Guideline sources The following summarized guidelines for the evaluation and management of exercise-induced bronchoconstriction (EIB) are prepared by our editorial team based on guidelines from the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2016) and the American Thoracic Society (ATS 2013). 1 2 Guidelines 1. Screening and diagnosis Diagnosis: confirm the diagnosis of EIB by demonstrating airways reversibility or challenge in association with a history consistent with EIB because self-reported symptoms are not adequate. B Differential diagnosis: Suspect the diagnosis of exercise-induced anaphylaxis instead of EIB based on a history of shortness of breath or other respiratory tract symptoms accompanied by systemic symptoms (such as pruritus, urticaria, and hypotension). B Refer patients for psychological evaluation if the symptoms (such as hyperventilation and anxiety disorders) are in the differential diagnosis of EIB. B 2. Diagnostic investigations https://web.pathway.md/diseases/rectXVq5lHLidOgxS 1/4 6/29/23, 4:21 AM Exercise-induced bronchoconstriction Pathway Bronchoprovocation testing: obtain a standardized bronchoprovocation (exercise or a surrogate) challenge for the diagnosis of EIB, as the prevalence of EIB varies with the type of challenge and the conditions under which the challenge is performed. A Show 12 more 3. Medical management General principles: recognize that EIB in patients with asthma can indicate lack of control of underlying asthma. Treat uncontrolled asthma to get control of EIB. B Show 2 more Inhaled beta-2 agonists: As per AAAAI 2016 guidelines, administer inhaled short-acting -agonists for protection against EIB and for accelerating recovery of pulmonary function when given after a decrease in pulmonary function after exercise. A Show 2 more As per ATS 2013 guidelines: Administer an inhaled short-acting -agonist before exercise (typically 15 minutes before, less than daily) in patients with EIB. A Do not use daily inhaled long-acting -agonist as single therapy in patients with EIB experiencing continuous symptoms despite using an inhaled short-acting -agonist before exercise or in patients requiring an inhaled short-acting -agonist daily or more frequently. D Inhaled corticosteroids: As per AAAAI 2016 guidelines, consider administering ICSs in combination with other therapies to decrease the frequency and severity of EIB. B Show 2 more As per ATS 2013 guidelines, administer daily ICS in patients with EIB having continuous symptoms despite using an inhaled short-acting -agonist before exercise or in patients requiring an inhaled short-acting -agonist daily or more frequently. Recognize that it may take 2-4 weeks after the initiation of therapy to see maximal improvement. Do not use ICSs only before exercise. B Inhaled mast cell stabilizers: As per AAAAI 2016 guidelines: Consider administering inhaled cromolyn sodium and nedocromil sodium shortly before exercise to attenuate EIB, recognizing that it has a short duration of action and does not have bronchodilator activity. B Consider administering cromolyn sodium and nedocromil sodium alone or as added therapy with other drugs in patients with EIB. B As per ATS 2013 guidelines, administer a mast cell stabilizer before exercise in patients with EIB experiencing continuous symptoms despite using an inhaled short-acting -agonist before exercise or in patients requiring an inhaled short-acting -agonist daily or more frequently. A Inhaled anticholinergics: https://web.pathway.md/diseases/rectXVq5lHLidOgxS 2/4 6/29/23, 4:21 AM Exercise-induced bronchoconstriction Pathway As per AAAAI 2016 guidelines, consider administering inhaled ipratropium bromide in patients not responding to other agents, recognizing that its ability to attenuate EIB is inconsistent. B As per ATS 2013 guidelines, consider administering an inhaled anticholinergic before exercise in patients with EIB experiencing continuous symptoms despite using an inhaled short-acting -agonist before exercise or in patients requiring an inhaled short-acting - agonist daily or more frequently. C Leukotriene receptor antagonists: As per AAAAI 2016 guidelines: Consider administering daily leukotriene inhibitors to attenuate EIB, recognizing that they do not lead to tolerance. B Consider administering leukotriene inhibitors for intermittent or maintenance prophylaxis, recognizing that they provide incomplete protection and are not effective for reversing airway obstruction. B As per ATS 2013 guidelines, administer daily leukotriene receptor antagonist in patients with EIB experiencing continuous symptoms despite using an short-acting -agonist before exercise or in patients requiring an inhaled short-acting -agonist daily or more frequently. B Antihistamines: Consider offering antihistamines to prevent EIB in patients with EIB and allergies experiencing continuous symptoms despite using an inhaled short-acting -agonist before exercise or requiring an inhaled short-acting -agonist daily or more frequently. C Do not offer antihistamines in non-allergic patients with EIB experiencing continuous symptoms despite using an inhaled short-acting -agonist before exercise or requiring an inhaled short-acting -agonist daily or more frequently. D 4. Nonpharmacologic interventions Warm-up exercises: As per AAAAI 2016 guidelines, advise practicing pre-exercise warm-up in patients with EIB to reduce the severity of EIB. A As per ATS 2013 guidelines, advise practicing interval or combination warm-up exercise before planned exercise in all patients with EIB. B Face masks: consider advising routine use of an air warming and humidifying device (mask) during exercise in patients with EIB exercising in cold weather. C Low-salt diet: As per AAAAI 2016 guidelines, consider advising reduction of sodium intake with caution in patients with EIB. C As per ATS 2013 guidelines, consider offering a low-salt diet in patients with EIB having an interest in dietary modifications to for symptom control. C Supplements: As per AAAAI 2016 guidelines, consider offering fish oil and ascorbic acid supplementation with caution in patients with EIB. C https://web.pathway.md/diseases/rectXVq5lHLidOgxS 3/4 6/29/23, 4:21 AM Exercise-induced bronchoconstriction Pathway As per ATS 2013 guidelines: Consider offering fish oil C and ascorbic acid in patients with EIB having an interest in dietary modifications for symptom control. C Avoid offering lycopene in patients with EIB having an interest in dietary modifications for symptom control. D Clinical findings Symptoms Past medical history Chest discomfort Asthma Chest pain Respiratory exam Cough Exercise intolerance Wheezing Fatigue Shortness of breath Sputum production Social history Sports participation References 1. John M Weiler, John D Brannan, Christopher C Randolph et al. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol. 2016 Nov;138 5 1292 1295.e36. Open 2. Jonathan P Parsons, Teal S Hallstrand, John G Mastronarde et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013 May 1;187 9 1016 27. Open https://web.pathway.md/diseases/rectXVq5lHLidOgxS 4/4