Mechanisms of exercise-induced asthma

Bronchoconstriction during cross-country skiing: is there really a refractory period?

PURPOSE

The asthmatic airway responds to exercise by bronchodilation (BD) during and bronchoconstriction (BC) after exercise. A refractory period induced by an initial exercise challenge that provides protection against BC during a subsequent exercise bout has also been observed. However, no studies examining during-exercise response or refractoriness during long-duration field exercise by elite athletes have been performed. This study examined airway response and refractoriness during approximately 42-min cross-country ski time trial preceded by a 6- to 9-min 2.5-km high-intensity warm-up ski.

METHODS

Eighteen elite athletes cross-country skied seven successive 2.5-km loops. Spirometry was performed pre- and at 5, 10, and 15 min post loop 1; loops 2-7 were treated as a race (XCR) with maneuvers performed within 20 s after loops 2-6 and serially for 15 min after lap 7.

RESULTS

Nine of 18 subjects demonstrated a >or=10% fall from baseline in FEV(1) (EIB+): five after lap 1 and four during or after laps 2-7. FEV(1) for EIB+ athletes during XCR was not different from post lap 1 FEV. Only one EIB+ subject demonstrated significant refractoriness. Four EIB+ athletes had a less than 10% fall in FEV after the initial 2.5-km exercise challenge but developed EIB (>or=10% fall) during the subsequent 6 x 2.5 km XCR exercise challenge. FEF(25-75) falls mirrored FEV(1), but demonstrated greater BD during XCR.

CONCLUSION

Bronchoconstriction occurs in athletes during prolonged exercise and may thus influence performance. Variability in bronchial hyperresponsiveness onset and the lack of significant refractoriness in our study cohort of athletes is consistent with an exercise bronchoconstrictive dysfunction that is different than frank asthma and is yet to be clearly defined.

Exercise-induced bronchospasm in the elite athlete

The term exercise-induced bronchospasm (EIB) describes the acute transient airway narrowing that occurs during and most often after exercise in 10 to 50% of elite athletes, depending upon the sport examined. Although multiple factors are unquestionably involved in the EIB response, airway drying caused by a high exercise-ventilation rate is primary in most cases. The severity of this reaction reflects the allergic predisposition of the athlete, the water content of the inspired air, the type and concentration of air pollutants inspired, and the intensity (or ventilation rate) of the exercise. The highest prevalence of EIB is seen in winter-sport populations, where athletes are chronically exposed to cold dry air and/or environmental pollutants found in indoor ice arenas. When airway surface liquid lost during the natural warming and humidification process of respiration is not replenished at a rate equal to the loss, the ensuing osmolarity change stimulates the release of inflammatory mediators and results in bronchospasm; this cascade of events is exacerbated by airway inflammation and airway remodelling. The acute EIB response is characterised by airway smooth muscle contraction, membrane swelling, and/or mucus plug formation. Evidence suggests that histamine, leukotrienes and prostanoids are likely mediators for this response. Although the presence of symptoms and a basic physical examination are marginally effective, objective measures of lung function should be used for accurate and reliable diagnosis of EIB. Diagnosis should include baseline spirometry, followed by an appropriate bronchial provocation test. To date, the best test to confirm EIB may simply be standard pulmonary function testing before and after high-intensity dry air exercise. A 10% post-challenge fall in forced expiratory volume in 1 second is used as diagnostic criteria. The goal of medical intervention is to limit EIB exacerbation and allow the athlete to train and compete symptom free. This is attempted through daily controller medications such as inhaled corticosteroids or by the prophylactic use of medications before exercise. In many cases, EIB is difficult to control. These and other data suggest that EIB in the elite athlete is in contrast with classic asthma.

Exercise-induced bronchospasm in children and adolescents

The early recognition and appropriate management of EIB can allow children and adolescents to participate fully in physical activities and sport. The diagnosis by history of chest congestion, coughing, and decreasing performance with exercise is helpful but is aided by a more systematic questionnaire that can detect otherwise "normal" people with EIB. The diagnosis is documented by performance of an exercise challenge test such as a treadmill or cycloergometer to verify bronchospasm induced by exercise. The management can be accomplished by nonpharmacologic means such as an early vigorous warm-up, the use of a mask for rebreathing warmed air, and participation in a physical training program to increase anaerobic fitness. Pharmacologic management includes the appropriate use of cromolyn sodium, beta-adrenergic agonists, theophylline, ipratromium bromide, and calcium channel blocking agents. In addition, the antihistamine, terfenadine, can be used to block EIB effectively. These pharmacologic agents can be utilized in both national and international competition when approved by the appropriate national governing body or the U.S. Olympic Committee and the International Olympic Committee.

