Asthma associated with exercise

Basis of preventive and non-pharmacological interventions in asthma

Asthma is one of the most common atopic disorders in all stages of life. Its etiology is likely due to a complex interaction between genetic, environmental, and lifestyle factors. Due to this, different non-pharmacological interventions can be implemented to reduce or alleviate the symptoms caused by this disease. Thus, the present narrative review aimed to analyze the preventive and non-pharmacological interventions such as physical exercise, physiotherapy, nutritional, ergonutritional, and psychological strategies in asthma treatment. To reach these aims, an extensive narrative review was conducted. The databases used were MedLine (PubMed), Cochrane (Wiley), Embase, PsychINFO, and CinAhl. Asthma is an immune-mediated inflammatory condition characterized by increased responsiveness to bronchoconstrictor stimuli. Different factors have been shown to play an important role in the pathogenesis of asthma, however, the treatments used to reduce its incidence are more controversial. Physical activity is focused on the benefits that aerobic training can provide, while physiotherapy interventions recommend breathing exercises to improve the quality of life of patients. Nutritional interventions are targeted on implement diets that prioritize the consumption of fruits and vegetables and supplementation with antioxidants. Psychological interventions have been proposed as an essential non-pharmacological tool to reduce the emotional problems associated with asthma.

Exercise-Induced Bronchoconstriction Among Adolescent Athletes With Asthma: A Systematic Review

Exercise-induced bronchoconstriction (EIB) is a concern that frequently affects athletes and regular exercisers. The main objective of this systematic review is to study recently published literature that evaluated the risk of EIB among adolescent athletes with asthma. PubMed, Web of Science, Science Direct, EBSCO, SCOPUS, Wiley, and Cochrane Library were searched. Study articles were screened by title and abstract using Rayyan QCRI then a full-text assessment was implemented. A total of ten studies with 3129 adolescent athletic subjects were included in this review. The prevalence of EIB ranged from 2.1% to 61%. Most studies have demonstrated that athletes in their adolescence suffer from EIB, which requires regular management. Two studies have reported that low-income communities and humidity levels are risk factors for EIB. We found that EIB is frequent among adolescent athletes. The prevalence varies between countries due to different social and environmental factors.

Pulmonary rehabilitation: promising nonpharmacological approach for treating asthma?

PURPOSE OF REVIEW

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation with a history of respiratory symptoms that vary over time and in intensity, together with variable expiratory airflow limitation. The goal of asthma treatment is to reach symptoms control, reduction in future risk and improvement in quality of life (QoL). Guideline-based pharmacologic therapies and the effect of inhaled steroids and bronchodilators have been widely studied over the past decades. We provide an overview of the available evidence on pulmonary rehabilitation as a nonpharmacologic therapy in asthmatic patients.

RECENT FINDINGS

Recently, some studies have highlighted the promising role of nonpharmacologic therapies in asthma, such as pulmonary rehabilitation demonstrating that a pulmonary rehabilitation programme consisting of exercise training, breathing retraining, educational and psychological support, improve exercise capacity, asthma control and QoL and reduce dyspnea, anxiety, depression and bronchial inflammation at any step of the disease.

SUMMARY

Pulmonary rehabilitation shows positive results on exercise tolerance, respiratory symptoms and QoL in asthmatic patients at any steps of the diseases. However, additional information is required to better characterize rehabilitation programmes in order to improve clinical care in asthma.

Sex and Gender Differences in Lung Disease

Sex differences in the anatomy and physiology of the respiratory system have been widely reported. These intrinsic sex differences have also been shown to modulate the pathophysiology, incidence, morbidity, and mortality of several lung diseases across the life span. In this chapter, we describe the epidemiology of sex differences in respiratory diseases including neonatal lung disease (respiratory distress syndrome, bronchopulmonary dysplasia) and pediatric and adult disease (including asthma, cystic fibrosis, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, lung cancer, lymphangioleiomyomatosis, obstructive sleep apnea, pulmonary arterial hypertension, and respiratory viral infections such as respiratory syncytial virus, influenza, and SARS-CoV-2). We also discuss the current state of research on the mechanisms underlying the observed sex differences in lung disease susceptibility and severity and the importance of considering both sex and gender variables in research studies' design and analysis.

