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Exercise-induced asthma
By Mayo Clinic staffMayo Clinic Health Manager
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Definition
If you cough, wheeze or feel out of breath during or after exercise, it may be more than exertion causing your symptoms. You might have exercise-induced asthma. As with asthma triggered by other things, exercise-induced asthma symptoms occur when your airways tighten and produce extra mucus.
If you have exercise-induced asthma — also called exercise-induced bronchospasm (BRONG-ko-spaz-um) — physical exertion may be the only thing that triggers your symptoms. Or, exercise may be just one of several things that trigger your asthma. But having exercise-induced asthma doesn't mean you shouldn't exercise. Proper treatment and precautions can keep you active — whether you're strolling through the park or competing for Olympic gold.
Symptoms
Exercise-induced asthma symptoms can include:
- Coughing
- Wheezing
- Shortness of breath
- Chest tightness or pain
- Fatigue during exercise
- Poor athletic performance
Exercise-induced asthma symptoms may start a few minutes after you begin exercising. Some people have symptoms 10 to 15 minutes after finishing a workout. It's possible to have symptoms both during and after exercise.
Feeling a little short of breath or fatigued when you work out is normal, especially if you aren't in great shape. But with exercise-induced asthma, these symptoms can be more severe.
For many people, exercise is just one of a few asthma triggers. Others can include pollen, pet dander and other airborne allergens.
When to see a doctor
See your doctor if you cough, wheeze, or have chest pain or tightness during or after exercise. Many people don't realize they have exercise-induced asthma because they think these are their body's normal responses to working out. Don't assume your symptoms are caused by being out of shape or short on endurance.
Seek immediate medical treatment if you have worsening symptoms. Severe asthma attacks can be life-threatening. Signs of an asthma attack that needs emergency treatment include:
- Shortness of breath or wheezing that are quickly getting worse
- No improvement even after using a short-acting bronchodilator (such as an albuterol inhaler)
- Shortness of breath that continues even after you've recovered from your workout
Causes
It isn't clear exactly what causes exercise-induced asthma, and why some people get it and others don't. In susceptible individuals, symptoms may be triggered by drying or cooling of the airways during heavy breathing.
Factors that can trigger or worsen exercise-induced asthma include:
- Cold air
- Dry air
- Air pollution such as smoke or smog
- High pollen counts
- Having a respiratory infection such as a cold
- Being out of shape
- Chemicals such as chlorine, paint, fertilizers or herbicides
There's no particular exercise you must avoid when you have exercise-induced asthma, but activities that make you breathe hard are more likely to trigger symptoms. For example, aerobic exercise, such as running or playing basketball, hockey or soccer, is more likely to trigger symptoms than is weightlifting, golfing or moderate-paced walking. Likewise, exercising in cold weather also can increase asthma symptoms because you're breathing in a lot of cold, dry air.
But don't let that discourage you. With proper treatment, you can do intense aerobic activities — and cold-weather workouts — without asthma symptoms slowing you down.
Risk factors
Exercise-induced asthma can occur in people of any age and activity level, but certain people are more likely to be diagnosed with the condition than others. Factors that increase your risk include:
- Already having asthma triggered by other things
- Having hay fever or other allergies
- Having a blood relative, such as a parent or sibling, with asthma
- Living in a large urban area, especially the inner city, which may increase exposure to air pollution
- Smoking or exposure to secondhand smoke
- Exposure to occupational triggers, such as chemicals used in farming and hairdressing, and in paint, steel, plastics and electronics manufacturing
- Being very overweight (obese)
- Participating in winter sports, such as figure skating, ice hockey or cross-country skiing
- Being a child — children are generally more active than adults
Complications
Asthma of any kind — including exercise-induced asthma — may cause a number of complications. Proper treatment can help you avoid them. Possible asthma complications include:
- Poor athletic performance
- Permanent narrowing of the airways (bronchial tubes), which causes difficulty breathing
- Emergency room visits and hospitalizations for severe asthma attacks
Preparing for your appointment
You're likely to start by first seeing your primary care doctor. Or, you may start by seeing a doctor who specializes in asthma (an allergist/immunologist or pulmonologist).
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Note when your symptoms are most likely to bother you — for example, if your symptoms are worse when the air is cold or dry, or when you do certain kinds of exercise.
