Exercise Induced Asthma

Introduction

Exercise-induced bronchoconstriction (EIB) describes the transient and reversible constriction of bronchial smooth muscle following physical exertion, which may or may not produce symptoms such as dyspnea, chest tightness, wheezing, and coughing. (EIB was formerly known as exercise-induced asthma) [1].

• EIB occurs in 40% to 90% of people with asthma and up to 20% of people without asthma.
• Regular exercise benefits everyone, and activity is an integral part of a healthy lifestyle.
• People with EIB may avoid exertion due to symptoms such as breathlessness, coughing, chest tightness, and wheezing. Avoiding exercise has been shown to increase social isolation among adolescents and may contribute to obesity and poor health.
• Paradoxically, exercise has been shown to improve lung function in severity of EIB and reduce airway inflammation in both asthma and EIB.
• Diagnosis of early detection, as evidenced by changes in lung function during exercise and treatment, can improve quality of life and, if managed properly, allow patients to freely participate in sport without limiting competition at an elite level. [1]

Epidemiology

• Exercise-induced bronchoconstriction occurs in 40% to 90% of people with asthma and up to 20% of the non-asthmatic general population.
• Elite athletes have a 30% to 70% increase in prevalence.
• Exercise-induced asthma is the most common medical problem among Winter Olympic athletes, especially cross-country skiers. Nearly 50% of these athletes suffer from the disorder, closely followed by 43% of short track speed skaters [2].
• Approximately 400 million people are expected to suffer from asthma by 2024, a large proportion of whom are expected to develop EIB.
• 250,000 people die each year from complications of asthma [1].

Cause

EIB is caused by a dramatic increase in the volume of air entering the airway that needs to be heated and humidified. In susceptible individuals, this leads to inflammatory neuronal and vascular changes, ultimately leading to constriction of bronchial smooth muscle and symptoms of dyspnea Cough, chest tightness, mucus production and wheezing. [1].[3]

Asthma is the result of a complex interplay between genetic predisposition and multiple environmental influences. The significant increase in the prevalence of asthma over the past 3 years suggests that environmental factors are key players in the allergic sensitization process. [4] Factors that can be triggered Exercise-induced asthma that may worsen or worsen includes:

• Cold air
• Dry air
• Air pollution such as smoke or smog
• High pollen counts
• have a respiratory infection such as COVID
• Chemicals such as chlorine in swimming pools. [5]

Characteristics/Clinical Presentation

Symptoms of exercise-induced bronchoconstriction can include mild to moderate chest tightness wheezing cough and dyspnea within 15 minutes of 5 to 8 minutes of high-intensity aerobic exercise. Severe symptoms of respiratory failure and death have rarely been reported.

Symptoms:

• Occurs more often in certain environments with cold, dry air or high concentrations of respiratory irritants.
• Usually resolves spontaneously within 30 to 90 minutes and induces a refractory period of 1 to 3 hours during which continued exercise does not produce bronchoconstriction. Patients may also be asymptomatic, so EIB may be missed.

Risk factors include:

• personal or family history of asthma
• Personal history of atopic or allergic rhinitis
• exposure to cigarette smoke,
• Participate in high-risk sports. High-risk sports include activities longer than 5 to 8 minutes in certain environments (such as cold, dry air or chlorinated pools), such as long-distance running, cycling, cross-country or downhill skiing, ice hockey, ice skating, high-altitude sports, swimming Water polo and triathlon.
• Live and practice in highly polluted areas
• female gender. [1]

Evaluation

A detailed history and examination are essential to help determine that movement is the cause of symptoms.

Lung function tests, such as spirometry. Standardized tests for diagnosis include direct and indirect methods, usually involving spirometry to measure change in FEV1 from baseline, expressed as a percent decrease. You may also be referred for bronchial challenge testing [3], such as

• It is well established that methacholine directly stimulates smooth muscle receptors to induce bronchoconstriction. Sensitivity for predicting EIB has been reported to range from 58.6% to 91.1%.
• A more specific indirect test for EIB could involve aerobic exercise in a controlled environment using cool, dry air, as these conditions are known to trigger EIB in susceptible individuals.
• Alternatives to exercise testing include normocapnic spontaneous hyperventilation or dry-air hyperventilation and airway provocation tests, including hypertonic 4.5% saline or dry powdered mannitol, which act to dehydrate the airway epithelium to induce EIB. [1]

Management

When properly addressed and treated, exercise-induced asthma should not limit a person’s ability to participate fully in vigorous physical activity. In addition, adequate asthma control should allow the patient to participate in any activity of choice without developing asthma symptoms [6]. Management of EIB should include identification of any allergens the patient may be present with, educating the patient on avoiding asthma triggers, and administering asthma medications when necessary [4]. The EPR 3 guidelines for the diagnosis and management of asthma recommend the following treatments Management of EIA [6]: Long-term pharmacotherapy (if applicable) Anti-inflammatory drugs, such as inhaled corticosteroids used to suppress airway inflammation, have been shown to reduce the frequency and severity of EIB when used daily for long-term control of asthma. long For patients with poorly controlled symptoms, including frequent severe EIB [6] pre-exercise therapy [6]1, controller therapy is recommended. Inhaled beta2-agonists: Short-acting beta2-agonists (SABAs), often called “rescue inhalers,” are used acutely before exercise to control Symptoms up to 2-3 hours Long-acting beta-agonists (LABAs) are used together with inhaled corticosteroids to provide additional protection against asthma symptoms for up to 12 hours. LABA is not intended for everyday use, but should be used as a pre-treatment for exercise. 2. leukotriene receptor Antagonist (LTRA): These are medicines used to treat allergies and prevent asthma symptoms. LTRA takes longer to work and may take hours to relieve symptoms. 3. Warming up with exercise: A warm-up period before exercise may help reduce symptoms associated with EIB4. Protect Cold resistance: Covering the mouth with a scarf before/during activity may help reduce cold-induced EIB

