and there we go. I do not have any disclosures. Injectives of our talk today are kind of review a differential diagnosis for exercise-induced dyspnea as well as different considerations, but then we're really going to focus on the non-emergent airway causes in athletes and otherwise healthy individuals. And then we're going to go through and differentiate mainly between asthma as well as exercise-induced bronchoconstriction or EIV, and at the end we'll touch briefly about EIL or exercise-induced laryngeal obstruction. So exercise-induced dyspnea can be a common cause of concern as well as a complaint in an athlete, and it can have a wide range of complaints from being specific to needing to catch my breath, difficulty breathing, shortness of breath, or a little bit more vague terminology where they're discussing fatigue or underperformance, and these are areas that we need to consider, as well as focusing on the history to figure out the clues that might lead us to a specific diagnostic track. But keeping your mind open for the dyspnea when we talk breakdown to five different areas of causes, first one being that jumps to mind is usually the respiratory system, and so that's where we're going to talk and focus today on some of the common pulmonary causes from airway kind of hyper-responsiveness, but also considerations for the oxygen transportation, so cardiac as well as blood or even anemia as a consideration for transporting the oxygen throughout that can cause increased respirations and fatigue. Working muscle considerations, structural considerations, we're looking at scoliosis, rib or chest pathology, as well as some psychological causes and kind of how to tease those apart potentially. So having an athlete come in with a complaint, I need to stop frequently to catch my breath, or maybe he's not performing as well next to his teammates or counterparts, and so that's when you're looking at the history and you want to really try to clarify these vague terminologies and ask some specific questions to fully understand the complaint, as well as find out what's going on with the exercise and kind of target a diagnostic plan. And so here is a a large slide with a lot of differential diagnoses to consider, and it's not meant to scare you, but just kind of to keep an open mind, and we'll talk about kind of each one of those considerations for causes we talked about. So first, again, the respiratory system that jumps to our mind, the common ones that we're going to go into a little bit more depth with the asthma, EIB, EILO, but also in this same airway path pathway, you want to think about pulmonary embolism, so especially if you have a female athlete who might be on birth control, cystic fibrosis, pulmonary fibrosis, COPD, again specific with the oxygen transportation systems, cardiac causes, so you want to ask specific symptoms about chest pain, palpitations or funny heartbeats, as well as if they have any dizziness, lightheaded syncope history, and then again the blood causes with common one being iron deficiency anemia, where you're not able to transport enough oxygen to meet the demand of your exercise. More rare cause with the working muscles, but if you have that early fatigue or myasthenia gravis, muscular dystrophy, and some mitochondrial diseases, and again with your physical exam looking at structural causes, so checking for scoliosis, if they have a large curve, kind of around 60 degrees or so, you start thinking about that pulmonary compromise, as well as pectus cavus, where the front of the chest might go in and again have some dysfunction with their breathing. We're also looking for any somatic dysfunctions around the rib cage can also be contributing. Deconditioning is also a consideration, it doesn't have to have a specific pathology underneath, but they might have, this would be kind of towards the end of exercise, you're having issues with your breathing, maybe even kind of some muscle fatigue associated with it, and then we always want to clue in to also psychological causes, because again there might not be a necessary pathology underlying, but this is where the history with key focus on questions to see does it happen all the time with exercise, is it just happening with competition, where there might be more stress, and you're okay when you're working out individually or practices, so good things to remember, and we'll talk about some of these with these specific history questions. I'm going to start with the open-ended questions to get a little bit more idea, see if they can describe or characterize what they're feeling a little bit better, so asking them to describe what their breathing feels like, and then are they having symptoms just with exercise, do they also have symptoms maybe at nighttime with other triggers, with seasonal changes or illnesses, what other associated symptoms they have with cluing in on those cardiovascular causes, again with the chest pain, palpitations, syncope, get into a little bit of timing specific, so how long into exercise do these symptoms start to appear, is it beginning in the first couple minutes when they really start the intense exercises, is it more when they're doing endurance, or is it just kind of at the end when they're overall fatigued or tired, and when they stop the exercise, how long does it take them to recover, is it immediate recovery and they're breathing normally again, does it take a couple minutes or even a couple hours or linger into the