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Pigakis KM, Stavrou VT, Kontopodi AK, Pantazopoulos I, Daniil Z, Gourgoulianis K. Impact of Isolated Exercise-Induced Small Airway Dysfunction on Exercise Performance in Professional Male Cyclists. Sports (Basel) 2024; 12:112. [PMID: 38668580 PMCID: PMC11054898 DOI: 10.3390/sports12040112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/13/2024] [Accepted: 04/17/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Professional cycling puts significant demands on the respiratory system. Exercise-induced bronchoconstriction (EIB) is a common problem in professional athletes. Small airways may be affected in isolation or in combination with a reduction in forced expiratory volume at the first second (FEV1). This study aimed to investigate isolated exercise-induced small airway dysfunction (SAD) in professional cyclists and assess the impact of this phenomenon on exercise capacity in this population. MATERIALS AND METHODS This research was conducted on professional cyclists with no history of asthma or atopy. Anthropometric characteristics were recorded, the training age was determined, and spirometry and specific markers, such as fractional exhaled nitric oxide (FeNO) and immunoglobulin E (IgE), were measured for all participants. All of the cyclists underwent cardiopulmonary exercise testing (CPET) followed by spirometry. RESULTS Compared with the controls, 1-FEV3/FVC (the fraction of the FVC that was not expired during the first 3 s of the FVC) was greater in athletes with EIB, but also in those with isolated exercise-induced SAD. The exercise capacity was lower in cyclists with isolated exercise-induced SAD than in the controls, but was similar to that in cyclists with EIB. This phenomenon appeared to be associated with a worse ventilatory reserve (VE/MVV%). CONCLUSIONS According to our data, it appears that professional cyclists may experience no beneficial impacts on their respiratory system. Strenuous endurance exercise can induce airway injury, which is followed by a restorative process. The repeated cycle of injury and repair can trigger the release of pro-inflammatory mediators, the disruption of the airway epithelial barrier, and plasma exudation, which gradually give rise to airway hyper-responsiveness, exercise-induced bronchoconstriction, intrabronchial inflammation, peribronchial fibrosis, and respiratory symptoms. The small airways may be affected in isolation or in combination with a reduction in FEV1. Cyclists with isolated exercise-induced SAD had lower exercise capacity than those in the control group.
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Affiliation(s)
- Konstantinos M. Pigakis
- Department of Respiratory & Critical Care Medicine, Creta Interclinic, 71304 Heraklion, Greece
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece; (V.T.S.); (Z.D.); (K.G.)
| | - Vasileios T. Stavrou
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece; (V.T.S.); (Z.D.); (K.G.)
| | - Aggeliki K. Kontopodi
- Department of Respiratory & Critical Care Medicine, Creta Interclinic, 71304 Heraklion, Greece
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | - Zoe Daniil
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece; (V.T.S.); (Z.D.); (K.G.)
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Konstantinos Gourgoulianis
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece; (V.T.S.); (Z.D.); (K.G.)
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
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Pigakis KM, Stavrou VT, Pantazopoulos I, Daniil Z, Kontopodi-Pigaki AK, Gourgoulianis K. Effect of Hydration on Pulmonary Function and Development of Exercise-Induced Bronchoconstriction among Professional Male Cyclists. Adv Respir Med 2023; 91:239-253. [PMID: 37366805 DOI: 10.3390/arm91030019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) is a common problem in elite athletes. Classical pathways in the development of EIB include the osmotic and thermal theory as well as the presence of epithelial injury in the airway, with local water loss being the main trigger of EIB. This study aimed to investigate the effects of systemic hydration on pulmonary function and to establish whether it can reverse dehydration-induced alterations in pulmonary function. MATERIALS AND METHODS This follow-up study was performed among professional cyclists, without a history of asthma and/or atopy. Anthropometric characteristics were recorded for all participants, and the training age was determined. In addition, pulmonary function tests and specific markers such as fractional exhaled nitric oxide (FeNO) and immunoglobulin E (IgE) were measured. All the athletes underwent body composition analysis and cardiopulmonary exercise testing (CPET). After CPET, spirometry was followed at the 3rd, 5th, 10th, 15th, and 30th min. This study was divided into two phases: before and after hydration. Cyclists, who experienced a decrease in Forced Expiratory Volume in one second (FEV1) ≥ 10% and/or Maximal Mild-Expiratory Flow Rate (MEF25-75) ≥ 20% after CPET in relation to the results of the spirometry before CPET, repeated the test in 15-20 days, following instructions for hydration. RESULTS One hundred male cyclists (n = 100) participated in Phase A. After exercise, there was a decrease in all spirometric parameters (p < 0.001). In Phase B, after hydration, in all comparisons, the changes in spirometric values were significantly lower than those in Phase A (p < 0.001). CONCLUSIONS The findings of this study suggest that professional cyclists have non-beneficial effects on respiratory function. Additionally, we found that systemic hydration has a positive effect on spirometry in cyclists. Of particular interest are small airways, which appear to be affected independently or in combination with the decrease in FEV1. Our data suggest that pulmonary function improves systemic after hydration.
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Affiliation(s)
- Konstantinos M Pigakis
- Department of Respiratory & Critical Care Medicine, Creta Interclinic, 71304 Heraklion, Greece
| | - Vasileios T Stavrou
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Ioannis Pantazopoulos
- Emergency Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Zoe Daniil
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | | | - Konstantinos Gourgoulianis
- Laboratory of Cardiopulmonary Testing and Pulmonary Rehabilitation, Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
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Støle Melsom H, Randa A, Hisdal J, Stang JS, Stensrud T. Prevalence of Asthma among Norwegian Elite Athletes. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:3887471. [PMID: 38655166 PMCID: PMC11022777 DOI: 10.1155/2022/3887471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/14/2022] [Indexed: 04/26/2024]
Abstract
Objective Asthma is a common problem among elite athletes and represents a health risk interfering with the athlete's performance status. This study aimed to evaluate the asthma prevalence among Norwegian summer and winter elite athletes and asthma prevalence across sport categories. We also aimed to examine whether bronchial hyperresponsiveness (BHR), lung function, fraction of exhaled nitric oxide (FENO), and allergy status differed between asthmatic and non-asthmatic elite athletes. Methods Norwegian athletes qualifying for the Beijing Olympic Summer Games 2008 (n = 80) and the Vancouver Olympic Winter Games 2010 (n = 55) were included. The athletes underwent clinical respiratory examination including lung function measurement, methacholine bronchial challenge for assessment of BHR, FENO, and skin prick testing. Asthma was diagnosed based on respiratory symptoms and clinical examination including objective measurements. Results Asthma was more prevalent among winter athletes (50%) than summer athletes (20%). Thirty-three (52%) endurance athletes, 3 (6%) team sport athletes, and 7 (33%) technical sport athletes had medically diagnosed asthma. Significantly lower lung function (p < 0.001) and higher prevalence of severe BHR (p < 0.001) were found in asthmatic athletes compared with non-asthmatic athletes. Conclusion Asthma is common among Norwegian elite athletes, with winter and endurance athletes showing the highest prevalence. Asthmatic athletes were characterized by lower lung function and more severe BHR compared with non-asthmatic counterparts. The high prevalence among winter and endurance athletes demonstrates a need for increased attention to prevent and reduce the prevalence of asthma among those athletes.
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Affiliation(s)
- Helene Støle Melsom
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| | - Anders Randa
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Jonny Hisdal
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| | - Julie Sørbø Stang
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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4
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Pigakis KM, Stavrou VT, Pantazopoulos I, Daniil Z, Kontopodi AK, Gourgoulianis K. Exercise-Induced Bronchospasm in Elite Athletes. Cureus 2022; 14:e20898. [PMID: 35145802 PMCID: PMC8807463 DOI: 10.7759/cureus.20898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 11/05/2022] Open
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5
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Satia I, Priel E, Al-Khazraji BK, Jones G, Freitag A, O'Byrne PM, Killian KJ. Exercise-induced bronchoconstriction and bronchodilation: investigating the effects of age, sex, airflow limitation and FEV 1. Eur Respir J 2021; 58:13993003.04026-2020. [PMID: 33446611 DOI: 10.1183/13993003.04026-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/05/2021] [Indexed: 11/05/2022]
Abstract
Exercise-induced bronchoconstriction (EIBc) is a recognised response to exercise in asthmatic subjects and athletes but is less well understood in an unselected broad population. Exercise-induced bronchodilation (EIBd) has received even less attention. The objective of this study was to investigate the effects of age, sex, forced expiratory volume in 1 s (FEV1) and airflow limitation (FEV1/forced vital capacity (FVC) <0.7) on the prevalence of EIBc and EIBd.This was a retrospective study based on incremental cardiopulmonary exercise testing on cycle ergometry to symptom limitation performed between 1988 and 2012. FEV1 was measured before and 10 min after exercise. EIBc was defined as a percentage fall in FEV1 post-exercise below the 5th percentile, while EIBd was defined as a percentage increase in FEV1 above the 95th percentile.35 258 subjects aged 6-95 years were included in the study (mean age 53 years, 60% male) and 10.3% had airflow limitation (FEV1/FVC <0.7). The lowest 5% of subjects demonstrated a ≥7.6% fall in FEV1 post-exercise (EIBc), while the highest 5% demonstrated a >11% increase in FEV1 post-exercise (EIBd). The probability of both EIBc and EIBd increased with age and was highest in females across all ages (OR 1.76, 95% CI 1.60-1.94; p<0.0001). The probability of EIBc increased as FEV1 % pred declined (<40%: OR 4.38, 95% CI 3.04-6.31; p<0.0001), with a >2-fold increased likelihood in females (OR 2.31, 95% CI 1.71-3.11; p<0.0001), with a trend with airflow limitation (p=0.06). The probability of EIBd increased as FEV1 % pred declined, in the presence of airflow limitation (OR 1.55, 95% CI 1.24-1.95; p=0.0001), but sex had no effect.EIBc and EIBd can be demonstrated at the population level, and are influenced by age, sex, FEV1 % pred and airflow limitation.
