Exercise Asthma Without Cough?
I have seen a number of athletic children who believe that they have exercise asthma (ie, exercise intolerance with shortness of breath) but deny an associated cough. They have all had normal pulmonary function at rest. Pre-exercise albuterol does not seem to help with symptoms. I have always thought that the hallmark of asthma is exercise cough. Can you have exercise asthma without a cough?
Paul Smolen, MD
I have contemplated this issue on a personal level this year. My son recently completed his first T-ball season which began in a cooler-than-usual spring. He is an athletic 6-year-old with seasonal allergies who takes cetirizine daily, had multiple episodes of bronchiolitis as an infant and toddler, and has a strong family history of atopy. His only complaint is that at times "my breathing gets hard when I run." He feels that this keeps him from doing his best. When he takes his cetirizine regularly, he rarely coughs. He has no audible wheeze after exercising and has a completely normal exam at rest. He inconsistently cooperates with peak flow testing. Is he a typical 6-year-old expressing his perception of normal physiologic changes to exercise, or is he experiencing episodic exercise-induced asthma (EIA)?
He is typical of the not-too-uncommon patient seen in the emergency department -- a school-aged child who has had to discontinue participation in a recreational or athletic event due to shortness of breath, chest pain, cough, or some combination of these 3 symptoms. By the time the child is evaluated (usually at least 1 hour after initial presentation of symptoms), the exam has normalized and the peak expiratory flow determination is near the predicted value. Many times, the parents' perception of the event provides minimal insight, as they commonly either grossly overestimate or underestimate the symptoms.
In reviewing references on EIA, I am impressed that most authors mention cough near the top of the list of frequently reported symptoms. However, the most commonly offered criterion for diagnosing EIA is a given change in force expiratory volume at 1 second (FEV1) in response to exercise, with no mention of cough.
As stated in the Global Initiative for Asthma, it may be best to view EIA as "one expression of airway hyperresponsiveness, not as a special form of asthma. EIA often indicates that the patient's asthma is not adequately controlled; therefore, appropriate anti-inflammatory therapy generally results in the reduction of exercise-related symptoms."
There is a good review in Pediatric Clinics of North America of numerous studies comparing various forms of preventative management for EIA. Although pretreatment with albuterol is commonly effective, its value may diminish over time, or it may be of no benefit for some patients. Anti-inflammatory management (inhaled steroids) or a leukotriene receptor antagonist may provide better management, with effects that persist over time.
We tend to underdiagnose EIA due to confusing history and inaccurate patient/parent assessment of symptoms. Our quick and easy tools for assessment (physical exam and peak flow determinations) are commonly not helpful. Yet, EIA is relatively common and needs to be treated. So, cough or no cough, after recent discussions with my pediatric pulmonologist colleagues, my son will be starting treatment with a leukotriene receptor antagonist next year, prior to "spring training."
I have seen a number of athletic children who believe that they have exercise asthma (ie, exercise intolerance with shortness of breath) but deny an associated cough. They have all had normal pulmonary function at rest. Pre-exercise albuterol does not seem to help with symptoms. I have always thought that the hallmark of asthma is exercise cough. Can you have exercise asthma without a cough?
Paul Smolen, MD
I have contemplated this issue on a personal level this year. My son recently completed his first T-ball season which began in a cooler-than-usual spring. He is an athletic 6-year-old with seasonal allergies who takes cetirizine daily, had multiple episodes of bronchiolitis as an infant and toddler, and has a strong family history of atopy. His only complaint is that at times "my breathing gets hard when I run." He feels that this keeps him from doing his best. When he takes his cetirizine regularly, he rarely coughs. He has no audible wheeze after exercising and has a completely normal exam at rest. He inconsistently cooperates with peak flow testing. Is he a typical 6-year-old expressing his perception of normal physiologic changes to exercise, or is he experiencing episodic exercise-induced asthma (EIA)?
He is typical of the not-too-uncommon patient seen in the emergency department -- a school-aged child who has had to discontinue participation in a recreational or athletic event due to shortness of breath, chest pain, cough, or some combination of these 3 symptoms. By the time the child is evaluated (usually at least 1 hour after initial presentation of symptoms), the exam has normalized and the peak expiratory flow determination is near the predicted value. Many times, the parents' perception of the event provides minimal insight, as they commonly either grossly overestimate or underestimate the symptoms.
In reviewing references on EIA, I am impressed that most authors mention cough near the top of the list of frequently reported symptoms. However, the most commonly offered criterion for diagnosing EIA is a given change in force expiratory volume at 1 second (FEV1) in response to exercise, with no mention of cough.
As stated in the Global Initiative for Asthma, it may be best to view EIA as "one expression of airway hyperresponsiveness, not as a special form of asthma. EIA often indicates that the patient's asthma is not adequately controlled; therefore, appropriate anti-inflammatory therapy generally results in the reduction of exercise-related symptoms."
There is a good review in Pediatric Clinics of North America of numerous studies comparing various forms of preventative management for EIA. Although pretreatment with albuterol is commonly effective, its value may diminish over time, or it may be of no benefit for some patients. Anti-inflammatory management (inhaled steroids) or a leukotriene receptor antagonist may provide better management, with effects that persist over time.
We tend to underdiagnose EIA due to confusing history and inaccurate patient/parent assessment of symptoms. Our quick and easy tools for assessment (physical exam and peak flow determinations) are commonly not helpful. Yet, EIA is relatively common and needs to be treated. So, cough or no cough, after recent discussions with my pediatric pulmonologist colleagues, my son will be starting treatment with a leukotriene receptor antagonist next year, prior to "spring training."