next day, and find out specific environments or maybe even triggers, so does it happen indoors versus outdoors, does it happen around any kind of seasonal or weather changes into the winter or the spring, the fall, and again to cluing in if there's any specific instances with does it just happen during games, does it happen during practice, or both, can kind of tease apart and really focus on some of the psychological aspects that may or may not be involved. And then moving on to the physical exam, so just one slide on this, I don't want to downplay because it's very important, but in things that we deal with that are exercise induced, a lot of times when we're seeing athletes or patients in the office, they're going to have a normal exam at that point, and that way you might be benefit if you are doing any sideline coverage, outdoor practices, or having very good communication with your athletic trainer that might be able to pull in some of that detail and clarification. But with this, starting with your head, eyes, ears, nose, and throat exam, you want to make sure that they have a patent NARES and pharynx, no obstructions you can see, no erythema or x-rays that might be kind of a viral illness consideration, and even checking for allergy or allergic symptoms, so if they have cobblestone in the back of their NARES, the allergic salute from kind of rubbing their nose up all the time and having a crease here, seeing if they have any kind of sinus tenderness or contributions for kind of above the airways. Making sure you're doing a thorough cardiac and pulmonary exam, so listening to the heart, as well as kind of with doing different maneuvers, whether it's a Valsalva, squatting, and standing. Obviously, listening to the lungs and doing a pulmonary exam from the front and back to make sure you're hearing good air flow throughout, they don't have any restrictions or any areas that you can appreciate might not be moving air or having that exchange as well. And the musculoskeletal exam that we talked about, make sure they check on their muscle tone, check for scoliosis, any kind of spine or rib cage pathology that could be there as well. And then when we hear these symptoms, a lot of times we want to jump to asthma. Asthma is very common, but these complaints do not always fit perfectly into asthma, and that's what we'll talk about some overlap in other considerations today. We want to make sure when we think this, and don't just throw inhalers at everyone, that can be kind of a gut reaction at time, but if you do that, make sure you're following up, because sometimes the medications can be overused, underused. We don't want to medicate people that we don't need to, but we also want to make sure we're treating them properly, because if they're doing the inhaler and they're using it properly and they're not getting better, you might want to think about the other causes that we talked about, not necessarily from a pulmonary standpoint. But with that in mind, asthma is very common, and so that's going to be our first one that we've discussed today. So asthma is defined as a complex lung disorder with multiple different characteristics. So it's variable, so it doesn't necessarily just have to occur with exercise. There can be other triggers and symptoms, and the symptoms kind of reoccur. A big component is it is reversible, and we'll talk about that with testing. So it's an airway obstruction, having difficulty with getting air out of your lungs with different medications that can improve and reverse our measurements, but underlying there is some baseline airway inflammation that occurs that contributes to the obstruction with getting the air out, as well as this bronchial hyper-response to a variety of stimuli, not just the exercise. And overall, it is a chronic disease that can be lingering and affect people for their lifetimes. So background a little bit. Asthma is thought to affect between 5 to 15 percent of the general population, with that exercise as being the most common trigger for these bronchial hyper-responsive events, somewhere in the range between 50 to 90 percent of asthmatics will be triggered by exercise. But there's also other calls that we want to be aware about, and that can be different stimuli, whether it's allergens such as pollen or pet dander, if you have any respiratory irritants, smoke, pollution, if you have any infectious disease, kind of wintertime with viral URIs that can cause this hyper-responsive to come, and then different environments that happens kind of in dry or cold air. Symptoms that people usually present with are going to be wheezing, tightness down in the chest, they might have some coughing. It's important to differentiate again because it's a variable condition, doesn't always happen with exercise. Nighttime symptoms can be a big trigger for kind of this hyper-responsive to any symptoms in athletes and patients, and then because it is reversible, knowing that it can improve with bronchodilator. So if you do use that as your first line measure for treatment before diagnostics, making sure they are improving and doing better with that. So the diagnosis really triggers on three things, your history and physical, doing pulmonary function tests, and exclusion of any alternative diagnoses that we kind of covered with other lung or cardiopulmonary considerations. So with the testing that you do, the pulmonary function tests are the mainstay for the diagnosis and checking in, and