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Affiliation(s)
- Imran Satia
- Dept of Medicine, McMaster University, Hamilton, ON, Canada .,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Eldar Priel
- Dept of Medicine, McMaster University, Hamilton, ON, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
| | | | - Graham Jones
- Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andy Freitag
- Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul M O'Byrne
- Dept of Medicine, McMaster University, Hamilton, ON, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
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6
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Bonini M, Cilluffo G, La Grutta S, Boccabella C, Usmani O, Viegi G, Palange P. Anti-muscarinic drugs as preventive treatment of exercise-induced bronchoconstriction (EIB) in children and adults. Respir Med 2020; 172:106128. [PMID: 32911137 DOI: 10.1016/j.rmed.2020.106128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 01/08/2023]
Abstract
Regular physical activity is strongly recommended to prevent chronic respiratory diseases, including asthma. On the other hand, vigorous physical training may trigger airway symptoms and bronchoconstriction. The transient airway narrowing occurring because of exercise is named exercise-induced bronchoconstriction (EIB). Despite management according to guidelines, a significant proportion of patients experiences uncontrolled EIB, which thus represents a relevant unmet medical need. In particular, although prevention and treatment of EIB are effectively based on the use of beta-2 bronchodilator drugs, high heterogeneity in individual responses has been reported. Furthermore, even though beta-2 adrenergic drugs remain the mainstay of EIB management, occurrence of tolerance and side effects, as well as doping concerns have been reported with their use. In regard to this, inhaled antimuscarinics could represent an alternative or additional effective and safe bronchodilator therapeutic option for achieving optimal EIB control and minimize adverse events. The present systematic review aims to collect and provide the most updated and evidence-based literature findings on the efficacy and safety of short- and long-acting inhaled anti-muscarinic drugs for the preventive treatment of EIB in both children and adults. Take-Home Message: Anti-muscarinic drugs are effective and safe in preventing EIB, despite response variability is reported. Further studies should focus on long-acting molecules, chronic administration and phenotype-driven effects.
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Affiliation(s)
- Matteo Bonini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy; National Heart and Lung Institute (NHLI), Royal Brompton Hospital & Imperial College London, UK
| | - Giovanna Cilluffo
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), Palermo, Italy.
| | - Stefania La Grutta
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), Palermo, Italy
| | - Cristina Boccabella
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Omar Usmani
- National Heart and Lung Institute (NHLI), Royal Brompton Hospital & Imperial College London, UK
| | - Giovanni Viegi
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), Palermo, Italy; Unità di Ricerca di Epidemiologia Ambientale Polmonare, Istituto di Fisiologia Clinica (IFC), CNR, Pisa, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Italy
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7
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Greiwe J, Cooke A, Nanda A, Epstein SZ, Wasan AN, Shepard KV, Capão-Filipe M, Nish A, Rubin M, Gregory KL, Dass K, Blessing-Moore J, Randolph C. Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2542-2555. [PMID: 32636147 DOI: 10.1016/j.jaip.2020.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 11/26/2022]
Abstract
Exercise-induced bronchoconstriction, otherwise known as exercise-induced bronchoconstriction with asthma or without asthma, is an acute airway narrowing that occurs as a result of exercise and can occur in patients with asthma. A panel of members from the American Academy of Allergy, Asthma & Immunology Sports, Exercise, & Fitness Committee reviewed the diagnosis and management of exercise-induced bronchoconstriction in athletes of all skill levels including recreational athletes, high school and college athletes, and professional athletes. A special emphasis was placed on the recommendations and regulations set forth by professional athletic organizations after a detailed review of their collective bargaining agreements, substance abuse policies, antidoping program manuals, and the World Anti-Doping Agency antidoping code. The recommendations in this review are based on currently available evidence in addition to providing guidance for athletes of all skill levels as well as their treating physicians to better understand which pharmaceutical and nonpharmaceutical management options are appropriate as well as which medications are permitted or prohibited, and the proper documentation required to remain compliant.
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Affiliation(s)
- Justin Greiwe
- Bernstein Allergy Group Inc, Cincinnati, Ohio; Division of Immunology/Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Andrew Cooke
- Lake Allergy, Asthma & Immunology PA, Tavares, Fla
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Texas; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Kirk V Shepard
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine and James A. Haley Veterans' Hospital, Tampa, Fla
| | | | - Andy Nish
- Northeast Georgia Physician's Group Allergy and Asthma, Gainesville, Ga
| | - Mark Rubin
- Asthma and COPD Emmi Solutions, Chicago, Ill; CME Education Program Steering Committee, The France Foundation, Old Lyme, Conn
| | - Karen L Gregory
- Oklahoma Allergy and Asthma Clinic, Oklahoma City, Okla; School of Nursing and Health Studies, Georgetown University, Washington, DC
| | - Kathleen Dass
- Michigan Allergy, Asthma & Immunology Center PLLC, Oak Park, Mich; Division of Immunology/Allergy Section, Department of Internal Medicine, Oakland University William Beaumont Hospital, Rochester, Mich
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Milanese M, Miraglia Del Giudice E, Peroni DG. Asthma, exercise and metabolic dysregulation in paediatrics. Allergol Immunopathol (Madr) 2019; 47:289-294. [PMID: 30789156 DOI: 10.1016/j.aller.2018.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023]
Abstract
Asthma is the most frequent chronic disease in childhood. Chest tightness, cough, wheezing and dyspnoea during or after exercise may be unique manifestations of asthma in up to 90% of subjects. Physical activity may be reduced by uncontrolled asthma symptoms and parental beliefs, impairing physical fitness of asthmatic children. Clinicians working in the field of allergy are aware of evidence supporting the benefits of physical activity for patients with asthma. Treatment of asthma is required in order to obtain its control and to avoid any limitation in sports and active play participation. As exercise performance in children with controlled asthma is not different from that of healthy controls, any exercise limitation cannot be accepted. Overweight and obesity may interfere with asthma and exercise, leading to dyspnoea symptoms. Evidences on the effect of insulin resistance on airway smooth muscle and on bronchial hyperactivity are presented. CONCLUSION: Exercise is part of the strategy to obtain the best control of asthma in childhood, but we have to optimise the asthma control therapy before starting exercise programming. Furthermore, it is crucial to give best attention on the effects of obesity and insulin resistance, because they could in turn influence patients' symptoms.
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Affiliation(s)
- Manlio Milanese
- Division of Respiratory Diseases, Azienda Sanitaria Locale 2 Savonese, Savona, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Women, Child and General and Special Surgery, Università della Campania Luigi Vanvitelli, Naples, Italy
| | - Diego G Peroni
- Department of Clinical and Experimental Medicine, Section of Paediatric, University of Pisa, Pisa, Italy.
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9
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Backer V, Mastronarde J. Pharmacologic Strategies for Exercise-Induced Bronchospasm with a Focus on Athletes. Immunol Allergy Clin North Am 2019; 38:231-243. [PMID: 29631732 DOI: 10.1016/j.iac.2018.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is the transient narrowing of the airways during and after exercise that occurs in response to increased ventilation in susceptible individuals. It occurs across the age spectrum in patients with underlying asthma and can occur in athletes without baseline asthma. The inflammatory mechanisms underlying EIB in patients without asthma may be distinct from those underlying EIB in patients with asthma. This review summarizes mechanistic and clinical data that can guide the choice of chronic and acute pharmacologic therapies targeting control of EIB. Relevant regulations from the World Anti-Doping Agency are also discussed.
