The National Asthma Education and P...

The National Asthma Education and Prevention Program (1) is a comprehensive statement of guidelines for the diagnosis and management of asthma. The master panel (1) uses the terminus exercise-induced bronchospasm (EIB) to describe a condition defined as the port of symptoms in relation to athletic performance or a significant decrease in forced expiratory tome at one second (FE[V.sub.1]) in relation to exercise. Typically, EIB begins after several minutes of vigorous physical activity and reaches its peak in five to 10 minutes.

Epidemiology

Exercise-induced bronchospasm is caused by dint of the loss of heat, water, or the pair from the lungs during exercise, stemming from hyperventilation of air that is drier and cooler than that in the respiratory tree Between 80 and 90 percent of patients with asthma also have EIB. (2) However, many patients have bronchospasm and nothing else during exercise. One study (3) has base unrecognized EIB in as many as 29 percent of athletes presenting for athletic preparticipation examinations.

Diagnosis

The diagnosis of EIB is based forward a detailed history suggestive of shortness of breath, decreased exercise endurance, chest tightness, cough or wheezing during or immediately following sustained exercise (Table 1) near patients also report having an turn upside down stomach or a sore throat. Symptoms that come into one's head during the first five minutes of exercise are usually not indicative of EIB; however, these symptoms may intimate other changes in pulmonary function, poorly controll underlying asthma, poor conditioning, or injury to the chest wall muscle. somebodys who engage in physical activities that involve and nothing else short bursts of exertion may perform well without becoming symptomatic. A detailed history should be obtained from family, coaches, and teammates, if possible, because the athlete may abjure symptoms as a result of fellow pressure or concerns about potential inadequacy or the inability to continue playing.

mostly patients with EIB have a normal physical examination, with no evidence of wheezing forward auscultation. Nevertheless, a focused physical examination should be performed to except sinusitis, nasal polyps, a deviated septum or vocal cord dysfunction.

The most numerous objective measure of EIB is a pulmonary function criterion coupled with an appropriate exercise challenge (Table 2) (4) However, replete pulmonary function testing is rarely required. If symptoms are vehemently suggestive of EIB, a trial of therapy using a short-acting bronchodilator may be useful to behold if the patient significantly improves in performance and symptoms.

Management

The goal of management is to obviate or reduce the symptoms of EIB, to enable patients to exercise at all intensity on a levels without serious respiratory limitations. Interventions should be tailored to the patient; a school-aged child participating in recreational and institute activities should be treated differently from an elite athlete. characters should not be excluded from participating in sports or working at do job-works with heavy physical demand based solely upon EIB. For example, in a cogitation of U.S. Army recruits, (5) EIB symptoms did not hinder physical performance gains, on a level during basic training.

NONPHARMACOLOGIC THERAPY

Patients, and anyone involved in their care, should be educated about the nature of EIB, its triggers, and for what cause to control it with or without medications. Table 3 lists simple nonpharmacologic manners for reducing the likelihood of EIB. (6)

Physical conditioning increases a patient's ability to work at a lower even of vital capacity, decreasing the cooling and drying stimuli, resulting in les bronchospasm. (7) Athletes should always warm up before vigorous exercise and take advantage of a "refractory period" induced by dint of short bursts of exercise. (78) Awareness of environmental allergens like as pollen or animal dander can impede concomitant aggravation of asthma by the agency of allergens and exercise.

PHARMACOLOGIC THERAPY

Considerable data indicate that most asthma medications can effectively restrain EIB. Figure 1 is a comprehensive management algorithm that incorporates diagnostic and therapeutic issues.

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Traditionally, the diagnosis is based forward a detailed history with symptoms suggestive of EIB and a normal FE[Vsub1] at cessation A therapeutic trial may be instituted in these patients. In patients whose answer is less than optimal following an adequate therapeutic trial, the entrance for conducting baseline pulmonary function testing should be gentle These patients may have undiagnosed asthma or other pulmonary conditions, and the first priority should be to optimize pulmonary function testing with the use of inhaled steroids. Table 4 lists the medications that are available to treat EIB.

Beta Agonists. Inhaled beta agonists are first-line medications in the management of EIB, the couple as prophylaxis and to treat the bronchospasm that arises with exercise. A short-acting beta agonist should be taken 15 minutes before exercise and may be repeated as necessary. (9) public beta agonists include metaproterenol (Alupent); albuterol (Ventolin); bitolterol mesylate (Tornalate); pirbuterol (Maxair); terbutaline sulfate (Bricanyl); and formoterol (Foradil Aerolizer). (10) Formoterol, a long-acting agent, has bronchoprotective powers for up to 12 hours. (11) It was approved at the U.S. Food and unsalable article Administration (FDA) in February, 2001 for pretreatment in children 12 years or older Formoterol is available as an inhalation triturate and is to be used with an aerolizer inhaler (Table 4)