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Dyspnea in a college athleteCase Editor - Victor Kim Reviewed By Allergy, Immunology & Inflammation Assembly Submitted byJonathan P. Parsons, M.D. Assistant Professor of Internal Medicine The Ohio State University Medical Center Columbus, Ohio HistoryAn 18 year-old female college student presents to the student health center complaining of cough and chest tightness that occurs frequently with exercise. She is on the varsity field-hockey team and notes she occasionally has trouble keeping up with the other players during practice and games. Her coach has been criticizing her frequently for what he construes as “poor effort.” Her cough is episodic and is non-productive. Her dyspnea seems to occur after several minutes of exercise, and she states it feels like she cannot get a deep breath. She does not notice symptoms at other times of the day when she is not exercising. She has been particularly stressed emotionally recently as her first final exam period in college is approaching, and her field-hockey team has advanced to the semifinals of the conference tournament. Her review of symptoms is otherwise unremarkable.
Her past medical history is only significant for a torn knee ligament two years prior to her current presentation. She has no known history of asthma and does not have problems with perennial allergies. She takes oral contraceptive pills and nutritional supplements and denies any known drug allergies. She is a freshman in college and does not smoke. She admits to alcohol use in moderation and denies any illicit drug use. Her family medical history is unremarkable; her sister and parents are healthy without significant medical problems including asthma. Physical ExamOn physical exam, she is a healthy, age-appropriate female in no acute distress. The 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. The extremities are without cyanosis, clubbing or edema. The neurologic exam is non-focal. LabSpirometry: FVC of 104% of predicted, FEV1 of 98% of predicted, normal FEV1/FVC ratio, and normal flow-volume loops.
Electrocardiogram: Normal sinus rhythm, normal intervals, and no ST-segment changes.
Eucapnic voluntary hyperventilation testing: 13% drop in FEV1 compared to baseline documented at 10 minutes post-test. The history and objective testing are most consistent with exercise-induced bronchospasm. Exercise-induced bronchospasm is acute and reversible airway narrowing that occurs during, and also frequently after, exercise. Exercise-induced bronchospasm occurs commonly in people with and without asthma. In people with a known history of asthma, exercise is one of the most common triggers of bronchospasm and affects 50-80% of asthmatics.(1) In the general population without asthma or atopy, the prevalence of exercise-induced bronchospasm is approximately 10%.(2) The prevalence of exercise-induced bronchospasm is even higher in competitive athletes, as prevalence rates in this group are as high as 50%.(3, 4)
Uncontrolled gastroesophageal reflux disease can also cause problems with symptoms during exercise. Gastroesophageal reflux disease occurs more frequently during exercise than at rest, and can be a cause of chest pain or abdominal pain during exertion. Studies have found that increased intensity of exercise can result in increased reflux in both trained athletes and untrained people.(5)
Palpitations, skipped beats, dizziness, or syncope may suggest cardiac arrhythmias or cardiomyopathies; however there was no history of this in the case and the electrocardiogram was normal.
One disorder than can be particularly difficult to differentiate from exercise-induced bronchospasm is vocal cord dysfunction. Vocal cord dysfunction is characterized by variable, extrathoracic airflow obstruction caused by paradoxical adduction of the vocal cords during respiration. Vocal cord dysfunction may present with throat tightness, hoarse voice, or inspiratory stridor on physical exam. Common triggers of vocal-cord dysfunction include exercise, stress, gastroesophageal reflux, post-nasal drip, and strong odors or fumes. A suspicion of vocal cord dysfunction may be raised if there is flattening of the inspiratory limb of the flow-volume loop during spirometry or if a patient with presumed exercise-induced bronchospasm is not responding to medical therapy.
The clinical manifestations of exercise-induced bronchospasm are extremely variable and can range from mild impairment of performance to severe bronchospasm and respiratory distress. Common symptoms of exercise-induced bronchospasm include cough, wheezing, dyspnea, fatigue, and chest tightness. Exertional chest pain and post-exercise cough in athletes are commonly found to be related to exercise-induced bronchospasm.
A history of symptoms occurring in specific environments (i.e. ice rinks or swimming pools) may also suggest exercise-induced bronchospasm. Environmental triggers may predispose certain populations of athletes to an increased risk for development of exercise-induced bronchospasm . Chlorine compounds in swimming pools (6) and chemicals related to ice-resurfacing machinery in ice rinks(7) such as carbon monoxide and nitrogen dioxide may put exposed athletic populations at additional risk. These environmental factors may act as “triggers” and exacerbate bronchospasm in athletes that are predisposed to exercise-induced bronchospasm .