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Affiliation(s)
- Vibeke Backer
- Department of Respiratory Medicine, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, Copenhagen NV 2400, Denmark.
| | - John Mastronarde
- Department of Medical Education, Providence Portland Medical Center, Pulmonary/Critical Care Medicine, Oregon Health & Science University, 5050 Northeast Hoyt Avenue, Suite 540, Portland, OR 97213, USA
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10
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Anderson SD. Repurposing drugs as inhaled therapies in asthma. Adv Drug Deliv Rev 2018; 133:19-33. [PMID: 29906501 DOI: 10.1016/j.addr.2018.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/26/2018] [Accepted: 06/06/2018] [Indexed: 01/06/2023]
Abstract
For the first 40 years of the 20th century treatment for asthma occurred in response to an asthma attack. The treatments were given by injection or orally and included the adrenergic agonists adrenalin/epinephrine and ephedrine and a phosphodiesterase inhibitor theophylline. Epinephrine became available as an aerosol in 1930. After 1945, isoprenaline, a non-selective beta agonist, became available for oral use but it was most widely used by inhalation. Isoprenaline was short-acting with unwanted cardiac effects. More selective beta agonists, with a longer duration of action and fewer side-effects became available, including orciprenaline in 1967, salbutamol in 1969 and terbutaline in 1970. The inhaled steroid beclomethasone was available by 1972 and budesonide by 1982. Spirometry alone and in response to exercise was used to assess efficacy and duration of action of these drugs for the acute benefits of beta2 agonists and the chronic benefits of corticosteroids. Early studies comparing oral and aerosol beta2 agonists found equivalence in bronchodilator effect but the aerosol treatment was superior in preventing exercise-induced bronchoconstriction. Inhaled drugs are now widely used including the long-acting beta2 agonists, salmeterol and formoterol, and the corticosteroids, fluticasone, ciclesonide, mometasone and triamcinolone, that act locally and have low systemic bio-availability. Repurposing drugs as inhaled therapies permitted direct delivery of low doses of drug to the site of action reducing the incidence of unwanted side-effects and permitting the prophylactic treatment of asthma.
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Affiliation(s)
- Sandra D Anderson
- Clinical Professor, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia.
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11
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Bonini M, Silvers W. Exercise-Induced Bronchoconstriction: Background, Prevalence, and Sport Considerations. Immunol Allergy Clin North Am 2018; 38:205-214. [PMID: 29631730 DOI: 10.1016/j.iac.2018.01.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The transient airway narrowing that occurs as a result of exercise is defined as exercise-induced bronchoconstriction (EIB). The prevalence of EIB has been reported to be up to 90% in asthmatic patients, reflecting the level of disease control. However, EIB may develop even in subjects without clinical asthma, particularly in children, athletes, patients with atopy or rhinitis, and following respiratory infections. The intensity, duration, and type of training have been associated with the occurrence of EIB. In athletes, EIB seems to be only partly reversible, and exercise seems to be a causative factor of airway inflammation and symptoms.
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Affiliation(s)
- Matteo Bonini
- Airways Disease Section, National Heart and Lung Institute (NHLI), Royal Brompton Hospital, Imperial College London, Dovehouse Street, London SW3 6LY, UK.
| | - William Silvers
- University of Colorado School of Medicine, 13001 E 17th Place, Aurora, CO 80045, USA
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12
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Couto M, Kurowski M, Moreira A, Bullens DMA, Carlsen K, Delgado L, Kowalski ML, Seys SF. Mechanisms of exercise-induced bronchoconstriction in athletes: Current perspectives and future challenges. Allergy 2018; 73:8-16. [PMID: 28599081 DOI: 10.1111/all.13224] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 01/08/2023]
Abstract
The evidence of exercise-induced bronchoconstriction (EIB) without asthma (EIBwA ) occurring in athletes led to speculate about different endotypes inducing respiratory symptoms within athletes. Classical postulated mechanisms for bronchial obstruction in this population include the osmotic and the thermal hypotheses. More recently, the presence of epithelial injury and inflammation in the airways of athletes was demonstrated. In addition, neuronal activation has been suggested as a potential modulator of bronchoconstriction. Investigation of these emerging mechanisms is of major importance as EIB is a significant problem for both recreational and competitive athletes and is the most common chronic condition among Olympic athletes, with obvious implications for their competing performance, health and quality of life. Hereby, we summarize the latest achievements in this area and identify the current gaps of knowledge so that future research heads toward better defining the etiologic factors and mechanisms involved in development of EIB in elite athletes as well as essential aspects to ultimately propose preventive and therapeutic measures.
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Affiliation(s)
- M. Couto
- Allergy Unit Hospital & Instituto CUF Porto Porto Portugal
| | - M. Kurowski
- Department of Immunology, Rheumatology and Allergy Healthy Ageing Research Centre Medical University of Łódź Łódź Poland
| | - A. Moreira
- Basic and Clinical Immunology Department of Pathology Faculty of Medicine University of Porto Porto Portugal
- Serviço de Imunoalergologia Centro Hospitalar São João E.P.E. Porto Portugal
| | - D. M. A. Bullens
- Laboratory of Pediatric Immunology Department of Microbiology and Immunology KU Leuven Leuven Belgium
- Division of Pediatrics UZ Leuven Leuven Belgium
| | - K.‐H. Carlsen
- Institute for Clinical Medicine University of Oslo Oslo Norway
| | - L. Delgado
- Basic and Clinical Immunology Department of Pathology Faculty of Medicine University of Porto Porto Portugal
- Serviço de Imunoalergologia Centro Hospitalar São João E.P.E. Porto Portugal
| | - M. L. Kowalski
- Department of Immunology, Rheumatology and Allergy Healthy Ageing Research Centre Medical University of Łódź Łódź Poland
| | - S. F. Seys
- Laboratory of Clinical Immunology Department of Microbiology and Immunology KU Leuven Leuven Belgium
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13
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Del Giacco S. Exercise, Asthma and the Olympics: A 2000-year-old tale. Porto Biomed J 2016; 1:127-128. [PMID: 32258562 DOI: 10.1016/j.pbj.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Two separated phenotypes of Exercise-Induced-Asthma existOlympic Athletes have won more medals than their non-asthmatic peersCompetitive swimmers show an increased asthma prevalenceAsthmatics have no limitations in sports practice if they receive adequate medical treatmentAerobic exercise programs are beneficial for asthmatics and should be included in asthma action plans.
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Affiliation(s)
- Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
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14
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Ghanei M, Aliannejad R, Mazloumi M, Saburi A. Exertional-induced bronchoconstriction: comparison between cardiopulmonary exercise test and methacholine challenging test. Ann Card Anaesth 2016; 18:479-85. [PMID: 26440232 PMCID: PMC4881686 DOI: 10.4103/0971-9784.166443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Exertional-induced bronchoconstriction is a condition in which the physical activity causes constriction of airways in patients with airway hyper- responsiveness. In this study, we tried to study and evaluate any relationship between the findings of cardiopulmonary exercise testing (CPET) and the response to methacholine challenge test (MCT) in patients with dyspnea after activity. MATERIALS AND METHODS Thirty patients with complaints of dyspnea following activity referred to "Lung Clinic" of Baqiyatallah Hospital but not suffering from asthma were entered into the study. The subjects were excluded from the study if: Suffering from any other pulmonary diseases, smoking more than 1 cigarette a week in the last year, having a history of smoking more than 10 packets of cigarettes/year, having respiratory infection in the past 4 weeks, having abnormal chest X-ray or electrocardiogram, and cannot discontinue the use of medicines interfering with bronchial provocation. Baseline spirometry was performed for all the patients, and the values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV/FVC were recorded. The MCT and then the CPET were performed on all patients. RESULTS The mean VO 2 (volume oxygen) in patients with positive methacholine test (20.45 mL/kg/min) was significantly lower than patients with negative MCT (28.69 mL/kg/min) (P = 0.000). Respiratory rates per minute (RR) and minute ventilation in the group with positive MCT (38.85 and 1.636 L) were significantly lower than the group with negative methacholine test (46.78 and 2.114 L) (P < 0.05). Also, the O 2 pulse rate in the group with negative methacholine test (116.27 mL/beat) was significantly higher than the group with positive methacholine test (84.26 mL/beat) (P < 0.001). CONCLUSION Pulmonary response to exercise in patients with positive methacholine test is insufficient. The dead space ventilation in these patients has increased. Also, dynamic hyperinflation in patients with positive methacholine test causes the reduced stroke volume and O 2 pulse in these patients.
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Affiliation(s)
| | | | | | - Amin Saburi
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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15
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Anderson SD. 'Indirect' challenges from science to clinical practice. Eur Clin Respir J 2016; 3:31096. [PMID: 26908255 PMCID: PMC4764958 DOI: 10.3402/ecrj.v3.31096] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022] Open
Abstract
Indirect challenges act to provoke bronchoconstriction by causing the release of endogenous mediators and are used to identify airway hyper-responsiveness. This paper reviews the historical development of challenges, with exercise, eucapnic voluntary hyperpnoea (EVH) of dry air, wet hypertonic saline, and with dry powder mannitol, that preceded their use in clinical practice. The first challenge developed for clinical use was exercise. Physicians were keen for a standardized test to identify exercise-induced asthma (EIA) and to assess the effect of drugs such as disodium cromoglycate. EVH with dry air became a surrogate for exercise to increase ventilation to very high levels. A simple test was developed with EVH and used to identify EIA in defence force recruits and later in elite athletes. The research findings with different conditions of inspired air led to the conclusion that loss of water by evaporation from the airway surface was the stimulus to EIA. The proposal that water loss caused a transient increase in osmolarity led to the development of the hypertonic saline challenge. The wet aerosol challenge with 4.5% saline, provided a known osmotic stimulus, to which most asthmatics were sensitive. To simplify the osmotic challenge, a dry powder of mannitol was specially prepared and encapsulated. The test pack with different doses and an inhaler provided a common operating procedure that could be used at the point of care. All these challenge tests have a high specificity to identify currently active asthma. All have been used to assess the benefit of treatment with inhaled corticosteroids. Over the 50 years, the methods for testing became safer, less complex, and less expensive and all used forced expiratory volume in 1 sec to measure the response. Thus, they became practical to use routinely and were recommended in guidelines for use in clinical practice.