- Write down key personal information, including any major life events and any changes in your job or workplace.
- Make a list of all medications, as well as any vitamins or supplements, that you're taking.
- Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. Some basic questions to ask your doctor include:
- Is exercise-induced asthma the most likely cause of my breathing problems or other symptoms?
- What are other possible causes for my symptoms or condition?
- What kinds of tests do I need?
- What is the best course of action?
- What are the alternatives to the primary approach that you're suggesting?
- I have these other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
- Is there a generic alternative to the medicine you're prescribing me?
- Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- What are your symptoms?
- When did you first notice your symptoms?
- How severe are your symptoms?
- Do you have breathing problems only when exercising, or at other times as well?
- Have you ever been diagnosed with allergies or asthma?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Do allergies or asthma run in your family?
- What medications do you take, including herbal remedies?
- Do you have any chronic health problems, such as heart disease?
Tests and diagnosis
Your doctor will probably start by doing a physical exam that includes your ears, nose, throat and chest and may ask you a number of questions.
You may need one or more tests to see what's going on and to make sure your symptoms aren't caused by something other than exercise-induced asthma. If you do have asthma, your doctor may want to do tests to determine how well your lungs are working and if something other than exercise also triggers your symptoms.
However, extensive testing isn't always needed to diagnose exercise-induced asthma. Your doctor may give you an inhaler to try before exercise. If it works, you probably do have asthma. For many people with exercise-induced asthma, taking one or two puffs of albuterol or another inhaled medication before exercise is enough to ease symptoms.
Ruling out other conditions
If it isn't clear whether asthma's causing your symptoms, your doctor may do tests to see whether your symptoms may be caused by something else. Other health problems that can mimic exercise-induced asthma include:
- Being out of shape
- Heart disease or heart failure
- Lung disorders
- Side effects of certain medications
- Central airway obstruction
- Vocal cord dysfunction (also called paradoxical vocal fold motion disorder)
- Hay fever or other allergies
Lung function tests
To see how well your lungs are working, and to see whether you show signs of asthma, you may need lung function tests that may include:
- Spirometry. This test, which measures how well you breathe, is the preferred test for diagnosing asthma. During this 10- to 15-minute test, you take deep breaths and forcefully exhale into a tube connected to a machine called a spirometer. If certain key measurements are below normal for a person your age and sex, your airways may be blocked by inflammation (obstructed). This is a key sign of asthma. Your doctor may ask you to inhale a bronchodilator drug used in asthma treatment to open your airways. Then you retake the spirometry test. If your breathing improves significantly, it's likely you have asthma.
- Exercise challenge. This test is used to see how exertion affects your lung function. With this test, your doctor may have you do a lung function test before and after you exercise. Exercise is usually done for six to eight minutes on a treadmill or other stationary workout machine. For competitive athletes, exercise challenge tests are sometimes done in the sporting environment.
- Peak flow measurement. To determine if you have asthma, and how well your lungs work, your doctor may ask you to carry a peak flow meter. This small, hand-held device measures how fast you can force air out of your lungs. The slower you exhale, the worse your asthma. You'll likely be asked to use your peak flow meter at certain times, such as during or following exercise.
- Nitric oxide test. This test is used to see how much nitric oxide gas is in your breath. High levels of nitric oxide are a sign of asthma.
- Methacholine challenge. During a methacholine (meth-uh-KOH-leen) challenge test, you inhale a small amount of methacholine mist to see if it causes asthma symptoms. Your lung function is tested before and after the methacholine is given to see how much it affects your ability to breathe. Challenge testing may also be done using cold air or histamine. These tests are done only at specialized clinics.
- Allergy skin tests. During a skin test, your skin is pricked with purified allergy extracts and observed for signs of an allergic reaction. These tests may be useful to see whether you have a reaction to things other than exercise, such as animal dander, mold, dust mites or latex.
Treatments and drugs
For many people with exercise-induced asthma, using an inhaled bronchodilator (brong-koh-DIE-lay-tur) opens the airways before working out and is enough to control symptoms. Other people need to take one or more other medications prior to exercise or on a daily basis to prevent asthma symptoms.