Asthma, atopy, and exercise: Sex differences in exercise-induced bronchoconstriction

Asthma is a chronic inflammatory lung disease affecting approximately 7.7% of the US population. Sex differences in the prevalence, incidence, and severity of asthma have been widely described throughout the lifespan, showing higher rates in boys than girls before puberty, but a reversed pattern in adults. Asthma is often associated with atopy, i.e. the tendency to develop allergic diseases, and can be worsened by environmental stimuli and/or exercise. While not exclusive to patients with asthma, exercise-induced bronchoconstriction (EIB) is a common complication of athletes and individuals who exercise regularly. Currently, there is limited research on sex differences in EIB and its relationship with atopy and asthma in men and women. In this minireview, we summarize the available literature on this topic. Overall, the collective knowledge supports the notion that physiological changes triggered during exercise affect males and females differently, suggesting an interaction among sex, exercise, sex hormones, and atopic status in the course of EIB pathophysiology. Understanding these differences is important to provide personalized management plans to men and women who exercise regularly and suffer from underlying asthma and/or atopy.

Association between Physical Activity and Respiratory Diseases in Adolescents: An Age- and Gender-Matched Study

The purpose of the present cross-sectional study was to examine the impacts of allergic respiratory diseases on physical activity (PA), sedentary behaviors (SB), and body mass index (BMI) by matching age and gender with those adolescents without allergic respiratory diseases. This present study analyzed data from the 2019 Korea Youth Risk Behavior Web-based Survey (KYRBWS). Among 57,303 Korean adolescents who responded to the survey, the study divided adolescents into three different groups (i.e., general, asthma, and allergic rhinitis group). Asthma and allergic rhinitis groups included adolescents who checked on asthma- or allergic rhinitis-related questions as ‘yes’ (n = 259, n = 259), but the general group responded to any diseases-related question as ‘no’ (n = 259). The age and gender of participants among the three groups were matched. The results showed weight and BMI were significantly higher in asthma and allergic rhinitis groups compared to the general group (p < 0.001, p < 0.001). Furthermore, age, asthma, and allergic rhinitis were observed to be strong risk factors for predicting obesity in adolescents (BMI, >25.0 kg/m²). In addition, this study found allergic respiratory diseases strong impacts on BMI levels because adolescents with ongoing asthma, or allergic rhinitis symptoms were more likely to have the inevitability of further weight gain compared to the general adolescents. Therefore, not only national interest in adolescents with allergic respiratory disease is essential, but PA should be encouraged to prevent and alleviate these diseases due to obesity.

Sex Differences in Exercise-Induced Bronchoconstriction in Athletes: A Systematic Review and Meta-Analysis

Exercise-induced bronchoconstriction (EIB) is a common complication of athletes and individuals who exercise regularly. It is estimated that about 90% of patients with underlying asthma (a sexually dimorphic disease) experience EIB; however, sex differences in EIB have not been studied extensively. With the goal of better understanding the prevalence of EIB in males and females, and because atopy has been reported to occur at higher rates in athletes, in this study, we investigated sex differences in EIB and atopy in athletes. A systematic literature review identified 60 studies evaluating EIB and/or atopy in post-pubertal adult athletes (n = 7501). Collectively, these studies reported: (1) a 23% prevalence of EIB in athletes; (2) a higher prevalence of atopy in male vs. female athletes; (3) a higher prevalence of atopy in athletes with EIB; (4) a significantly higher rate of atopic EIB in male vs. female athletes. Our analysis indicates that the physiological changes that occur during exercise may differentially affect male and female athletes, and suggest an interaction between male sex, exercise, and atopic status in the course of EIB. Understanding these sex differences is important to provide personalized management plans to athletes with underlying asthma and/or atopy.

