Exercise-Induced Dyspnea in Collegiate Athletes: Are We Missing the Diagnosis?

OBJECTIVES: Exercise-induced dyspnea (EID) can disrupt an athlete's participation and performance in their given sport. Differential diagnosis of EID is often completed using subjective report and may be inaccurate, therefore increasing the frustration and stress of the athlete. This nonexperimental research study was used to determine prevalence of EID and related respiratory symptoms in athletes at a small, Division I university. METHODS: An anonymous survey was provided to athletes at Murray State University as they registered for participation in sports for the 2020-2021 school year. Data from this survey was analyzed as to reported physician-given diagnosis of a respiratory disorder as well as reported symptoms of EID. RESULTS: Results showed that athletes with a physician-given diagnosis often did not report symptoms or responses to medications that support that diagnosis. Additionally, athletes frequently reported symptoms of EID without a formal diagnosis of a respiratory disorder. CONCLUSIONS: These findings provide preliminary insight and pilot data that may be used to understand the prevalence of EID in collegiate athletes and the need for improved methods of diagnosis for etiologies of EID.

Cough in exercise and athletes.

In the general population, particularly in individuals with asthma, cough is a common symptom, often reported after exertion, although regular exercise may be associated with a reduction in the prevalence of cough. In athletes, exercise-induced cough is also a particularly frequent symptom. The main etiologies of cough in athletes are somewhat similar to non-athletes, including asthma/airway hyperresponsiveness, upper airways disorders such as allergic or non-allergic rhinitis, and exercise-induced laryngeal obstruction, although these conditions are more frequently observed in athletes. In these last, this symptom can also be related to the high ventilation and heat exchange experienced during exercise, particularly during exposure to cold/dry air or pollutants. However, gastroesophageal reflux, a common cause of cough in the general population, despite being highly prevalent in athletes, has not been reported as a main cause of cough in athletes. Cough may impair quality of life, sleep and exercise performance in the general population and probably also in athletes, although there are few data on this. The causes of cough should be documented through a systematic evaluation, the treatment adapted according to identified or most probable cough etiology and pattern of presentation, while respecting sports anti-doping regulations. More research is needed on exercise-induced persistent cough in the athlete to determine its pathophysiology, optimal management and consequences.

Allergic acute coronary syndrome in exercise-induced anaphylaxis.

In this case report we present a 49-year-old male who was seen in the emergency department after collapsing due to anaphylactic shock, with ECG findings suggesting myocardial ischaemia. We linked both diagnoses to Kounis syndrome, which describes an acute coronary syndrome due to an allergic event. His circulatory collapse was explained by exercise-induced anaphylaxis.

Association of exercise-induced wheeze and other asthma symptoms with emergency department visits and hospitalizations in a large cohort of urban adolescents.

OBJECTIVE: Exercise-induced wheeze (EIW) has been found to be associated with asthma-related urgent care in school-aged children. Despite asthma's high prevalence and morbidity among adolescents, this association has not been examined in adolescents. We tested the association of EIW and other asthma symptoms to asthma-related ED visits and hospitalizations in urban adolescents with probable asthma. We hypothesized that EIW would be associated with urgent care. METHODS: In this cross-sectional study 30,467 high school students (mean age = 16.0) from 49 NYC schools completed two brief validated measures, one assessing probable asthma and the other the frequency of six asthma symptoms over the past year. Adolescents also reported if in the past year they had an asthma-related ED visit or hospitalization. Analyses presented here included students with probable asthma (n = 9149). Using logistic regression, we modeled each asthma symptom as a function of ED visits and hospitalizations adjusting for sex, age, race/ethnicity and asthma severity. Multivariable models included all symptoms to account for the potential interaction between symptoms. RESULTS: Among adolescents with probable asthma, EIW was associated with ED visits and hospitalizations. In multivariable models wheeze without a cold, chest tightness, night wakening, but not EIW, were significantly associated with both ED visits and hospitalizations. CONCLUSIONS: Unlike findings with younger children, EIW does not appear to be associated with ED visits and hospitalizations among urban adolescents with probable asthma. Instead, symptoms, such as chest tightness and night wakening, appear to be important at identifying adolescents at risk for asthma-related urgent care.

Dyspnea in Children: What is driving it and how to approach it.

Dyspnea in children has important physical and psychosocial impact. It is useful to define the quality of the dyspnea and quantify its magnitude in a child-friendly manner. Through careful history taking and physical examination, a targeted investigation can lead to identification of the cause and potential treatment. This article provides a framework for the clinical approach to dyspnea in children, including important information to gather during the history, physical assessment, how to quantify dyspnea, and choice and use of laboratory measurements.

