Practice parameter
Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter

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Table of Contents

I. Classification of Recommendations and Evidence.....S3

II. Glossary..........................................S4

III. Preface..........................................S4

IV. Algorithm.........................................S5

V. Executive Summary..................................S6

VI. Summary Statements.................................S11

VII. Pathophysiology of Exercise-Induced Bronchoconstriction............S13

VIII. Prevalence......................................S17

IX.

Acknowledgments

The Joint Task Force acknowledges the following individuals who also contributed substantially to the creation of this parameter: Erin Shae Johns, PhD, and Jessica Karle, MS, for their immense help with formatting and restructuring this document, and Susan Grupe for providing key administrative help to the contributors and reviewers of this parameter. The Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded

Category of evidence

  • Ia

    Evidence from meta-analysis of randomized controlled trials

  • Ib

    Evidence from at least 1 randomized controlled trial

  • IIa

    Evidence from at least 1 controlled study without randomization

  • IIb

    Evidence from at least 1 other type of quasi-experimental study

  • III

    Evidence from nonexperimental descriptive studies, such as comparative studies

  • IV

    Evidence from expert committee reports or opinions or clinical experience of respected authorities or both

Strength of recommendation

  • A

    Directly based on category I evidence

  • B

    Directly based on category II evidence or

Glossary

Exercise-induced bronchoconstriction (EIB) is defined as a transient narrowing of the lower airway following exercise in the presence or absence of clinically recognized asthma. The term exercise-induced asthma (EIA) is not used in this document because it may imply incorrectly that exercise causes rather than exacerbates or triggers an attack of asthma.

Bronchial hyperresponsiveness (BHR) is an increase in sensitivity to an agent and is expressed as the dose or concentration of a substance that

Preface

The goal of “Pathogenesis, Prevalence, Diagnosis, and Management of Exercise-Induced Bronchoconstriction: A Practice Parameter” is to empower health care specialty practitioners to provide outstanding health care services to their patients in diagnosing and managing EIB. This practice parameter is designed to accomplish this goal by providing the most up-to-date, evidence-based information and recommendations on the diagnosis and management of EIB. The term EIA is not used in this document

1

History, physical examination, and pulmonary function tests pre and postbronchodilator (with flow volume loops, and pre/postbronchodilator functions) are necessary if there is suspicion of asthma or EIB. History alone should not be used to diagnose or exclude the diagnosis of EIB. If pulmonary function equipment (i.e., spirometry) is not available in the clinic setting, patients should be referred to a pulmonary function laboratory or to a physician with office spirometry equipment. Peak flow

Introduction and Definition (Summary Statement 1)

Exercise-induced bronchoconstriction is defined as the transient narrowing of the lower airways that occurs after vigorous exercise.1, 2, 3, 4 Exercise-induced bronchoconstriction may be observed in patients who have or do not have chronic asthma based on spirometry.1, 2, 3, 4, 5, 6, 7, 8 The term EIA should no longer be used because exercise does not induce asthma but rather is a trigger of bronchoconstriction. The diagnosis of EIB usually requires a decrease in FEV1 after exercise of 10% to

Summary Statement 1

Exercise-induced bronchoconstriction is defined as the transient narrowing of the lower airways that occurs after vigorous exercise. It may appear with or without asthma. The term EIA should not be used because exercise does not induce asthma but rather is a trigger of bronchoconstriction. D

Summary Statement 2

Exercise-induced bronchoconstriction occurs in response to heating and humidifying large volumes of air during a short period. The most important determinants of expression of EIB response and severity are

References (493)

  • L. Ramage et al.

    Reduced protection against exercise induced bronchoconstriction after chronic dosing with salmeterol

    Respir Med.

    (1994)
  • S. Haney et al.

    Rapid onset of tolerance to beta-agonist bronchodilation

    Respir Med.

    (2005)
  • J.M. Weiler et al.

    Effect of fluticasone/salmeterol administered via a single device on exercise-induced bronchospasm in patients with persistent asthma

    Ann Allergy Asthma Immunol.

    (2005)
  • M. Kattan et al.

    The response to exercise in normal and asthmatic children

    J Pediatr.

    (1978)
  • V. Niinimaa et al.

    The switching point from nasal to oronasal breathing

    Respir Physiol.

    (1980)
  • O. Bar-Or et al.

    Effects of dry and humid climates on exercise-induced asthma in children and preadolescents

    J Allergy Clin Immunol.

    (1977)
  • E. Daviskas et al.