spirometry is being the primary source of that. And when you're doing the spirometry, there's two different categories that you're looking at. One is your forced vital capacity, or FBC, and this is how much breath you can expire from your lungs after taking a maximal inspiration. And then you're comparing that with your FEV1, or forced decadal volume within one second, and this ratio we'll look at for the airway obstructions at the bottom of the screen, is you're looking at your FEV1 over your FBC, and this kind of tells you the percent of air that's emptied totally within the body within that first second that you can really expel out hard on your own. And if this is less than 80% of predicted, that's when you want to consider obstructive airway causes with asthma being one of those. And here's a picture, most people might be familiar, but you kind of have this this tube attached to a monitor that's measuring the airflow, how much you can totally breathe out, as well as how much is captured within that that first second. In spirometry, the results we get will come up in a flow volume loop, which are down at the bottom here, but to have the diagnosis for asthma, because it again is a reversible condition, so when we give a bronchodilator, such as the Saba or the short-acting beta agonist, your albuterol inhalers, you want to see an improvement of 12% with that FEV1. So you want to see a 12% increase in volume can expel from your lungs within that first second. And so when we look at the two graphs on the bottom, the one on the left has volume over time. So if you look over at the x-axis for that first second and compare going up, you can see that the pre-bronchodilators on the bottom and the post-bronchodilators on the top, and see that there is an increase in that total volume that's been expelled in that first second. And for this, it's labeled as 13%, which would be consistent with that asthma. And then we have the loop, so you have flow over volume here. And what they're pointing, I'm assuming is around the first second, and you're looking at the total area under the curve here for that kind of volume that's expelled. And again, the higher curve here being that post-bronchodilator phase, and seeing that more air and volume was expelled in that first second. So being able to be familiar with those charts, as well as really knowing, especially for testing, that greater than 12% increase in your FUV1 after a bronchodilator when doing spirometry is consistent with an asthma diagnosis, if that's on your differential. But spirometry can be equivocal sometimes. And if you still have a strong suspicion that the athlete or patient has asthma, there are some alternative diagnostic testing that we can do. This one is called methylcholine challenge test. And this uses mucochronic receptors to trigger smooth muscle contraction within the bronchioles and the airways. And this is supposed to trigger kind of that hyper-responsive event, and kind of cause that airway obstruction with breathing out. And here, again, you're looking at that forced expired volume within one second, and you're expected to see a drop of more than 20% in individuals with airway hyper-responsiveness. So when we talk about this test, it's very sensitive, because it's very likely that individuals with asthma will have a response and have this reduction. But it's not very specific, because we're still having an irritant into the airways. So people that even don't have underlying asthma might still develop a hyper-responsive constriction just because of the medication. So it's not as sensitive, and will pick up people that don't necessarily have asthma, but still have a positive test. We go next, we kind of look at the overview here. And this kind of takes you through the flow chart, starting with your concern for asthma, and then obtaining your pulmonary function test with the baseline numbers that we talked about. One thing that is added on here that they talk about, again, if you're having kind of equivocal diagnostics tests, is some people will use peak flow volumes. And they'll test this about three times a day, morning, afternoon, and evening, over a two-week period, to see how much variability someone might have with their peak flow. And again, with asthma, we talk about, you know, sometimes being fine, sometimes having these exacerbations, and then this fluctuation in how much you can expel within the peak flow. So if that is positive with greater than 20% variability, then you can diagnose asthma just with those testing. So again, the big numbers to remember for testing, if you're doing the spirometry, post-bronchodilator, and a more than 12% increase in your FEV1, versus if you're just checking variability with peak flows over a two-week period, greater than 20% variability. And again, 20%, if you're doing the methylcholine challenge test, where you'll see a drop in your FEV1. So really knowing about the FEV1 and having those numbers in your mind can be helpful. And moving on to how asthma is classified. And this is done by symptom frequency and exacerbations. So there's four different classifications, with intermittent, mild persistent, moderate persistent, and severe persistent. A lot of times people get confused, and a lot of tests try to differentiate by giving a vignette between the intermittent and mild persistent symptoms, and that's where the rule of two comes in. So for the intermittent asthma classification, you're going to see less than