Food-Dependent, Exercise-Induced Anaphylaxis: Diagnosis and Management in the Outpatient Setting.

Food-dependent, exercise-induced anaphylaxis is a disorder in which anaphylaxis develops most predictably during exercise, when exercise takes place within a few hours of ingesting a specific food. IgE to that food should be demonstrable. It is the combination of the food and exercise that precipitates attacks, whereas the food and exercise are each tolerated independently. Recently, it was demonstrated that exercise is not essential for the development of symptoms, and that if enough of the culprit food is ingested, often with additional augmentation factors, such as alcohol or acetylsalicylic acid, symptoms can be induced at rest in the challenge setting. Thus, food-dependent, exercise-induced anaphylaxis appears to be more correctly characterized as a food allergy syndrome in which symptoms develop only in the presence of various augmentation factors, with exercise being the primary one. However, additional factors are not usually present when the patient exercises normally, so ongoing investigation is needed into the physiologic and cellular changes that occur during exercise to facilitate food-induced anaphylaxis.

Cough in the Athlete: CHEST Guideline and Expert Panel Report.

BACKGROUND: Cough is a common symptom experienced by athletes, particularly after exercise. We performed a systematic review to assess the following in this population: (1) the main causes of acute and recurrent cough, either exercise-induced or not, (2) how cough is assessed, and (3) how cough is treated in this population. From the systematic review, suggestions for management were developed. METHODS: This review was performed according to the CHEST methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework until April 2015. To be included, studies had to meet the following criteria: participants had to be athletes and adults and adolescents aged ≥ 12 years and had to complain of cough, regardless of its duration or relationship to exercise. The Expert Cough Panel based their suggestions on the data extracted from the review and final grading by consensus according to a Delphi process. RESULTS: Only 60 reports fulfilled the inclusion criteria, and the results of our analysis revealed only low-quality evidence on the causes of cough and how to assess and treat cough specifically in athletes. Although there was no formal evaluation of causes of cough in the athletic population, the most common causes reported were asthma, exercise-induced bronchoconstriction, respiratory tract infection (RTI), upper airway cough syndrome (UACS) (mostly from rhinitis), and environmental exposures. Cough was also reported to be related to exercise-induced vocal cord dysfunction among a variety of less common causes. Although gastroesophageal reflux disease (GERD) is frequent in athletes, we found no publication on cough and GERD in this population. Assessment of the causes of cough was performed mainly with bronchoprovocation tests and suspected disease-specific investigations. The evidence to guide treatment of cough in the athlete was weak or nonexistent, depending on the cause. As data on cough in athletes were hidden in a set of other data (respiratory symptoms), evidence tables were difficult to produce and were done only for cough treatment in athletes. CONCLUSIONS: The causes of cough in the athlete appear to differ slightly from those in the general population. It is often associated with environmental exposures related to the sport training environment and occurs predominantly following intense exercise. Clinical history and specific investigations should allow identification of the cause of cough as well as targeting of the treatment. Until management studies have been performed in the athlete, current guidelines that exist for the general population should be applied for the evaluation and treatment of cough in the athlete, taking into account specific training context and anti-doping regulations.

A Study To Assess The Prevalence Of Exercise-Induced Bronchoconstriction In Inter-County Hurling.

Exercise-Induced Bronchoconstriction (EIB) is an acute, transient airway narrowing occurring after exercise which may impact athletic performance. Studies report 10% of the general population and up to 90% of asthmatics experience EIB. Ninety-two players from three elite hurling squads underwent a spirometric field-based provocation test with real-time heart rate monitoring and lactate measurements to ensure adequate exertion. Players with a new diagnosis of EIB and those with a negative field-test but with a previous label of EIB or asthma underwent further reversibility testing and if negative, methacholine challenge. Eight (8.7%) of players had EIB, with one further athlete having asthma with a negative field test. Interestingly, only three out of 12 players who had previously been physician-labelled with EIB or asthma had their diagnosis objectively confirmed. Our study highlights the role of objective testing in EIB.

Paradoxical vocal fold motion in children presenting with exercise induced dyspnea.

