Emotional Burden of Exercise-Related Respiratory Symptoms in Patients With Asthma:
What the Specialist Should Know
Authors: Gene Colice1, Timothy Craig2, Nemr Eid3, Stuart Stoloff4, Marylou Hayden5,
1Washington Hospital Center, Silver Spring, MD
2Pennsylvania State University, Hershey, PA
3University of Louisville, Louisville, KY
4University of Nevada School of Medicine, Reno, NV
5University of Virginia, Charlottesville, VA
6Ohio State University Asthma Center, Columbus, OH
Gene Colice, MD
Washington Hospital Center
110 Irving Street, NW
Dept. of Medicine
Washington, DC 20010-2975
Exercise-related respiratory symptoms in patients with asthma are associated with a high emotional and psychological burden of disease. Such symptoms also have a negative impact on quality of life compared to patients with asthma who do not have these symptoms. Physicians who treat patients with these symptoms should be aware of, and be able to recognize, the emotional toll exercise-induced symptoms take on these patients. Therefore, health care providers should understand the importance of proper management of asthma in preventing and/or controlling these symptoms. We present a case scenario of a patient with asthma and exercise-induced bronchospasm (EIB) who exhibits the emotional and psychological disturbances associated with the condition. The emotional burden of EIB is discussed with regard to clinical presentation in order to increase awareness of the spectrum of symptoms that may be observed beyond those related to the respiratory system.
A 37-year-old man with a history of asthma returned to his pulmonary specialist for routine follow-up. The patient had been using a medium-dose inhaled corticosteroid (ICS) with good overall control of his symptoms. His asthma control test score was 22. He had needed his short-acting inhaled beta2-agonist (SABA) on a rescue basis less than one time per week. However, he reported difficulty with exercise. About 6 months ago, because his asthma was so well controlled, he had started to train with a group of friends for a half-marathon. Unfortunately, he found that he could not keep up with others during the training runs, especially in cold weather. On occasion he had experienced difficulty breathing, chest tightness, and cough during the runs. A few times these symptoms were so severe that he could not finish his training run and the other members of his group had to drive back to pick him up. This left him feeling frustrated and embarrassed. Three months ago, just after completing a training run, the patient developed such severe chest tightness and shortness of breath that he required a trip to an emergency room. After nebulized albuterol, his symptoms rapidly improved. The patient admits not taking his SABA prior to exercising.
The patient reported that he recently lost interest in running. He felt tired most of the time and seemed to need more sleep. He has no past medical history or family history of depression. Baseline spirometry was normal but a pulmonary exercise study documented a 25% decline in forced expiratory volume in 1 second (FEV1) following exercise. The pulmonary specialist noted that asthma control was satisfactory but EIB was limiting exercise and may have been contributing to feelings of depression. The pulmonary specialist emphasized the value of using a SABA prior to each training run to prevent EIB. At post-evaluation 1 month later the patient is routinely using his SABA prior to exercise and notes that he can now keep up with the others in long-distance runs and feels better in general.
Diagnosis of EIB
Assessment of patients with suspected EIB should include a detailed history, physical examination, and assessment of lung function before and after the administration of a SABA (Weiler et al, 2007). Unfortunately, history alone might not be a reliable tool for diagnosing EIB because exercise-related respiratory symptoms can easily be confused with vocal cord dysfunction (US Department of Health and Human Services, EPR-3 Guidelines, 2007). Furthermore, common differential diagnoses when a young adult patient complains of shortness of breath include asthma and other pulmonary diseases, cardiovascular disease, obesity, poor conditioning, and dyspnea due to anemia. To confirm the diagnosis of EIB, exercise challenge should be considered. Exercise challenges can be performed either in the laboratory or in the setting that has previously caused the symptoms (EPR-3 Guidelines, 2007). According to the Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma (EPR-3 Guidelines), EIB is defined as a 15% decrease in peak expiratory flow or FEV1 compared to baseline, following physical exertion that increases baseline heart rate to 80% of maximum for 4-6 minutes (EPR-3 Guidelines). However, guidelines such as those of the American Thoracic Society (Crapo et al, 2000), the European Respiratory Society (Carlsen et al, 2008), and the American Academy of Allergy, Asthma & Immunology Exercise-Induced Workgroup (Weiler et al, 2007) define a 10% decline in FEV1 as the threshold for an abnormal response. This definition of EIB is commonly used in practice. The presence of accompanying symptoms (eg, cough, wheezing, chest tightness) strengthens the diagnosis (Weiler et al, 2007). It is also important to monitor pulmonary function for at least 30 minutes after the completion of exercise to ensure that delayed declines in FEV1 are not overlooked (Weiler et al, 2007).
