This article was first published in Vermont Sports Magazine. 

David K. Lisle, MD, CAQSM, is a sports medicine physician at the University of Vermont Medical Center’s Orthopedic and Rehabilitation Center. He is also an assistant professor in the Department of Orthopaedics and Rehabilitation and the Department of Family Medicine.

David K. Lisle, MD, CAQSM, is a sports medicine physician at the University of Vermont Medical Center’s Orthopedic and Rehabilitation Center. He is also an assistant professor in the Department of Orthopaedics and Rehabilitation and the Department of Family Medicine.

Having trouble breathing? It could be allergies, asthma or EIB. And each has a different treatment.

If you’re like me, you’re welcoming the warm weather and looking forward to a long summer. But if you are one of the many folks who suffer from asthma or allergies, this may not be your favorite time of year.

For those of us who are active in the outdoors, allergies and asthma can make exercising challenging and unpleasant — sometimes even impossible — as we fight to fill our lungs with air.

Fortunately, allergies and asthma can be managed effectively both with the help of a physician and by avoiding triggers.

Is it allergy season…?

Our immune system helps us fight off colds and infections. Think of it as a gatekeeper, a complex system that recognizes the abnormal things that come in contact with our bodies: bacteria, viruses and many other things from the environment.

When the immune system responds too aggressively to things in the environment, we get allergic symptoms. Allergens can be dust, smoke, pet dander or certain ingredients in perfumes.  During spring, the most common allergens are pollens from trees and flowers. Ragweed, mold and grass are also environmental allergens.

Usually, when you come in contact with an allergen for the first time your body has very little response.  After this first contact, the immune system is primed and the next contact causes an allergic reaction.  Sneezing, watery eyes, running nose or a rash may result.

Histamine is the chemical in our bodies responsible for this response.  If you have allergies, notify your physician. An anti-histamine may be a good medication to prevent symptoms from happening. Also, consider modifying your exercise routine; pollen counts are often highest in the mornings and evenings.

Or is it asthma or EIB?

But if you are also having trouble breathing, it may be more than just allergies you are fighting. Asthma is a chronic lung disease involving inflammation in the airways. It is extremely common and often worsens when people come in contact with the same triggers that cause allergies.

During an asthma attack, inflammation in the airways makes it more difficult to breathe: a person may wheeze, cough or have chest tightness.  Inhaled medications are often helpful to prevent asthma attacks or abort symptoms when they start.

In people who have asthma, exercise may also be a trigger for an attack.  This is called exercise-induced asthma or EIA.  EIA will often begin about 20 to 30 minutes after exercise begins and lead to severe coughing and shortness of breath.  It is often found in those who perform vigorous cardiovascular exercise such as running or cycling.  Exercising in the cold can also be a trigger.

However if you don’t have asthma, and find you still experience many of the same symptoms (shortness of breath, wheezing) from time to time, you may have exercise-induced bronchoconstriction (EIB).

Unlike with EIA, with EIB there is no inflammation. EIB is “a constriction of the airways as a consequence of vigorous exertion,” Christian Hermansen, M.D. writes in an article in The Physician and Sports Medicine (Dec. 2005) Source: [http://www.isdbweb.org/documents/file/468_11.htm].

Unlike asthma, a chronic disease, EIB is a transient, or temporary reaction, a bronchial spasm that causes the airways in the lungs to constrict leading to difficulty breathing, coughing and wheezing.

About 10 percent of the general population and almost 90 percent of people already diagnosed with asthma have EIB.  The prevalence of EIB in athletes is somewhere between 10 and 50 percent, however it approaches 90 percent in athletes with asthma.

Why some athletes get EIB and others don’t is not known but many doctors suspect that some inflammatory mediators are released in the airway during exercise.  Irritants, allergens, cold/dry air and chlorine in swimming pools are all possible triggers and, if you are susceptible, may cause a stronger response, making exercise very difficult.

It’s hard to diagnose EIB during a routine physical exam since the breathing is usually normal. If an athlete is examined while symptomatic, the most common findings are rapid breathing and wheezing, especially at the end of exhalation.

A simple spirometry test at your doctor’s office can help measure how much air you inhale and exhale. A spirometry test can help rule out underlying asthma but won’t necessarily catch EIB.

Further testing, often reserved for elite athletes, includes bronchial provocation testing, tests that are usually done in pulmonary function laboratories.

What to do?

If you do think you have EIB, start with avoiding known triggers such as allergens or choosing sports that don’t require long spans of high intensity exercise. Slowly warming up and cooling down prior to and after exercise can help and often a 15 minute warm up and cool down is adequate to help prevent an attack.

If this is not sufficient, an inhaled medication such as albuterol, taken about 30 minutes prior to vigorous exercise can help.  Avoiding exercise during extreme cold or when pollen counts are high is also wise. In cold weather, a heat exchange mask designed to limit exposure to cold air can help during exercise.

But the mainstay for treating EIB is using beta2 agonist inhaler medications 15 to 30 minutes prior to exercise.  Short acting beta2 agonists such as albuterol (brand names include Proventil and Ventolin) help relax the muscles and open the airwaves. These are the recommended first line treatment.

Inhaled corticosteroids have not been studied sufficiently for treating EIB.  Oral medication in the form of leukotriene receptor antagonists have also been shown to help with EIB.  Montelukast (trade name is Singulair) takes effect within two hours and continues to work for up to 24 hours.  Although its action is longer, montelukast is not as effective in prevention of EIB as short-acting beta2 agonists.

Also, keep in mind that the NCAA and the United States Olympic Committee (USOC) refer to many of these medications as banned substances because of their potential for aiding performance.  Albuterol is allowed by prescription and Olympic athletes must declare its use.  All other medications listed above and used to treat EIB are not prohibited including inhaled corticosteroids and leukotriene receptor antagonists.

When to call it quits.

In rare circumstances, allergies and asthma can be very severe.  This is called anaphylaxis and typically involves dramatic narrowing of the airways and sometimes closure of the airways altogether, making breathing impossible.

Anaphylaxis, most often caused by an allergic reaction to foods, should be treated as an emergency and requires immediate medical attention.

However, in some people exercise can lead to anaphylaxis (exercise-induced anaphylaxis) and it is not known why some are affected this way.  Those with allergies and asthma should be prepared if their symptoms are severe and should stop exercise immediately. Injectable epinephrine should be carried by anyone who has the risk of severe allergy or asthma attacks that may lead to anaphylaxis.

If you notice coughing or wheezing shortly after starting exercise or when exercising in extreme temperatures, talk to a doctor. For most of us, all it takes is proper management and avoidance of triggers, and you can breathe easier.

Learn more about Sports Medicine at the University of Vermont Medical Center. 

David Lisle, MD, is a sports medicine physician in Burlington, Vt. He holds dual appointments as assistant professor in the Department of Orthopaedics and the Department of Family Medicine at the Larner College of Medicine at UVM. He is the director for the sports medicine curriculum in the University of Vermont Family Medicine residency program. Dr. Lisle serves as the team physician for St. Michael’s College, the Vermont Lake Monsters Single A baseball affiliate and several Burlington-area high schools. He is also an assistant team physician for University of Vermont athletics.

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