Association between Allergic Rhinitis and Regular Physical Activity in Adults: A Nationwide Cross-Sectional Study

Evidence regarding the association between allergic rhinitis (AR) and physical activity (PA) is conflicting. Previous studies have mostly relied only on self-reported symptoms to define AR, did not classify AR by severity or persistence, and included only children or athletes. The present cross-sectional study evaluated the association between PA and objectively-defined AR and its subtypes in the general adult population using data for 1932 eligible participants aged 19 years or older in the 2010 Korea National Health and Nutrition Examination Survey. Multivariable logistic regression analyses were performed to evaluate the relationship between three types of PA and overall AR, AR subtypes, and rhinoscopy findings showed that moderate-severe AR was positively associated with vigorous (odds ratio [OR] = 3.392, p = 0.002) and moderate (OR = 3.623, p = 0.007) PA compared to mild AR, while persistent AR was associated with vigorous (OR = 3.954, p = 0.004) and moderate (OR = 3.411, p = 0.022) PA compared to intermittent AR. On rhinoscopy, vigorous PA was significantly associated with watery rhinorrhea (OR = 2.203, p = 0.048) but not pale mucosa. Total immunoglobulin E (IgE) and three allergen-specific IgE were not significantly elevated in participants who performed PA. Therefore, regular vigorous PA is associated with subjective and objective aggravation of AR symptoms, which may not necessarily manifest as increased serum IgE levels.

Pulmonary Rehabilitation and Asthma

Asthma is a chronic inflammatory disease characterized by airflow limitation and variable respiratory symptoms. It is characterized by variable symptoms such as cough, wheeze, chest tightness, and shortness of breath which vary in intensity and time. In order to reach a comprehensive approach of disease management, the importance of non-pharmacological treatment in addition to pharmacological therapy has been recently highlighted. Studies have documented that pulmonary rehabilitation has beneficial effects in patients with asthma, at any stage of the disease, improving exercise capacity, asthma control, and quality of life and reducing wheezing, anxiety, depression, and bronchial inflammation. Although several evidences suggest a role of pulmonary rehabilitation in patients with asthma, additional information is required to identify a specific program in order to improve clinical care based on specific patient’s needs.

A review of guidelines and pharmacologic options for asthma treatment, with a focus on exercise-induced bronchoconstriction

Asthma affects millions of individuals worldwide. Exercise-induced bronchoconstriction is common in patients diagnosed with asthma, but may also occur in patients without chronic asthma. Patients with isolated exercise-induced bronchoconstriction may require pretreatment with inhaled short-acting β-agonists prior to exercise. Patients diagnosed with asthma can achieve good control of the symptoms of exercise-induced bronchoconstriction with appropriate treatment of underlying chronic asthma. Current guidelines suggest staging patients with asthma based on severity of symptoms and initiating therapy according to their stage. Pharmacotherapy for asthma management consists of both quick-relief medications (short-acting β-agonists) as well as maintenance, or long-term control, medications (inhaled corticosteroids, long-acting β-agonists, leukotriene receptor antagonists, cromolyn, and theophylline).

The effects of a multisite aerobic exercise intervention on asthma morbidity in sedentary adults with asthma: the Ex-asthma study randomised controlled trial protocol

OBJECTIVE

Aerobic exercise can improve cardiovascular fitness and does not seem to be detrimental to patients with asthma, though its role in changing asthma control and inflammatory profiles is unclear. The main hypothesis of the current randomised controlled trial is that aerobic exercise will be superior to usual care in improving asthma control. Key secondary outcomes are asthma quality of life and inflammatory profiles.

DESIGN

A total of 104 sedentary adults with physician-diagnosed asthma will be recruited. Eligible participants will undergo a series of baseline assessments including: the asthma control questionnaire; the asthma quality-of-life questionnaire and the inflammatory profile (assessed from both the blood and sputum samples). On completion of the assessments, participants will be randomised (1:1 allocation) to either 12-weeks of usual care or usual care plus aerobic exercise. Aerobic exercise will consist of three supervised training sessions per week. Each session will consist of taking a short-acting bronchodilator, 10 min of warm-up, 40 min of aerobic exercise (50-75% of heart rate reserve for weeks 1-4, then 70-85% for weeks 5-12) and a 10 min cool-down. Within 1 week of completion, participants will be reassessed (same battery as at baseline). Analyses will assess the difference between the two intervention arms on postintervention levels of asthma control, quality of life and inflammation, adjusting for age, baseline inhaled corticosteroid prescription, body weight change and pretreatment dependent variable level. Missing data will be handled using standard multiple imputation techniques.

