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The article discusses the prevalence of exercise-induced bronchoconstriction (EIB) in adolescent recreational athletes and the challenges in diagnosing and managing this condition. Screening strategies, such as the use of FeNO levels and the AQUA questionnaire, are highlighted as potential tools for early detection of EIB. The study emphasizes the need for better screening methods to identify athletes with EIB and ensure appropriate management. Additionally, the correlation between atopy, asthma, and EIB is explored, with findings suggesting that atopy may be linked to underlying Type 2 inflammation. [Extracted from the article]

Background: Exercise‐induced bronchoconstriction (EIB) is a frequent and highly specific symptom of childhood asthma. Inhaled corticosteroids (ICS) are the mainstay of controller therapy for EIB and asthma; however, a proportion of asthmatic children and adolescents is less responsive to ICS. We hypothesized that a single dose response to ICS could function as a predictor for individual long‐term efficacy of ICS. Objective: To assess the predictive value of the bronchoprotective effect of a single‐dose beclomethasone dipropionate (BDP) against EIB for the bronchoprotective effect of 4 weeks of treatment, using an exercise challenge test (ECT). Methods: Thirty‐two steroid‐naïve children and adolescents aged 6 to 18 years with EIB were included in this prospective cohort study. They performed an ECT at baseline, after a single‐dose BDP (200µg) and after 4 weeks of BDP treatment (100 µg twice daily) to assess EIB severity. Results: The response to a single‐dose BDP on exercise‐induced fall in FEV1 showed a significant correlation with the response on exercise‐induced fall in FEV1 after 4 weeks of BDP treatment (r =.38, p =.004). A reduction in post‐exercise fall in FEV1 of more than 8% after a single‐dose BDP could predict BDP efficacy against EIB after 4 weeks of treatment with a positive predictive value of 100% (CI: 86.1–100%) and a negative predictive value of 29.4% (CI: 11.7%–53.7%). Conclusion: We found that the individual response to a single‐dose BDP against EIB has a predictive value for the efficacy of long‐term treatment with BDP. This could support clinicians in providing personalized management of EIB in childhood asthma. [ABSTRACT FROM AUTHOR]

Background: Self‐reported exercise‐induced dyspnea (EID) is common among adolescents. Possible underlying pathologies are exercise‐induced bronchoconstriction (EIB) and laryngeal obstruction (EILO). The forced oscillation technique (FOT) may evaluate exercise‐induced changes in airway caliber. Aim: To investigate in adolescents the relationship between EID, EIB (post‐exercise fall in forced expiratory volume in 1s (FEV1)≥10%), EILO, and post‐exercise challenge changes in FOT parameters. Methods: One hundred and forty‐three subjects (97 with EID) of 13–15 years old underwent a standardized exercise challenge with FOT measurement and spirometry repeatedly performed between 2 and 30 min post‐exercise. EILO was studied in a subset of 123 adolescents. Subjects showing greater changes than the healthy subgroup in the modulus of the inspiratory impedance were considered FOT responders. Results: EID‐nonEIB subjects presented similar post‐exercise changes in all FOT parameters to nonEID‐nonEIB adolescents. Changes in all FOT parameters correlated with FEV1 fall. 45 of 97 EID subjects responded neither by FEV1 nor FOT to exercise. 19 and 18 subjects responded only by FEV1 (onlyFEV1responders) or FOT (onlyFOTresponders), respectively. Only a lower baseline forced vital capacity (FVC)%predicted and a higher FEV1/FVC distinguished the onlyFEV1responders from onlyFOTresponders. FOT parameters did not present specific post‐exercise patterns in EILO subjects. Conclusion: FOT can be used to identify post‐exercise changes in lower airway function. However, EID has a modest relation with both FEV1 and FOT responses, highlighting the need for objective testing. More research is needed to understand whether onlyFEV1responders and onlyFOTresponders represent different endotypes. [ABSTRACT FROM AUTHOR]

