Exercise-Induced Bronchospasm and Allergy

Exercise-Induced Bronchoconstriction in Children: State of the Art from Diagnosis to Treatment

Exercise-induced bronchoconstriction (EIB) is a common clinical entity in people with asthma. EIB is characterized by postexercise airway obstruction that results in symptoms such as coughing, dyspnea, wheezing, chest tightness, and increased fatigue. The underlying mechanism of EIB is not completely understood. "Osmotic theory" and "thermal or vascular theory" have been proposed. Initial assessment must include a specific work-up to exclude alternative diagnoses like exercise-induced laryngeal obstruction (EILO), cardiac disease, or physical deconditioning. Detailed medical history and clinical examination must be followed by basal spirometry and exercise challenge test. The standardized treadmill running (TR) test, a controlled and standardized method to assess bronchial response to exercise, is the most adopted exercise challenge test for children aged at least 8 years. In the TR test, the goal is to reach the target heart rate in a short period and maintain it for at least 6 min. The test is then followed by spirometry at specific time points (5, 10, 15, and 30 min after exercise). In addition, bronchoprovocation tests like dry air hyperpnea (exercise and eucapnic voluntary hyperpnea) or osmotic aerosols (inhaled mannitol) can be considered when the diagnosis is uncertain. Treatment options include both pharmacological and behavioral approaches. Considering medications, the use of short-acting beta-agonists (SABA) just before exercise is the commonest option strategy, but daily inhaled corticosteroids (ICS) can also be considered, especially when EIB is not controlled with SABA only or when the patients practice physical activity very often. Among the behavioral approaches, warm-up before exercise, breathing through the nose or face mask, and avoiding polluted environments are all recommended strategies to reduce EIB risk. This review summarizes the latest evidence published over the last 10 years on the pathogenesis, diagnosis using spirometry and indirect bronchoprovocation tests, and treatment strategies, including SABA and ICS, of EIB. A specific focus has been placed on EIB management in young athletes, since this condition can not only prevent them from practicing regular physical activity but also competitive sports.

Exercise-induced bronchoconstriction, allergy and sports in children

Exercise-induced bronchoconstriction (EIB) is characterized by the narrowing of airways during or after physical activity, leading to symptoms such as wheezing, coughing, and shortness of breath. Distinguishing between EIB and exercise-induced asthma (EIA) is essential, given their divergent therapeutic and prognostic considerations. EIB has been increasingly recognized as a significant concern in pediatric athletes. Moreover, studies indicate a noteworthy prevalence of EIB in children with atopic predispositions, unveiling a potential link between allergic sensitivities and exercise-induced respiratory symptoms, underpinned by an inflammatory reaction caused by mechanical, environmental, and genetic factors. Holistic management of EIB in children necessitates a correct diagnosis and a combination of pharmacological and non-pharmacological interventions. This review delves into the latest evidence concerning EIB in the pediatric population, exploring its associations with atopy and sports, and emphasizing the appropriate diagnostic and therapeutic approaches by highlighting various clinical scenarios.

Biomarkers in allergen immunotherapy: Focus on eosinophilic inflammation

Asthma and allergic rhinitis (AR) are 2 of the most common chronic inflammatory disorders and they appear to be on the rise. Current pharmacotherapy effectively controls symptoms but does not alter the underlying pathophysiology. Allergen immunotherapy (AIT) is an evidence-based therapy for asthma and AR and has been recognized as the only therapeutic method that actually modifies the allergic disease process. There is a lack of objective markers that accurately and reliably reflect the therapeutic benefits of AIT. A biomarker indicating patients that would benefit most from AIT would be invaluable. Eosinophilic inflammation is a cardinal feature of many allergic diseases. Biomarkers that accurately reflect this inflammation are needed to better diagnose, treat, and monitor patients with allergic disorders. This review examines the current literature regarding AIT's effects on eosinophilic inflammation and biomarkers that may be used to determine the extent of these effects.