ETHICS AND DISSEMINATION

The study has been approved by all relevant research ethics boards. Written consent will be obtained from all participants who will be able to withdraw at any time.

RESULTS

The result will be disseminated to three groups of stakeholder groups: (1) the scientific and professional community; (2) the research participants and (3) the general public.

REGISTRATION DETAILS CLINICALTRIALSGOV IDENTIFIER

NCT00953342.

Diagnostic accuracy of exhaled nitric oxide in exercise-induced bronchospasm: Systematic review

INTRODUCTION

The gold-standard method for the diagnosis of exercise-induced bronchospasm (EIB) is an exercise test combined with spirometry. However, this test is expensive, time consuming and requires specialized equipment and trained personnel. Exhaled nitric oxide (eNO) is a fast, easy, noninvasive method for the diagnosis of EIB. The aim of the present study was to assess the accuracy of the measurement of eNO for the diagnosis of EIB through a systematic review of the literature.

METHODS

A search was carried out in the PubMed, Lilacs, SciELO and SCOPUS databases by two independent researchers.

RESULTS

Fifty-six papers were found. Following the application of the eligibility criteria to the title, abstract and text, six papers remained for analysis. There was a significant heterogeneity in sex (X(2)=56.44, p=0.000) and clinical spectrum (X(2)=504.00, p=0.000) between studies. In children between 3.8 and 7.8 years old a cutoff point >28ppb EIB can be ruled in and in children between 5 and 16 years old at a cutoff point <20EIB can be ruled out. For adults a cutoff point <7EIB can be ruled out and it can be ruled in with a cutoff point >12. Four papers reported negative predictive values above 88%.

CONCLUSION

The measurement of eNO seems to be effective for ruling in and ruling out EIB in some specific groups. Therefore, the measurement of eNO levels could be an important tool to safely avoid the need for an exercise test when the result is negative, reducing the individual and economic impact of this disease.

Management of exercise-induced bronchospasm in adolescents with asthma

Physical activity in persons with asthma is important at any age but even more so in adolescents. Collaboration between the nurse practitioner and adolescent is essential to develop an asthma management plan that will provide for optimal physical activity and prevent asthma exacerbations while exercising.

State of the art: how to set up a pulmonary rehabilitation program

Pulmonary rehabilitation plays an essential role in the management of symptomatic patients with COPD. The benefits of rehabilitation include a decrease in dyspnoea and fatigue, and improvements in exercise tolerance and health-related quality of life. Importantly, rehabilitation reduces hospitalization for acute exacerbations and is cost-effective. Although most of the evidence for pulmonary rehabilitation has been obtained in patients with COPD, symptomatic individuals with other respiratory diseases have been shown to benefit. In this review we outline a stepwise approach to establish, deliver and evaluate a pulmonary rehabilitation program (PRP) that would be feasible in most settings. Throughout the review we have specified the minimum requirements for a PRP to facilitate the establishment of programs using limited resources. Recommendations for staffing and other resources required for a PRP are presented in the first section. Exercise training is a focus of the section on program delivery as this is the component of rehabilitation that has the strongest level of evidence for benefit. Program considerations for patients with respiratory conditions other than COPD are described. Different approaches for delivering the education component of a PRP are outlined and recommendations are made regarding topics for group and individual sessions. The problems commonly encountered in pulmonary rehabilitation, together with recommendations to avoid these problems and strategies to assist in their resolution, are discussed. The review concludes with recommendations for evaluating a PRP.

Challenges in the management of exercise-induced asthma

Exercise and physical activity are common triggers of symptoms in patients with asthma, although some individuals - especially athletes - may have symptoms with exercise alone. Exercise-induced bronchospasm (EIB) describes airway hyper-reactivity that is observed following exercise in a patient who is not otherwise diagnosed with asthma; exercise-induced asthma (EIA) describes airway hyper-reactivity associated with exercise in a patient who has persistent asthma. Specific challenges affecting both the diagnosis and treatment of these conditions are discussed in this review. The past decade has seen substantial advances in our understanding of EIA and EIB, including new guidelines on their management. With appropriate therapy, all patients with exercise-related symptoms should be able to reach their desired level of performance.

