Exercise Induced Bronchospasm and associated factors in primary school children: a cross-sectional study.

BACKGROUND: Exercise Induced Bronchospasm(EIB) is not equivalent to asthma. As many as 20%of school aged children are estimated to have EIB. In Nigeria, there is still a dearth of information on EIB as a clinical entity. This study determined the presence of EIB(using pre and post-exercise percentage difference in peak expiratory flow rate(PEFR) and associated factors such as age, gender, social class and nutritional status in primary school children in Nnewi, Anambra state, South-East Nigeria. The study also grouped those with EIB into those with asthma(EIBA) and those without asthma(EIBWA). METHODS: This was a community based cross-sectional study involving 6-12 year olds. The PEFR was taken at rest and after a 6 min free running test on the school play-ground using a Peak Flow Meter. A diagnosis of EIB was made if there was a decline of ≥ 10%. Those who had EIB were grouped further based on the degree of decline in post-exercise PEFR (a decline ≥ 10% < 25% → Mild EIB, ≥ 25% < 50% → Moderate EIB and ≥ 50% → Severe EIB) and then categorized as those with EIBWA/EIBA. RESULTS: EIB in the various minutes post-exercise was as follows: 19.2%(1stmin), 20.9%(5thmin), 18.7%(10thmin), 10%(20thmin), 0.7%(30thmin). Mild EIB accounted for the greater proportion in all minutes post-exercise and none of the pupils had severe EIB. Using values obtained in the 5thmin post-exercise for further analysis, EIBWA/EIBA = 84.1%/15.9% respectively. Mean difference in the post-exercise PEFR of EIB/no EIB and EIBWA/EIBA was -48.45(t = -7.69, p = < 0.001) and 44.46(t = 3.77, p = 0.01) respectively. Age and gender had a significant association to the presence of EIB and 58% of the pupils with EIB were of high social class. The BMI for age and gender z-scores of all study subjects as well as those with EIB was -0.34 ± 1.21, -0.09 ± 1.09 respectively. Other features of allergy(history of allergic rhinitis: OR-5.832, p = 0.001; physical findings suggestive of allergic dermatitis: OR-2.740, p = 0.003)were present in pupils diagnosed with EIB. CONCLUSION: EIB has a high prevalence in primary school children in Nnewi and the greater proportion of those with EIB had EIBWA. EIB therefore needs to be recognized as a clinical entity and stratified properly based on the presence or absence of asthma. This will help the proper management and prognostication.

Exercise-induced laryngeal obstruction (EILO) in children and young adults: From referral to diagnosis.

OBJECTIVE: To identify different presentations, referral patterns, comorbidities, and laryngoscopy findings in children and young adults with exercise-induced laryngeal obstruction (EILO). METHODS: We performed a retrospective chart review of 112 patients, age <26 years, with EILO between 2013 and 2016. RESULTS: Of the 112 patients who met criteria, 91 were female and 21 were male. Patients were most frequently referred by pulmonologists (60.7%). The majority of patients (93%) participated in organized sports, most of them at a competitive level. The mean age at symptom onset was 13.8 ± 3.3 years, and the mean age of diagnosis was 15.4 ± 3.0 years. Sixty-seven (59.8%) patients presented with a prior diagnosis of asthma, the majority of whom had failed asthma treatment. The most common symptoms reported were dyspnea (93.8%), wheezing/stridor (78.6%), and throat tightness (48.2%). Ninety-one (81.3%) patients had spirometry performed, with 46 (51.1%) showing inspiratory loop flattening. On flexible laryngoscopy, 87 (78.4%) of 111 patients had paradoxical vocal fold motion. Supraglottic involvement was observed to obstruct the airway in 26 (23.9%) patients, with patterns of obstruction similar to those observed in children with laryngomalacia. CONCLUSION: Most patients participated in competitive sports, were female, and presented with exertional dyspnea. Most patients were diagnosed with exercise-induced asthma but treated unsuccessfully. Almost one-quarter of our patients showed supraglottic collapse obstructing the airway. Exercise-induced laryngeal obstruction is a more descriptive term than paradoxical vocal fold motion or vocal cord dysfunction, which only describe vocal fold involvement. The time to diagnosis of EILO was shorter than previously reported, suggesting that awareness of this condition is increasing. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E400-E406, 2020.

