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COPYRIGHT 2003 American Academy of Family Physicians
The National Asthma Education and Prevention Program (1) is a comprehensive statement of guidelines for the diagnosis and management of asthma. The expert panel (1) uses the term exercise-induced bronchospasm (EIB) to describe a condition defined as the presence of symptoms in relation to athletic performance or a significant decrease in forced expiratory volume 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 the loss of heat, water, or both 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 only during exercise. One study (3) has found unrecognized EIB in as many as 29 percent of athletes presenting for athletic preparticipation examinations.
Diagnosis
The diagnosis of EIB is based on a detailed history suggestive of shortness of breath, decreased exercise endurance, chest tightness, cough, or wheezing during or immediately following sustained exercise (Table 1). Some patients also report having an upset stomach or a sore throat. Symptoms that occur during the first five minutes of exercise are usually not indicative of EIB; however, these symptoms may suggest other changes in pulmonary function, poorly controlled underlying asthma, poor conditioning, or injury to the chest wall muscle. Persons who engage in physical activities that involve only 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 deny symptoms as a result of peer pressure or concerns about potential inadequacy or the inability to continue playing.
Most patients with EIB have a normal physical examination, with no evidence of wheezing on auscultation. Nevertheless, a focused physical examination should be performed to exclude sinusitis, nasal polyps, a deviated septum, or vocal cord dysfunction.
The most objective measure of EIB is a pulmonary function test coupled with an appropriate exercise challenge (Table 2). (4) However, full pulmonary function testing is rarely required. If symptoms are strongly suggestive of EIB, a trial of therapy using a short-acting bronchodilator may be useful to see if the patient significantly improves in performance and symptoms.
Management
The goal of management is to prevent or reduce the symptoms of EIB, to enable patients to exercise at all intensity levels without serious respiratory limitations. Interventions should be tailored to the patient; a school-aged child participating in recreational and school activities...
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