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Affiliation(s)
- Sandra D Anderson
- Sydney Medical School, Central Clinical School, University of Sydney, Sydney, NSW, Australia;
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16
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Del Giacco SR, Firinu D, Bjermer L, Carlsen KH. Exercise and asthma: an overview. Eur Clin Respir J 2015. [PMID: 26672959 DOI: 10.3402/ecrj.v2.27984.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The terms 'exercise-induced asthma' (EIA) and 'exercise-induced bronchoconstriction' (EIB) are often used interchangeably to describe symptoms of asthma such as cough, wheeze, or dyspnoea provoked by vigorous physical activity. In this review, we refer to EIB as the bronchoconstrictive response and to EIA when bronchoconstriction is associated with asthma symptoms. EIB is a common occurrence for most of the asthmatic patients, but it also affects more than 10% of otherwise healthy individuals as shown by epidemiological studies. EIA and EIB have a high prevalence also in elite athletes, especially within endurance type of sports, and an athlete's asthma phenotype has been described. However, the occurrence in elite athletes shows that EIA/EIB, if correctly managed, may not impair physical activity and top sports performance. The pathogenic mechanisms of EIA/EIB classically involve both osmolar and vascular changes in the airways in addition to cooling of the airways with parasympathetic stimulation. Airways inflammation plays a fundamental role in EIA/EIB. Diagnosis and pharmacological management must be carefully performed, with particular consideration of current anti-doping regulations, when caring for athletes. Based on the demonstration that the inhaled asthma drugs do not improve performance in healthy athletes, the doping regulations are presently much less strict than previously. Some sports are at a higher asthma risk than others, probably due to a high environmental exposure while performing the sport, with swimming and chlorine exposure during swimming as one example. It is considered very important for the asthmatic child and adolescent to master EIA/EIB to be able to participate in physical activity on an equal level with their peers, and a precise early diagnosis with optimal treatment follow-up is vital in this aspect. In addition, surprising recent preliminary evidences offer new perspectives for moderate exercise as a potential therapeutic tool for asthmatics.
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Affiliation(s)
- Stefano R Del Giacco
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy;
| | - Davide Firinu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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17
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Del Giacco SR, Firinu D, Bjermer L, Carlsen KH. Exercise and asthma: an overview. Eur Clin Respir J 2015; 2:27984. [PMID: 26672959 PMCID: PMC4653278 DOI: 10.3402/ecrj.v2.27984] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 09/04/2015] [Indexed: 01/03/2023] Open
Abstract
The terms 'exercise-induced asthma' (EIA) and 'exercise-induced bronchoconstriction' (EIB) are often used interchangeably to describe symptoms of asthma such as cough, wheeze, or dyspnoea provoked by vigorous physical activity. In this review, we refer to EIB as the bronchoconstrictive response and to EIA when bronchoconstriction is associated with asthma symptoms. EIB is a common occurrence for most of the asthmatic patients, but it also affects more than 10% of otherwise healthy individuals as shown by epidemiological studies. EIA and EIB have a high prevalence also in elite athletes, especially within endurance type of sports, and an athlete's asthma phenotype has been described. However, the occurrence in elite athletes shows that EIA/EIB, if correctly managed, may not impair physical activity and top sports performance. The pathogenic mechanisms of EIA/EIB classically involve both osmolar and vascular changes in the airways in addition to cooling of the airways with parasympathetic stimulation. Airways inflammation plays a fundamental role in EIA/EIB. Diagnosis and pharmacological management must be carefully performed, with particular consideration of current anti-doping regulations, when caring for athletes. Based on the demonstration that the inhaled asthma drugs do not improve performance in healthy athletes, the doping regulations are presently much less strict than previously. Some sports are at a higher asthma risk than others, probably due to a high environmental exposure while performing the sport, with swimming and chlorine exposure during swimming as one example. It is considered very important for the asthmatic child and adolescent to master EIA/EIB to be able to participate in physical activity on an equal level with their peers, and a precise early diagnosis with optimal treatment follow-up is vital in this aspect. In addition, surprising recent preliminary evidences offer new perspectives for moderate exercise as a potential therapeutic tool for asthmatics.
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Affiliation(s)
- Stefano R Del Giacco
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy;
| | - Davide Firinu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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18
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Bonini M, Palange P. Exercise-induced bronchoconstriction: new evidence in pathogenesis, diagnosis and treatment. Asthma Res Pract 2015; 1:2. [PMID: 27965757 PMCID: PMC4970375 DOI: 10.1186/s40733-015-0004-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 05/07/2015] [Indexed: 11/10/2022] Open
Abstract
The acute airway narrowing that occurs as a result of exercise is defined exercise-induced bronchoconstriction (EIB). Most recent guidelines recommend distinguishing EIB with underlying clinical asthma (EIBA) from the occurrence of bronchial obstruction in subjects without other symptoms and signs of asthma (EIBwA). EIB has been in fact reported in up to 90 % of asthmatic patients, reflecting the level of disease control, but it may develop even in subjects without clinical asthma, particularly in children, athletes, patients with atopy or rhinitis and following respiratory infections. Both EIBA and EIBwA have peculiar pathogenic mechanisms, diagnostic criteria and responses to treatment and prevention. The use of biomarkers, proteomic approaches and innovative technological procedures will hopefully contribute to better define peculiar phenotypes and to clarify the role of EIB as risk factor for the development of asthma, as well as an occupational disease.
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Affiliation(s)
- Matteo Bonini
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Viale dell'Universita', 37, 00185 Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Viale dell'Universita', 37, 00185 Rome, Italy
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19
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Akar HH, Tahan F, Gungor HE. The association of forced expiratory volume in one second and forced expiratory flow at 50% of the vital capacity, peak expiratory flow parameters, and blood eosinophil counts in exercise-induced bronchospasm in children with mild asthma. Asia Pac Allergy 2015; 5:98-102. [PMID: 25938074 PMCID: PMC4415185 DOI: 10.5415/apallergy.2015.5.2.98] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 03/03/2015] [Indexed: 12/03/2022] Open
Abstract
Background Exercise-induced bronchoconstriction (EIB), which describes acute airway narrowing that occurs as a result of exercise, is associated with eosinophilic airway inflammation, bronchial hyperresponsiveness. The forced expiratory volume in one second (FEV1) is the most commonly used spirometric test in the diagnosis of EIB in exercise challenge in asthma. Other parameters such as forced expiratory flow at 50% of the vital capacity (FEF50%) and peak expiratory flow (PEF) are used less often in the diagnosis of EIB. Objective The purpose of this study is to evaluate the association of FEV1 and FEF50%, PEF parameters, blood eosinophil counts in EIB in children with mild asthma. Methods Sixty-seven children (male: 39, female: 28) with mild asthma were included in this study. Pulmonary functions were assessed before and at 1, 5, 10, 15, and 20 minutes after exercise. The values of spirometric FEV1, FEF50%, PEF, and blood eosinophil counts were evaluated in EIB in children with mild asthma. Results There was a positive correlation between FEV1 with FEF50% and PEF values (p<0.05; FEF50%, r=0.68; PEF, r=0.65). Also, a positive correlation was found between blood eosinophil counts and the values of spirometric FEV1, FEF50%, and PEF (p<0.05; FEV1, r=0.54; FEF50%, r=0.42; PEF, r=0.26). In addition to these correlations, in the exercise negative group for FEV1, the FEF50% and PEF values decreased more than the cutoff values in 3, and 2 patients, respectively. Conclusion According to the presented study, eosinophil may play a major role in the severity of EIB in mild asthma. FEF50% and PEF values can decrease in response to exercise without changes in FEV1 in mild asthmatic patients.
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Affiliation(s)
- H Haluk Akar
- Department of Pediatric Allergy, Erciyes University School of Medicine, 38039 Kayseri, Turkey
| | - Fulya Tahan
- Department of Pediatric Allergy, Erciyes University School of Medicine, 38039 Kayseri, Turkey
| | - Hatice Eke Gungor
- Department of Pediatric Allergy, Erciyes University School of Medicine, 38039 Kayseri, Turkey
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20
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Abstract
In "Notes on Asthma" published in 1873, John Thorowgood stated that "daily exercise in the open air should not be neglected, and several cases testify to the effect of a steady walk in preventing an attack of asthma even when it already threatens". Similarly, Salter (1868) suggested that he was "puzzled by the fact" that exercise appeared to help some of his patients. From what we know today, it may be suggested that these patients were in fact, benefiting from the bronchodilation caused by exercise.
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21
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Godfrey S, Fitch KD. Exercise-induced bronchoconstriction: celebrating 50 years. Immunol Allergy Clin North Am 2013; 33:283-97, vii. [PMID: 23830125 DOI: 10.1016/j.iac.2013.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article examines in detail the history of more than half a century of investigations into elucidating the causation of exercise-induced bronchoconstriction. Despite earnest attempts by many researchers from many countries, answers to some pivotal questions await the next generation of investigators into exercise-induced bronchoconstriction.