The Visual Analog Scale detects exercise-induced bronchoconstriction in children with asthma.

Objective: Exercise-induced bronchoconstriction (EIB) is a specific morbidity of childhood asthma and an important sign of uncontrolled asthma. The occurrence of EIB is insufficiently identified by the Childhood Asthma Control Test (C-ACT) and Asthma Control Test (ACT). This study aimed to (1) evaluate the Visual Analog Scale (VAS) for dyspnea as a tool to detect EIB in asthmatic children and (2) assess the value of combining (C-)ACT outcomes with VAS scores. Methods: We measured EIB in 75 asthmatic children (mean age 10.8 years) with a standardized exercise challenge test (ECT) performed in cold and dry air. Children and parents reported VAS dyspnea scores before and after the ECT. Asthma control was assessed by the (C-)ACT. Results: Changes in VAS scores (ΔVAS) of children and parents correlated moderately with fall in forced expiratory volume in 1 second (FEV1), respectively rs=0.57 (p < .001) and rs=0.58 (p < .001). At a ΔVAS cutoff value of ≥3 in children, sensitivity and specificity for EIB were 80% and 79% (AUC 0.82). Out of 38 children diagnosed with EIB, 37 had a (C-)ACT score of ≤19 and/or a ΔVAS of ≥3, corresponding with a sensitivity of 97% and a negative predictive value of 96%. Conclusion: This study shows that the VAS could be an effective additional tool for diagnosing EIB in children. A reported difference in VAS scores of ≥3 after a standardized ECT combined with low (C-)ACT scores was highly effective in detecting and excluding EIB.

Los efectos del entrenamiento físico en niños asmáticos / Effects of exercise training in children with asthma

Asthma is a chronic obstructive respiratory disease with high prevalence in children. Several factors may trigger asthma symptoms, including exercise, which can lead to exercise-induced bronchoconstriction (EIB). Although physical exercise may represent a risk factor for triggering bronchial obstruction in asthmatics, studies have also indicated several positive effects. Thus, this article aimed to summarize current evidence on the effects of exercise training in children with asthma. There is substantial available evidence on the topic. Most of the findings show that exercise induce positive effects, including the increase of aerobic fitness, decrease of EIB levels, as well as an increase in both disease control and quality of life levels in asthmatic children. As for possible influencing factors in order to obtain exercise-induced positive effects, an adequate prescription of exercise intensity highlights and should be personalized, as well as established close to the anaerobic threshold. Thus, considering the evidence showing beneficial effects and the fact that the practice of physical exercise consists of a low cost and safe non-pharmacological therapy, supervised, personalized and individual recommendation of exercise training by health professionals are indicated to asthmatic children.

El asma es una enfermedad respiratoria obstructiva crónica con alta prevalencia en niños. Varios factores pueden desencadenar síntomas de asma, incluido el ejercicio, que puede conducir a la broncoconstricción inducida por el ejercicio (BIE). Aunque el ejercicio físico puede representar un factor de riesgo para desencadenar la obstrucción bronquial en los asmáticos, estudios también han indicado varios efectos positivos. Este artículo tiene como objetivo resumir la evidencia actual sobre los efectos del entrenamiento físico en niños con asma. Hay evidencia sustancial disponible sobre el tema. La mayoría de los hallazgos muestran que el ejercicio induce efectos positivos, incluido el aumento de la aptitud aeróbica, la disminución de los niveles de la BEI, así como un aumento tanto en el control de la enfermedad como en los niveles de calidad de vida en niños asmáticos. Se destaca la importancia de una prescripción de la intensidad del ejercicio adecuada y personalizada, cerca del umbral anaeróbico, para obtener los efectos positivos inducidos por el ejercicio. Por lo tanto, considerando la evidencia que muestra efectos beneficiosos y el hecho de que la práctica del ejercicio físico consiste en una terapia no farmacológica, segura y de bajo costo, el entrenamiento físico supervisado, personalizado e individualizado por parte de profesionales de la salud es recomendado para niños asmáticos.