More subtle indicators may include unexplained, poor performance for the level of conditioning in competitive athletes. This may commonly be seen in track athletes or swimmers who are unable to meet their targeted times. Another subtle indicator of possible exercise-induced bronchospasm is avoidance of physical activity, which is commonly seen in school-aged children. Children with exercise-induced bronchospasm may associate exercise and physical activity with increased symptoms and/or discomfort and then begin to avoid such activities to prevent symptoms from occurring. The presence of exercise-induced bronchospasm has been shown to be difficult to diagnose clinically as symptoms are often non-specific. Despite the value of a comprehensive history of the athlete with exertional dyspnea, the diagnosis of exercise-induced bronchospasm based on self-reported symptoms alone has been shown to be inaccurate. Hallstrand et al(8) found screening history identified subjects with symptoms or a previous diagnosis suggestive of exercise-induced bronchospasm in 40% of the participants, but only 13% of these persons actually had exercise-induced bronchospasm after objective testing. The poor predictive value of the history and physical exam in the evaluation of exercise-induced bronchospasm strongly suggests clinicians should perform objective diagnostic testing when there is a suspicion of exercise-induced bronchospasm. However, evidence has shown that a significant number of health-care providers do not utilize objective testing when evaluating exercise-induced bronchospasm despite the data that indicate it is essential.(9)
Vocal cord dysfunction and exercise-induced bronchospasm can occur in the same patient. In a study of 370 elite athletes 5% had inspiratory stridor suggestive of vocal-cord dysfunction (10). Of note, 53% of the athletes with vocal-cord dysfunction had exercise-induced bronchospasm as well, indicating vocal-cord dysfunction and exercise-induced bronchospasm often occur concomitantly.
Healthcare providers and coaches also may not consider exercise-induced bronchospasm as a possible explanation for respiratory symptoms occurring during exercise. Athletes are generally fit and healthy and the presence of a significant medical problem often is not considered. The athlete is often considered to be “out of shape” and vague symptoms are not interpreted as a possible manifestation of exercise-induced bronchospasm. Athletes themselves are often “poor perceivers” of exercise-induced bronchospasm and are commonly not aware that they may have a physical problem. Furthermore, if they do recognize they have a medical problem, they often do not want to admit to health personnel that a problem exists due to fear of social stigma or losing playing time. Objective testing should begin with spirometry before and after inhaled bronchodilator therapy, which will help identify athletes that may have chronic asthma. However, many people who experience exercise-induced bronchospasm will have normal baseline lung function.(11) In these patients, spirometry alone is not adequate to diagnose exercise-induced bronchospasm. Significant numbers of false-negatives may occur if adequate exercise and environmental stress is not provided in the evaluation for exercise-induced bronchospasm. In patients being evaluated for exercise-induced bronchospasm who have a normal physical examination and normal spirometry, bronchoprovocation testing is strongly recommended.
Eucapnic voluntary hyperventilation testing is the modality recommended to document exercise-induced bronchospasm in Olympians.(12) Alternatives to eucapnic voluntary hyperventilation testing include field or lab-based exercise challenges. Mannitol inhalation is a recent promising method for diagnosing exercise-induced bronchospasm and may be approved for clinical use in the near future. (13) A positive bronchoprovocation test indicates the need for treatment for exercise-induced bronchospasm. Specific tests have varying positive values, but in general a significant change (usually >10% decrease in FEV1) between pre and post-bronchoprovocation testing values is suggestive of exercise-induced bronchospasm.(14) The most common therapeutic recommendation to minimize or prevent symptoms of exercise-induced bronchospasm is the prophylactic use of short-acting bronchodilators (selective β2-receptor agonists) such as albuterol shortly before exercise.(15) Treatment with two puffs of short-acting β2-receptor agonists shortly before exercise (15 minutes) will provide peak bronchodilation in 15-60 minutes and protection from exercise-induced bronchospasm for at least 3 hours in most patients.
Many athletes find that a period of pre-competition warm-up reduces the symptoms of exercise-induced bronchospasm that occur during their competitive activity. Athletes often draw this conclusion without any guidance from health care specialists. It has been shown by investigators that this phenomenon of the “refractory period” does occur in some athletes with asthma and that athletes can be refractory to an exercise task performed within 2 hours of an exercise warm-up.(16) However, the refractory period has not been consistently proven across different athletic populations, has not been well documented in exercise-induced bronchospasm-positive athletes that are not asthmatic, and it is currently not possible to identify which athletes will experience this refractory period.(17)
There are other non-pharmacologic strategies that can be employed to help reduce the frequency and severity of symptoms of exercise-induced bronchospasm. Breathing through the nose rather than the mouth may also help ameliorate exercise-induced bronchospasm by warming, filtering and humidifying the air, which subsequently reduces airway cooling and dehydration.(18) Wearing a face-mask during activity warms and humidifies inspired air when outdoor conditions are cold and dry and is especially valuable to elite and recreational athletes that exercise in the winter.(19) In addition, people with knowledge of triggers (i.e. freshly cut grass) should attempt to avoid them if possible.
