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Anderson SD, Kippelen P. A proposal to account for the stimulus, the mechanism, and the mediators released in exercise-induced bronchoconstriction. FRONTIERS IN ALLERGY 2023; 4:1004170. [PMID: 38026130 PMCID: PMC10657894 DOI: 10.3389/falgy.2023.1004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
Exercise induced bronchoconstriction (EIB) describes the transient narrowing of the airways that follows vigorous exercise. It commonly occurs in children and adults who have asthma and in elite athletes. The primary stimulus is proposed to be loss of water, by evaporation, from the airway surface due to conditioning inspired air. The mechanism, whereby this evaporative loss of water provokes contraction of the bronchial smooth muscle, is thought to be an increase in osmolarity of the airway surface liquid. The increase in osmolarity causes mast cells to release histamines, prostaglandins, and leukotrienes. It is these mediators that contract smooth muscle causing the airways to narrow.
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Affiliation(s)
- Sandra D. Anderson
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Pascale Kippelen
- Division of Sport, Health and Exercise Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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Weiler JM, Brannan JD, Randolph CC, Hallstrand TS, Parsons J, Silvers W, Storms W, Zeiger J, Bernstein DI, Blessing-Moore J, Greenhawt M, Khan D, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Tilles SA, Wallace D. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol 2016; 138:1292-1295.e36. [PMID: 27665489 DOI: 10.1016/j.jaci.2016.05.029] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/13/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022]
Abstract
The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.
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Abstract
Histamine is an important mediator in airway inflammation. It is elevated in the airways of asthmatic patients and is responsible for many of the pathophysiological features in asthma. Antihistamines block the actions of histamine and also have effects on inflammation which is independent of histamine-H(1)-receptor antagonism. Antihistamines have been shown to have bronchodilatory effects, effects on allergen-, exercise-, and adenosine-monophosphate-challenge testing, and also to prevent allergen-induced nonspecific airways hyperresponsiveness. Clinical studies have shown mixed results, and some studies have reported beneficial effects of azelastine, cetirizine, desloratadine, and fexofenadine on asthma symptoms or physiological measures in patients with asthma. The combination of an antihistamine and a leukotriene receptor antagonist has been shown to have additive effects in certain studies. Antihistamines have also been shown to delay or prevent the development of asthma in a subgroup of atopic children. These data suggest that antihistamines may have beneficial effects in the management of asthma.
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Affiliation(s)
- Andrew M Wilson
- Biomedicine Group, Faculty of Medicine, Health and Policy Practice, University of East Anglia, Norwich, England
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Rundell KW, Anderson SD, Sue-Chu M, Bougault V, Boulet LP. Air quality and temperature effects on exercise-induced bronchoconstriction. Compr Physiol 2016; 5:579-610. [PMID: 25880506 DOI: 10.1002/cphy.c130013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is exaggerated constriction of the airways usually soon after cessation of exercise. This is most often a response to airway dehydration in the presence of airway inflammation in a person with a responsive bronchial smooth muscle. Severity is related to water content of inspired air and level of ventilation achieved and sustained. Repetitive hyperpnea of dry air during training is associated with airway inflammatory changes and remodeling. A response during exercise that is related to pollution or allergen is considered EIB. Ozone and particulate matter are the most widespread pollutants of concern for the exercising population; chronic exposure can lead to new-onset asthma and EIB. Freshly generated emissions particulate matter less than 100 nm is most harmful. Evidence for acute and long-term effects from exercise while inhaling high levels of ozone and/or particulate matter exists. Much evidence supports a relationship between development of airway disorders and exercise in the chlorinated pool. Swimmers typically do not respond in the pool; however, a large percentage responds to a dry air exercise challenge. Studies support oxidative stress mediated pathology for pollutants and a more severe acute response occurs in the asthmatic. Winter sport athletes and swimmers have a higher prevalence of EIB, asthma and airway remodeling than other athletes and the general population. Because of fossil fuel powered ice resurfacers in ice rinks, ice rink athletes have shown high rates of EIB and asthma. For the athlete training in the urban environment, training during low traffic hours and in low traffic areas is suggested.
