrease of 23% in FEV1 compared to baseline documented at 5 minutes of exercise.

Question 1

Given the history and objective testing provided, what is the most likely diagnosis in this case?


  1. Parsons JP, Hallstrand TS, Mastronarde JG, Kaminsky DA, Rundell KW, Hull JH,Storms WW, Weiler JM, Cheek FM, Wilson KC, et al.; American Thoracic Society Subcommittee on Exercise-induced Bronchoconstriction. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013;187:1016–1027.
  2. Weiler JM, Bonini S, Coifman R, Craig T, Delgado L, Capao-Filipe M, Passali D, Randolph C, Storms W. American Academy of Allergy, Asthma & Immunology work group report: exercise-induced asthma. J Allergy Clin Immunol 2007;119:1349–1358.
  3. Parsons JP, Kaeding C, Phillips G, Jarjoura D, Wadley G, Mastronarde JG. 2007. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc. 39(9):1487-92.
  4. Mannix ET, Roberts M, Fagin DP, Reid B, Farber MO. The prevalence of airways hyperresponsiveness in members of an exercise training facility. J Asthma 2003;40:349–355. 3.
  5. Mannix ET, Roberts MA, Dukes HJ, Magnes CJ, Farber MO. Airways
  6. Rundell KW and Jenkinson DM. 2002. Exercise-induced bronchospasm in the elite athlete. Sports Med. 32(9):583-600.
  7. Parsons JP and Mastronarde JG. 2005. Exercise-induced bronchoconstriction in athletes. Chest 128(6):3966-74.
  8. Shawdon, A. 1995. Gastro-oesophageal reflux and exercise. Important pathology to consider in the athletic population. Sports Med 20(2):109-16.
  9. Becker JM, Rogers J, Rossini G, Mirchandani H, D’Alonzo GE Jr. Asthma deaths during sports: report of a 7-year experience. J Allergy Clin Immunol 2004;113:264–267.
  10. Scollo M, Zanconato S, Ongaro R, Zaramella C, Zacchello F, Baraldi E. Exhaled nitric oxide and exercise-induced bronchoconstriction in asthmatic children. Am J Respir Crit Care Med 2000;161:1047–1050.
  11. Hallstrand TS, Curtis JR, Koepsell TD, Martin DP, Schoene RB, Sullivan SD, Yorioka GN, and Aitken ML. 2002. Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction. J.Pediatr. 141(3):343-348.
  12. Parsons JP, O'Brien JM, Lucarelli MR, and Mastronarde JG. 2006. Differences in the evaluation and management of exercise-induced bronchospasm between family physicians and pulmonologists. J Asthma 43(5):379-84.
  13. Rundell KW and Spiering BA. 2003. Inspiratory stridor in elite athletes. Chest 123(2):468-74.
  14. Rundell, KW, Wilber RL, Szmedra L, Jenkinson DM, Mayers LB, and Im J. 2000. Exercise-induced asthma screening of elite athletes: field versus laboratory exercise challenge. Med.Sci.Sports Exerc. 32(2):309-316.
  15. Anderson SD, Silverman M, Konig P, Godfrey S. Exercise-induced asthma. Br J Dis Chest 1975;69:1–39.
  16. Cropp GJ. The exercise bronchoprovocation test: standardization of procedures and evaluation of response. J Allergy Clin Immunol 1979;64:627–633.
  17. Kattan M, Keens TG, Mellis CM, Levison H. The response to exercise in normal and asthmatic children. J Pediatr 1978;92:718–721.
  18. Argyros GJ, Roach JM, Hurwitz KM, Eliasson AH, Phillips YY. Eucapnic voluntary hyperventilation as a bronchoprovocation technique: Development of a standardized dosing schedule in asthmatics. Chest 1996;109:1520-1524.
  19. Mannix ET, Manfredi F, Farber MO. A comparison of two challenge tests for identifying exercise-induced bronchospasm in figure skaters. Chest 1999;115:649-653.
  20. Holzer K and Douglass JA. 2006. Exercise induced bronchoconstriction in elite athletes: measuring the fall. Thorax 61(2):94-6.
  21. Anderson SD, Argyros GJ, Magnussen H, and Holzer K. 2001. Provocation by eucapnic voluntary hyperpnoea to identify exercise induced bronchoconstriction. Br J Sports Med 35(5):344-7.
  22. Hurwitz KM, Argyros GJ, Roach JM, Eliasson AH, Phillips YY. Interpretation of eucapnic voluntary hyperventilation in the diagnosis of asthma. Chest 1995;108:1240- 1245.
  23. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics--2002. J Allergy Clin Immunol 110(5 Suppl):S141-219.
  24. McKenzie DC, McLuckie SL, and Stirling DR. 1994. The protective effects of continuous and interval exercise in athletes with exercise-induced asthma. Med.Sci.Sports Exerc. 26(8):951-956.
  25. Elkins MR, Brannan JD. Warm-up exercise can reduce exercise-induced bronchoconstriction. Br J Sports Med 2013;47: 657-8.
  26. Rundell KW, Spiering BA, Judelson DA, and Wilson MH. 2003. Bronchoconstriction during cross-country skiing: is there really a refractory period? Med.Sci.Sports Exerc. 35(1):18-26.
  27. Shturman-Ellstein R, Z. R., Buckley JM, Souhrada JF. 1978. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Respir Dis. 118(1):65-73.
  28. Schacter, E. 1982. The protective effects of a cold weather mask on EIA. Ann Allergy(46):12-16.
  29. Ram FS, Robinson SM, Black PN, Picot J. Physical training for asthma. Cochrane Database Syst Rev 2005;CD001116.
  30. Cutrufello PT, Smoliga JM, Rundell KW. Small things make a big difference: particulate matter and exercise. Sports Med 2012;42:1041-58
  31. Miller MG, Weiler JM, Baker R, Collins J, and D'Alonzo G. 2005. National athletic trainers' association position statement: management of asthma in athletes. J Athl Train 40(3):224-45.