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Sx only during (or minutes after) exercise: Cough, SOB, chest pain/tightness, wheeze, endurance problems
Pre-tx w/ SABA to prevent EIB sx;1 advise warm-up, mask/scarf; monitor sx - SABA 1st line [A] (albuterol, levalbuterol):2 2 puffs, 5 min before (or as close as possible to) exercise. Non-1st-line tx: LABA,3 LTRA,4 cromolyn,5 zileuton,6 etc.7
- Warm-up pre-exercise; mask/scarf over mouth may attenuate cold-induced EIB. [C]Avoid outdoor exercise when air pollution high, if possible [C]
- Exercise challenge8 can establish dx, in lab or usual exercise setting. Hx alone may under/over-dx EIB. Vocal cord dysfxn9 often mimics asthma or may coexist w/ EIB
Offer action plan + pt ed, f/u - Written action plan based on sx or peak flow. [B]EIB should not limit participation/success in vigorous activities.10 Encourage/praise to build confidence
- F/U in 2-6 wks while gaining control, q1-6mo to monitor control. [D]Monitor sx and ↓ PEF outside of exercise, as EIB often indicates inadequate asthma mgmt; frequent severe EIB may indicate need to start/increase daily long-term control tx11
- Regular SABA use >2 days/wk for sx control (not to prevent EIB), increasing use, or lack of expected effect indicates inadequate control
- Educate: sx, meds, inhaler technique, environment control,12 comorbidity13 mgmt [B]
- Inactivated flu vaccine annually [A]
Footnotes 1 Usually occurs during or minutes after vigorous activity, peaks 5–10 min after activity, resolves in another 20–30 min. EIB is caused by loss of heat/H2O from lungs during hyperventilation of air cooler/dryer than respiratory tree air. Tx immediately before exercise/ vigorous activity usually prevents EIB.
2 Inhaled beta-2-agonists prevent EIB in >80% of pts. [A]SABAs act w/in 3-5 min; may help for 2-3 hrs. Increasing use/lack of effect indicates diminished control. Regular use >2 days/wk for sx control (not for EIB prevention) indicates need to step up tx. Available SABAs from 2007 Guideline (in alpha order):
• albuterol MDI 90 mcg, 2 puffs, 5 min before (or as close as possible to) exercise
• levalbuterol MDI 45 mcg, 2 puffs, 5 min before (or as close as possible to) exercise
3 LABA: May be used to prevent EIB, [B]but frequent/chronic LABA to prevent EIB should be discouraged (may disguise poorly-controlled persistent asthma that warrants daily anti-inflammatory tx). Can be protective up to 12 hrs, but duration ≤5 hrs w/ chronic regular use. Available LABAs from 2007 Guideline (in alpha order):
• formoterol DPI 12 mcg, 1 cap q12h
• salmeterol DPI 50 mcg, 1 blister q12h
4 LTRAs (montelukast, zafirlukast) can attenuate EIB in up to 50% of pts. [B]Onset of action=hrs after dose. Few comparisons w/ other protective agents are available. Available LTRAs from 2007 Guideline (in alpha order):
• montelukast (chew/tab) 10 mg PO qhs as long-term tx may attenuate EIB in some pts [FDA-approved acute EIB dose: 10 mg PO ≥2 hrs pre-exercise | Epocrates note]
• zafirlukast 20 mg PO bid
5 Cromolyn taken shortly before exercise is an alternative to prevent EIB, but not as effective as SABA. [B]Adding cromolyn to SABA helpful in some EIB pts. 1 dose pre-exercise provides 1-2 hrs prophylaxis, reducing acute response to exercise, cold dry air.
• cromolyn NEB 20 mg, 1 dose pre-exercise
6 Zileuton: Capable of attenuating bronchoconstriction from exercise; LFT monitoring essential.
7 Oral beta-2-agonists not recommended. Nonselective agents (epinephrine, isoproterenol, metaproterenol) not recommended due to potential for excessive cardiac stimulation, esp. in high doses. Ipratropium bromide doesn’t block EIB.
8 Exercise challenge in lab setting or free-run challenge, sufficient to ↑ baseline HR to 80% of maximum x4-6 min. Alternatively, pt does the task that causes sx. ✓ PEF or FEV1 pre-exercise and @ 5-min intervals for 20-30 min; 15% ↓ compatible w/ EIB.
9 Vocal cord dysfxn often mimics asthma: episodic dyspnea/wheeze from intermittent paradoxical vocal cord adduction during inspiration (sometimes expiration). Some pts develop VCD in response to irritant triggers (fumes, cold air, exercise). Resp. distress from VCD may be severe and lead to intubation that stops wheezing/distress, unlike in asthma. VCD dx is difficult: variable flattening on inspiratory flow loop is strongly suggestive but may be absent between episodes; dx is made by indirect/direct vocal cord viz during episode. VCD treated w/ speech tx and relaxation techniques; asthma drugs don’t treat pure VCD. VCD and asthma may coexist; elite athletes particularly prone to both.