Brief bout of exercise alters gene expression in peripheral blood mononuclear cells of early- and late-pubertal males

Peripheral blood mononuclear cells (PBMCs) are stimulated by exercise and contribute not only to host defense, but also to growth, repair, and disease pathogenesis. Whether PBMC gene expression is altered by exercise in children is not known. Ten early pubertal boys (8-12 y) and 10 late pubertal boys (15-18 y) performed ten 2-min bouts of strenuous, constant work rate exercise with 1-min rest intervals. PBMCs were isolated before and after exercise and microarray (Affymetrix U133 + 2 chips) analyzed. Statistical criterion to identify gene expression changes was less than 5% false discovery rate (FDR) with 95% confidence interval. One thousand two hundred forty-six genes were altered in older boys (517 up, 729 down), but only 109 were altered in the younger group (79 up, 30 down). In older boys, 13 gene pathways (using Expression Analysis Systematic Explorer, p < 0.05) were found (e.g. natural killer cell cytotoxicity, apoptosis). Epiregulin gene expression (EREG, a growth factor involved in wound healing) increased in older boys. In older boys exercise altered genes such as TBX21, GZMA, PGTDR, and CCL5 also play roles in pediatric inflammatory diseases like asthma. Sixty-six genes were changed significantly in both groups. The pattern of PBMC gene expression suggests the initiation of an immunologic "danger" signal associated with a sudden change in energy expenditure.

The role of gastroesophageal reflux in exercise-triggered asthma: a randomized controlled trial

BACKGROUND

Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms.

AIMS

To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients.

METHODS

We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated.

RESULTS

A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009).

CONCLUSION

Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression.

Exercise-induced bronchospasm in children

This review will encompass definition, history, epidemiology, pathogenesis, diagnosis, and management of exercise -induced bronchospasm in the pediatric individual with and without known asthma. Exercise induced asthma is the conventional term for transient airway narrowing in a known asthma in association with strenuous exercise usually lasting 5-10 minutes with a decline in pulmonary function by at least 10%. Exercise induced asthma will be referred to as exercise induced bronchospasm in an asthmatic. Exercise-induced bronchospasm (EIB ) is the same phenomenon in an individual without known asthma. EIB can be seen in healthy individuals including children as well as defense recruits and competitive or elite athletes. The diagnosis with objective exercise challenge methods in conjunction with history is delineated. Management is characterized with pharmacotherapy and non pharmacotherapeutic measures for underlying asthma as well as exercise induced bronchospasm and inhalant allergy. Children can successfully participate in all sports if asthma is properly managed.

Serum from exercising humans suppresses t-cell cytokine production

Exercise affects t-cell cytokine production. Whether or not these effects are caused by circulating factors associated with physical activity (e.g., inflammatory mediators, acidosis) is unknown. To investigate this, we incubated sera (10%), obtained from 16 young-adults before (PRE) and after (END) 30-min of exercise, with commercially available Jurkat cells, a t-lymphocyte model, that, of course, had never been exposed to an exercise milieu. After 1 and 6h in culture, we measured in the supernatant four cytokines (each known to be altered by exercise and involved in disease pathophysiology): IL-2, TGF-beta1, TNF-alpha, and IL-1ra. Cell proliferation was assessed with proliferating nuclear cell antigen (PNCA). Statistical analysis consisted of a linear mixed model for repeated measurement. There was no effect of exercise on t-cell production of either TGF-beta1 or IL-1ra. In contrast, both IL-2 (p=0.025) and TNF-alpha (p=0.031) production was significantly suppressed in sera from the exercising participants. The suppression of these two cytokines occurred despite the fact that PNCA significantly increased (p=0.0004) in the END serum. In conclusion, exercise alters circulating factors that can, subsequently, influence t-cell cytokine production in vitro.