Background: Respiratory symptoms after exercise are frequently reported by asthmatic patients, and exercise‐induced bronchoconstriction (EIB) is a frequent cause, which requires objective testing for diagnosis. Eucapnic voluntary hyperpnea (EVH) is recommended as a surrogate stimulus for this purpose. Its short‐term reproducibility is not yet established in children and young adolescents with asthma. Objective: To evaluate the short‐term test‐retest agreement and reproducibility of FEV1 changes after EVH in this population. Methods: Asthmatic patients aged between 10 and 20 years underwent EVH for EIB diagnosis on two occasions 2–4 days apart at a specialized university clinic. FEV1 was measured at 5, 15, and 30 min after EVH with a target ventilation rate 21 times the baseline FEV1. EIB was diagnosed as a decrease ≥10% in FEV1 from baseline. Results: A total of 26 of 62 recruited individuals tested positive for EIB on both visits (positive group) and 17 on one visit only (divergent group), while 19 tested negative on both visits (negative group). The overall agreement was 72.5% (95%CI 61.6%, 83.6%), and Cohen's kappa coefficient was 0.452. Low bias (0.87%) and high intra‐class correlation coefficient (0.854, 95%CI 0.758,0.912; p <.001) for FEV1 response between test days were found, but with wide limits of agreement (±20.72%). There were no differences in pre‐challenge FEV1 or achieved ventilation rate between visits either between groups (p =.097 and p =.461) or within groups (p =.828 and p =.780). There were no safety issues. Conclusions: More than one EVH test should be performed in children and young adolescents with asthma to exclude EIB and minimize misdiagnosis and mistreatment. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to evaluate the role of body mass index with regard to exercise performance, exercise‐induced bronchoconstriction (EIB), and respiratory symptoms in 7‐ to 16‐year‐old children. Methods: A total of 1120 outdoor running exercise challenge test results of 7‐ to 16‐year‐old children were retrospectively reviewed. Lung function was evaluated with spirometry, and exercise performance was assessed by calculating distance per 6 minutes from the running time and distance. Respiratory symptoms in the exercise challenge test were recorded, and body mass index modified for children (ISO‐BMI) was calculated for each child from height, weight, age, and gender according to the national growth references. Results: Greater ISO‐BMI and overweight were associated with poorer exercise performance (P <.001). In addition, greater ISO‐BMI was independently associated with cough (P =.002) and shortness of breath (P =.012) in the exercise challenge. However, there was no association between ISO‐BMI and EIB or with wheeze during the exercise challenge. Conclusion: Greater ISO‐BMI may have a role in poorer exercise performance and appearance of respiratory symptoms during exercise, but not in EIB in 7‐ to 16‐year‐old children. [ABSTRACT FROM AUTHOR]

Background Children with asthma may be less physically active than their healthy peers. We aimed to investigate whether perceived exercise limitation ( EL) was associated with lung function or bronchial hyper-responsiveness ( BHR), socioeconomic factors, prenatal smoking, overweight, allergic disease, asthma severity, or physical activity ( PA). Methods The 302 children with asthma from the 10-year examination of the Environment and Childhood Asthma birth cohort study underwent a clinical examination including perceived EL (structured interview of child and parent(s)), measure of overweight (body mass index by sex and age passing through 25 kg/m2 or above at 18 years), exercise-induced bronchoconstriction (forced expiratory volume in one-second ( FEV1) pre- and post-exercise), methacholine bronchial challenge (severe BHR; provocative dose causing ≥20% decrease in FEV1 ≤ 1 μmol), and asthma severity score (dose of controller medication and exacerbations last 12 months). Multivariate logistic regression analyses were conducted to assess associations with perceived EL. Results In the final model explaining 30.1%, asthma severity score ( OR: 1.49, (1.32, 1.67)) and overweight ( OR: 2.35 (1.14, 4.82)) only were significantly associated with perceived EL. Excluding asthma severity and allergic disease, severe BHR ( OR: 2.82 (1.38, 5.76)) or maximal reduction in FEV1 post-exercise ( OR: 1.48 (1.10, 1.98)) and overweight ( OR: 2.15 (1.13, 4.08) and 2.53 (1.27, 5.03)) explained 9.7% and 8.4% of perceived EL, respectively. Conclusions Perceived EL in children with asthma was independently associated with asthma severity and overweight, the latter doubling the probability of perceived EL irrespectively of asthma severity, allergy status, socioeconomic factors, prenatal smoking, or PA. [ABSTRACT FROM AUTHOR]