Medication and Competitive Sport

For professional and semi-professional athletes this is a major concern as the issue of drugs in sports and any drugs or drug supplements can have a significant impact.Many sports bodies require athletes professionals and semi-professionals provide evidence of such EIB that a Bronchial Challenge Test has occurred before they are allowed to use EIB drugs during competition. So for any athlete competing at this level before taking any drugs or supplements even if prescribed by your doctor, always check with the relevant authorities.[3]

Physical Therapy Management

See here too! Asthma

Education

In addition to taking medication as prescribed, the following tips can help some people with EIB manage their symptoms:

• Warming up before exercise
• Be as fit as possible – increasing your fitness will raise the threshold of EIB so that moderate-intensity exercise does not trigger an episode.
• exercising in a warm and humid environment
• Avoid environments with allergen pollution, irritating gases, or high levels of particulate matter in the air.
• Breathing through the nose helps warm and humidify the air
• Using a mask to remove air although this may not be practical or may make breathing difficult
• Then vigorous exercise is a cooling exercise after breathing through the nose and covering the mouth in cold dry weather
• If client smokes consider talking to a physician about smoking cessation.

Acute Management: Because EIB is triggered by exercise, physical therapists may be the first to recognize asthma symptoms in patients with undiagnosed EIB. For this reason, it is important that the physical therapist is aware of the associated signs and symptoms of EIB and any red flags that may indicate the need for For medical referral and treatment. If a patient develops an acute asthma attack during treatment, the physiotherapist should assess the severity of the attack and then place the patient in the high Fowler position to allow diaphragmatic and pursed lip breathing as appropriate. If the patient has The physical therapist should provide assistance to allow the patient to self-administer the medication while helping the patient to relax [7]. Long-term management has several factors that can prevent EIB patients from exercising detrimental to their condition. Although there is insufficient evidence to support breathing exercises or inspiratory muscle training in patients with asthma, there is strong evidence that physical activity is beneficial for cardiovascular training in this patient population [7]. so Physical therapists can play an important role in care management by providing patient education and exercise prescriptions. A study protocol will provide the effectiveness of physical therapy on quality of life in children with asthma [8]. Preferred practice mode for this patient According to the Physical Therapy Practice Guidelines [9], the population [7] includes:

• Mode 6B: Impaired aerobic capacity/endurance associated with dysregulation
• Example 6C: Breathing Ventilation/Ventilation Exchange and Nondegradation of Ventilatory Capacity/Endurance Associated with Airway Ventilation Practices
• Example 6E: Ventilation and Breathing Damage/Air Exchanger Associated with Air Pump Malfunction or Failure
• Pattern 6F: Ventilatory and Respiratory Distress/Ventilation Associated with Respiratory Disorders

Exercise and Medication:

Metered dose inhalation (MDI) should be self-administered approximately 20-30 minutes before the patient participates in exercise. Gentle stretching and exercise warm-ups should also be done during that time to help prevent the onset of asthma symptoms. Physiotherapists should be aware of any side effects or toxic drugs associated with asthma medications. Some symptoms that may indicate drug toxicity include nausea and vomiting tremors anxiety tachycardia arrhythmia and low blood pressure. If the patient exhibits symptoms of asthma while exercising otherwise controlled with current medication the physical therapist should inform the patient’s physician to adjust the dose[7].Vital Signs:It is important for the physical therapist to monitor the patient’s vital signs prior to exercise -exercise and after exercise to detect any abnormal changes in pulmonary lung function. Auscultation of the lungs should be performed regularly to detect any abnormal wheezing breath sounds or the presence of rhonchi. A red flag that could indicate worsening asthma or chemical toxicity could be a bout of tachypnea (respiratory rate above standard values). headache and vomiting. The patient’s chronic asthma-related hypertension may be abnormally elevated[7]Other considerations:Decreased bone mass has been associated with inhaled corticosteroids use time long in patients with moderate to severe asthma. This is chronic corticosteroid use also has an increased risk of primary asymptomatic vertebral fractures. Physical therapists should be aware of the patient’s medical history and exercise caution when performing physical therapy on patients who may be at risk for fracture. Exercise can enhance medical management and play an important role in the care of patients with status asthmaticus. Physical therapists can teach the patient various cough breathing techniques and positioning techniques to help eliminate fluids reduce hypoxemia and increase V/Q a compatibility has improved. Intensive treatments such as energy creation in this population should be avoided to prevent provocation of pneumonia[7].

Differential Diagnosis

Symptoms of chest tightness as a virulent cough and dyspnea on exercise may indicate an infection throughout the airways. Exercise-induced pulmonary fibrosis is not easily diagnosed by clinical symptoms and it is important to obtain objective data showing a decrease in lung function with exercise [1]

The most common differential diagnoses for EIB include [10]:

• Vocal Cord Dysfunction
• Laryngeal/tracheal processes
• Respiratory tract infection
• Gastro-esophageal reflux
• Hyperventilation syndromes

EIB can also be associated with underlying conditions such as[11]:

• COPD
• Obesity
• Pectus Excavatum
• Diaphragmatic paralysis
• Interstitial Fibrosis