Exercise-induced bronchoconstriction

Last updated: November 1, 2023

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Summarytoggle arrow icon

Exercise-induced bronchoconstriction (EIB) is the acute constriction of the lower airways that manifests during physical exertion. Although EIB most commonly affects individuals with asthma, it can also manifest in those without a history of asthma. The typical presentation includes dyspnea, wheezing, cough, and chest tightness that begins within 15 minutes of initiating intense exercise and resolves within an hour. The initial diagnostic workup comprises of spirometry with bronchial reversibility testing, and depending on results, may be followed by additional studies (e.g., bronchial provocation studies, evaluation of differential diagnoses) or the initiation of treatment. The first step in management is nonpharmacological therapy (e.g., pre-exercise warm-up, reduction of environmental triggers) for all patients and therapeutic optimization in patients with asthma. First-line pharmacological therapy consists of inhaled beta-agonists 15–30 minutes before exercise; usage should be limited to no more than 3 times a week to prevent tachyphylaxis. Patients with refractory symptoms or those who require inhaled beta-agonists ≥ 4 times a week should be started on daily pharmacological therapy (e.g., with inhaled corticosteroids or montelukast); referral to a pulmonologist may be considered.

Epidemiologytoggle arrow icon

  • 10–15% of the general population [2]
  • 80–90% of individuals with asthma [2]

Epidemiological data refers to the US, unless otherwise specified.

Clinical featurestoggle arrow icon

  • Symptoms typically start within 15 minutes of initiation of intense exercise, and resolve within 60 minutes. [3]
  • Common symptoms include: [3]
    • Dyspnea
    • Wheezing
    • Cough
    • Chest tightness (or chest pain, in children)
    • Increased mucus production
    • Reduced exercise tolerance

EIB typically develops within 15 minutes of exercise and may continue to worsen despite cessation of exercise; if SOB rapidly resolves with cessation of physical activity, consider differential diagnoses of EIB, e.g., deconditioning. [3][4]

Diagnosticstoggle arrow icon

Approach [3][5][6]

Spirometry with reversibility testing [3][5][6]

Baseline spirometry should be performed in all patients to assess for asthma and help exclude differential diagnoses of EIB.

Interpretation of spirometry results in suspected EIB [6][7]
Reversible with bronchodilation Not reversible with bronchodilation
FEV1 < 70%
FEV1 ≥ 70%

Bronchial provocation tests

Exercise challenge tests can also be performed in the field using portable spirometry; this may be helpful for individuals whose EIB is triggered by particular sports or weather conditions. [3]

Differential diagnosestoggle arrow icon

Differential diagnoses of exercise-induced bronchoconstriction and their workup [2][3][6]
Features in addition to exertional dyspnea Suggested diagnostic studies
Exercise-induced anaphylaxis
Exercise-induced laryngeal dysfunction
Cardiac disorders
Pulmonary vascular disease
Restrictive lung disease Interstitial lung disease
Neuromuscular disorders
  • Muscle weakness
Skeletal abnormalities
  • Muscle weakness [9]
  • Fatigue [9]
Obesity [2][6]
  • Increased body habitus
  • Subjective perception of increased dyspnea
Metabolic or mitochondrial myopathy
  • Muscle cramps and pain with exercise [2]

Exercise-induced bronchoconstriction can coexist with other conditions causing exercise-induced dyspnea, including exercise-induced laryngeal dysfunction, cardiac disorders, and anxiety. [6]

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [3][5][6]

  • Advise all patients on nonpharmacological therapy.
  • Patients with known asthma: optimize asthma treatment, including inhaler technique and medication adherence. [4]
  • Patients with no history of asthma: Start an inhaled beta-agonist to be used before exercise.
  • Reevaluate patients regularly.
  • Patients with refractory symptoms may benefit from daily therapy.
  • Consider referral to a pulmonologist for patients with atypical or refractory symptoms.

Nonpharmacological therapy [3]

  • Pre-exercise warm-up and breathing exercises. [3][6]
    • Warm-up should be for 10–15 minutes at 50–80% of the maximum heart rate.
    • May create a refractory period for up to 3 hours in which symptoms are not experienced [6]
  • Reduction of environmental triggers, e.g.: [3]
    • Cold weather
      • Advise patients to exercise indoors during the winter months.
      • For outdoor exercise, patients should cover the mouth with a mask or scarf and/or breathe through the nose.
    • Allergens
      • Avoid exercising near high-traffic roads or during peak travel hours.
      • Train indoors if the pollen count is high; avoid exercising outdoors early in the morning and late in the day, and shower immediately afterward. [3]
      • Patients who react to chlorine should avoid indoor pools and consider swimming in water disinfected using other methods. [3]
  • Recommend smoking cessation. [10]
  • There is some weak evidence to support a low sodium diet, and fish oil and ascorbic acid supplementation. [3][5]

Pharmacological therapy [3][4][5]

First-line: beta-agonist therapy

Refractory symptoms

Elite athletes require both specific confirmatory testing and therapeutic use exemptions for some medications in order to compete; check with the relevant sporting bodies (e.g., World Anti-Doping Agency) before prescribing medications. [3]

Patients should not use an inhaled SABA or LABA ≥ 4 times/week, as chronic use can result in tolerance. [6]

Referencestoggle arrow icon

  1. $Contributor Disclosures - Exercise-induced bronchoconstriction. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Weiss P, Rundell KW. Imitators of exercise-induced bronchoconstriction. All Asth Clin Immun. 2009; 5 (1).doi: 10.1186/1710-1492-5-7 . | Open in Read by QxMD
  3. Greiwe J, Cooke A, Nanda A, et al. Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes. J Allergy Clin Immunol Pract. 2020; 8 (8): p.2542-2555.doi: 10.1016/j.jaip.2020.05.020 . | Open in Read by QxMD
  4. Global Strategy for Asthma Management and Prevention (2022 update). Updated: January 1, 2022. Accessed: August 29, 2022.
  5. Parsons JP, Hallstrand TS, Mastronarde JG, et al. An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction. Am J Respir Crit Care Med. 2013; 187 (9): p.1016-1027.doi: 10.1164/rccm.201303-0437st . | Open in Read by QxMD
  6. Weiler JM, Brannan JD, Randolph CC, et al. Exercise-induced bronchoconstriction update—2016. J Allergy Clin Immunol. 2016; 138 (5): p.1292-1295.e36.doi: 10.1016/j.jaci.2016.05.029 . | Open in Read by QxMD
  7. Bonini M, Palange P. Exercise-induced bronchoconstriction: new evidence in pathogenesis, diagnosis and treatment. Asthma Res Pract. 2015; 1 (1).doi: 10.1186/s40733-015-0004-4 . | Open in Read by QxMD
  8. Saboo SS, Chamarthy M, Bhalla S, et al. Pulmonary arteriovenous malformations: diagnosis. Cardiovasc Diagn Ther. 2018; 8 (3): p.325-337.doi: 10.21037/cdt.2018.06.01 . | Open in Read by QxMD
  9. Falvey JR, Mangione KK, Stevens-Lapsley JE. Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift. Phys Ther. 2015; 95 (9): p.1307-1315.doi: 10.2522/ptj.20140511 . | Open in Read by QxMD
  10. Perelman JM, Nakhamchen LG, Prikhodko AG. Tobacco smoking in asthma patients with exercise-induced bronchoconstriction is associated with greater desaturation during dosed exercise. European Respiratory Journal. 2021.doi: 10.1183/13993003.congress-2021.pa410 . | Open in Read by QxMD

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