Background Cooling of the airways and inflammation have been pointed as possible mechanisms for exercise-induced asthma ( EIA). We aimed to investigate the effect of training and asthma on exhaled breath temperature ( EBT) of elite swimmers. Methods Elite swimmers annually screened (skin prick tests, spirometry before and after salbutamol inhalation, induced sputum cell counts, and methacholine bronchial challenge) at our department (n = 27) were invited to this prospective study. Swimmers who agreed to participate in the present study (n = 22, 10 with asthma) had axillary temperature and EBT measured (X-halo®) before and after a swimming training session (aerobic/non-aerobic). Linear regression models were used to assess the effect of asthma and other possible explanatory variables (demographics, PD20, baseline EBT, training intensity, axillary temperature, and the number of hours trained in that week) on EBT change. Results EBT significantly increased after training independently of lung function, airway responsiveness, and inflammation in all swimmers (mean ± SD: 0.32 ± 0.57; p = 0.016). No differences were observed between asthmatic swimmers and others. A significant correlation was observed between baseline and post-exercise EBTs ( r = 0.827, p < 0.001). Asthma was not a predictor of Δ EBT after adjusting for confounders; baseline EBT was the variable most strongly associated with Δ EBT, explaining by itself alone 46% of the outcome ( r2 = 0.464). Conclusion Although these are preliminary data, a relationship between airway's inflammation and respiratory heat loss during exercise could not be confirmed, suggesting that the increase in exhaled breath temperature is a physiologic rather than a pathological response to exercise. [ABSTRACT FROM AUTHOR]

Background: The diagnosis of exercise-induced asthma or bronchospasm (EIB) is a complex dare in daily clinical practice. The consensus is that if bronchial hyperresponsiveness (BHR) is demonstrated in a patient with symptoms consistent with EIB, then that patient can be diagnosed with exercise-induced bronchospasm. The aim of this study was to determine which BHR test is the most efficient to diagnose EIB. Methods: Children under 16, without previous asthma diagnosis, or with stable asthma, complaining of asthma-like symptoms triggered by exercise were included. Bronchodilator, methacholine, mannitol, and exercise tests were performed on all patients, following established protocols. The performance of single and combined tests was determined. Results: Of 46 patients (median age: 12 yr, ranged 8-16 y.o.) were recruited, 30 (70%) previously diagnosed of asthma. BHR was detected in 93.47% of the children. The exercise challenge test detected BHR in 11 of 46 (23.90%) patients, bronchodilator test in 10 of 46 (21.70%), mannitol in 36 of 45 (80%) and methacholine in 41 of 45 (91.11%). The total number of patients with BHR was detected using a combination of the methacholine and mannitol tests. A combination of the methacholine test performed first, followed by the mannitol test, was able to diagnose BHR in 100% of children with lower number of tests (n = 45) than if the order was reversed (n = 50). Conclusions: Methacholine and mannitol tests detect BHR in most children with suspected EIB. Bronchodilator and exercise tests show a low positivity rate. A combination of the methacholine test, followed by the mannitol test, gives the highest return to identify BHR in children for the diagnosis of EIB. [ABSTRACT FROM AUTHOR]

To cite this article: Linkosalo L, Lehtimäki L, Holm K, Kaila M, Moilanen E. Relation of bronchial and alveolar nitric oxide to exercise-induced bronchoconstriction in atopic children and adolescents. Pediatr Allergy Immunol 2012: 23: 360-366. Abstract Background and objective: Exercise challenge test is widely used in diagnostics and follow-up of childhood asthma, but the method is complex, time consuming, and expensive. In this study, we aimed to find out whether flow-independent nitric oxide (NO) parameters (bronchial NO flux [J′awNO] and alveolar NO concentration [CANO]) predict exercise-induced bronchoconstriction (EIB) in atopic children and adolescents with asthma-like symptoms. Also, the respective NO parameters corrected for axial backward diffusion (J′awNO[TMAD] and CANO[TMAD]) were calculated and included in the analysis. Methods: Thirty patients (6-19 yr old) with confirmed atopy (positive skin prick tests or allergen-specific IgE) and asthma-like respiratory symptoms were included in the study. Before the current investigations, none of the patients had been diagnosed to have asthma and none were on inhaled corticosteroids. Exhaled NO was measured at multiple exhalation flow rates, and exercise challenge test was carried out. Bronchial NO flux and alveolar NO concentration were calculated according to the linear method with and without correction for axial backward diffusion. Sixty-six healthy school children served as controls. Results: The patients were divided into two groups according to EIB. Patients with EIB (EIB+ group, n = 18) had enhanced bronchial NO output as compared to patients without EIB (EIB− group, n = 12); but the EIB− group did not differ from healthy controls. EIB+ group had also higher alveolar NO concentration than EIB− group and healthy controls, but EIB− group did not differ from healthy controls. When bronchial NO flux and alveolar NO concentration were corrected for axial diffusion, J′awNO(TMAD) had equal difference as J′awNO between the groups as expected. However, only EIB+ had higher CANO(TMAD) than healthy controls, and the patient groups did not differ from each other. In patients, bronchial NO output correlated with the magnitude of exercise-induced change in PEF (rs = −0.388, p = 0.034), FEV1 (rs = −0.395, p = 0.031), and FEF50% (rs = −0.431, p = 0.020), i.e., the higher the bronchial NO output, the larger the decrease in PEF/FEV1/FEF50%. Alveolar NO concentrations correlated with the change in FEV1 (rs = −0.439, p = 0.015), FEF50% (rs = −0.454, p = 0.013), FEF75% (rs = −0.447, p = 0.017), and FVC (rs = −0.375, p = 0.045). For J′awNO(TMAD), the correlations and p-values were equal to those of J′awNO, but, interestingly, CANO(TMAD) had no significant correlations with any of the exercise-induced changes in lung function. Conclusion: The results showed that in atopic children and adolescents, increased bronchial NO output as well as J′awNO(TMAD) were associated with EIB, while alveolar NO concentration (but not CANO[TMAD]) correlated with the degree of obstruction in smaller airways induced by exercise challenge. [ABSTRACT FROM AUTHOR]