You may need daily long-term control medications if you have frequent asthma symptoms when you're not exercising, or if using a medication before exercise doesn't keep your symptoms under control. Your asthma may not be under control if you need to use an albuterol or other inhaled bronchodilator more than twice a week for asthma flare-ups in addition to using the inhaler before you exercise.
Medications used to treat exercise-induced asthma include:
- Short-acting beta agonists. These inhaled bronchodilator medications are also called rescue or quick-relief medications because they can rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA), pirbuterol (Maxair Autohaler) and ipratropium (Atrovent HFA). For most people, one to two puffs of albuterol or another inhaled short-acting beta agonist 10 to 15 minutes before exercise is enough to prevent symptoms for up to four hours.
- Inhaled corticosteroids. These medications include fluticasone (Flovent Diskus, Flovent HFA), budesonide (Pulmicort Flexhaler), mometasone (Asmanex), triamcinolone (Azmacort), flunisolide (Aerobid), beclomethasone (Qvar) and others. They are the most commonly prescribed type of long-term asthma medication. You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, these medications have a relatively low risk of serious side effects.
- Long-acting beta agonists. These inhaled medications include salmeterol (Serevent Diskus) and formoterol (Foradil). Taken 30 minutes before exercise, long-acting beta agonists can prevent symptoms of exercise-induced asthma for up to 12 hours. These medications are always used in combination with an inhaled corticosteroid. In some people, long-acting beta agonists may increase the risk of a severe asthma attack.
- Leukotriene modifiers. These oral medications include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo, Zyflo CR). These medications can prevent symptoms for up to 24 hours. With regular use of zileuton, you may need regular blood tests to make sure the medication isn't causing liver problems. In rare cases, these medications may increase your risk of certain psychological reactions, such as agitation, aggression, hallucinations, suicidal thinking and depression. See your doctor if you have any unusual reactions.
- Combination inhalers. These medications include an inhaled corticosteroids plus a long-acting bronchodilator. Advair HFA and Advair Diskus combine the corticosteroid fluticasone and the bronchodilator salmeterol. Symbicort contains the corticosteroid budesonide plus the bronchodilator formoterol.
- Oral corticosteroids. Because oral corticosteroids can cause long-term side effects, they're generally reserved for severe asthma symptoms. Examples include prednisone, methylprednisolone and hydrocortisone.
Allergy shots (immunotherapy)
If your asthma is triggered or worsened by allergies, allergy-desensitization shots may be an option. These injections are generally given once a week for a few months, then once a month for a period of three to five years. Over time, they gradually reduce your immune system reaction to specific allergens.
Prevention
There's no way to keep from getting exercise-induced asthma. But you can take steps to keep symptoms under control:
- Warm up for 15 minutes before strenuous exercise.
- Do your best to avoid colds and other respiratory infections. Don't do strenuous exercise when you have a cold.
- Choose a humid environment for your workout, such as a trail alongside a lake or a gym with an indoor pool.
- Avoid allergens when exercising if they worsen your symptoms. Examples include air pollution, pollen or pet dander.
- Learn to breathe through your nose to warm air before it goes into your lungs.
- Keep your mouth and nose covered during exercise in cold weather.
- Don't avoid exercise because you have asthma. Staying in good shape can ease asthma symptoms in the long run.
- O'Byrne P. Exercise-induced bronchoconstriction. http://www.uptodate.com/home/index.html. Accessed Sept. 30, 2009.
- Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma. National Institutes of Health. Bethesda, Md. http://www.nhlbi.nih.gov/guidelines/asthma/07_sec3_comp4.pdf. Accessed Sept. 30, 2009.
- American Academy of Allergy, Asthma & Immunology work group report: Exercise-induced asthma. American Academy of Allergy, Asthma & Immunology. http://www.aaaai.org/members/academy_statements/position_statements/exercise_induced.pdf. Accessed Sept. 30, 2009.
- McFadden ER. Approach to the patient with exercise-induced airway narrowing. In: Adkinson NF. Middleton's Allergy: Principles and Practice. 7th ed. Philadelphia, Pa.: 2008. http://www.mdconsult.com/das/book/body/163002133-3/0/1806/82.html?tocnode=56311172&fromURL=82.html#4-u1.0-B978-0-323-05659-5..00078-4_2735. Accessed Sept. 30, 2009.