two symptoms less than two days a week, as well as nighttime symptoms less than two times a month, compared if you advance to the mild persistent, then it's going to happen more than two days a week, more than two nights a month, and you're going to be using your albuterol or controller inhaler a little bit more. But then when you start talking about daily symptoms, or one night a week of having nighttime symptoms, is when you move into the moderate persistent category. And this is with the daily symptoms, you might be using your albuterol or rescular inhaler every day. And then the last category is the severe persistent, and this is happening throughout the day, frequent kind of even nightly symptoms of asthma, and you're kind of needing more help than you can get just with the albuterol, and sometimes even controller medications. So again, having this classification in mind, remembering the rule of two, specifically for the intermittent and mild persistent symptoms, and another two that is thrown in there at the bottom of the screen, is if you do have more than, despite what your symptom classification is, more than two exacerbations in a year that require oral steroids to help control, you fall into the at least mild persistent category. And with that, when we talk about asthma treatment, it's usually broken into two different levels with relievers, which is your short-acting beta agonist, and that's usually your albuterol inhaler with the brand names kind of Ventolin and Pro-Air versus, and those are just used as needed when symptom develops, or sometimes people, athletes will pre-medicate before exercise, compared to your controller medicines that you might be using every day. The first one usually being those inhaled corticosteroids, so Flovent, Pulmicort, Q-Bar are common ones. If you need to escalate from that, there are the long-acting beta agonists, but you want to be clued into this and a common question, you don't want to use a LABA or a long-acting beta agonist as monotherapy. Studies have shown that it actually increases your risk for acute exacerbations if it's used alone, so if you are considering using a LABA medication, make sure they have another controller medication, typically inhaled corticosteroid with that, because the combination of those two is safe and effective. Other medication considerations are the Leukotriene modifiers. This is a good bridge for those asthmatic athletes that also have some allergy symptoms, because it helps kind of control both of those, so Montelupast or Singulair is an example of that, and if you do need additional medicine on top of this, sometimes long-acting anti-muscarinic inhalers are beneficial to decrease some of that smooth muscle contraction and hyper-responsiveness that contributes to the airway obstruction, and so when we talk about how do you treat, which inhaler do you usually choose, there's this nice kind of six-step continuum that you can reference and use, and the steps typically go through at least at the beginning, correlate well with the symptom classification, so with step one just being your albuterol or short-acting beta agonist inhaler as needed, and that's consistent with the intermittent classification. When you move on to the mild persistent classification, you're jumping up to kind of step two, and that's when you might add on a low-dose inhaled corticosteroid, and this will be, again, that daily controller medication in addition to using the albuterol inhaler as needed. If that's still not getting you enough control, you move on to step three, and then you talk about either increasing the dose of the inhaled corticosteroid you're on or adding on a dual therapy, and that's when you can add on that long-acting beta agonist because you're using it in conjunction with the inhaled corticosteroid. Moving on from there, if you do need to go to step four and that's still not giving you enough control, that's when you're talking about like the leukotriene receptor antagonist and other medications. If you do get up to step five and six and having a really difficult time of controlling it, that's when you might want to get a referral to a pulmonologist because there are some different immune modifiers that people can use that have been shown to help with the difficult-to-control asthmatics. But in all of this, remember that it's not this is your classification, this is your treatment. It is a continuum. Depending on exercise level, the seasons, people's symptoms are available, will be variable. So checking whether it is every three months or so, seeing what their symptoms level are. If they are controlled, not having exacerbations, can you stay at that level or can you de-escalate and lose a medication and kind of reassess after that? Or if they're still describing symptoms and you don't feel they're very well controlled, moving up to that next step. So it's not like someone is pigeonholed into a specific treatment plan for the year or for their lifetime. It should be a fluid situation that you're constantly assessing and checking in with their asthma action plan. Going on to that, and the last thing I wanted to talk about with treatment is education with that continuum. So whether it's the athletes, parents, even coaches, school, all know. And having a physical asthma action plan is very helpful when it tells you, hey, these are my symptoms. These are why I don't feel controlled. What can I do or what are the next steps that I need to take