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Affiliation(s)
- Kenneth W Rundell
- Department of The Basic Sciences, The Commonwealth Medical College, Scranton, PA, USA
| | - Sandra D Anderson
- Clinical Professor Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Malcolm Sue-Chu
- Department of Thoracic Medicine, St Olavs Hospital, Trondheim University Hospital, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Parsons JP, Hallstrand TS, Mastronarde JG, Kaminsky DA, Rundell KW, Hull JH, Storms WW, Weiler JM, Cheek FM, Wilson KC, Anderson SD. An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction. Am J Respir Crit Care Med 2013; 187:1016-27. [DOI: 10.1164/rccm.201303-0437st] [Citation(s) in RCA: 370] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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van Leeuwen JC, Driessen JMM, Kersten ETG, Thio BJ. Assessment of exercise-induced bronchoconstriction in adolescents and young children. Immunol Allergy Clin North Am 2013; 33:381-94, viii-ix. [PMID: 23830131 DOI: 10.1016/j.iac.2013.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Recent research shows important differences in exercise-induced bronchoconstriction (EIB) between children and adults, suggesting a different pathophysiology of EIB in children. Although exercise can trigger classic symptoms of asthma, in children symptoms can be subtle and nonspecific; parents, children, and clinicians often do not recognize EIB. With an age-adjusted protocol, an exercise challenge test can be performed in children as young as 3 years of age. However, an alternative challenge test is sometimes necessary to assess potential for EIB in children. This review summarizes age-related features of EIB and recommendations for assessing EIB in young children and adolescents.
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Affiliation(s)
- Janneke C van Leeuwen
- Department of Pediatrics, Medisch Spectrum Twente, VKC poli 17, Haaksbergerstraat 55, Enschede 7513 ER, The Netherlands.
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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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Weiler JM, Anderson SD, Randolph C, Bonini S, Craig TJ, Pearlman DS, Rundell KW, Silvers WS, Storms WW, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Spector SL, Tilles SA, Wallace D, Henderson W, Schwartz L, Kaufman D, Nsouli T, Shieken L, Rosario N. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol 2011; 105:S1-47. [PMID: 21167465 DOI: 10.1016/j.anai.2010.09.021] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 09/26/2010] [Indexed: 02/06/2023]
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Manjra AI, Nel H, Maharaj B. Effect of desloratadine on patients with allergic rhinitis and exercise-induced bronchoconstriction: a placebo controlled study. J Asthma 2009; 46:156-9. [PMID: 19253122 DOI: 10.1080/02770900802538251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Exercise induced broncho-constriction (EIB) is a significant problem in asthmatic patients. The link between allergic rhinitis and asthma is now well established. Patients with allergic rhinitis may have EIB. OBJECTIVE This study compared the effects of desloratadine and placebo on EIB in a group of patients with allergic rhinitis and EIB. METHODS This was a double blind placebo controlled, randomized, crossover study. Exercise challenge tests were performed before and after 7 days of treatment with either 5 mg desloratadine or placebo. Patients then underwent a washout period for 7 days and were crossed over to receive either 5mg desloratadine or placebo. The exercise challenge tests were repeated. RESULTS Desloratadine had no effect on the reduction in percentage fall in FEV(1), the AUC (0-60 min) and the time to recovery. CONCLUSIONS Desloratadine has no effect in attenuating the broncho-constriction caused by exercise in patients with allergic rhinitis and exercise induced broncho-constriction. CLINICAL IMPLICATIONS Patients with allergic rhinitis and exercise induced broncho-constriction must be treated with either a beta(2)-agonist or LRTA for relief or prophylaxis of their EIB. CAPSULE SUMMARY Desloratadine does not have an effect on exercise induced bronchoconstriction. Patients with allergic rhinitis with exercise induced bronchoconstriction who are on desloratadine will still require treatment with beta(2) agonist or leukotriene receptor antagonist for their symptoms.
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Affiliation(s)
- A I Manjra
- Paediatric Allergy and Asthma Centre, Westville Hospital, Durban, South Africa.