Respiratory oscillometry testing in relation to exercise in healthy and asthmatic Thoroughbreds

BACKGROUND

Racehorses may experience exercise-induced bronchodilation or bronchoconstriction, with potential differences between healthy and asthmatic individuals.

OBJECTIVES

To identify exercise-related lung function variations by oscillometry in racehorses, compare lung function between healthy and mild equine asthma (MEA) horses, assess oscillometry's potential as a predictor of racing fitness.

STUDY DESIGN

Prospective case-control clinical study.

METHODS

Fourteen Thoroughbred racehorses (5 healthy, 9 MEA) underwent a protocol including respiratory oscillometry at rest, exercise with fitness monitoring, oscillometry at 15 and 45 min post-exercise, and bronchoalveolar lavage fluid (BALf) cytology. Oscillometry parameters (resistance [Rrs] and reactance [Xrs]) were compared within and between healthy and MEA groups at different timepoints. Associations between Rrs and Xrs at rest and 15 min post-exercise and BALf cytology and fitness indices were evaluated.

RESULTS

MEA horses showed higher Rrs at 15 min post-exercise (0.6 ± 0.2 cmH2 O/L/s) than healthy horses (0.3 ± 0.1 cmH2 O/L/s) (p < 0.01). In healthy horses, Rrs decreased at 15 min post-exercise compared with resting values (0.5 ± 0.1 cmH2 O/L/s) (p = 0.04). In MEA horses, oscillometry parameters did not vary with time. Post-exercise Xrs inversely correlated with total haemosiderin score (p < 0.01, r2  = 0.51). Resting Rrs inversely correlated with speed at 200 bpm (p = 0.03, r2  = -0.61), and Xrs with maximum heart rate (HR) during exercise (p = 0.02, r2  = -0.62). Post-exercise Rrs inversely correlated with mean (p = 0.04, r2  = -0.60) and maximum speed (p = 0.04, r2  = -0.60), and HR variability (p < 0.01, r2  = -0.74).

MAIN LIMITATIONS

Small sample size, oscillometry repeatability not assessed, potential interference of upper airway obstructions, external variables influencing fitness indices.

CONCLUSIONS

Oscillometry identified lung function differences between healthy and MEA horses at 15 min post-exercise. Only healthy horses exhibited exercise-induced bronchodilation. Oscillometry showed potential in predicting subclinical airway obstruction.

Advances in pulmonary rehabilitation for children with bronchial asthma

Bronchial asthma is a heterogeneous disease characterized by chronic airway inflammation and airway hyperresponsiveness. With the development of the whole-life-cycle health concept, the focus of treatment for bronchial asthma in children has gradually shifted from pharmacological control to an integrated management model of functional rehabilitation and pharmacological assistance. As a non-pharmacological integrated approach, pulmonary rehabilitation plays an equally important role in the management of childhood asthma as pharmacological treatments. Breathing techniques such as Buteyko breathing, pursed lip breathing, diaphragmatic breathing training, threshold-pressure inspiratory muscle training and yoga breathing can improve lung function indicators such as forced expiratory volume in first second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF) and maximal voluntary ventilation (MVV) in children. Comprehensive pre-exercise assessment, development of exercise prescriptions, and implementation and evaluation of exercise effects can improve physical fitness, neuromuscular coordination, and self-confidence of children with asthma. The comprehensive interventions of health education, psychological support and nutritional intervention can improve the compliance and effectiveness of rehabilitation training. This article reviews the research progress on respiratory training, physical exercise, and comprehensive interventions in the pulmonary rehabilitation of asthmatic children, to provide theoretical basis and practical guidance for the scientific and rational management of pulmonary rehabilitation of asthmatic children in clinical settings.