Can EVH Results Predict Post-Exercise Changes in FEV1 Following Interval and Continuous Exercise?

The eucapnic voluntary hyperpnea (EVH) challenge is used to determine the presence of exercise-induced bronchoconstriction (EIBC) by monitoring changes in forced expiratory volume in 1 s (FEV1). However, the predictability of the post-EVH decline in FEV1 on post-exercise FEV1 remains unclear. Participants completed an EVH challenge to confirm EIBC and completed a continuous exercise (CONT; n = 21), high-intensity interval exercise (HI; n = 13), and sprint interval exercise (SPRT; n = 8) sessions on separate days. FEV1 was assessed pre- and post exercise. A 1% decline in FEV1, post EVH was associated with 0.44%, 0.85%, and 0.56% declines in FEV1 post CONT, post HI, and post SPRT, respectively. The decline in FEV1 following the EVH challenge was associated with the decline in FEV1 following all exercise conditions, with the strongest association being observed following HI. These findings may have implications for exercise prescription and asthma education for recreationally active adults with EIBC.

Cold air exercise screening for exercise induced bronchoconstriction in cold weather athletes.

Exercise Induced Bronchoconstriction (EIB) prevalence in cold weather athletes is high. Currently, no standardized cold air exercise provocation test exists. Thus we aimed to determine EIB prevalence using a Cold Air Test (CAT; 5 km outdoor running; -15 °C) compared to the most common EIB screen the Eucapnic Voluntary Hyperpnea (EVH) test in cold weather athletes. Sixteen (9 male; 20-35 years old) cold weather athletes completed EVH 72 h before CAT. Spirometry, Fractional Expired Nitric Oxide (FENO), respiratory symptoms were measured and atopy status was determined. Five and 7 participants were EIB + on the EVH and CAT, respectively. Level of agreement was 50% between tests. FEV1 recovery was significantly prolonged and Peak Expiratory Flow was decreased after CAT compared to EVH. Predictive characteristics of EIB + included FENO >12 ppb, FEV1/FVC ratio (<0.75) and BMI < 20. EVH does not always reflect EIB triggered by cold weather exercise. More research is required to understand the best EIB screens for cold weather athletes.

Acute Reduction in Spirometry Values After Prolonged Exercise Among Recreational Runners.

BACKGROUND: Prolonged endurance running may acutely reduce spirometric lung values. This study examined changes in spirometry before and immediately after prolonged endurance exercise (running and/or walking). Specifically, we examined potential factors that predict the presence of at least a 10% postexercise reduction in FEV1. METHODS: After institutional review board approval, recruitment occurred at a pre-race exposition, where informed consent was obtained. Pre-and post-race spirometry measurements were taken from 79 study subjects who competed in a half-marathon (n = 66) or a marathon (n = 13). Spirometry was performed 1-2 days before the marathon or half-marathon and 25 min after finish the race. RESULTS: We identified a subgroup of 23 subjects with a postexercise decrease in FEV1 of ≥10%. In this subgroup, the mean post-race values for FEV1, FVC, and peak expiratory flow were 19-24% lower than the pre-race values. In the 56 subjects with a change in FEV1 of <10%, the mean post-race changes in spirometry values were not >6%. There was no difference between the 2 groups in sex distribution or between subjects who completed the half-marathon or the full marathon. For every 1-y increase in age, the likelihood of developing a postexercise reduction in FEV1 of at least 10% decreased by nearly 10% (R2 = 0.15, P = .003). CONCLUSIONS: Exercise-induced bronchoconstriction (EIB) is the most probable explanation for the reduction in post-race FEV1. Prolonged endurance exercise reduced spirometric lung function by ∼20% in those with EIB. Age was the only predictor for EIB, and EIB did not affect the finish times among recreational runners and/or walkers.