is very helpful in having that education piece. So the athlete, as well as those who are involved and care for the athlete, are aware of and can help facilitate. But you also know kind of those next steps, what might be your triggers, and how to manage your symptoms and condition a little bit better. And then moving on to exercise-induced bronchoconstriction. And so we have this chart here to show that there is a lot of overlap between the two conditions. They are both kind of bronchial hyper-responsive diseases and they can happen in tandem or coexist together, but also people can have asthma as an individual entity, as well as EIB as an individual entity. And there'll be differentiations that we can talk about. Main ones being asthma, again, is a variable condition and can happen outside of just exercise. And there is a baseline inflammation that's associated with it versus the EIB is really just associated with exercise. So at baseline, they will have normal pulmonary function, normal lung volume, but when they exercise, that's when they can get those symptoms and get kind of those decreases. And so we talk about definition of exercise-induced bronchoconstriction is acute airway narrowing that occurs as a result of exercise. So this is transient and reversible as well, but exercise is the only trigger for this. And again, it can occur in individuals without asthma. So it is its own standalone entity. And we'll talk about kind of the workup as well as treatment for prevalence. So again, they can coexist together a lot between EIB and asthma. And it's thought that up to 90% of asthmatics have exercise-induced bronchoconstriction, which makes sense with exercise being the most common trigger for these hyper-responsiveness in asthmatics. In the general population, the prevalence is thought to be somewhere between 5% to 20%, but it has been studied and found to be much higher in elite athletes, especially with Olympic athletes, prevalence, a wide range, but somewhere between 30% to 70% and highest in kind of these winter athletes and swimmers, which we'll talk about now in the environments that they live in. So a couple of different studies that tried to differentiate the prevalence. So around 30% of people that looked into ice rink athletes. And again, this is in an indoor environment. There's gonna be dry air. There may even be kind of pollutants or different triggers, whether it's the Zamboni machine or kind of machinery in that's within the closed environment. When we talk about swimmers, they're also in this enclosed environment, especially during the winter months, but even the pool, the treatments that we have with different chlorination products can trigger some of the pathology that we will talk about. And studies have found somewhere between 11% to 29% of swimmers had this condition. Again, we talked about Nordic skiers as well as distance runners. So now we're getting into some endurance population. And these are people who might be outside for long periods of time, as well, especially with the Nordic skiers and kind of the winter cold environments, that air can be a big trigger to have these hyper responsive events. And we'll talk about the pathophysiology with this, but these higher level athletes, and the thought is they are exerting themselves very much to an elite level. And this kind of triggers the increase in ventilation as well as the pathology postulated to be contributing to the exercise and induce bronchoconstriction. So here, when we talk about the proposed pathology, it's thought that with this increase in minute ventilation, you're having more air and heat exchange within the bronchioles. And this causes a change in your osmotic gradient and can kind of lacer injure cells, which then releases inflammatory cascade and mediators that trigger smooth muscle and kind of obstruction within the airways. So then it becomes difficult to breathe that air out. And with this different irritants that we talked about, whether it's in the indoor ice rink environments, in the swimmers with the chemicals, or even those kind of endurance outdoor athletes that might be running within the cities with pollutions, poor air quality might be additional triggers along with the thought of this dehydration of the airways. Because when you're breathing, again, with the rapid exchange, you're pulling in a cold or dry air within kind of the warm, moist environment of your bronchioles. And this causes a big kind of, again, heat and water exchange that can dehydrate, injure the cells and start this cascade of obstructions and developing symptoms for the athlete while they're exercising. So presentation can be quite similar to asthma. And that's why just focusing on the subjective symptoms is not always the best and clue into what's going on. And we'll talk about the diagnostic workup for this, but whether it's wheezing, chest tightness or pain, cough, and talked about a locker room cough that's just kind of, I just get this cough after I exercise. I go home, I don't have it anymore, doesn't bother me, except after my exercise periods. Shortness of breath, increased mucus production that happens with the passive physiology and kind of cell injury we talked about. And then over the more vague complaints being lower exercise tolerance or decreased performance. And then with this, the clue, and we get back to history and asking about the different timing and occurrences that happen, because the exercise induced bronchoconstriction