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Airway injury as a mechanism for exercise-induced bronchoconstriction in elite athletes. J Allergy Clin Immunol 2008; 122:225-35; quiz 236-7. [PMID: 18554705 DOI: 10.1016/j.jaci.2008.05.001] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 04/30/2008] [Accepted: 05/01/2008] [Indexed: 12/28/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is a consequence of evaporative water loss in conditioning the inspired air. The water loss causes cooling and dehydration of the airway surface. One acute effect of dehydration is the release of mediators, such as prostaglandins, leukotrienes, and histamine, that can stimulate smooth muscle, causing contraction and a change in vascular permeability. Inspiring cold air increases dehydration of the surface area and causes changes in bronchial blood flow. This article proposes that the pathogenesis of EIB in elite athletes relates to the epithelial injury arising from breathing poorly conditioned air at high flows for long periods of time or high volumes of irritant particles or gases. The evidence to support this proposal comes from many markers of injury. The restorative process after injury involves plasma exudation and movement of cells into the airways, a process repeated many times during a season of training. This process has the potential to expose smooth muscle to a wide variety of plasma- and cell-derived substances. The exposure to these substances over time can lead to an alteration in the contractile properties of the smooth muscle, making it more sensitive to mediators of bronchoconstriction. It is proposed that cold-weather athletes have airway hyperresponsiveness (AHR) to pharmacologic agents as a result of epithelial injury. In those who are allergic, AHR can also be expressed as EIB. The role of beta(2)-receptor agonists in inhibiting and enhancing the development of AHR and EIB is discussed.
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Hsieh CC, Goto H, Kobayashi H, Chow WC, Peng WH, Tang RB. Changes in serum eosinophil cationic protein levels after exercise challenge in asthmatic children. J Asthma 2007; 44:569-73. [PMID: 17885861 DOI: 10.1080/02770900701537354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The aim of the present study was to assess the relationship between serum eosinophil cationic protein levels and the severity of exercise-induced bronchoconstriction in asthmatic children. The 48 asthmatic children were divided into exercise-induced bronchoconstriction group and non-exercise-induced bronchoconstriction group. In the exercise-induced bronchoconstriction group, the post-exercise serum eosinophil cationic protein levels were significantly increased as compared with the pre-exercise serum eosinophil cationic protein levels. These results suggested that eosinophil cationic protein may serve as a possible contributor to the pathophysiology of exercise-induced bronchoconstriction in asthmatic children.
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Affiliation(s)
- Chia-Chang Hsieh
- First Department of Internal Medicine, School of Medicine, Kyorin University, Tokyo, Japan
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Anderson SD, Caillaud C, Brannan JD. Beta2-agonists and exercise-induced asthma. Clin Rev Allergy Immunol 2007; 31:163-80. [PMID: 17085791 DOI: 10.1385/criai:31:2:163] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
Beta2-agonists taken immediately before exercise provide significant protection against exercise- induced asthma (EIA) in most patients. However, when they are taken daily, there are some negative aspects regarding severity, control, and recovery from EIA. First, there is a significant minority (15-20%) of asthmatics whose EIA is not prevented by beta2-agonists, even when inhaled corticosteroids are used concomitantly. Second, with daily use, there is a decline in duration of the protective effect of long-acting beta2-agonists. Third, if breakthrough EIA occurs, recovery of lung function is slower in response to a beta2-agonist, and additional doses are often required to achieve pre-exercise values. If a person who takes a beta2-agonist daily experiences problems with exercise, then the physician should consider changing the treatment regimen to achieve better control of EIA. These problems likely result from desensitization of the beta2-receptor on the mast cell, which enhances mediator release, and on the bronchial smooth muscle, which enhances the bronchoconstrictor response and delays recovery from EIA. These effects are reversed within 72 h after cessation of a beta2-agonists. The important clinical question is: Are we actually compromising the beneficial effects of beta2-agonists on the prevention and recovery from EIA by prescribing them daily? Patients with EIA need to ensure that their doses of inhaled corticosteroid or other anti-inflammatory therapy are optimized so that, if necessary, a beta2-agonist can be used intermittently as prophylactic medication with greater confidence in the outcome.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia.