Efficient Use of Simple Exercise-Induced Bronchoconstriction Challenge Testing in Pediatric Exercise-Induced Dyspnea.

BACKGROUND: A simple exercise test to evaluate for exercise-induced bronchoconstriction (EIB) is routinely ordered in pediatric patients with exercise-induced dyspnea. However, the utility of this test in establishing the cause of exercise-induced dyspnea is not thoroughly examined in the pediatric population. We sought to assess the efficiency of a simple EIB challenge test in finding the cause of exercise-induced dyspnea in pediatric patients referred to our tertiary center in the last 5 y. METHODS: We performed a retrospective chart review for all of these exercise tests done at Akron Children's Hospital from March 2011 to March 2016. Patients with chronic conditions (eg, cystic fibrosis, cardiac abnormality) were excluded. Demographics, clinical diagnosis of asthma, a presumptive diagnosis of exercise-induced asthma or EIB by the referring provider, symptoms with and without exercise, albuterol use, spirometry, and simple EIB challenge test results were collected. The chi-square test of independence was utilized in the examination of potential dependent relationships between categorical variables. A P value < .05 was considered to be statistically significant. RESULTS: Out of 164 enrolled subjects (57 males; age 6-20 y), only 19% showed evidence of EIB. There were no significant associations between EIB status (ie, EIB-positive or EIB-negative) based on exercise testing and gender, typical symptoms of EIB, diagnosis of exercise-induced asthma or EIB, and albuterol use (P > .05). However, a subject without asthma was 2.8 times more likely to have negative exercise test for EIB (odds ratio 2.8, 95% CI 1.3-6.5); in addition, approximately 85% of tests in subjects without asthma were negative. CONCLUSION: In a majority of subjects without asthma, a simple EIB challenge testing failed to uncover the cause of exercise-induced dyspnea and thus was inefficient. In these subjects, cardiopulmonary exercise testing may be more useful and cost-effective to explore other causes of dyspnea including EIB.

Exercise-induced bronchospasm in children and adolescents with allergic rhinitis by treadmill and hyperventilation challenges.

BACKGROUND: Respiratory complaints after exercise are common in patients with rhinitis. Exercise-induced bronchospasm (EIB) may be one of the causes. OBJECTIVES: To evaluate EIB prevalence in a group of children and adolescents with allergic rhinitis, to compare the treadmill running (TR) and eucapnic voluntary hyperventilation (EVH) challenge methods as diagnostic tools and to assess the association between respiratory complaints on exercise and EIB. METHODS: Patients aged between 10 and 20 years were studied at the Pulmonology Department of the Hospital das Clínicas -UFPE- Recife, Brazil. The severity of symptoms of rhinitis and exercise-related respiratory complaints in the past year were evaluated. Challenges were performed in random sequence, no more than 72 h apart and followed international guidelines. Forced expiratory volume in the first second (FEV1) was determined before and 3, 5, 7, 10, 15 and 30 min after each challenge. A >10% reduction in FEV1 from baseline at two points after the challenge was considered sufficient to diagnose EIB. RESULTS: Of the thirty-five subjects evaluated, thirteen (37%) showed EIB, six by both methods, three only after TR and four only after EVH (Coens' Kappa = 0.489). There was no association between respiratory complaints after exercise and EIB (p = 0.74). CONCLUSION: A high prevalence of EIB was found in this population but only moderate agreement between the challenges used to diagnose EIB. Caution should be adopted when comparing these methods or interpreting their results interchangeably. There was no association between reported respiratory symptoms after exercise and EIB.

Mechanisms and Biomarkers of Exercise-Induced Bronchoconstriction.