To cite this article: Del Giacco SR, Carlsen K-H, Du Toit G. Allergy and sports in children. Pediatric Allergy Immunol 2012: 23: 11-20. Abstract Physical activity is beneficial for children with positive outcomes for mental and physical well-being. Allergic conditions unique to the sporting arena may serve as an impediment to participation in physical activity for allergic children. A common example is exercise-induced asthma; less common activity-related allergic conditions include food-dependent exercise-induced anaphylaxis, exercise-induced anaphylaxis, and exercise-induced urticaria. Allergic children may also be at risk of allergic reactions when exposed to allergens that are more commonly found in the sports environment, e.g., latex, sports drinks, and medications such as NSAIDs. Recent advances in our understanding of the patho-physiological and immunologic mechanisms that may account for these conditions have facilitated more effective and safer management strategies. There are also important immunologic lessons to be learnt with respect to specific physical factors that may result in diminished allergen tolerance; indeed, these lessons may facilitate safer allergen desensitisation regimens. The role of the immune system in exercise-induced immunoallergic syndromes, clinical aspects, and diagnostic and therapeutic approaches are discussed in this review. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the timing of onset and the duration of action of a single oral-dose treatment with montelukast in comparison to placebo on exercise-induced asthma (EIA) in asthmatic children. Nineteen children (7–13 years) with stable asthma were evaluated. Patients undertook three consecutive treadmill exercise tests, respectively, 2, 12 and 24 h after a single-dose administration. A double-blind randomized, single-dose, placebo-controlled, crossover design was used. To assess bronchoconstriction after the exercise challenge, the maximal percentage fall in FEV1 (ΔFEV1 ) from the baseline value was considered. Two hours after dosing, ΔFEV1 was -15.33 ± 2.93 for placebo and -13.33 ± 2.03 for montelukast. At 12 h, ΔFEV1 was -18.69 ± 2.83 for placebo, -9.78 ± 1.85 for montelukast (p < 0.005). No difference was observed between placebo (ΔFEV1 -10.21 ± 2.07) and montelukast (ΔFEV1 -9.10 ± 2.02) at 24 h. Analysis of the degree of protection showed a significant efficacy of montelukast (p = 0.02) in comparison with placebo only at 12 h. Montelukast showed a significant protective effect 12 h after dosing, but no effect after 2 and 24 h. In mild asthmatics, the timing of administration of single dosage before exercise should be strictly considered in order to obtain the drug protective effects. [ABSTRACT FROM AUTHOR]