Dangerous exercise: lessons learned from dysregulated inflammatory responses to physical activity

Exercise elicits an immunological “danger” type of stress and inflammatory response that, on occasion, becomes dysregulated and detrimental to health. Examples include anaphylaxis, exercise-induced asthma, overuse syndromes, and exacerbation of intercurrent illnesses. In dangerous exercise, the normal balance between pro- and anti-inflammatory responses is upset. A possible pathophysiological mechanism is characterized by the concept of exercise modulation of previously activated leukocytes. In this model, circulating leukocytes are rendered more responsive than normal to the immune stimulus of exercise. For example, in the case of exercise anaphylaxis, food-sensitized immune cells may be relatively innocuous until they are redistributed during exercise from gut-associated circulatory depots, like the spleen, into the central circulation. In the case of asthma, the prior activation of leukocytes may be the result of genetic or environmental factors. In the case of overuse syndromes, the normally short-lived neutrophil may, because of acidosis and hypoxia, inhibit apoptosis and play a role in prolongation of inflammation rather than healing. Dangerous exercise demonstrates that the stress/inflammatory response caused by physical activity is robust and sufficiently powerful, perhaps, to alter subsequent responses. These longer term effects may occur through as yet unexplored mechanisms of immune “tolerance” and/or by a training-associated reduction in the innate immune response to brief exercise. A better understanding of sometimes failed homeostatic physiological systems can lead to new insights with significant implication for clinical translation.

Asma induzida pelo exercício: aspectos atuais e recomendações

OBJETIVO: Descrever os mecanismos da asma induzida pelo exercício (AIE), bem como os efeitos de diferentes tipos de treinamento físico na função pulmonar e nas capacidades aeróbia e anaeróbia. Destaca-se a importância de um diagnóstico correto mediante o teste de exercício e, no manejo, o uso de drogas beta-adrenérgicas e anticolinérgicas. FONTE DOS DADOS: Os artigos foram criteriosamente escolhidos utilizando as bases de dados PubMed e Scielo pelo ano de publicação e dando preferência a ensaios clínicos randomizados, com critérios de seleção da amostra bem definidos. SÍNTESE DOS DADOS: Os mecanismos para explicar a AIE permanecem sem conclusão, mas parece haver uma interação fisiológica entre as hipóteses aqui apresentadas. O uso de medicamentos e as freqüentes crises durante o exercício aparecem como fatores limitantes para a prática de exercícios físicos, conduzindo para um estilo de vida sedentário. CONCLUSÃO: Deve-se incentivar a prática de exercícios devidamente prescritos e minimizar as restrições aos sujeitos com AIE.

6. Asthma: Factors underlying inception, exacerbation, and disease progression

Asthma is a heterogeneous disorder that is characterized by variable airflow obstruction, airway inflammation and hyperresponsiveness, and reversibility either spontaneously or as a result of treatment. Multiple causes no doubt exist for both its inception and symptom exacerbation once the disease is established. Factors underlying inception can range from viral respiratory tract infections in infancy to occupational exposures in adults. Factors underlying asthma exacerbations include allergen exposure in sensitized individuals, viral infections, exercise, irritants, and ingestion of nonsteroidal anti-inflammatory agents among others. Exacerbating factors might include one or all of these exposures and vary both among and within patients. Asthma treatment is determined to a large extent after an assessment of severity, which can be variable over time and assessed in 2 domains: impairment (current) and risk (long-term consequences). Unfortunately, despite the availability of effective therapies, suboptimal asthma control exists in many patients on a worldwide basis. The future development of novel therapies and treatment paradigms should address these disparities.

Making the diagnosis of asthma in the athlete

This article encompasses a discussion of the clinical presentation and features as various diagnostic modalites of bronchoprovocation and differential diagnosis used in screening for asthma in the athlete. A comparative analysis of these modalities, including questionnaire, treadmill, eucapneic hyperventilation, as well as field challenge, is provided with sensitivities and specificities, predictive value, and application to clinical practice. The indication and mechanics of each diagnostic modality is discussed, providing the clinician with a comprehensive understanding of the principles and procedures used to diagnosis asthma in the athlete.

Medical screening of the athlete: How does asthma fit in?

There are 4 million high school athletes in the United States, and there are 30 million athletes under age 18 yr competing in organized sports. The prevalence number of emergency room visits and deaths from asthma are significant. Medical clearance is required by all states for participation in high school sports. This article discusses the issues regarding the medical screening of the athlete and how asthma fits into the process. The preparticipation sports physical is an overlooked and underutilized opportunity to improve asthma diagnosis and management in adolescents.