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22
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Weiss P, Rundell KW. Exercise-Induced Lung Disease: Too Much of a Good Thing? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2011; 24:149-157. [PMID: 35927868 DOI: 10.1089/ped.2011.0066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Exercise in children has important health benefits. However, in elite endurance athletes, there is an increased prevalence of exercise-induced bronchoconstriction and airway inflammation. Particularly at risk are those who practice in cold weather, ice rinks, swimming pools, and air pollution. The inflammation is caused by repetitive episodes of hyperventilation of cold, dry air, allergens, or toxins such as chlorine or air pollution. Children may be particularly at risk for lung injury under these conditions because of the immaturity and ongoing development of their lung. However, studies in pediatric athletes and exercising young children are sparse. Epithelial injury associated with hyperventilation of cold, dry air has not been described in children. However, exercise in the presence of air pollution and chlorine is associated with airway injury and the development of asthma in children; the effect appears to be modulated by both atopy and genetic polymorphisms. While management of exercise-induced bronchoconstriction and asthma is well established, there is little data to guide treatment or prevention of remodeling in athletes or inhalational lung injury in children. Studies underscore the need to maintain high levels of air quality. More investigations should be undertaken to better define the natural history, pathophysiology, and treatment of exercise-induced pulmonary inflammation in both elite athletes and exercising children.
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Affiliation(s)
- Pnina Weiss
- Department of Pediatric Respiratory Medicine, Yale University, New Haven, Connecticut
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23
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Poussel M, Chenuel B. [Exercise-induced bronchoconstriction in non-asthmatic athletes]. Rev Mal Respir 2010; 27:898-906. [PMID: 20965404 DOI: 10.1016/j.rmr.2010.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2009] [Accepted: 02/10/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A new clinical entity, exercise-induced bronchoconstriction (EIB), has been recently defined which describes bronchoconstriction occurring in association with exercise in susceptible non-asthmatic persons. STATE OF ART There is considerable evidence that the pathogenesis of this condition is related to airway injury, due to prolonged hyperventilation and aggressive environmental factors. If the objective diagnostic tests are identical for the diagnosis of exercise induced asthma and EIB, the diagnoses are established differently, according to the high sensitivity of provocation by exercise "in the field" or the eucapnic voluntary hyperventilation provocation test. PERSPECTIVES Current pharmacological treatment is based upon the inhalation of ß2-agonists prior to exercise, but to be granted permission to use them, athletes are required to provide documentation of objective evidence of EIB. Therefore, the diagnostic pathway in athletes is essential and respiratory physicians need to know the specific features of this new clinical entity. CONCLUSIONS EIB distinct from the presence of asthma is prevalent in elite athletes and its determinants should be well known by their health care providers to assure an optimal management of this peculiar disease, in respect to drug doping regulations.
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Affiliation(s)
- M Poussel
- Service des explorations fonctionnelles respiratoires et de l'aptitude à l'exercice, CHU de Nancy-Brabois Adultes, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
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24
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Lee SY, Kim HB, Yu J, Hong SJ. Exercise-induced asthma in children. Expert Rev Clin Immunol 2010; 5:193-207. [PMID: 20477066 DOI: 10.1586/1744666x.5.2.193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exercise-induced bronchoconstriction affects 40-90% of people with asthma, compared with 3-15% of the general population. Exercise-induced asthma (EIA) is diagnosed on the basis of subjective symptoms of airflow obstruction during and after exercise, objective measures of airflow obstruction and the exclusion of alternative diagnoses. Although the pathogenesis of EIA has not been fully elucidated, two major theories have been proposed: the airway rewarming theory and the hyperosmolarity theory. Increasing evidence suggests that airway inflammation plays a major role in the pathogenesis of EIA. In this article, we review the prevalence, pathogenesis, methods for diagnosis and treatment of EIA, as well as the responsiveness of children and adolescents to EIA therapies.
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Affiliation(s)
- So-Yeon Lee
- Department of Pediatrics, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Youngdeungpo-dong, Youngdeungpo-gu, Seoul, Korea.
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25
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Milanese M, Saporiti R, Bartolini S, Pellegrino R, Baroffio M, Brusasco V, Crimi E. Bronchodilator effects of exercise hyperpnea and albuterol in mild-to-moderate asthma. J Appl Physiol (1985) 2009; 107:494-9. [PMID: 19541736 DOI: 10.1152/japplphysiol.00302.2009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In asthmatic patients, either bronchodilatation or bronchoconstriction may develop during exercise. In 18 patients with mild-to-moderate asthma, we conducted two studies with the aims to 1) quantify the bronchodilator effect of hyperpnea induced by incremental-load maximum exercise compared with effects of inhaled albuterol (study 1, n=10) and 2) determine the time course of changes in airway caliber during prolonged constant-load exercise (study 2, n=8). In both studies, it was also investigated whether the bronchodilator effects of exercise hyperpnea and albuterol are additive. Changes in airway caliber were measured by changes in partial forced expiratory flow. In study 1, incremental-load exercise was associated with a bronchodilatation that was approximately 60% of the maximal bronchodilatation obtainable with 1,500 microg of albuterol. In study 2, constant-load exercise was associated with an initial moderate bronchodilatation and a late airway renarrowing. In both studies, premedication with inhaled albuterol (400 microg) promoted sustained bronchodilatation during exercise, which was additive to that caused by exercise hyperpnea. In conclusion, in mild-to-moderate asthmatic individuals, hyperpnea at peak exercise was associated with a potent yet not complete bronchodilatation. During constant-load exercise, a transient bronchodilatation was followed by airway renarrowing, suggesting prevalence of constrictor over dilator effects of hyperpnea. Finally, the bronchodilator effect of hyperpnea was additive to that of albuterol.
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26
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Katz I, Moshe S, Levin M, Slodownik D, Yagev Y. Does exercise cause asthma? Occup Med (Lond) 2008; 58:480-4. [PMID: 18725382 DOI: 10.1093/occmed/kqn096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Israel Defence Forces needed to define the correlation between physical activity and asthma. AIM To determine whether combat unit (CU) soldiers are more susceptible to exercise-induced asthma (EIA) than other military units. METHODS A follow-up study of recruits with normal clinical and pulmonary function tests over a period of 30 months after having been assigned to CU, maintenance units (MU) or clerical tasks (CT). The participants chosen had already been subjected to additional tests 6 weeks after induction to eliminate any cases of active asthma. RESULTS Out of 799 subjects, 125 developed asthma during the follow-up. Twenty-one per cent of those in the CU developed asthma against 15% in the MU and 5% in the CT. The relative risks for newly diagnosed asthma were 3.7 for CU/CT (P < 0.001), 2.7 for MU/CT (P < 0.001) and 1.4 for CU/MU (P < 0.05). EIA was observed as the only manifestation of asthma in 32% of the soldiers posted in CU compared to 13 and 11% in MU and CT, respectively. CONCLUSION The increased risk of EIA in CU compared to MU and CT may indicate that any one or all the factors associated with CU service conditions could contribute to this increased risk of uncovering the mild cases of asthma, especially EIA, that had been overlooked up to the time of induction into the army.
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Affiliation(s)
- Ido Katz
- The Israel Lung Association, University of Tel Aviv, Tel Aviv, Israel
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27
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Abstract
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.
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Affiliation(s)
- Chris Randolph
- Center for Allergy, Asthma, Immunology, 1389 West Main Street, Suite 205, Waterbury, CT 06708, USA.
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28
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Weiler JM, Bonini S, Coifman R, Craig T, Delgado L, Capão-Filipe M, Passali D, Randolph C, Storms W. American Academy of Allergy, Asthma & Immunology Work Group report: exercise-induced asthma. J Allergy Clin Immunol 2007; 119:1349-58. [PMID: 17433829 DOI: 10.1016/j.jaci.2007.02.041] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 02/20/2007] [Indexed: 11/23/2022]
Affiliation(s)
- John M Weiler
- CompleWare Corporation, Iowa Clinical Research Corporation and Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
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29
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Abstract
The changes in diet associated with the development of a more affluent lifestyle have been considered one of the environmental factors that may have contributed to the rise in the prevalence of asthma over the past few decades, and dietary sodium has been considered to be a dietary constituent which may be implicated in this phenomenon. The data presented in this review demonstrate that adoption of a low sodium diet for a period of 2-5 weeks may improve lung function and decrease bronchial reactivity in adults with asthma, while sodium loading appears to have a detrimental effect. Similarly, a low sodium diet maintained for 1-2 weeks decreases bronchoconstriction in response to exercise in individuals with asthma. There is no data as to the longer-term effect of a low sodium diet on either the prevalence or severity of asthma or on exercise-induced bronchoconstriction. As a low sodium diet has other beneficial health effects, it can be considered as a therapeutic option for adults with asthma, although it should be considered as an adjunctive intervention to supplement optimal pharmacological management of asthma and not as an alternative. If the relationship between higher sodium intake and increased prevalence and severity of asthma is causal, then there are potential population benefits for asthma as well as cardiovascular disease to be derived from public health measures to reduce sodium consumption.