    Local airway heat and water vapour losses

    Respir Physiol.

    (1991)
  • T.S. Hallstrand et al.

    Aerobic conditioning in mild asthma decreases the hyperpnea of exercise and improves exercise and ventilatory capacity

    Chest

    (2000)
  • E.R. McFadden

    Hypothesis: exercise-induced asthma as a vascular phenomenon

    Lancet

    (1990)
  • S.D. Anderson

    Is there a unifying hypothesis for exercise-induced asthma?

    J Allergy Clin Immunol.

    (1984)
  • E.D. Moloney et al.

    Release of inflammatory mediators from eosinophils following a hyperosmolar stimulus

    Respir Med.

    (2003)
  • Z. Tabka et al.

    Effect of dry warm air on respiratory water loss in children with exercise-induced asthma

    Chest

    (1988)
  • A.H. Eliasson et al.

    Sensitivity and specificity of bronchial provocation testingAn evaluation of four techniques in exercise-induced bronchospasm

    Chest

    (1992)
  • E.T. Mannix et al.

    A comparison of two challenge tests for identifying exercise-induced bronchospasm in figure skaters

    Chest

    (1999)
  • K.W. Rundell et al.

    Field exercise vs laboratory eucapnic voluntary hyperventilation to identify airway hyperresponsiveness in elite cold weather athletes

    Chest

    (2004)
  • G.J. Argyros et al.

    Eucapnic voluntary hyperventilation as a bronchoprovocation technique: development of a standardized dosing schedule in asthmatics

    Chest

    (1996)
  • K.M. Hurwitz et al.

    Interpretation of eucapnic voluntary hyperventilation in the diagnosis of asthma

    Chest

    (1995)
  • K.W. Rundell et al.

    Self-reported symptoms and exercise-induced asthma in the elite athlete

    Med Sci Sports Exerc.

    (2001)
  • J.P. Parsons et al.

    Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes

    Med Sci Sports Exerc.

    (2007)
  • K.W. Rundell et al.

    Exercise and other indirect challenges to demonstrate asthma or exercise-induced bronchoconstriction in athletes

    J Allergy Clin Immunol.

    (2008)
  • M.R. Bye et al.

    The importance of spirometry in the assessment of childhood asthma

    Am J Dis Child.

    (1992)
  • R.O. Crapo et al.

    Guidelines for methacholine and exercise challenge testing—1999This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999

    Am J Respir Crit Care Med.

    (2000)
  • M.S. Koh et al.

    Inhaled corticosteroids compared to placebo for prevention of exercise induced bronchoconstriction

    Cochrane Database Syst Rev.

    (2007)
  • T.S. Hallstrand et al.

    An update on the role of leukotrienes in asthma

    Curr Opin Allergy Clin Immunol.

    (2010)
  • C. Ober et al.

    Asthma genetics 2006: the long and winding road to gene discovery

    Genes Immun.

    (2006)
  • T. Hilberg et al.

    Transcription in response to physical stress—clues to the molecular mechanisms of exercise-induced asthma

    FASEB J.

    (2005)
  • D. Cockcroft et al.

    Direct and indirect challenges in the clinical assessment of asthma

    Ann Allergy Asthma Immunol.

    (2009)
  • M. Weinberger et al.

    Perceptions and pathophysiology of dyspnea and exercise intolerance

    Pediatr Clin North Am.

    (2009)
  • T. Grzelewski et al.

    Exercise-induced bronchoconstriction in asthmatic children: a comparative systematic review of the available treatment options

    Drugs

    (2009)
  • K.H. Carlsen et al.

    Treatment of exercise induced asthma, respiratory and allergic disorders in sports and the relationship to doping: Part II of the report from the Joint Task Force of European Respiratory Society (ERS) and European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA(2)LEN

    Allergy

    (2008)
  • H.H. Raissy et al.

    Pretreatment with albuterol versus montelukast for exercise-induced bronchospasm in children

    Pharmacotherapy

    (2008)
  • F.E. Simons et al.

    Tolerance to the bronchoprotective effect of salmeterol in adolescents with exercise-induced asthma using concurrent inhaled glucocorticoid treatment

    Pediatrics

    (1997)
  • C.H. Spooner et al.

    Mast-cell stabilising agents to prevent exercise-induced bronchoconstriction

    Cochrane Database Syst Rev.

    (2003)
  • P. Kippelen et al.

    Effect of sodium cromoglycate on mast cell mediators during hyperpnea in athletes

    Med Sci Sports Exerc.