Exercise is a common trigger of bronchoconstriction. In recent years, there has been increased understanding of the pathophysiology of exercise-induced bronchoconstriction. Although evaporative water loss and thermal changes have been recognized stimuli for exercise-induced bronchoconstriction, accumulating evidence points toward a pivotal role for the airway epithelium in orchestrating the inflammatory response linked to exercise-induced bronchoconstriction. Overproduction of inflammatory mediators, underproduction of protective lipid mediators, and infiltration of the airways with eosinophils and mast cells are all established contributors to exercise-induced bronchoconstriction. Sensory nerve activation and release of neuropeptides maybe important in exercise-induced bronchoconstriction, but further research is warranted.

Exercise-Induced Bronchoconstriction and the Air We Breathe.

An association between airway dysfunction and airborne pollutant inhalation exists. Volatilized airborne fluorocarbons in ski wax rooms, particulate matter, and trichloromines in indoor environments are suspect to high prevalence of exercise-induced bronchoconstriction and new-onset asthma in athletes competing in cross-country skiing, ice rink sports, and swimming. Ozone is implicated in acute decreases in lung function and the development of new-onset asthma from exposure during exercise. Mechanisms and genetic links are proposed for pollution-related new-onset asthma. Oxidative stress from airborne pollutant inhalation is a common thread to progression of airway damage. Key pollutants and mechanisms for each are discussed.

The Future of Exertional Respiratory Problems: What Do We Know About the Total Airway Approach and What Do We Need to Know?

Exercise is increasingly viewed as a preventative and therapeutic modality for medical and behavioral health disorders. Therefore, it is imperative that the medical and scientific communities minimize barriers that discourage exercise. This issue of Immunology and Allergy Clinics of North America details a "total airway approach" to the evaluation of exertional respiratory problems. Reviews guide clinicians through evaluation and therapy. Moving forward, there is much room for growth with respect to research in each of these areas as well as for common inflammatory pathways and neurophysiologic coupling across all airway segments.

Exercise-induced Bronchoconstriction with Firefighting Contained Breathing Apparatus.

PURPOSE: Protective self-contained breathing apparatus (SCBA) used for firefighting delivers decompressed (cold) dehumidified air that may enhance the severity of exercise-induced bronchoconstriction (EIB) in those susceptible. We investigated the effect of SCBA during exercise on airway caliber in people with asthma and healthy controls. METHODS: Two exercise challenges (EC) designed to elicit EIB were performed on separate days within 1 wk. The initial challenge was breathing room air (ECRA) with workload titrated to elicit >60% estimated maximum voluntary ventilation. The exercise intensity was repeated for the second challenge using SCBA (ECSCBA). Forced expiratory volume in 1 s (FEV1) was measured before and up to 20 min after exercise. Bronchial hyperresponsivenss (BHR) to the hyperosmolar mannitol test was measured in the subjects with asthma. RESULTS: Twenty subjects with current asthma (mean [SD]: age 27 [6] yr) and 10 healthy controls (31 [5] yr, P = 0.1) were studied. The percent fall in FEV1 after ECSCBA was greater in the mannitol-positive asthma subjects (14.4% [15.1%]) compared with mannitol-negative asthmatic subjects (1.6% [1.7%]; P = 0.02) and controls (2.3% [2.3%]; P = 0.04). The FEV1 response was not different between ECRA and ECSCBA (0.49% [5.57%]; P = 0.6). No BHR to mannitol (n = 7) was highly sensitive for identifying a negative response to ECSCBA (negative predictive value 100%). CONCLUSIONS: The SCBA does not increase the propensity or severity for EIB in subjects with BHR. Those subjects with asthma but no BHR to inhaled mannitol did not exhibit EIB. The BHR to a hyperosmolar stimulus maybe considered a useful screening tool for potential recruits with a history of asthma.

Eucapnic voluntary hyperventilation test in children.