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Affiliation(s)
- T D Mickleborough
- Department of Kinesiology, Human Performance and Exercise Biochemistry Laboratory, Indiana University, Bloomington, Indiana 47401, USA.
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30
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Komarow HD, Postolache TT. Seasonal allergy and seasonal decrements in athletic performance. Clin Sports Med 2006; 24:e35-50, xiii. [PMID: 15892916 PMCID: PMC7119062 DOI: 10.1016/j.csm.2004.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Hirsh D Komarow
- Laboratory of Allergic Disease, National Institute of Allergy and Infectious Disease, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
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31
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Gustafsson PM, Watson L, Davis KJ, Rabe KF. Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice. Int J Clin Pract 2006; 60:321-34. [PMID: 16494648 DOI: 10.1111/j.1368-5031.2006.00798.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The objectives of this study is to compile current knowledge about asthma control in children in relation to goals proposed in international guidelines, to elucidate the factors associated with insufficient asthma control and to address the implications for clinical practice. Review of recent worldwide large population epidemiological surveys and clinical asthma studies of more than 20,000 children are the methods used in this study. The studies report high frequencies of sleep disturbances, emergency visits, school absence and limitations of physical activity due to asthma. Only a small percentage of children with asthma reach the goals of good asthma control set out by Global Initiative for Asthma (GINA). There is evidence of underuse of inhaled corticosteroids even in children with moderate or severe persistent asthma and over-reliance on short-acting beta(2)-agonist rescue medication. Both parents and physicians generally overestimate asthma control and have low expectations about the level of achievable control. Many children with asthma are not being managed in accordance with guideline recommendations, and asthma management practices vary widely between countries. Asthma control falls short of guideline recommendations in large proportions of children with asthma worldwide. Simple methods for assessing asthma control in clinical practice are needed. Treatment goals based on raised expectations should be established in partnership with the asthmatic child and the parents. Effective anti-inflammatory treatment should be used more frequently, and patients should be reviewed regularly.
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Affiliation(s)
- P M Gustafsson
- Queen Silvia Children's Hospital, University of Gothenburg, Gothenburg, Sweden.
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32
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Cassol VE, Trevisan ME, Moraes EZCD, Portela LOC, Barreto SSM. Broncoespasmo induzido pelo exercício em crianças e adolescentes com diagnóstico de asma. J Bras Pneumol 2004. [DOI: 10.1590/s1806-37132004000200005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: A broncoconstrição temporária após o exercício físico tem elevada prevalência em crianças e adolescentes asmáticos. OBJETIVO: Determinar a freqüência e gravidade do broncoespasmo induzido pelo exercício em crianças e adolescentes, com diagnóstico clínico de asma leve, moderada e grave. MÉTODO: Foi realizado um estudo descritivo, tipo transversal, não controlado. A amostra constituiu-se de 40 indivíduos asmáticos, de ambos os sexos, com idade entre 7 e 18 anos, que não utilizavam regularmente medicação anti-inflamatória. Foi realizado teste padronizado de provocação brônquica com exercício de corrida em esteira rolante. A espirometria foi padronizada em seis manobras expiratórias, realizadas antes e aos 1, 5, 10, 15, 20 e 30 minutos após o término do exercício, sendo escolhida a de maior valor. O volume expiratório forçado no primeiro segundo (VEF1) foi utilizado para o diagnóstico e classificação da gravidade do broncoespasmo. Os pacientes asmáticos apresentavam condições clínicas e espirométricas adequadas para os testes (VEF1 > 70% do valor previsto). Foi utilizada como critério de positividade para o broncoespasmo induzido pelo exercício queda >10% em relação ao VEF1 prévio ao exercício. RESULTADOS: Vinte e seis (65%) pacientes desenvolveram broncoespasmo após o exercício. Dos pacientes com asma leve 44%, e dos com asma moderada e grave, 100% desenvolveram broncoespasmo. Houve associação significativa entre a freqüência do broncoespasmo induzido pelo exercício e a gravidade da asma (p< 0,05), e diferença significativa entre a sua gravidade (confirmada por uma queda no VEF1) e a gravidade da asma (p < 0,05). CONCLUSÃO: A freqüência e gravidade do broncoespasmo induzido pelo exercício estiveram relacionadas com a gravidade clínica da asma.
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Abstract
The organization of medicine in Europe, the UK and the Commonwealth countries was always much less formal than in the USA for many years and pediatricians interested in pediatric lung disease and asthma often started off as adult internists or specialists in adult pulmonary medicine. The early leaders in developing a special interest in the breathing of children during the 1940s and 1950s were predominantly physiologists and clinicians who began to apply physiological techniques to the study lung function in healthy and sick infants and children. A major contribution to our understanding of the epidemiology of wheezing in children was the early establishment of a cohort study in Australia which is still yielding important information. It was during the early 1970s that pediatric pulmonary "politics" began to emerge in the UK when pediatricians interested in lung diseases began to arrange an informal society and meet regularly under the auspices of the British Paediatric Association. In fairly characteristic fashion, pulmonology in Europe was represented for a while by several different societies but due to the efforts of some dedicated enthusiasts there finally emerged the Paediatric Assembly of the European Respiratory Society (ERS) and its first Head, Max Zach, went to become President of the ERS itself. Despite some early doubts abut the future for pediatric pulmonology as a specialty in Europe and Australasia it is clearly flourishing as shown by the rising membership of the professional societies and the constant stream of high quality basic science and clinical publications.
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Affiliation(s)
- Simon Godfrey
- Institute of Pulmonology, Hadassah University Hospital, POB 12000, Jerusalem 91120, Israel.
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Fonseca-Guedes CHF, Cabral ALB, Martins MA. Exercise-induced bronchospasm in children: comparison of FEV1 and FEF25-75% responses. Pediatr Pulmonol 2003; 36:49-54. [PMID: 12772223 DOI: 10.1002/ppul.10309] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The response of asthmatic children to exercise has usually been evaluated by forced expiratory volume in 1 sec (FEV(1)). We reasoned that other respiratory indexes derived from the forced vital capacity maneuver such as forced expiratory flow between 25-75% of vital capacity (FEF(25-75%)) would add significant information in the evaluation of the relationship between asthma severity and response to exercise. We studied 164 children with intermittent (n = 63), mild persistent (n = 30), moderate persistent (n = 40), and severe persistent asthma (n = 31). Subjects exercised for 6 min on a cycle ergometer at 80% of their maximum heart rate, and spirometry was performed before and 5, 10, and 20 min after exercise. There was good correlation between changes in FEV(1) and FEF(25-75%) after exercise (r = 0.60, P < 0.001 for intermittent asthma and r = 0.80, P < 0.001 for severe persistent asthma). The presence of a fall in both FEV(1) (>/=10%) and in FEF(25-75%) (>/=26%) when compared to a decrease in only one of these two indexes was significantly greater in children with more severe asthma (60.0% for intermittent asthma and 94.4% for severe persistent asthma, P = 0.022). FEF(25-75%) can decrease in response to exercise without changes in FEV(1), mainly in children with mild asthma. In the evaluation of the response to exercise in children with different asthma severities, more than one maximum expiratory flow-volume parameter should be used.
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Witte KKA, Thackray SDR, Nikitin NP, Cleland JGF, Clark AL. Pattern of ventilation during exercise in chronic heart failure. Heart 2003; 89:610-4. [PMID: 12748213 PMCID: PMC1767691 DOI: 10.1136/heart.89.6.610] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the pattern of the abnormal ventilatory response in heart failure and how it relates to symptoms by looking at tidal volume (VT) and frequency (f) during exercise. METHODS 45 patients with heart failure and 21 controls underwent maximal treadmill based exercise testing with metabolic gas exchange analysis. The relation of ventilation (VE) to VT was plotted to look for an inflection point where VT failed to increase further. The slope of the relation before this inflection point was documented. Time to the inflection point, VT, and f at the inflection point were recorded. The relation of symptom scores to f and E was also examined. RESULTS Peak oxygen consumption (PVO2) (mean (SD)) was lower (19.7 (4.5) v 37.9 (8.6) ml/kg/min; p < 0001) and the ventilation to carbon dioxide production (VE/VCO2) slope was steeper (40.0 (6.5) v 26.0 (1.6); p < 0.0001) in patients with heart failure than in the control group. The patients reached the inflection point of the VE/VT slope sooner during exercise than the controls (271 (110) v 502 (196) seconds; p < 0.0001). Patients had a higher f and a smaller VT at that point and throughout exercise until the peak where f was the same for patients and controls. VT at the inflection point correlated with PVO2 (r = 0.67; p < 0.0001). Despite having an increased sensation of breathlessness for a given E, patients were less symptomatic of f than controls. CONCLUSIONS Patients with heart failure breathe at a higher f throughout exercise, reaching an apparent maximal VT earlier. The VT at an inflection point on the VE/VT slope predicts PVO2.
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Affiliation(s)
- K K A Witte
- Academic Cardiology, Castle Hill Hospital, Cottingham, Hull HU16 5JQ, UK.