Studying Respiratory Symptoms Related to Swimming Pools Attendance in Young Athletes: The SPHeRA Study

This study investigates the prevalence of respiratory symptoms and the training factors possibly associated with them in a sample of young Italian competitive swimmers. A questionnaire about training information and symptoms was administered to participants during the winter and summer 2021 training seasons. In total, 396 athletes took part in the study. In the winter training subgroup (n = 197), we found significant associations between increasing training hours per session and the presence of nasal congestion/rhinorrhoea (OR = 3.10; p = 0.039) and cough (OR = 3.48; p = 0.015). Total training hours per week were significantly associated with nasal congestion/rhinorrhoea (OR = 1.12; p = 0.010). In the summer group (n = 199), the same factors were not associated with respiratory symptoms. Having an allergy was significantly related to nasal congestion/rhinorrhea in both the logistic models (model 1 OR = 2.69, p = 0.013; model 2 OR = 2.70, p = 0.012), while having asthma significantly increased the risk of coughing (OR = 3.24, p = 0.033). The kind of environment (indoor or outdoor facilities) did not affect the studied symptoms either in summer or winter. Further investigations are needed to better understand the mechanisms involved in the development of respiratory symptoms in swimmers, particularly on how inflammation and remodelling develop and which environmental conditions can favour these processes.

Adolescents with Atopic Dermatitis Have Lower Peak Exercise Load Capacity and Exercise Volume Compared with Unaffected Peers

Background: Sweating and increased skin temperature caused by exercise can reduce physical activity and the willingness to exercise in adolescents with atopic dermatitis. This study was conducted to investigate the exercise load capacity of adolescents with atopic dermatitis and analyzed their exercise behavior and motivation. Methods: Adolescents with and without atopic dermatitis were assigned to the atopic dermatitis group and control group (n = 27 each). Both groups completed a cardiopulmonary exercise test and questionnaires to assess their exercise capacity, weekly exercise volume, exercise motivation, and self-efficacy, respectively. Results: The ratio of measured forced vital capacity to the predicted forced vital capacity and the peak oxygen consumption of the atopic dermatitis group were significantly lower than those of the control group. The Godin Leisure-Time Exercise Questionnaire scores of the atopic dermatitis group were significantly lower than those of the control group. As for the Behavioral Regulation in Exercise Questionnaire 2, the scores for the introjected and identified regulations of the atopic dermatitis group were significantly lower than those of the control group. Regarding the Multidimensional Self-Efficacy for Exercise Scale, the scheduling efficacy and total scores of the atopic dermatitis group were significantly lower than those of the control group. Conclusions: Adolescents with atopic dermatitis had lower peak exercise capacity and lower weekly exercise volume. Furthermore, they lacked the negative feelings toward inactivity and the self-confidence to plan regular exercise independently. The results of this study suggest that adolescents with atopic dermatitis should be encouraged to engage in regular indoor exercise.

Exercise-Induced Bronchoconstriction in Children

Exercise-induced bronchoconstriction (EIB) is a transient airflow obstruction, typically 5-15 min after physical activity. The pathophysiology of EIB is related to the thermal and osmotic changes of the bronchial mucosa, which cause the release of mediators and the development of bronchoconstriction in the airways. EIB in children often causes an important limitation to physical activities and sports. However, by taking appropriate precautions and through adequate pharmacological control of the condition, routine exercise is extremely safe in children. This review aims to raise awareness of EIB by proposing an update, based on the latest studies, on pathological mechanisms, diagnosis, and therapeutic approaches in children.

Evaluation of exercise-induced bronchoconstriction and rhinitis in adolescent elite swimmers

OBJECTIVE

Exercise-induced bronchoconstriction (EIB) without asthma and non-allergic rhinitis is frequently reported in athletes who are facing high-risk of airway dysfunctions such as elite swimmers. Therefore, we aimed to evaluate the effect of exercise on nasal and pulmonary functions, additionally to determine the prevalence of EIB and rhinitis in adolescent elite swimmers.

METHODS

The study included 47 adolescent licensed-swimmers (26 males and 21 females) aged between 10 and 17 years old. The prevalence of asthma and allergic disease and the symptom severity scores measured before and after swimming training were assessed through an interview form which includes information related to our study goal. In addition, acoustic rhinometry was utilized to evaluate nasal airway, spirometry was utilized to evaluate EIB in accordance with standard protocols.