Allergic responses and subsequent development of airway hyperreactivity to cold provocation in the rat trachea: pharmacological modulation

An in vitro model of airway hyperreactivity to cold provocation was developed. Cold provocation (10 degrees C) alone was not sufficient to cause contraction of rat isolated tracheal smooth muscle preparations. However, following recovery from antigen-induced responses in sensitized rat tracheal segments, cold provocation resulted in marked contractile responses. L-652,731 (a Paf-acether antagonist) and atropine significantly attenuated antigen-induced responses and subsequent development of airway hyperreactivity to cold provocation. Indomethacin augmented allergic responses and subsequent development of airway hyperreactivity to cold challenge. Nordihydroguaiaretic acid, FPL 55712 and theophylline did not exert any effect. The data obtained in this study showed that (i) Paf-acether and acetylcholine may play an important role in the mediation of allergic responses and subsequent development of airway hyperreactivity to cold provocation; (ii) the significant attenuation of antigen-induced airway hyperreactivity to cold provocation by Ca2+ channel blockers (nifedipine, bepridil and TMB-8) suggests an increase in Ca2+ influx/permeability following antigen challenge which appears to be responsible for the development of airway hyperreactivity to cold provocation; and (iii) 5-HT, prostaglandins or thromboxanes and leukotrienes play little or no role in the mediation of allergic responses and subsequent development of airway hyperreactivity to cold exposure in rat trachea.

Exercise intensity determines and climatic conditions modify the severity of exercise-induced asthma

Recent studies have shown some evidence that exercise-induced asthma (EIA) may not be entirely explained by respiratory heat loss (RHL). We investigated the interrelationship between heat exchange, exercise intensity and EIA. In order to differentiate between the effects of RHL and exercise intensity, we arranged for tests to be performed with the same RHL, but with different intensities of exercise and inspired air conditions. Each of 8 asthmatic children exercised twice in random order for 6 min on a cycle ergometer. One test consisted of exercise performed at a greater level of effort while breathing room air, mean (+/- SE) air conditions being 25.0 +/- 0.4 degrees C and 15.7 +/- 0.2 mg H2O/L. The other test was performed at a lesser level of effort while breathing cold (0.0 +/- 0.5 degrees C) and dry air (O mg H2O/L). The mean ratio of minute ventilations in the 2 exercise tests was 1.78 +/- 0.03, but the RHL was similar in both tests. The EIA after the exercise at the greater level was more severe than after the lesser level, the percent fall in FEV2 from baseline being 36 +/- 7% and 21 +/- 5%, respectively (p less than 0.025). We conclude that the exercise level has a major role in determining the severity of EIA and that climatic conditions act as modifying factors.

The obligatory role of calcium in the development of antigen-induced airway hyperreactivity to cold provocation in the rat isolated trachea

The effect of antigen challenge on cold provocation (30-10 degrees C) in isolated tracheal segments from control (normal) and ovalbumin-sensitized rats was studied. Sensitization alone or acute cold provocation (10 degrees C) alone was not sufficient to cause contraction of tracheal smooth muscle preparation. Following recovery from antigen-induced responses (Schultz-Dale phenomenon) in sensitized rat segments, cold provocation induced strong contractile responses. Both the antigen-induced contractions and the subsequent development of airway hyperreactivity to cold were dependent on extracellular Ca2+ and inhibited by verapamil. The data in this study indicate that extracellular Ca2+ plays an obligatory role in the mediation of antigen-induced contractile responses as well as the subsequent development of hyperreactivity to cold provocation in rat tracheal smooth muscle.

Airway response to methacholine during exercise induced refractoriness in asthma

To investigate the mechanisms contributing to refractoriness in exercise induced asthma a methacholine challenge test was performed 30 minutes before and 30 minutes after two exercise tests 45 minutes apart. Exercise was performed by 12 asthmatic patients while they were breathing cold air. There was a smaller airway response to the second exercise test than to the first, though there was wide variation between subjects. The response to the second methacholine challenge was reduced in some patients but showed no significant change overall. Refractoriness to exercise induced asthma positively correlated with a reduced response to methacholine. These data suggest that mediator depletion does not fully explain refractoriness.