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36
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Abstract
Exercise-induced asthma, or more appropriately, exercise-induced bronchoconstriction (EIB), occurs in 80 to 90% of individuals with asthma and in approximately 11% of the general population without asthma. EIB is characterised by post-exercise airways obstruction resulting in reductions in forced expiratory volume in 1 second (FEV(1)) of greater than 10% compared with pre-exercise values. The mechanism of EIB remains elusive, although both cooling and drying of airways play prominent roles. Cold, dry inhaled air during exercise or voluntary hyperventilation is the most potent stimulus for EIB. Inflammatory mediators play central roles in causing the post-exercise airways obstruction. Diagnosis of EIB requires the use of an exercise test. The exercise can be a field or laboratory based test, but should be of relatively high intensity (80 to 90% of maximal heart rate) and duration (at least 5 to 8 minutes). Pre- and post-exercise pulmonary function should be compared, and post exercise pulmonary function determined over 20 to 30 minutes for characterisation of EIB. A pre- to post-exercise drop in FEV(1) of greater than 10% is abnormal. Approaches to treatment of EIB include both nonpharmacological and pharmacological strategies. A light exercise warm up prior to moderate to heavy exercise reduces the severity of EIB. More recently, studies have supported a role for dietary salt as a modifier of the severity of EIB, suggesting that salt restrictive diets should reduce symptoms of EIB. Short acting, inhaled beta(2)-agonists constitute the most used prophylactic treatment for EIB. However, antileukotriene agents are emerging as effective, well tolerated, long-term treatments for EIB.
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Affiliation(s)
- Robert W Gotshall
- Health and Exercise Science, Colorado State University, Fort Collins, Colorado 80523-1582, USA.
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Hawksworth RJ, Sykes AP, Faris M, Mant T, Lee TH. Albuterol HFA is as effective as albuterol CFC in preventing exercise-induced bronchoconstriction. Ann Allergy Asthma Immunol 2002; 88:473-7. [PMID: 12027068 DOI: 10.1016/s1081-1206(10)62385-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Secondary to the phase-out of chlorofluorocarbons (CFCs), the albuterol (Ventolin, GlaxoSmithKline, Uxbridge, Middlesex, United Kingdom) pressurized metered-dose inhaler (MDI) has been formulated in a non-ozone-depleting propellant, hydrofluoroalkane (HFA) 134a. OBJECTIVE To compare the efficacy of albuterol HFA to albuterol CFC and placebo HFA in protecting patients from exercise-induced bronchospasm (EIB). METHODS Randomized, double-blind, placebo-controlled, three-way crossover study in patients with documented EIB. Patients (n = 24) aged 18 to 45 years old received albuterol HFA or albuterol CFC, (total dose of 180 microg ex-actuator), or placebo HFA via an MDI, 30 minutes before a standardized exercise challenge. Serial forced expiratory volume in 1 second (FEV1) measurements were made 5 minutes before exercise and 5, 10, 15, 20, 25, 30, and 60 minutes postexercise. The primary outcome measure was the maximum percentage fall in FEV1 over the 60 minutes after exercise. RESULTS The adjusted mean maximum percentage falls in FEV1 postexercise for albuterol HFA and CFC groups were 15.4% and 14.9%, respectively. The two formulations were comparable with a treatment difference of -0.5% (P = 0.848; 95% confidence interval, -5.3 to 4.4%). When compared with the fall in FEV1 for placebo (33.7%), both active treatments demonstrated a significantly smaller fall in FEV1 postexercise (P < 0.001). Safety profiles were similar among the three treatment groups. CONCLUSIONS The results provide assurance to prescribers that the formulation of albuterol in the non-ozone-depleting propellant HFA 134a has not affected its efficacy in the treatment of EIB in asthmatic patients. Single doses of albuterol HFA and CFC from an MDI are comparable in terms of efficacy and safety on a microgram per microgram basis.
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Affiliation(s)
- Richard J Hawksworth
- Dept of Respiratory Medicine and Allergy, Guy's Hospital, London, United Kingdom
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38
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Cherginets A, Cherginets V. Heterogeneity of bronchial response to exercise among children with asthma. Allergol Int 2001. [DOI: 10.1046/j.1440-1592.2001.00212.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gotshall RW, Mickleborough TD, Cordain L. Dietary salt restriction improves pulmonary function in exercise-induced asthma. Med Sci Sports Exerc 2000; 32:1815-9. [PMID: 11079508 DOI: 10.1097/00005768-200011000-00001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Exercise-induced asthma (EIA) occurs in approximately 90% of persons with asthma. The mechanism has not been delineated. Epidemiological studies have suggested that dietary salt may play a role in airway responsiveness. Therefore, the purpose of this study was to determine the influence of both elevated and restricted salt diets on pulmonary function in subjects with EIA. METHODS Eight subjects with EIA and eight subjects without EIA (control) participated in a double-blind crossover study. Pulmonary function was determined pre- and post-exercise challenge before and after 2 wk on a normal salt, sodium chloride, diet (NSD), a low salt diet (LSD), and a high salt diet (HSD). A 1-wk washout occurred between diets. RESULTS Diet had no effect on preexercise pulmonary function values in either group and had no effect on postexercise pulmonary function values in control subjects. However, LSD improved and HSD worsened postexercise pulmonary function values in EIA subjects. Forced expiratory volume in 1 s (FEV1) decreased by at least 10% in EIA subjects with exercise. In EIA subjects, FEV1 decreased by 14+/-6% on LSD, 20+/-7% on NSD, and 24+/-6% on HSD at 15 min postexercise. Similar patterns were observed for forced vital capacity and peak expiratory flow rates. Although LSD did not normalize pulmonary function in EIA, it did improve it. CONCLUSIONS These data suggest that individuals with EIA might benefit from lower salt diets.
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Affiliation(s)
- R W Gotshall
- Department of Health and Exercise Science, Colorado State University, Fort Collins 80523-1582, USA.
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Bjermer L, Bisgaard H, Bousquet J, Fabbri LM, Greening A, Haahtela T, Holgate ST, Picado C, Leff JA. Montelukast or salmeterol combined with an inhaled steroid in adult asthma: design and rationale of a randomized, double-blind comparative study (the IMPACT Investigation of Montelukast as a Partner Agent for Complementary Therapy-trial). Respir Med 2000; 94:612-21. [PMID: 10921768 DOI: 10.1053/rmed.2000.0806] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Asthma patients who continue to experience symptoms despite taking regular inhaled corticosteroids represent a management challenge. Leukotrienes play a key role in asthma pathophysiology, and since pro-inflammatory leukotrienes are poorly suppressed by corticosteroids it seems rational to add a leukotriene receptor antagonist (LTRA) when a low to moderate dose of inhaled corticosteroids does not provide sufficient disease control. Long acting beta2-agonist (LABA) treatment represents an alternative to LTRAs and both treatment modalities have been shown to provide additional disease control when added to corticosteroid treatment. To compare the relative clinical benefits of adding either a LTRA or a LABA to asthma patients inadequately controlled by inhaled corticosteroids, a randomized, double-blind, multi-centre, 48-week study will be initiated at approximately 120 centres throughout Europe, Latin America, Middle East, Africa and the Asia-Pacific region in early 2000. The study will compare the oral LTRA montelukast with the inhaled LABA salmeterol, each administered on a background of inhaled fluticasone, on asthma attacks, quality of life, lung function, eosinophil levels, healthcare utilization, and safety, in approximately 1200 adult asthmatic patients. The requirements for study enrollment include a history of asthma, FEV1 or PEFR values between 50% and 90% of the predicted value together with > or = 12% improvement in FEV1 after beta-agonist administration, a minimum pre-determined level of asthma symptoms and daily beta-agonist medication. The study will include a 4-week run-in period, during which patients previously taking inhaled corticosteroids are switched to open-label fluticasone (200 microg daily), followed by a 48-week double-blind, treatment period in which patients continuing to experience abnormal pulmonary function and daytime symptoms are randomized to receive montelukast (10 mg once daily) and salmeterol placebo, or inhaled salmeterol (100 microg daily) and montelukast placebo. All patients will continue with inhaled fluticasone (200 microg daily). During the study, asthma attacks, overnight asthma symptoms, and morning peak expiratory flow rate will be assessed using patient diary cards; quality of life will also be assessed using an asthma-specific quality-of life questionnaire. The results of this study are expected to provide physicians with important clinical evidence to help them make a rational and logical treatment choice for asthmatic patients experiencing breakthrough symptoms on inhaled corticosteroids.
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Affiliation(s)
- L Bjermer
- Department of Lung Medicine, University Hospital, Trondheim, Norway.