has a fairly consistent presentation with people. And so when we talk about the timing, whenever you get into a more intense exercise, symptoms usually begin two to five minutes after that brief intense exercise. We'll peak about 10 minutes, but then when you stop or calm down with your exercise, everything resolves kind of, usually typically within 60 minutes, but can go up to 90 minutes post activity. And that's what we talk about kind of the locker room symptoms or cough, but when they would kind of leave that environment getting better. And again, this is a concern a lot for athletes in our care because this causes a decrease in performance and might actually cause people to avoid these high intense activities because it triggers the symptoms. So they might be finding alternative sports or other activities. And so the diagnosis with this, just going on symptoms alone is typically not enough. So we want to make sure there are some diagnostic ways that we can pinpoint and confirm this as our diagnostic. And these are the objective measurements that we're going to talk about. Again, the FEV1 or forced expiratory volume within one second is a big classification. Like we talked about with asthma, that will help diagnose our EIB and it shows to have better repeatability than some other tests. We talk about the variability with asthma and using those peak flow rates at different time points during the day, not as successful with this condition because it only again happens with exercise. So usually baseline lung function and peak flows will be normal when they're not kind of exercising or having that trigger. And the number that we look for this diagnosis is greater than a 10% decrease in your FEV1 within 30 minutes after exercise. And we'll talk about the diagnostic testing for this now. The main one which I think intuitively makes sense is an exercise challenge test because this is the trigger for the exercise induced bronchoconstrictions. So you can see at the picture on the below here, it does involve some equipment. So usually people are exerting themselves, whether it's on there's different protocols for on a bike, on a treadmill, on an ergonometer, but you're hooked up with this mask that's again giving this dry air and it's about should be consistent around 5% of CO2 or carbon dioxide. As we think about that dry air, going back to that water and heat exchange within the bronchioles being the root cause of that pathophysiology. And so when you do this, you're gonna very quickly increase your exercise to get to an intense activity. While you're doing this, you're breathing and everything to the mask and you're hooked up to a computer screen where you can test the spirometry and your numbers again. So you're gonna have your baseline value and that's gonna give you your baseline FEV1. The main goal in doing this exercise is to increase that baseline to around 17 and a half to 21% higher. And you're gonna try and sustain this for four to six minutes. And after doing that, you're going to test your FEV1 at five, 10, 15, and 30 minutes after activity. And with those test things, you wanna see two different measurements of your FEV1 decreased by more than 10% to solidify the diagnosis of EIB. But as you can imagine, getting up to 20 times your FEV1 baseline and doing that for six minutes is very demanding because you'll have, it's very challenging to do that. But again, goes into that quick intense activity to trigger these symptoms and see what happens when you stop exercise to check those FEV1s and compare and contrast to the baseline. If you don't have the exercise testing and the cardiopulmonary exercise testing available, there are some surrogate testings that has been accepted. The most common one is something called eucapnic voluntary hyperpnea or EVH. And this is a similar test, but instead of actually having the athlete or individual exercise, they just use hyperventilation as the trigger. So again, with this, you're hooked up to a mask and you have your computerized readings to have your FEV1 measurements to compare. But this time again, you're breathing in that dry air with 5% carbon dioxide and you're gonna hyperventilate yourself for six minutes. And your goal from comparing your baseline FEV1, you're gonna try and ventilate 22 to 30 times your baseline. So you're gonna imagine, again, there's no exercise involved with this, but you're gonna be sitting there and really high ventilation rate for six minutes. So that's very demanding and that causes a lot of that air exchange and it's in a very controlled environment because you have that mask with the dry air. And you're gonna see again, if this triggers that bronchial hyperresponsive just with that ventilatory exchange. And after doing this, you're gonna check your spirometry, one, three, five, 10, and 20 minutes afterwards. And again, you're looking for a greater than 10% decrease in your FEV1 after doing this intervention with the hyperventilation. And studies have shown that this is very reproducible, it's well standardized, and this is a diagnostic test that the IOC or International Olympic Committee will accept for EIB. And that becomes an important part we'll talk about with different medications that the athlete might be prescribed to be treating with this. And especially it's important that the IOC has this in their differential because we saw before the prevalence, these elite athletes, these Olympians, there seems to be a higher