Since predicting when an episode of exercise-induced bronchospasm may occur is impossible, acute management of exercise-induced bronchospasm requires athletes, parents, athletic trainers, and coaches to be prepared to intervene if an acute episode of exercise-induced bronchospasm occurs. All athletic trainers should have pulmonary function measuring devices such as peak flow meters at all athletic events including practices.(20) In addition, a rescue inhaler should be available during all games and practices. Spacers are recommended to be used with the rescue inhalers, and nebulizers should be readily available for emergencies in which inhalers do not work.(20)
References- Rundell, K. W., and D. M. Jenkinson. 2002. Exercise-induced bronchospasm in the elite athlete. Sports Med. 32(9):583-600.
- Gotshall, R. W. 2002. Exercise-induced bronchoconstriction. Drugs 62(12):1725-1739.
- Parsons, J. P., Kaeding, C., Phillips G., Jarjoura, D., Wadley, G., Mastronarde, J.G. 2007. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc.In Press.
- Parsons, J. P., and J. G. Mastronarde. 2005. Exercise-induced bronchoconstriction in athletes. Chest 128(6):3966-74.
- Shawdon, A. 1995. Gastro-oesophageal reflux and exercise. Important pathology to consider in the athletic population. Sports Med 20(2):109-16.
- Helenius, I., and T. Haahtela. 2000. Allergy and asthma in elite summer sport athletes. J.Allergy Clin.Immunol. 106(3):444-452.
- Brauer, M., and J. D. Spengler. 1994. Nitrogen dioxide exposures inside ice skating rinks. Am.J.Public Health 84(3):429-433.
- Hallstrand, T. S., J. R. Curtis, T. D. Koepsell, D. P. Martin, R. B. Schoene, S. D. Sullivan, G. N. Yorioka, and M. L. Aitken. 2002. Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction. J.Pediatr. 141(3):343-348.
- Parsons, J. P., J. M. O'Brien, M. R. Lucarelli, and J. G. Mastronarde. 2006. Differences in the evaluation and management of exercise-induced bronchospasm between family physicians and pulmonologists. J Asthma 43(5):379-84.
- Rundell, K. W., and B. A. Spiering. 2003. Inspiratory stridor in elite athletes. Chest 123(2):468-74.
- Rundell, K. W., R. L. Wilber, L. Szmedra, D. M. Jenkinson, L. B. Mayers, and J. Im. 2000. Exercise-induced asthma screening of elite athletes: field versus laboratory exercise challenge. Med.Sci.Sports Exerc. 32(2):309-316
- Holzer, K., and J. A. Douglass. 2006. Exercise induced bronchoconstriction in elite athletes: measuring the fall. Thorax 61(2):94-6
- Holzer, K., S. D. Anderson, H. K. Chan, and J. Douglass. 2003. Mannitol as a challenge test to identify exercise-induced bronchoconstriction in elite athletes. Am J Respir Crit Care Med 167(4):534-7.
- Anderson, S. D., G. J. Argyros, H. Magnussen, and K. Holzer. 2001. Provocation by eucapnic voluntary hyperpnoea to identify exercise induced bronchoconstriction. Br J Sports Med 35(5):344-7.
- 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.
- McKenzie, D. C., S. L. McLuckie, and D. R. Stirling. 1994. The protective effects of continuous and interval exercise in athletes with exercise-induced asthma. Med.Sci.Sports Exerc. 26(8):951-956.
- Rundell, K. W., B. A. Spiering, D. A. Judelson, and M. H. Wilson. 2003. Bronchoconstriction during cross-country skiing: is there really a refractory period? Med.Sci.Sports Exerc. 35(1):18-26.
- 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.
- Schacter, E. 1982. The protective effects of a cold weather mask on EIA. Ann Allergy(46):12-16.
- Miller, M. G., J. M. Weiler, R. Baker, J. Collins, and G. D'Alonzo. 2005. National athletic trainers' association position statement: management of asthma in athletes. J Athl Train 40(3):224-45.
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