INTRODUCTION: Although dyspnea with exercise in the pediatric population can be multifactorial, the diagnosis of paradoxical vocal fold motion disorder (PVFMD) in this group is not well characterized. The objective of this study is to review the multiple causes of dyspnea with exercise in children, including the prevalence of PVFMD within this study population. METHODS: A retrospective review was conducted of patients seen at a tertiary pediatric hospital for exercise-induced dyspnea suspected to be related to PVFMD between January 2007 and July 2015. Inclusion criteria included assessment in a specialty exercise clinic and evaluation by a pediatric otolaryngologist and pulmonologist. Pre- and post-exercise pulmonary function tests and laryngoscopic examinations were performed. Data including co-morbidities, presenting symptoms, prior diagnoses and treatments, final diagnoses, prescribed treatments and outcomes were collected and analyzed. RESULTS: 294 patients were evaluated at our institution during the study period. 4 patients were excluded for insufficient data, which left 290 for analysis. 75 were male, 215 female. All patients underwent treadmill testing with monitoring to simulate strenuous exercise. Average patient age was 14.6 years; average BMI was 21.53. The most common sports to elicit symptoms were running and soccer. Patients most frequently complained of stridor or wheezing in addition to dyspnea. Throat tightness was also a common complaint. After evaluation, 86 patients were given the primary diagnosis of exercise-induced PVFMD. 54 patients were diagnosed with physiologic dyspnea and 30 with exercise-induced asthma. CONCLUSION: Pediatric patients presenting with exercise-induced dyspnea can have multiple etiologies for their symptoms including PVFMD. Other causes of dyspnea with exercise should not be underestimated.

Overweight effect on spirometric parameters in adolescents undergoing exercise.

OBJECTIVE: To evaluate effects of overweight on spirometric parameters in adolescents who underwent bronchial provocation test for exercise. METHODS: We included 71 male adolescents. The diagnosis of asthma was done based on participants' clinical history and on the International Study Questionnaire Asthma and Allergies in Childhood, and the diagnosis of obesity was based on body mass index above 95th percentile. The bronchospasm induced by exercise was assessed using the run-walk test on a treadmill for eight minutes. The decrease in forced expiratory volume in one second > or equal to 10% before exercise was considered positive, and to calculate the intensity in exercise-induced bronchospasm we measured the maximum percentage of forced expiratory volume in one second and above the curve area. Data analysis was carried out using the Mann-Whitney U test and Friedman test (ANOVA), followed by Wilcoxon test (p<0.05). In addition, we used Fisher's exact test to analyze the exercise-induced bronchospasm frequency. RESULTS: Significant differences were observed among obese adolescents in exercise-induced bronchospasm frequency (p=0,013) and in relation to time required for recovery after exercise (p=0,007). CONCLUSION: Overweight can influence the increase in the exercise-induced bronchospasm frequency in non-asthmatic adolescents compared with eutrophic adolescents. OBJETIVO: Avaliar o efeito do excesso de peso sobre parâmetros espirométricos em adolescentes submetidos ao teste de broncoprovocação por exercício. MÉTODOS: Participaram do estudo 71 adolescentes do sexo masculino. O diagnóstico de asma foi obtido por meio de histórico clínico e do questionário International Study of Asthma and Allergies in Childhood, e o de obesidade, pelo índice de massa corporal acima do percentil 95. Para avaliar o broncoespasmo induzido pelo exercício, utilizou-se o teste correr/caminhar em esteira ergométrica, com duração de 8 minutos, considerando positivo se diminuição do volume expiratório forçado no primeiro segundo >10% do valor pré-exercício e, para a intensidade do broncoespasmo induzido pelo exercício, foram utilizados o cálculo da queda percentual máxima do volume expiratório forçado no primeiro segundo e a área acima da curva. A análise dos dados foi realizada pelo teste U Mann-Whitney e pela ANOVA de Friedman, seguido do teste de Wilcoxon (p<0,05). O teste de Fisher foi empregado para analisar a frequência de broncoespasmo induzido pelo exercício. RESULTADOS: Foram encontradas diferenças significativas quanto à frequência de broncoespasmo induzido pelo exercício (p=0,013) e ao tempo de recuperação pós-exercício (p=0,007) nos adolescentes obesos. CONCLUSÃO: O excesso de peso pode influenciar no aumento da frequência de broncoespasmo induzido pelo exercício em adolescentes não asmáticos, quando comparados a eutróficos.