prevalence. So making sure they're properly diagnosed as well as treated so they can perform at their highest level. So here's again, looking at the flow chart of the eucapnic voluntary hyperpnea protocol. And we just talked about the single step protocol over here. I like this chart because it does also give some guidance. If you are medicated before going through this diagnostic testing, it gives you the timeline, whether it's hours or days that you need to be off medication to get the best result and reproducibility with this challenge. But also people who might have asthma associated with this, other pulmonary or respiratory conditions, there is a step protocol that uses a lower percent of your maximal voluntary ventilation. That's what the MVB over here is for. Starting at 30%, 60% and 90%, going up as the athlete or patient tolerates and rechecking those spirometries with the same baseline numbers of seeing a greater than 10% decrease in the FEV1. The severity here again is based on FEV1, mild being between 10 to 25%, moderate 25 to 50% and severe greater than 50%. But there is a caveat to the severe if they are premedicated with corticosteroids, which is one of the treatments. There's a more than 30% decrease in the FEV1 that can also be characterized into the severe category. With that, there's some other tests that aren't necessarily involved with that ventilation or exercise. These ones are not really as reproducible and accepted, but it is breathing in some hyper osmolar solution to again, trigger that bronchial spasm result to obstruct the airway, as well as kind of after exercising, checking if there's any elevated nitric oxide that's being inhaled. And these again are not, are talked about briefly, but not really diagnostic and accepted to confirm the diagnosis of EIB. And we talk about treatments. Again, education about this is a big component because a lot of times people, as long as they know, figure out their triggers, they can modify their activities and perform well without any specific medication interventions. And this is really talked about doing interval or sprint activities before you have a practice game competition. Doing this, figuring out how long it takes you to do, if I do intense exercise or sprint training, 10 to 15 minutes in that activity, I'm gonna have these symptoms come on. And then if I stop the activity, we'll get better 20 minutes, an hour. But knowing that, because a lot of times people will go into a refractory period for about two hours after having that initial insult, where as long as they can plan that time and have that happen, they can go into their competition knowing that they're not gonna have a trigger to these symptoms and have a fine performance moving forward. Especially with the pathophysiology thought with the dehydration of the cells, as people warm up and exercise, there is a thought that using a mask to kind of warm or humidify the air, that we might kind of have a better idea now with what we're doing with the coronavirus and our mask lies, but you can kind of feel how warm that air gets and might limit kind of the heat exchange that happens down in your bronchioles to stop that obstruction and inflammatory cascade from happening. But this is a weaker recommendation compared to that interval training for the refractory period. Other weaker recommendations here at the bottom are some dietary modifications, whether it's a low salt diet, fish oil, or other anti-inflammatories or something you can try, but don't have a lot of recommendation behind them. When you get to the pharmacologic or medication treatment for EIB, the initial and mainstay is using that short acting beta agonist before exercise. It's just like asthma, kind of using it as needed. And there's a strong recommendation and good evidence that this is beneficial. But it works for two to four hours. So planning around the timing. And if you start using it too frequently, you can get taxiflaxis, which is where you build up a tolerance to the medication and it no longer helps dilate the smooth muscles. And it's not as effective. So even though you're using the medication, the symptoms can still occur. And that's when, if that is happening, you feel you're using it daily or very frequently, making sure you're adding on a more of a controller medication. And that's when we talk about, again, the inhaled corticosteroids being a strong recommendation to start as the controller medication in addition to the albuterol as needed. The long acting beta agonist can also be used, but again, not as monotherapy for this. Leukotriene receptor antagonists are also helpful for this condition, as well as more of the mast cell stabilizing agents like Cromelin can be used as needed before exercise to limit the mast cell trigger for that inflammatory response. So those are all important things to remember with the recommendations attached to counsel your athletes if doing the non-pharmalogic measures are not enough. And here is a lot of what we talked about in a chart or picture form for reference later on. And that covers the asthma and EIB. Also wanted to touch very briefly on exercise-induced laryngeal obstruction. This is sometimes commonly confused with vocal cord dysfunction, but that's not as much of an inclusive term. The vocal cords are part of the larynx and they can have the dysfunction, but a lot of times it'll actually happen higher up in the supraglottic airways and not necessarily affect the vocal cords. So