Synopsis
Recognise the physiology and mimics of exercise-induced bronchoconstriction, confirm it with appropriate objective testing, and preserve safe participation through anti-inflammatory asthma care.
- Exercise-induced bronchoconstriction is a transient fall in expiratory airflow after exertion; it is common in asthma but can occur without otherwise typical chronic asthma.
- Symptoms alone perform poorly: exertional cough, wheeze and breathlessness also arise from inducible laryngeal obstruction, dysfunctional breathing, poor fitness, obesity, cardiac disease and anaemia.
- EIB often peaks shortly after intense exercise, particularly in cold dry air; inspiratory noise and throat tightness at peak exercise favour exercise-induced laryngeal obstruction.
- Confirm the diagnosis with spirometry before and serially after a standardised exercise or indirect bronchial challenge, using the laboratory's validated protocol and interpretation criteria.
- Baseline spirometry may be normal and does not exclude EIB; conversely, resting obstruction should prompt standard asthma assessment and safe planning before challenge.
- In a person with asthma, recurrent EIB often signals inadequate anti-inflammatory control, poor adherence or technique, so review the whole asthma regimen rather than adding pre-exercise reliever indefinitely.
- Warm-up, gradual conditioning, trigger management and protection from cold dry air support participation but do not replace inhaled corticosteroid when asthma is present.
- For people using AIR or MART, preventive use of the prescribed ICS-formoterol may be appropriate under the exact product and asthma action plan.
- A SABA can prevent predictable EIB in a person whose plan includes inhaled corticosteroid, but frequent preventive reliance indicates the need for control review.
- Elite athletes must also check current anti-doping rules and therapeutic-use documentation; ordinary prescribing advice does not guarantee competition compliance.
Key red flags
Exercise symptoms accompany night waking, variable daytime symptoms, increasing reliever use, attacks or poor inhaled corticosteroid use. EIB is then a control signal rather than an isolated sporting problem.
Early fatigue without airflow change, chest pain, syncope, palpitations, desaturation or systemic symptoms should prompt evaluation for fitness, anaemia, cardiac disease, pulmonary vascular disease or another cause.
Breathlessness with urticaria, angioedema, hypotension or gastrointestinal symptoms is not ordinary EIB and requires immediate anaphylaxis treatment and emergency assessment, including possible food or drug cofactors.
Investigation priorities
Identify resting obstruction and broader variable airflow disease.
Management branches
Breathlessness, cough or noisy breathing is repeatedly associated with exercise.
- Describe exact activity, intensity, environment, onset relative to peak effort, inspiratory versus expiratory noise, throat or chest sensation and recovery time.
- Ask about asthma outside exercise, attacks, inhaler use, allergic triggers, food or medicine cofactors, cardiac symptoms and training history.
- Identify emergency features such as syncope, chest pain, systemic allergy or prolonged severe distress and investigate those before elective bronchial challenge.
- Arrange baseline spirometry and an objective provocation strategy rather than using a therapeutic trial as the only diagnostic evidence.
The person is stable and objective confirmation of EIB will change management.
- Select exercise or indirect challenge with the physiology service, accounting for the person's sport, environment, baseline airflow and medicine-withholding instructions.
- Check baseline clinical stability and spirometry, explain stop criteria, and ensure trained staff and rescue bronchodilator are immediately available.
- Achieve the validated exercise or ventilation target, then obtain serial FEV1 through the expected recovery period rather than one late measurement.