BACKGROUND: In children, exercise-induced dyspnea is a common symptom that can be due to dysfunctional breathing. EVH test has bee used especially in elite athletes as bronchoprovocation test. Currently, there are only few studies on the EVH test. New research methods are required alongside the traditionally used tests especially due to dysfunctional breathing disorder. PURPOSE: The purpose of the "pilot study" was to study the usability of the EVH test with real time biofeedback in children of 10-16 years of age in the diagnostics of exercise-induced dyspnea. METHODS: Six 10-16-year-old teenagers with history of exercise-induced dyspnea and three healthy control subjects were selected for the study. A 6-minute EVH test with realtime biofeedback was performed on the patients and the diagnosis was confirmed on the basis of clinical findings and spirometry follow-up either as normal, asthma or dysfunctional breathing. RESULTS: The study was successful in the patients. In the spirometry follow-up, three patients had bronchoconstriction (FEV1 decline over 10%), dysfunctional breathing condition was observed in three patients and three control patients experienced no symptoms. Only two DFB-patients didn't reach the target level of minute ventilation due to a clinical symptom (inspiratory stridor). CONCLUSION: The EVH test was successful in the 10-16-year-old children having participated in the study and the test was well tolerated. Through the study, it was possible to provoke both dysfunctional breathing disorder and bronchoconstriction in the symptomatic patients. Based on the pilot study, EVH test seems to be usable in the diagnostics of pediatric exercise-induced dyspnea but larger studies are warranted to confirm our preliminary findings.

Exercise-Induced Anaphylaxis in an Air Force Aviator Taking a HMG-CoA Reductase Inhibitor: A Case Report and Review of the Presentation, Diagnoses, and Treatment.

BACKGROUND: A 46-year-old healthy male Air Force pilot presented to the emergency department (ED) experiencing symptoms of exercise-induced anaphylaxis (EIAn), during a vigorous outdoor run. The patient recovered in the ED and was seen, subsequently, by a civilian allergist; eventually a diagnosis consistent with EIAn was made. EIAn is a rare but potentially life-threatening syndrome believed to involve IgE mediated release of histamine and other immunoactive compounds, during or after exercise. The diagnosis is determined by a strong clinical suspicion along with careful exclusion of other potential diagnoses. Interestingly, this particular patient was also found to have a possible correlation between the introduction of 3-hydroxy-3-methylglutaryl-coenzyme A, for hyperlipidemia, shortly before his first episode of EIAn, and remission of the condition since discontinuing the statin medication. METHODS: A detailed review of the clinical notes, ED presentation, and all subspecialty consultation notes were include in the compilation of this case report, in conjunction with a careful review of all current literature pertaining to drug exacerbated, exercise-induced EIAn. The review of literature was also conducted to review potential mechanisms of this particular hypersensitivity reaction, and to give a thorough discussion of the history and presentation of this disorder. RESULTS: The patient described in this case was successfully treated over a 2-year period, with exercise modifications and a daily second generation antihistamine. Nearly a year after his initial diagnoses, in an acute visit to the flight medicine clinic for muscle soreness and elevated creatine kinase isoenzymes, the patient's medication profile was reviewed and his statin medication was discontinued. The clinical notes revealed that the statin was started a few months before his first onset of EIAn, and following its discontinuation, the patient has been asymptomatic for over a year, exercising regularly, and completed a successful forward deployment to an austere desert environment. DISCUSSION: To our knowledge, this is the first reported case of possible statin exacerbated, EIAn. Data concerning the incidence of drug-induced hypersensitivity to statins are limited as is any discussion on prevalence of EIAn in adult populations. There have been, however, case reports documenting statin immunological effects on serum IgE levels, which may offer a potential mechanism of statin-exacerbated EIAn. However, the role of IgE antibodies in drug-induced anaphylactic reactions remains unclear. In this patient's case, there was no measure of statin-specific immune reactivity performed; however, the timing of statin initiation of monotherapy in relation to presentation of EIAn strongly supports the diagnosis of statin-exacerbated EIAn. Although the mechanisms involving statin-induced EIAn remain elusive, this case report illustrates the need for military providers to recognize this condition and cofactors that may contribute to its genesis. Moreover, this case also illustrates the need for increased research and surveillance of this condition in civilian and military populations.