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Hallstrand TS, Moody MW, Wurfel MM, Schwartz LB, Henderson WR, Aitken ML. Inflammatory basis of exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2005; 172:679-86. [PMID: 15947280 PMCID: PMC2041799 DOI: 10.1164/rccm.200412-1667oc] [Citation(s) in RCA: 170] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
RATIONALE Exercise-induced bronchoconstriction (EIB) is a highly prevalent condition with unclear pathogenesis. Two competing theories of the pathogenesis of EIB differ regarding the inflammatory basis of this condition. OBJECTIVES Our goals were to establish whether epithelial cell and mast cell activation with release of inflammatory mediators occurs during EIB and how histamine and cysteinyl leukotriene antagonists alter the airway events occurring during EIB. METHODS Induced sputum was used to measure mast cell mediators and eicosanoids at baseline and 30 minutes after exercise challenge in 25 individuals with asthma with EIB. In a randomized, double-blind crossover study, the cysteinyl leukotriene antagonist montelukast and antihistamine loratadine or two matched placebos were administered for two doses before exercise challenge. MAIN RESULTS The percentage of columnar epithelial cells in induced sputum at baseline was associated with the severity of EIB. After exercise challenge, histamine, tryptase, and cysteinyl leukotrienes significantly increased and prostaglandin E(2) and thromboxane B(2) significantly decreased in the airways, and there was an increase in columnar epithelial cells in the airways. The concentration of columnar epithelial cells was associated with the levels of histamine and cysteinyl leukotrienes in the airways. Treatment with montelukast and loratadine inhibited the release of cysteinyl leukotrienes and histamine into the airways, but did not inhibit the release of columnar epithelial cells into the airways. CONCLUSIONS These data indicate that epithelial cells, mast cell mediators, and eicosanoids are released into the airways during EIB, supporting an inflammatory basis for EIB.
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Affiliation(s)
- Teal S Hallstrand
- Department of Medicine, Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington 98195-6522, USA.
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Anderson SD. Single-dose agents in the prevention of exercise-induced asthma: a descriptive review. ACTA ACUST UNITED AC 2005; 3:365-79. [PMID: 15658883 DOI: 10.2165/00151829-200403060-00004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Exercise-induced asthma (EIA) refers to the transient narrowing of the airways that occurs after vigorous exercise in 50-60% of patients with asthma. The need to condition the air inspired during exercise causes water to be lost from the airway surface, and this is thought to cause the release of inflammatory mediators (histamine, leukotrienes, and prostaglandins) from mast cells. EIA is associated with airway inflammation and its severity is markedly reduced following treatment with inhaled corticosteroids. Drugs that inhibit the release of mediators and drugs that inhibit their contractile effects are the most successful in inhibiting EIA. Single doses of short-acting beta(2)-adrenoceptor agonists, given as aerosols immediately before exercise, are very effective in the majority of patients with asthma, providing about 80% protection for up to 2 hours. Long-acting beta(2)-adrenoceptor agonists (LABAs) given in single doses can be effective for up to 12 hours when used intermittently, but tolerance to the protective effect occurs if they are taken daily. Drugs such as cromolyn sodium (sodium cromoglicate) and nedocromil given as aerosols are less effective than beta(2)-adrenoceptor agonists (beta(2)-agonists), providing 50-60% protection for only 1-2 hours, but they have some advantages. They do not induce tolerance, the aerosol dosage can be easily titrated for the individual, and the protective effect is immediate. Because they cause no significant adverse effects, multiple doses can be used in a day. Leukotriene receptor antagonists, such as montelukast and zafirlukast, are also used for the prevention of EIA and provide 50-60% protection for up to 24 hours when given as tablets. Tolerance to the protective effect does not develop with regular use. If breakthrough EIA occurs, a beta(2)-agonist can be used effectively for rescue medication. For those patients with more persistent symptoms, the use of a LABA in combination with an inhaled corticosteroid has raised a number of issues with respect to the choice of prophylactic treatment for EIA. The most important issue is the development of tolerance to the protective effect of a LABA such that extra treatment may be needed in the middle of a treatment period. Recommending extra doses of a beta(2)-agonist to control EIA is not advisable on the basis that multiple doses can enhance the severity of EIA, delay spontaneous recovery from bronchoconstriction, and enhance responses to other contractile stimuli. It is time to take into account the advantages and disadvantages of the different drugs available to prevent EIA and to recognize that there are some myths related to their use in EIA.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory Medicine, 11 West, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia.