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Clark AL, Davies LC, Francis DP, Coats AJ. Ventilatory capacity and exercise tolerance in patients with chronic stable heart failure. Eur J Heart Fail 2000; 2:47-51. [PMID: 10742703 DOI: 10.1016/s1388-9842(99)00060-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Patients with chronic heart failure complain of breathlessness. This is associated with an increase in the ventilatory response to carbon dioxide production (VE/VCO(2) slope), yet a reduction in the maximal ventilation achieved at peak exercise. We analysed ventilatory capacity in heart failure in relation to exercise capacity. METHODS We analysed data from 74 patients with chronic stable heart failure [age (S.D.) 50.6 (8.8) years; left ventricular ejection fraction 30 (15)%] and 36 controls [48.9 (11.5) years]. Subjects undertook maximal incremental exercise testing with metabolic gas exchange measurements to derive peak oxygen consumption (VO(2)), the VE/VCO(2) slope and ventilation. Spirometry was used to measure FEV(1) and FVC. Maximal voluntary ventilation (MVV) was calculated as FEV(1)x 35. RESULTS Peak VO(2) was lower in patients [20.9 (7.5) ml min(-1) kg(-1) vs. 34.5 (10.1); P<0.001] and VE/VCO(2) greater [33.4 (10.7) vs. 26.0 (4.7); P<0.001]. Ventilation at peak exercise was lower in patients [63.5 (20.4) l/min vs. 86.9 (29.5); P<0.001], as was MVV [110.1 (37.9) l/min vs. 136.2 (53.1); P<0.001], but ventilation at peak as a proportion of MVV was the same in patients [60.0 (19.0)%] as controls [65.7 (12.4)%)]. There was an inverse relation between peak VO(2) and VE/VCO(2) slope (r=-0. 62; P<0.001). Percentage predicted FEV(1) correlated with ventilation at peak (r=0.62; P<0.001) and inversely with VE/VCO(2) slope (r=-0.32; P<0.001). There was no relation between percentage of MVV achieved and peak VO(2), or VE/VCO(2) slope. CONCLUSIONS Although ventilation at peak exercise is lower in patients with heart failure than normal subjects, ventilation is the same proportion of maximal voluntary ventilation. These findings suggest that ventilatory capacity does not limit exercise capacity in heart failure.
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Affiliation(s)
- A L Clark
- Department of Cardiology, Castle Hill Hospital, Castle Road, Cottingham, HU16, 5JQ, Hull, UK.
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Double-blind, placebo-controlled study of single doses of chlorofluorocarbon (CFC) and CFC-Free cromolyn sodium for exercise-induced bronchoconstriction. Curr Ther Res Clin Exp 1999. [DOI: 10.1016/s0011-393x(99)90001-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Yang XX, Ho G, Xu LJ, Powell WS, Martin JG. The beta(2)-agonist salbutamol inhibits bronchoconstriction and leukotriene D(4) synthesis after dry gas hyperpnea in the guinea-pig. Pulm Pharmacol Ther 1999; 12:325-9. [PMID: 10545287 DOI: 10.1006/pupt.1999.0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Isocapnic dry gas hyperpnea-induced bronchoconstriction (HIB) in the guinea-pig is mediated by both tachykinin release from airway sensory nerve C-type fiber terminals and secondary synthesis of cysteinyl-leukotrienes, in particular LTD(4). Beta (beta)(2)-agonists are potent bronchodilators but potentially could also inhibit the airway response to hyperpnea challenge via effects on the release of LTD(4)from airway cells in vivo. The purpose of this study was to test the hypothesis that beta(2)agonists attenuate HIB in guinea-pigs, in part, by reduction in LTD(4)release in vivo. Twenty-six guinea-pigs (400-550 g) were anesthetized with xylazine (7 mg/kg) and pentobarbital (65 mg/kg), tracheotomized and mechanically ventilated with a small animal ventilator using a tidal volume of 3 ml and a breathing frequency of 60 breaths/min. Dry gas (95%O(2)/5%CO(2)) with a 4 ml tidal volume and a breathing frequency of 150/min was used for hyperpnea challenge. Challenge with isocapnic dry gas triggered a significant increase in pulmonary resistance (0.3 +/- 0.02 vs. 0.57 +/- 0.06 cmH(2)O/ml per s; P=0. 017; n=13) and excretion of LTD(4)in the bile (baseline: 2.43 vs. HIB: 4.66 pmol/h; P=0.04). Salbutamol pretreatment completely blocked the airway response to the challenge (0.3+/-0.02 vs. 0.3+/-0. 05 cmH(2)O/ml per s; n=13) and reduced the biliary excretion of LTD(4)(baseline: 2.42 pmol/h; vs. HIB: 2.40 pmol/h). We conclude that salbutamol inhibited the airway responses to dry gas hyperpnea challenge and LTD(4)synthesis by the airway cells.
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Affiliation(s)
- X X Yang
- Meakins-Christie Laboratories, McGill University, Montreal, Quebec, H2X 2P2, Canada
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Cabral AL, Conceição GM, Fonseca-Guedes CH, Martins MA. Exercise-induced bronchospasm in children: effects of asthma severity. Am J Respir Crit Care Med 1999; 159:1819-23. [PMID: 10351925 DOI: 10.1164/ajrccm.159.6.9805093] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The prevalence of exercise-induced bronchospasm (EIB) in asthmatic individuals has been reported to vary from 40% to 90%. There are, however, few studies addressing the effects of asthma severity on airway responsiveness to exercise. The purpose of the present study was to investigate the effects of asthma severity on EIB in children. We studied 164 children classified as having intermittent (n = 63), mild persistent (n = 30), moderate persistent (n = 40), and severe persistent asthma (n = 31) according to the Global Initiative for Asthma classification. Subjects exercised for 6 min on a cycle ergometer at 80% of their maximum heart rate, and spirometry was performed before and 5, 10, and 20 min after exercise challenge. The prevalence of EIB in children with moderate or severe persistent asthma was significantly greater than in children with intermittent asthma (p < 0.001). EIB-positive children with intermittent asthma exhibited smaller changes in FEV1 than children in the other three groups (p < 0.001). There was no significant relationship between baseline FEV1 and the decline in FEV1 after exercise. We conclude that the prevalence of EIB is greater in children with more severe asthma, and that the intensity of response to exercise is not consistently related to the clinical severity of asthma.
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Affiliation(s)
- A L Cabral
- Pulmonary Pediatric Division, Darcy Vargas Hospital, São Paulo; and Departments of Medicine and Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
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Murata T, Imamura M, Taniguchi M, Tanaka Y. Localization of the bronchodilatory effects of isoproterenol and aminophylline in patients with bronchial asthma: an investigation using selective alveolobronchography. J Int Med Res 1997; 25:325-39. [PMID: 9427166 DOI: 10.1177/030006059702500603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The effect of isoproterenol (isoprenaline) and aminophylline on airway calibre in 18 adult patients with bronchial asthma was measured directly using selective alveolobronchography. Isoproterenol caused a significant dilation in the maximal calibre of the central airway from bifurcation numbers 1-5 (P < 0.05) and number 6 (P < 0.01). There was no change in bifurcation number 0 (trachea). Aminophylline caused a significant dilatation in bifurcation numbers 3 and 4 (P < 0.01), with no change in bifurcation numbers 0-2 and 5-6. In the minimal calibre of the central airway, both drugs displayed a significant dilatory effect only at bifurcation number 3 (P < 0.05). These results indicate that the central airway is the main site of the dilatory effects of these drugs. Although their precise mechanisms of action are not known, these results suggest that mechanisms of action of the two drugs are different. Isoproterenol acts on the whole region of the central airway, while the action of aminophylline tends to be limited to bifurcation numbers 3 and 4.
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Affiliation(s)
- T Murata
- Department of Radiology, Kansai Medical University, Osaka, Japan
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Randolph C. Exercise-induced asthma: update on pathophysiology, clinical diagnosis, and treatment. CURRENT PROBLEMS IN PEDIATRICS 1997; 27:53-77. [PMID: 9059761 DOI: 10.1016/s0045-9380(97)80002-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- C Randolph
- Pediatric Department, Yale University School of Medicine, Conn., USA
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Anderson SD. Challenge tests to assess airway hyperresponsiveness and efficacy of drugs used in the treatment of asthma. JOURNAL OF AEROSOL MEDICINE : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR AEROSOLS IN MEDICINE 1997; 9:95-109. [PMID: 10184583 DOI: 10.1089/jam.1996.9.95] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Bronchial provocation tests are useful to diagnose and assess severity of asthma and to follow response to treatment. The tests used include those stimuli that act "directly" on receptors causing contraction of airway smooth muscle, e.g., pharmacological agents, and those stimuli that act "indirectly" by causing release of endogenous mediators that cause the airways to narrow. These "indirect" stimuli include physical ones such as airway drying from hyperpnea and changes in airway osmolarity from inhaling aerosols of water and hyperosmolar saline. Indirect stimuli cause the airways to narrow in response to endogenously released substances from inflammatory cells or nerves and responses are thought to reflect the presence and severity of inflammation of asthma. Challenge with hyperosmolar saline is now being used as an indirect test because it also identifies persons with exercise-induced asthma and is appropriate to assess suitability for diving with SCUBA. Hyperosmolar challenge is also useful to assess the effect of both the acute and chronic treatment with antiinflammatory drugs. This, combined with the potential to collect inflammatory cells in sputum induced by the same stimulus should result in this challenge being more widely used, not only in the hospital laboratory but also in epidemiology and occupational asthma.
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Affiliation(s)
- S D Anderson
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Affiliation(s)
- K J Nastasi
- Department of Pediatrics, University of Tennessee, Memphis 38105, USA
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