10 Competitive athletes: med use should be disclosed; adhere to standards set by sports-governing bodies.
11 Appropriate long-term control w/ anti-inflammatory tx reduces airway responsiveness, and is associated w/ reduced EIB frequency/severity.
12 Allergens, [A]irritants, pollutants: ✓ hx exposure-related sx. Avoid tobacco smoke.
13 Identify comorbidities: [B]Rhinitis, sinusitis, GERD, obesity, OSA, ABPA, stress, depression, etc.
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Sx occur at times other than during (or minutes after) exercise: Cough, SOB, chest pain/tightness, wheeze, endurance problems
Tx EIB in light of overall asthma control; EIB/poor endurance can indicate poorly controlled, persistent asthma warranting long-term control tx;1 educate, f/u - SABA 1st line for EIB2,3 [A](albuterol, levalbuterol):4 2 puffs 5 min before (or as close as possible to) exercise
- Warm-up pre-exercise. Mask/scarf over mouth may attenuate cold-induced EIB. [C]Avoid outdoor exercise when air pollution high, if possible [C]
- Start/increase long-term control tx [A]if sx not well-controlled.5 For pts frequently using SABA, anti-inflammatory tx should be initiated/intensified. If sx occur during usual activities, step up long-term tx
Preferred asthma tx by step; use w/ prn SABA Offer action plan + pt ed, f/u - Written action plan based on sx or peak flow. [B]EIB should not limit participation/success in vigorous activities.12 Encourage/praise to build confidence
- F/U in 2-6 wks while gaining control, q1–6mo to monitor control, q3mo if step-down tx anticipated [D]
- Monitor sx and ↓ PEF outside of exercise. Spirometry q1–2yrs
- Educate: Sx, meds, inhaler technique, environment control,13 comorbidity14 mgmt [B]
- Inactivated flu vaccine annually [A]
Footnotes 1 Appropriate, long-term control w/ anti-inflammatory tx reduces airway responsiveness and is associated w/ reduced EIB frequency/severity.
2 Usually occurs during or minutes after vigorous activity, peaks 5–10 min after activity, resolves in another 20–30 min. EIB is caused by loss of heat/H2O from lungs during hyperventilation of air cooler/dryer than respiratory tree air. Tx immediately before exercise/ vigorous activity usually prevents EIB.
3 Non-1st-line tx: LABA, LTRA, cromolyn, zileuton, etc.
LABA: May be used to prevent EIB, [B]but frequent/chronic LABA to prevent EIB should be discouraged (may disguise poorly-controlled persistent asthma that warrants daily anti-inflammatory tx). Can be protective up to 12 hrs, but duration ≤5 hrs w/ chronic regular use. Available LABA from 2007 Guideline (in alpha order):
• formoterol DPI 12 mcg, 1 cap q12h
• salmeterol DPI 50 mcg, 1 blister q12h
LTRAs (montelukast, zafirlukast): can attenuate EIB in up to 50% of pts. [B]Onset of action=hrs after dose. Few comparisons w/ other protective agents are available. Available LTRAs from 2007 Guideline (in alpha order):
• montelukast (chew/tab) 10 mg PO qhs as long-term tx may attenuate EIB in some pts [FDA-approved acute EIB dose: 10 mg PO ≥2 hrs pre-exercise | Epocrates note]
• zafirlukast 20 mg PO bid
Cromolyn taken shortly before exercise is an alternative to prevent EIB, but not as effective as SABA. [B]Adding cromolyn to SABA helpful in some EIB pts. 1 dose pre-exercise provides 1-2 hrs prophylaxis, reducing acute response to exercise, cold dry air.
• cromolyn NEB 20 mg, 1 dose pre-exercise
Zileuton: Capable of attenuating bronchoconstriction from exercise; LFT monitoring essential.
Other: Oral beta-2-agonists not recommended. Nonselective agents (epinephrine, isoproterenol, metaproterenol) not recommended due to potential for excessive cardiac stimulation, esp. in high doses. Ipratropium bromide doesn’t block EIB.
4 Inhaled beta-2-agonists prevent EIB in >80% of pts. [A]SABAs act w/in 3-5 min; may help for 2-3 hrs. Increasing use/lack of effect indicates diminished control. Regular use >2 days/wk for sx control (not for EIB prevention) indicates need to step up tx. Available SABAs from 2007 Guideline (in alpha order):
• albuterol MDI 90 mcg, 2 puffs, 5 min before (or as close as possible to) exercise
• levalbuterol MDI 45 mcg, 2 puffs, 5 min before (or as close as possible to) exercise
5 Regular SABA >2 days/wk for sx control (not for EIB prevention), increasing SABA use, or lack of expected effect indicates inadequate control.