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Hayden ML. Allergic rhinitis: proper management benefits concomitant diseases. Nurse Pract 2005; 29:26-30, 35-7; quiz 37-9. [PMID: 15614083 DOI: 10.1097/00006205-200412000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Exercise is the most common trigger of persistent childhood asthma. The history for EIA can be complicated by the lack of perception of significant airway obstruction during exercise. One must carefully identify those children with EIA from the group of children who report low level of activity because of lack of interest or because they are out of shape. Baseline spirometry of children with persistent asthma is frequently normal. Spirometry is important to identify those children with EIA who underrecognize their disease, but normal results should not be used as evidence of absence of disease. Formal exercise testing should be considered when the diagnosis is unclear or if there seems to be a lack of bronchoprotection with inhaled albuterol. The goal of treatment of EIA should be the attainment of a normal activity level for children and adolescents. Identification of the limits imposed by EIA and establishment of goals of therapy with the child and family should be the initial action. Inactivity or reduced exertion, in the presence of this diagnosis. should not be accepted. Therapy for EIA starts with control of the underlying persistent asthma. Inhaled corticosteroids are the most effective initial treatment of both EIA and persistent asthma in children and adolescents. Exercise-induced asthma is a common aspect of a prevalent disease that warrants proper diagnosis and treatment. With appropriate therapy, children with EIA should be able to participate in sports and maintain normal activity. They should strive to compete in the same playing field as their peers and have the same goals as those children and athletes who do not have exercise-induced asthma.
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Affiliation(s)
- Ketan K Sheth
- Allergy/Asthma Section, Arnett Clinic, 1500 Salem Street, Lafayette, IN 47904, USA.
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Anderson SD, Brannan JD. Methods for "indirect" challenge tests including exercise, eucapnic voluntary hyperpnea, and hypertonic aerosols. Clin Rev Allergy Immunol 2003; 24:27-54. [PMID: 12644717 DOI: 10.1385/criai:24:1:27] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Bronchial provocation tests that use stimuli that act indirectly to cause airway narrowing have a high specificity for identifying people with active asthma who have the potential to respond to treatment with antiinflammatory drugs. The first test to be developed was exercise and it was used to assess the efficacy of drugs such as sodium cromoglycate. Eucapnic voluntary hyperpnea was developed later, as a surrogate test for exercise. Hypertonic aerosols were introduced to mimic the dehydrating effects of evaporative water loss that occurs during hyperpnea. A wet aerosol of 4.5% saline or a dry powder formulation of mannitol is used. At present the indirect challenge tests are becoming increasingly recognised as appropriate for monitoring treatment with inhaled steroids. Indirect tests identify those with potential for exercise-induced bronchoconstriction, an important problem for some occupations, such as the defence forces, fire fighters and the police force and for some athletic activities. The advantage in using an indirect challenges, over a direct challenge with a single pharmacological agonist, is that a positive response indicates that inflammatory cells and their mediators (prostaglandins, leukotrienes and histamine) are present in the airways in sufficient numbers and concentration to indicate that asthma is active at the time of testing. The corollary to this is that a negative test in a known asthmatic indicates good control or mild disease. Another advantage is that healthy subjects do not have significant airway narrowing to indirect challenge tests. The protocols used for challenge with indirectly acting stimuli are presented in detail.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, NSW Australia.
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Anderson SD, Brannan JD. Exercise-induced asthma: is there still a case for histamine? J Allergy Clin Immunol 2002; 109:771-3. [PMID: 11994697 DOI: 10.1067/mai.2002.123644] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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