having EILO is a more inclusive and maybe a better terminology for the exact pathophysiology going on, but it's defined overall as abnormal closure of your supraglottic or glottic levels of the larynx. This typically happens during inspiration. So sometimes you can trigger out from the history that asthma and EIB will be an obstructive airway disease where it's difficult to get air out. This is more restrictive where you're having a hard time with inspiration or getting air in. Backgrounds thought to be around 5% of the athletic population. And again, this can happen, co-exist with asthma or EIB or be its own solo entity as well. It's more common in females and the thought behind that is they have shorter, more narrow larynxes that might kind of contribute to the paradoxical closing, which happens in this picture, again, focusing on the vocal cords, but usually when you're breathing in, normally the vocal cords should abduct or open up so that air exchange can happen. But for this, for a reason, they are paradoxically closed and really limit that air exchange. There's also more common in adolescents as well as type A personalities have been having a higher prevalence of this. Presentation of shortness of breath. Here they might have the inspiratory strider where they're breathing in and having a hard time and differentiating from the breathing out conditions. Shortness of breath, they might instead of the chest tightness, more tightness up in their throat, have a choking sensation, or even described as transient dysphonia or change vocal cord or voice changes whenever they're symptomatic. The timing of this is important because that can help differentiate what might be going on. Again, with exercise-induced bronchoconstrictions, it's most severe five to 10 minutes after having that intense exercise, while EIL will occur during exercise and will quickly resolve usually within five minutes once you stop exercising. Again, doing a quick look at flow volume loops. We talked before about the expiratory causes of the one on top peaking. And now for this, because it's more of an inspiratory pathology, the below curve or a convex shape of a normal inspiration is really blunted or flat because you're not getting as much air through that obstructions that's happening within the larynx. So it's much shorter and you can see those pictured and sometimes on tests and CAQs as well. So the diagnosis of this is direct visualization of everything going on. So people will do a continuous laryngeal endoscopy or exercise-induced laryngeal scope, where they'll have this fancy contraption down at the bottom of them, where they'll actually have the laryngeal scope go through their nares down to the larynx where they can visualize everything going on. And it's attached to the head so they can still move, run, exercise to induce the triggers. And you wanna make sure you're looking at kind of the supraglottic, glottic and subglottic levels to see where the pathology really going on, if it's happening when they're breathing in, where they're breathing out and how long it happens into and after exercise. So this can give you, it's a difficult test, can be hard to find, but can give you a lot of good information. The treatment for this is really focused around kind of speech and behavioral therapy. So doing a lot of larynx exercise and strengthening, diaphragmatic breathing. Sometimes people will try neuromodulating medications such as gabapentin or Lyrica. Supraglottic injections like Botox has also been tried to stop that closure abduction of the larynx from happening. But really the breathing process, visualization, psychotherapy to get some biofeedback control is helpful for these athletes and treat the condition. With that, you also want to, with all of these conditions consider allergies as a complicating etiology as well. And whether they're gonna have sinus tenderness, congestion, eustachian tube dysfunction, you can treat this as well. Recommending nasal saline rinses to clear out any kind of pollutants, irritants that might be in the sinuses as well as antihistamines to help treat. Overall take home points is make sure you're taking a good history for sometimes these vague complaints and the more specifics you can get, especially within those exercise timing can help pinpoint the pathology that might be going on and work up the evaluation and diagnostic testing. Diagnosis for these because symptoms are so similar is very unreliable. So making sure that you can confirm with objective testing that we talked about. And it's important to be able to identify these so we can properly treat them and get the athletes back to their wellbeing as well as their performance. And knowing that asthma and exercise induced bronchoconstriction are not the same entity and can happen together as well as on their own. And the diagnosis are really based on FEV1s with asthma being greater than 12% increase after a bronchodilator and EIB being a decrease greater than 10% within 30 minutes after stopping exercise. So that brings the end to my talk. So thank you for entertaining me and I hope it was helpful and educational. Reach out to me individually with my email as well. And I think we're available for some questions afterwards as well.

2nd Edition, CASE 43

2nd Edition

Pulmonary

exercise-induced dyspnea

non-emergent airway causes

asthma

exercise-induced bronchoconstriction

exercise-induced laryngeal obstruction

athletes

diagnosis

treatment