    (2010)
  • D. Pearlman et al.

    Fluticasone propionate/salmeterol and exercise-induced asthma in children with persistent asthma

    Pediatr Pulmonol.

    (2009)
  • P. Kippelen et al.

    Acute effects of beclomethasone on hyperpnea-induced bronchoconstriction

    Med Sci Sports Exerc.

    (2010)
  • Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007

    J Allergy Clin Immunol.

    (2007)
  • T.D. Mickleborough

    A nutritional approach to managing exercise-induced asthma

    Exerc Sport Sci Rev.

    (2008)
  • K.D. Fitch et al.

    Asthma and the elite athlete: summary of the International Olympic Committee's consensus conference, Lausanne, Switzerland, January 22–24, 2008

    J Allergy Clin Immunol.

    (2008)
  • P.J. Sterk et al.

    Airway response. Standardized provocation tests in adults: pharmacological, physical and sensitizing stimuli. Work Group on Standardization of Respiratory Function Tests. European Community for Coal and Steel. Official position of the European Respiratory Society.

    Eur Respir J

    (1993)
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    These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “Pathogenesis, Prevalence, Diagnosis, and Management of Exercise-Induced Bronchoconstriction: A Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

    Reprint requests: Joint Task Force on Practice Parameters; 50 N. Brockway St., #3-3; Palatine, IL 60067.

    Disclosures: Dr Weiler is an employee of CompleWare Corporation. He also holds stock in CompleWare Corporation and Iowa Clinical Research Corporation, neither of which is an ACCME defined Commercial Interest, and he sold shares of Johnson & Johnson. CompleWare Corporation and Iowa Clinical Research Corporation provided contracted or granted services to MedImmune, Sandoz, GlaxoSmithKline, NIH, ALK, Pharmaxis, Novartis, Abbott, TEVA, Boehringer Ingelheim, Schering-Plough/Merck, Forest, Roxane Labs, Amgen, Repros, and Watson. Dr Anderson is the inventor of the mannitol test and receives a percentage of the royalties paid to her employer, Sydney South West Area Health Service. Dr Randolph has been a member of the speakers' bureau for Alcon, ISTA, GlaxoSmithKline, AstraZeneca, ScheringPlough/Merck, UCB, Wallace, Dey, Sciele, Baxter, Accredo, Critical Care, Genentech/Novartis, Sepracor, Meda, Sanofi-Aventis, TEVA, Pfizer, and Verus. He has acted as an advisor or consultant to AstraZeneca, Merck, GlaxoSmithKline, and Sanofi-Aventis and provided granted services to ScheringPlough and Novartis/Genentech. Dr Bonini is a member of the expert forums and/or a speaker at sponsored symposia for ALK, Allergen Manufacturers, AstraZeneca, Chiesi, GlaxoSmithKline, Menarini, Merck Sharp & Dohme, Novartis, Nycomed, Phadia, Schering-Plough, Sigma-Tau, Scalargenes, and UCB. Dr. Pearlman acts as an ad hoc consultant to AstraZeneca. He has also performed contract pharmaceutical research on EIB as a principal investigator between Colorado Allergy and Asthma Centers, P.C. (which pays him a salary) and each of the following companies: Merck, Novartis, Sepracor, GSK. Dr. Pearlman is also on the speakers' bureau of Merck. Dr Storms has provided granted services to Alcon Labs, Amgen, and Sepracor. He has acted as an advisor or consultant to Alcon Labs, AstraZeneca, Consumer Reports/Consumers Union, Merck, Nexcura, Novartis, Sepracor, Strategic Pharmaceutical Advisors, TEVA, and the TREAT Foundation. He also serves on the speakers' bureau for Alcon Labs, AstraZeneca, Meda, Merck, Novartis, Sepracor, Strategic Pharmaceutical Advisors, and the TREAT Foundation. Dr. Rundell is currently employed by Pharmaxis Inc. Dr. Oppenheimer has performed research, acted as a consultant, or served on the speakers' bureau for AstraZeneca, Merck, GlaxoSmithKline, Alcon Labs, and Novartis. Drs Craig, Silvers, Bernstein, Blessing-Moore, Cox, Khan, Lang, Nicklas, Portnoy, Schuller, Spector, Tilles, and Wallace have nothing to disclose.

    Requests for reprints should be addressed to: Joint Council of Allergy, Asthma & Immunology, 50 N Brockway St, #3-3, Palatine, IL 60067

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