RESULTS

Six swimmers had a history of allergic rhinitis (12.8%), while three (6.4%) had asthma. Post-swim mean forced vital capacity (FVC) was significantly higher than pre-swim FVC (p=0.019) and forced expiratory volume 1 (FEV-l)/FVC ratio was significantly lower than pre-swim FEV-l/FVC ratio (p=0.034). In addition, the prevalence of EIB was 8.5%. Moreover, level of nasal discharge statistically increased in post-swim period (p=0.003).

CONCLUSION

We have documented that swimming cause's nasal discharge but do not effect nasal passages. In addition, we observed that the overall prevalence of EIB in swimmers was not different from that of the general population, furthermore swimming exercise significantly increased FVC of swimmers. Therefore, we concluded swimming training can be recommended for children diagnosed with asthma or allergic rhinitis.

Impact of climate variability on exercise-induced bronchospasm in adolescents living in a semi-arid region

OBJECTIVE

To examine the impact of climate variability on the occurrence of exercise-induced bronchospasm in the rainy and dry seasons of a Brazilian semi-arid region.

METHODS

This sample comprised 82 adolescents aged 15 to 18 years, who were submitted to exercise-induced bronchospasm assessment on a treadmill and outdoors, during the rainy and the dry season. Anthropometric variables, sexual maturity and forced expiratory volume in the first second were analyzed. Air temperature and humidity, decline in forced expiratory volume in the first second (%) and frequency of bronchospasm were compared between seasons using the independent Student's t test, the Wilcoxon and McNemar tests, respectively. The level of significance was set at p<0.05.

RESULTS

The mean age was 15.65±0.82 years. Air temperature, air humidity and decline in forced expiratory volume in the first second (%) differed between seasons, with higher air temperature and humidity in the rainy season (29.6ºC±0.1 and 70.8%±0.6 versus 28.5ºC±0.2 and 48.5%±0.6; p<0.05). The decline in forced expiratory volume in the first second (%) was greater in the dry season (9.43%±9.97 versus 12.94%±15.65; p<0.05). The frequency of bronchospasm did not differ between seasons.

CONCLUSION

The dry season had a negative impact on forced expiratory volume in the first second in adolescents, with greater decrease detected during this period. Findings of this study suggested bronchospasm tends to be more severe under low humidity conditions.

Serum perfluoroalkyl substances (PFAS) and risk of asthma and various allergies in adolescents. The Tromsø study Fit Futures in Northern Norway

BACKGROUND

Exposure to environmental pollutants may contribute to the development of asthma and other allergies. The aim of this study was to investigate possible associations between asthma and other allergies with exposure to perfluoroalkyl substances (PFASs) in adolescents from the Arctic region of Norway.

METHODS

The Tromsø study Fit Futures 1 (TFF1) and 3-year follow-up Fit Futures 2 study (TFF2) included 675 adolescents that completed a questionnaire about health conditions and underwent a clinical examination with blood tests and fractional nitric oxide (FeNO) measurement. Serum concentrations of 18 PFASs were measured by UHPLC-MS/MS method.

RESULTS

Total PFASs (ΣPFAS) serum concentration over 4th quartile was positively associated with asthma in the TFF1 (OR 3.35 (95% CI 1.54-7.29), p = 0.002). Total perfluorooctane sulfonate (ΣPFOS), linear PFOS (linPFOS), linear perfluorohexane sulfonate (linPFHxS) concentrations over 4th quartiles were associated with 2 times higher odds of asthma in the TFF1. The positive associations between ΣPFAS, ΣPFOS, linPFOS and asthma remained statistically significant in the TFF2. ΣPFAS and linPFHxS concentrations over 3rd tertiles were associated with positive marker of eosinophilic airways inflammation FeNO> 25 ppb. Concentrations of ΣPFOS and linPFOS over 3rd quartiles were positively associated with self-reported nickel allergy (OR 2.25 (95% CI 1.17-4.35) p = 0.016 and OR 2.53 (95% CI 1.30-4.90) p = 0.006, respectively). Allergic rhinitis, self-reported pollen allergy, food allergy and atopic eczema were not associated with PFASs concentrations.