Mechanisms, measurement and management of exertional dyspnoea in asthma: Number 5 in the Series "Exertional dyspnoea" Edited by Pierantonio Laveneziana and Piergiuseppe Agostoni.

Asthma is a heterogeneous condition, with dyspnoea during exercise affecting individuals to a variable degree. This narrative review explores the mechanisms and measurement of exertional dyspnoea in asthma and summarises the available evidence for the efficacy of various interventions on exertional dyspnoea. Studies on the mechanisms of dyspnoea in asthma have largely utilised direct bronchoprovocation challenges, rather than exercise, which may invoke different physiological mechanisms. Thus, the description of dyspnoea during methacholine challenge can differ from what is experienced during daily activities, including exercise. Dyspnoea perception during exercise is influenced by many interacting variables, such as asthma severity and phenotype, bronchoconstriction, dynamic hyperinflation, respiratory drive and psychological factors. In addition to the intensity of dyspnoea, the qualitative description of dyspnoea may give important clues as to the underlying mechanism and may be an important endpoint for future interventional studies. There is currently little evidence demonstrating whether pharmacological or non-pharmacological interventions specifically improve exertional dyspnoea, which is an important area for future research.

New insights into treatment of children with exercise-induced asthma symptoms.

BACKGROUND: Exercise is one of the most common triggers of bronchoconstriction and affects up to 80% of children with asthma. OBJECTIVE: The purpose of this randomized, double-blind, placebo-controlled study was to assess the effectiveness of treatment with ciclesonide 160 microgram, either alone, with a higher dose, with a leukotriene receptor antagonist (LTRA), or with a long-acting beta-agonist (LABA) in children with asthma with postexercise-induced symptoms. METHODS: Eighty adolescents, ages 1218 years, with asthma and postexercise symptoms were enrolled. Children were treated in one of four treatment groups: ciclesonide 160 microgram daily dose (cic 160), ciclesonide 320 microgram daily dose (cic 320), ciclesonide 160 microgram daily dose combined with montelukast (cic + LTRA), or ciclesonide 160 microgram daily combined with formoterol (cic + LABA). The impact of treatment on clinical symptoms, maximum percentage decrease in forced expiratory volume in 1 second after intense exercise effort, fractional exhaled nitric oxide in exhaled breath, and the contribution of inflammatory mediators in exhaled breath condensate were assessed. RESULTS: In children with asthma and with postexercise symptoms, 8-week daily administration of ciclesonide 320 microgram, ciclesonide 160 microgram plus LABA, and ciclesonide 160 microgram alone decreased daytime symptoms; decrease in maximal fall in forced expiratory volume in 1 second reached the level of significance in the cic 320, cic + LABA, and cic + LTRA groups. A higher prevalence of positive responses to treatment after addition of an LTRA or LABA to ciclesonide 160 microgram for patients with exercise treadmill challengeinduced clinical symptoms only was revealed. CONCLUSION: Monotherapy with ciclesonide 320 microgram can be as effective as combined therapy in reducing exercise-induced bronchoconstriction. We revealed a higher prevalence of positive responses to treatment after the addition of LTRA or LABA to ciclesonide 160 microgram for patients with exercise treadmill challengeinduced clinical symptoms only. ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="http://www.ClinicalTrials.gov"www.ClinicalTrials.gov/ext-link NCT01798823.

The athlete "out of breath".

Athletes often complain about breathing problems. This is a crucial issue due to potential implications not only on their general health, but also on their competing performance. Asthma and exercise-induced bronchoconstriction are prevalent conditions in elite athletes, which leads doctors to rely most of the times on asthma medication to treat athletes feeling "out of breath". However, there are several other conditions that may mimic asthma and cause dyspnea in athletes. Effective treatment of dyspnea requires appropriate identification and treatment of all disorders. Proper knowledge and accurate diagnosis of such entities is mandatory, since asthma medication is not effective in those conditions. Herein we review the most common differential diagnosis of dyspnea in athletes, and describe the diagnostic strategies in order to increase awareness and to improve doctor's confidence on dealing with these patients.