6 Step 1: SABA (albuterol, levalbuterol) q20min prn sx x 3 treatments. Available drugs from 2007 Guideline (in alpha order):
• albuterol MDI 90 mcg 2 puffs
• albuterol NEB 1.25-5 mg in 3 cc saline
• levalbuterol MDI 45 mcg 2 puffs
• levalbuterol NEB 0.63-1.25 mg
7 Step 2: Daily low-dose ICS + prn SABA (options listed in EPR-3 Quick Reference 2012, in alpha order; higher mcg forms preferred to ↓ # of puffs):
• beclomethasone MDI 40 mcg 1-3 puffs bid, or 80 mcg 1 puff qam + 2 puffs qpm
• budesonide DPI 90 mcg 1-3 puffs bid, or 180 mcg 1 puff qam + 2 puffs qpm
• ciclesonide MDI 80 mcg 1-2 puffs bid
• flunisolide MDI 80 mcg 2 puffs bid
• fluticasone propionate MDI 44 mcg 1-3 puffs bid, or DPI 50 mcg 1-3 puffs bid
• mometasone DPI 110 mcg 1-2 puffs qpm, or 220 mcg 1 puff qpm
8 Step 3: Either low-dose ICS + LABA, [A]or med-dose ICS (equal-weight options) + prn SABA:
Low-dose ICS + LABA (fixed-dose combos listed in EPR-3 Quick Reference 2012, in alpha order):
• budesonide/formoterol MDI 80/4.5 mcg 2 puffs bid
• fluticasone propionate/salmeterol MDI 45/21 mcg 2 puffs bid [2 puffs represents FDA-approved dosing | Epocrates note]
• fluticasone propionate/salmeterol DPI 100/50 mcg 1 puff bid
Med-dose ICS (in alpha order; higher mcg forms preferred to ↓ # of puffs):
• beclomethasone MDI 40 mcg 4-6 puffs bid, or 80 mcg 2-3 puffs bid
• budesonide DPI 180 mcg 2-3 puffs bid
• ciclesonide MDI 80 mcg 3-4 puffs bid, or 160 mcg 2 puffs bid
• flunisolide MDI 80 mcg 3-4 puffs bid
• fluticasone propionate MDI 110 mcg 2 puffs bid, or 220 mcg 1 puff bid; or DPI 100 mcg 2 puffs bid, or 250 mcg 1 puff bid
• mometasone DPI 110 mcg 3-4 puffs qpm or 2 puffs bid, or 220 mcg 1 puff bid or 2 puffs qpm
9 Step 4: Med-dose ICS + LABA (fixed-dose combos listed in EPR-3 Quick Reference 2012, in alpha order) + prn SABA:
• budesonide/formoterol MDI 160/4.5 mcg 2 puffs bid
• fluticasone propionate/salmeterol DPI 250/50 mcg 1 puff bid
• fluticasone propionate/salmeterol MDI 115/21 mcg 2 puffs bid [2 puffs represents FDA-approved dosing | Epocrates note]
• mometasone/formoterol MDI 100/5 mcg 2 puffs bid
10 Step 5: High-dose ICS + LABA + prn SABA + if allergies, consider omalizumab.
High-dose ICS + LABA (fixed-dose combos listed in EPR-3 Quick Reference 2012, in alpha order):
• fluticasone propionate/salmeterol DPI 500/50 mcg 1 puff bid
• fluticasone propionate/salmeterol MDI 230/21 mcg 2 puffs bid [2 puffs represents FDA-approved dosing | Epocrates note]
Omalizumab 150 mg SC INJ: 150-375 mg SC q2-4wk based on body wt, pre-tx IgE levels. Omalizumab tx requires preparation to tx anaphylaxis.
11 Step 6: High-dose ICS + LABA + oral steroids + prn SABA + if allergies, consider omalizumab. Before PO steroids, trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, though not studied in clinical trials.
High-dose ICS + LABA (fixed-dose combos listed in EPR-3 Quick Reference 2012, in alpha order):
• fluticasone propionate/salmeterol DPI 500/50 mcg 1 puff bid
• fluticasone propionate/salmeterol MDI 230/21 mcg 2 puffs bid [2 puffs represents FDA-approved dosing | Epocrates note]
Omalizumab 150 mg SC INJ: 150-375 mg SC q2-4wk based on body wt, pre-tx IgE levels. Omalizumab tx requires preparation to tx anaphylaxis.
Oral steroids (options listed in EPR-3 Quick Reference 2012, in alpha order): methylprednisolone, prednisolone, or prednisone: 7.5–60 mg daily (single AM dose) or every other day as needed for control. Short-course burst to gain control: 40–60 mg/day single dose (or 2 divided doses) x3–10 days.
12 Competitive athletes: Med use should be disclosed; adhere to standards set by sports-governing bodies.
13 Allergens, [A]irritants, pollutants: ✓ hx exposure-related sx. Avoid tobacco smoke.
14 Identify comorbidities: [B]Rhinitis, sinusitis, GERD, obesity, OSA, ABPA, stress, depression, etc.
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