CONCLUSIONS

This study of Norwegian adolescents showed a positive association between several PFASs and asthma, as well as between PFOS and nickel allergy.

Treating Pediatric Asthma According Guidelines

Asthma is a common chronic inflammatory disorder of the lower respiratory airways in childhood. The management of asthma exacerbations and the disease control are major concerns for clinical practice. The Global Strategy for Asthma Management and Prevention, published by GINA, updated in 2017, the British Thoracic Society/Scottish Intercollegiate Guideline Network, revised in 2016, the National Institute for Health and Care Excellence asthma guideline consultation, available in 2017, are widely accepted documents, frequently implemented, with conflicting advices, and different conclusion on asthma definition and treatment. An International Consensus on Pediatric Asthma was carried out in 2012 by a Committee with expertise in the field, to critically review differences on current guidelines. In addition, the specific issue of treating severe and difficult asthma has been recently highlighted throughout the International European Respiratory Society/American Thoracic Society guidelines on severe asthma. The aim of this paper is to describe conventional treatments and some new therapeutic approaches to pediatric asthma according to guidelines, highlighting key aspects, and differences on proposed clinical recommendations for asthma management. Age specific therapy are proposed in steps, according to clinical severity and the level of disease control. If control is not achieved within 3 months, stepping-up should be considered; otherwise, if control is achieved after 3 months, stepping down may be considered. The most used drug classes of asthma medications are beta-2 adrenergic agonists, corticosteroids, and leukotriene modifiers. Intramuscolar triamcinolone has been used for severe asthma treatment. Chromones and xanthines have been extensively used in the past, but they have shown limits related to their efficacy and safety profile. Omalizumab, a monoclonal antibody against IgE, is an immunomodulatory biological agent, used as new drug in patients with confirmed IgE-mediated allergic asthma, only for patient's specific range of total IgE level. There are low evidences in the efficacy of metotrexate, as well as macrolide antibiotics in children with asthma. Antifungal agents are also not recommended in asthmatic patients. Non-pharmacological measures that may improve patient's quality of life should also be attempted. We conclude that treatment decisions on childhood asthma management should be critically made, pondering the differences suggested by agreed international consensus documents.

Exercise-induced bronchoconstriction: prevalence, pathophysiology, patient impact, diagnosis and management

Exercise-induced bronchoconstriction (EIB) can occur in individuals with and without asthma, and is prevalent among athletes of all levels. In patients with asthma, symptoms of EIB significantly increase the proportion reporting feelings of fearfulness, frustration, isolation, depression and embarrassment compared with those without symptoms. EIB can also prevent patients with asthma from participating in exercise and negatively impact their quality of life. Diagnosis of EIB is based on symptoms and spirometry or bronchial provocation tests; owing to low awareness of EIB and lack of simple, standardised diagnostic methods, under-diagnosis and mis-diagnosis of EIB are common. To improve the rates of diagnosis of EIB in primary care, validated and widely accepted symptom-based questionnaires are needed that can accurately replicate the current diagnostic standards (forced expiratory volume in 1 s reductions observed following exercise or bronchoprovocation challenge) in patients with and without asthma. In patients without asthma, EIB can be managed by various non-pharmacological methods and the use of pre-exercise short-acting β2-agonists (SABAs). In patients with asthma, EIB is often associated with poor asthma control but can also occur in individuals who have good control when not exercising. Inhaled corticosteroids are recommended when asthma control is suboptimal; however, pre-exercise SABAs are also widely used and are recommended as the first-line therapy. This review describes the burden, key features, diagnosis and current treatment approaches for EIB in patients with and without asthma and serves as a call to action for family physicians to be aware of EIB and consider it as a potential diagnosis.