Among asthmatics, exercise-induced wheeze (EIW) is a frequent symptom, and 40–77% of asthmatics demonstrate exercise-induced bronchoconstriction (EIB). In the North-Trøndelag population-based survey of 8,571 adolescents (YOUNG-HUNT), 26% reported wheeze during the previous 12 months (current wheeze). Of those subjects, 50% reported EIW. The aim of the present study was to investigate the association between EIW and EIB in randomly selected adolescents with EIW as the only or predominant asthma-like symptom, and to relate our findings to results from methacholine bronchoprovocation tests (MT) and measurements of exhaled nitric oxide (ENO). Sixty-three subjects with current wheeze induced by exercise, but not by allergen exposure, were investigated using a treadmill exercise test (ET) and measurements of ENO. Fifty-eight subjects completed a MT on a separate study day. EIB was defined as a fall of ≥ 10% in the forced expiratory volume in 1 second (FEV 1 ) after exercise (ΔFEV 1 %ex ). Twenty-one subjects (33%) had EIB and 33 (57%) had a positive MT. The degree of reported dyspnea during the ET was not correlated to the ΔFEV 1 %ex. The correlation between EIB and methacholine-induced bronchoconstriction (MIB) was poor, and the ΔFEV 1 %ex was more pronounced in smokers than in non-smokers. Moreover, ENO was not increased in subjects with positive vs. negative ET. Hence, EIW, when reported as the only or predominant asthma-like symptom, was linked to EIB in only one-third of the patients. We conclude that EIW is a poor predictor of EIB in epidemiological studies. The poor correlation between EIB and MIB indicates that these two tests measure different mechanisms of bronchial hyper-responsiveness. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare the clinical efficacy of low‐dose inhaled budesonide (once or twice daily) and placebo, administered via Turbuhaler®, on exercise‐induced bronchoconstriction (EIB) in children with mild asthma. Fifty‐seven steroid‐naive children (7–16 years old; 41 boys, 16 girls) with EIB participated in this sub‐population study according to the following inclusion criterion: a maximum fall in forced expiratory volume in 1 s (FEV1) ≥ 10% after a standardized treadmill test. Mean baseline FEV1 was 100.3% of predicted, and mean maximum fall in FEV1 after the standardized exercise test was 22%. The study was a double‐blind, randomized, parallel‐group design. After 2 weeks of run‐in, the children received inhaled budesonide 100 µg or 200 µg once daily in the morning, 100 µg twice daily, or placebo, for 12 weeks. After 12 weeks of treatment, the fall in FEV1 after the exercise test was significantly less in all three budesonide groups (7.2–7.8%) vs. placebo (16.7%). Daytime symptom scores were significantly lower in all three budesonide groups compared with placebo (p < 0.02). The three budesonide groups did not differ significantly, and no significant change in lung function was found in any group. Therefore children with mild asthma, but with significant EIB, improved their exercise tolerance and symptom control after 3 months of treatment with a low dose of inhaled budesonide given once or twice daily. [ABSTRACT FROM AUTHOR]

Nedocromil sodium (Ned) 4 mg, sodium cromoglycate (SCG) 10 mg, and placebo were compared for their efficacy in preventing exerciseinduced asthma. Nineteen asthmatic children aged six to 15 years performed a treadmill exercise test before and 20' after a single dose of drug in a double-blind trial. Both active drugs performed significantly better than placebo; in fact the exercise challenge resulted in a mean maximum fall in FEVl of 26.1 ± 14.9% after placebo, but only of 14.6 ± 11.5% after SCG (P <0.05), and 11.0 ± 12.4% after Ned (p < 0.01). Measurements of PEFR gave similar results, while the effect of treatment on FEF 25-75 was significant for Ned alone (p < 0.05). Direct comparison between Ned and SCG at different time points demonstrated significant differences in FEVl at 1 min (p CO.05) with a better overall performance of Ned. In individual patients, complete protection was provided in 9 patients with SCG, in 14 patients with Ned and in 2 with placebo. No side effects were observed. This study suggests that at the dosages used there are only slight differences between SCG and Ned activity in the prevention of exercise-induced asthma. [ABSTRACT FROM AUTHOR]

To study the roles of eosinophils and catecholamines in the pathophysiology of exercise-induced asthma (EIA), an exercise challenge test was performed in 22 asthmatic children, using a bicycle ergometer, and the changes in lung function, plasma norepinephrine (NE), epinephrine (E) and eosinophil cationic protein (ECP) levels with exercise were eval-uated. Subjects were classified into three groups from the results of lung function test, respectively: EIA-negative group. EIA-positive groups with good recovery and poor reccovery. Eosinophil counts before exercise in the EIA-positive groups were significantly higher than those in the EIA negative group. The ECP levels rose with exercise in all groups. Five minutes after exercise. ECP values fell to the pre-exercise level in the EIA-negative group, but rose to higher levels in EIA-positive groups. Plasma E levels rose with exercise and showed 4-fold increase in the EIA-negative group, whereas only 1.5 fold increase of plasma E levels was observed in the EIA-positive group with poor recovery. From these findings, a possible contribution of sympathoadrenal hypofunction and a probable involvement of eosinophils in the patho-physiology of EIA have been suggested. [ABSTRACT FROM AUTHOR]