Overweight effect on spirometric parameters in adolescents undergoing exercise / Efeito do excesso de peso sobre parâmetros espirométricos de adolescentes submetidos ao exercício

ABSTRACT Objective To evaluate effects of overweight on spirometric parameters in adolescents who underwent bronchial provocation test for exercise. Methods We included 71 male adolescents. The diagnosis of asthma was done based on participants’ clinical history and on the International Study Questionnaire Asthma and Allergies in Childhood, and the diagnosis of obesity was based on body mass index above 95th percentile. The bronchospasm induced by exercise was assessed using the run-walk test on a treadmill for eight minutes. The decrease in forced expiratory volume in one second > or equal to 10% before exercise was considered positive, and to calculate the intensity in exercise-induced bronchospasm we measured the maximum percentage of forced expiratory volume in one second and above the curve area. Data analysis was carried out using the Mann-Whitney U test and Friedman test (ANOVA), followed by Wilcoxon test (p<0.05). In addition, we used Fisher’s exact test to analyze the exercise-induced bronchospasm frequency. Results Significant differences were observed among obese adolescents in exercise-induced bronchospasm frequency (p=0,013) and in relation to time required for recovery after exercise (p=0,007). Conclusion Overweight can influence the increase in the exercise-induced bronchospasm frequency in non-asthmatic adolescents compared with eutrophic adolescents.

RESUMO Objetivo Avaliar o efeito do excesso de peso sobre parâmetros espirométricos em adolescentes submetidos ao teste de broncoprovocação por exercício. Métodos Participaram do estudo 71 adolescentes do sexo masculino. O diagnóstico de asma foi obtido por meio de histórico clínico e do questionário International Study of Asthma and Allergies in Childhood, e o de obesidade, pelo índice de massa corporal acima do percentil 95. Para avaliar o broncoespasmo induzido pelo exercício, utilizou-se o teste correr/caminhar em esteira ergométrica, com duração de 8 minutos, considerando positivo se diminuição do volume expiratório forçado no primeiro segundo >10% do valor pré-exercício e, para a intensidade do broncoespasmo induzido pelo exercício, foram utilizados o cálculo da queda percentual máxima do volume expiratório forçado no primeiro segundo e a área acima da curva. A análise dos dados foi realizada pelo teste U Mann-Whitney e pela ANOVA de Friedman, seguido do teste de Wilcoxon (p<0,05). O teste de Fisher foi empregado para analisar a frequência de broncoespasmo induzido pelo exercício. Resultados Foram encontradas diferenças significativas quanto à frequência de broncoespasmo induzido pelo exercício (p=0,013) e ao tempo de recuperação pós-exercício (p=0,007) nos adolescentes obesos. Conclusão O excesso de peso pode influenciar no aumento da frequência de broncoespasmo induzido pelo exercício em adolescentes não asmáticos, quando comparados a eutróficos.

Asma / No disponible

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Ejercicio físico: asma y equivalentes asmáticos en la infancia. Broncomotricidad / Physical excercise: asthma and asthmatic equivalents in childhood. Bronchomotricity

Se hace un recuerdo de la patogenia del asma, desde los antecedentes familiares, y posibles diagnósticos de otros procesos con sintomatología similar. Esta revisión se centra en la valoración y estudio de los episodios de disnea causados por el ejercicio físico, un hecho frecuente tanto en pacientes asmáticos como en los que faltando las crisis agudas de disnea, se diagnostican de bronquitis asmatiforme. Se presenta un estudio de 40 pacientes de entre 7 y 18 años de edad, todos ellos con antecedentes familiares de alergia, de los que 23 fueron diagnosticados de asma y los otros 17 de bronquitis asmatiforme. En todos constan episodios de disnea causada por ejercicio físico. Se efectuó prueba de provocación con metacolina para conocer el grado de hiperreactividad y también prueba de ejercicio físico. En los asmáticos la prueba de sobreesfuerzo fue positiva en el 65,2% mientras que en el otro grupo fue en el 41,1% de los bronquíticos. Se proponen las medidas terapéuticas apropiadas (AU)

A review is made of the pathogeny of asthma from the family histories and possible diagnoses of other processes with similar symptoms. This review focuses on the evaluation and study of dyspnea episodes caused by physical exercise, a frequent event in both asthmatic patients and in those who, without acute dyspnea episodes, are diagnosed of asthmatiform bronchitis. A study of 40 patients, aged 7 to 18 years, is presented. All had family histories of allergy. Of these, 23 were diagnosed of asthma and 17 others of asthmatiform bronchitis. Episodes of dyspnea caused by physical exercise was reported in all of them. Methacholine challenge test to know the degree of hyperreactivity’ and a physical exercise test were performed. The overexertion test was positive in 65.2% in the asthmatic patients while in the other group it was 41.1% of the bronchitic patients. Appropriate therapeutic measures are proposed (AU)

Increased postexercise lipoxin A4 levels in exhaled breath condensate in asthmatic children with exercise-induced bronchoconstriction

Background: Lipoxins could be potential modulators of inflammation in the lungs. To our knowledge, the role of exhaled breath condensate (EBC) lipoxin A4 (LXA4) in asthmatic children with exercise-induced bronchoconstriction (EIB) has not been investigated. Objective: The aim of our study was to determine the involvement of EBC LXA4 in EIB. Methods: Forty-five patients aged between 5 and 17 years were included in the study. Patients were divided into 2 groups: asthmatic children with a positive response to exercise (n=17) and asthmatic children with a negative response to exercise (n=28). Levels of LXA4 were determined in EBC before and immediately after the exercise challenge using ELISA. Results: EBC LXA4 levels were significantly increased immediately after exercise in asthmatic children with a positive response to the exercise challenge (P=.05). No significant differences were observed in children with a negative response to exercise (P>.05). There was an inverse correlation between LXA4 levels and the percent degree of reduction in forced expiratory volume in the first second (FEV1%) postexercise in children with a positive exercise challenge (P=.05, r=-0.50). No significant differences were observed in LXA4 levels between atopic and nonatopic asthmatics (P>.05, Mann-Whitney U test). Conclusions: Levels of EBC LXA4 increased immediately after exercise in asthmatic children with a positive exercise challenge response. We hypothesize that airway LXA4 levels increase to compensate bronchoconstriction and suppress acute inflammation, and that spontaneous bronchodilatation after EIB may be due to LXA4 (AU)

Introducción: Las lipoxinas pueden actuar potencialmente como inmunomoduladores de la actividad inflamatoria en el pulmón. A nuestro entender, el papel de la lipoxina A4 (LXA4), determinada en condensado de aire exhalado (EBC) en niños asmáticos con broncoconstricción inducida por el ejercicio (BEI) no ha sido previamente investigado. Objetivo: El objetivo de nuestro estudio fue determinar la implicación de la LXA4 determinada en EBC, en el broncoespasmo inducido por ejercicio. Métodos: Se incluyeron en el estudio un total de cuarenta y cinco pacientes de edades comprendidas entre 5 y 17 años. Los pacientes se dividieron en dos grupos: niños asmáticos con respuestas positivas (n = 17) y negativas (n = 28) a la provocación bronquial con ejercicio. Los niveles de LXA4 en EBC se determinaron inmediatamente antes y después de la provocación bronquial mediante un método ELISA. Resultados: Los niveles de LXA4 en EBC aumentaron significativamente tras la provocación con ejercicio en aquellos niños asmáticos con respuestas positivas en la provocación (p = 0,05). Sin embargo, no pudimos encontrar ninguna diferencia estadísticamente significativa en pacientes con respuesta negativa al ejercicio (p > 0,05). Hubo una correlación inversa entre el incremento de los niveles de LXA4 y el grado de reducción porcentual del volumen espiratorio forzado en un segundo (FEV1%) en los pacientes con respuesta positiva a la provocación (p = 0,05, r = -0,50). No se observaron diferencias significativas en los niveles de LXA4 entre asmáticos alérgicos y no alérgicos (p> 0,05, prueba de Mann-Whitney). Conclusiones: Los niveles de EBC LXA4 se incrementan inmediatamente después de la broncoconstricción inducida por el ejercicio en niños asmáticos. Se postula que los niveles de las vías respiratorias aumentan LXA4 para suprimir la inflamación aguda en la vía respiratoria, y podrían ser responsables de la inducción de broncodilatación espontánea que aparece tras el EIB (AU)

Measurement of lung function and bronchial inflammation in children is underused by spanish allergists

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Eucapnic Voluntary Hyperventilation to Detect Exercise-Induced Bronchoconstriction in Cystic Fibrosis.

BACKGROUND: Exercise-induced bronchoconstriction (EIB) has not been well studied in cystic fibrosis (CF), and eucapnic voluntary hyperventilation (EVH) testing has not been used as an objective assessment of EIB in CF to date. METHODS: A prospective cohort pilot study was completed where standard EVH testing was completed by 10 CF patients with forced expiratory volume in 1 s (FEV1) ≥70% of predicted. All patients also completed a cardiopulmonary exercise test (CPET) with pre- and post-CPET spirometry as a comparative method of detecting EIB. RESULTS: No adverse events occurred with EVH testing. A total of 20% (2/10) patients were diagnosed with EIB by means of EVH. Both patients had clinical symptoms consistent with EIB. No patient had a CPET-based exercise challenge consistent with EIB. CONCLUSIONS: EVH testing was safe and effective in the objective assessment for EIB in patients with CF who had well-preserved lung function. It may be a more sensitive method of detecting EIB then exercise challenge.