Effect on Quality of Life
Patients with asthma and EIB can have a decreased quality of life that is not attributable to physical limitations alone. Although there are limited data published on the impact of asthma and EIB on quality of life, the disease has an impact beyond the physical, with impairments manifesting as emotional and psychological symptoms. In one study, adolescent athletes with a prior physician diagnosis of asthma and those with dyspnea during exercise had lower health-related quality-of-life summary scores, and lower physical functioning, general well-being, and emotional functional domain scores compared to those without a prior diagnosis (Hallstrand et al, 2003). No differences in health-related quality-of-life scores were observed in those with and without spirometrically diagnosed EIB, although the sample size may have been too small to detect a difference (Hallstrand et al, 2003). Other studies have shown that there is a significant correlation between respiratory symptoms and psychiatric symptoms (eg, depression and anxiety) (Rimington et al, 2001; Di Marco et al, 2010).
The recent EIB Landmark Survey (Strategic Pharma Solutions, 2009; www.eiblandmarksurvey.com) has also demonstrated that patients with asthma who experience exercise-related respiratory symptoms experience a significant burden of disease. This includes not only limitations in physical activity but also emotional and psychological disturbances. The survey included a national sample of 1001 adults and 516 children aged ≥4 years diagnosed with asthma, and who either had asthma symptoms in the past 12 months or who were taking medicine for their asthma (www.eiblandmarksurvey.com p 1). In those with one or more of six exercise-related respiratory symptoms (coughing, shortness of breath, chest tightness, wheezing, noisy breathing, and trouble getting a deep breath), emotional disturbances were two to four times more commonly reported than in those without symptoms of EIB (www.eiblandmarksurvey.com Fig 29). Specifically, over half (52%) felt frustrated, 25% felt fearful, approximately one-fifth (19%-21%) felt depressed or embarrassed, and 13% to 15% felt isolated or alone (www.eiblandmarksurvey.com Fig 29). As a result of these symptoms, approximately twice as many patients with asthma with exercise-related respiratory symptoms or those diagnosed with EIB indicated that their symptoms interfered “a lot” or “moderately” in their life compared to those with asthma but without exercise-related respiratory symptoms (28%-30% vs 9%, respectively) (www.eiblandmarksurvey.com Fig 25). In addition, patients with exercise-related respiratory symptoms were twice as likely to report a decreased ability to keep up with other persons their own age in physical activities compared to those with asthma but without exercise-related respiratory symptoms (39%-40% vs 19%, respectively) (www.eiblandmarksurvey.com Fig 26). Further, the study found that higher proportions of patients with exercise-related symptoms stated that fear of exercise-related symptoms keeps them from exercising regularly (26% vs 8%), that they avoid physical activities that could trigger an asthma attack (38% vs 16%), or are afraid to exercise too vigorously (43% vs 15%) compared with asthma patients with no exercise-related symptoms (www.eiblandmarksurvey.com Fig 31).
The EPR-3 Guidelines indicate that patients with asthma should be evaluated for effects on quality of life and symptoms of depression since these manifestations can impede the successful management of asthma (EPR-3 Guidelines). This includes any reductions in usual activities such as recreation and exercise. A decreased ability to function physically has a particularly large impact when patients are unable to engage in activities that are pleasurable and meaningful (EPR-3 Guidelines). Thus, it is recommended that clinicians routinely inquire whether asthma has caused the patient to reduce his or her usual activities (EPR-3 Guidelines). Although no specific recommendations are provided in the guidelines for the evaluation of depression in patients with EIB, consideration of an evaluation in these patients is prudent because the presence of depression may impair the ability of patients to self-manage their disease and may even indirectly affect clinical outcomes (EPR-3 Guidelines).
Prevention of EIB should include both premedication and warm-up calisthenics and stretching (Weiler et al, 2007). Warm-up should last 10 to 15 minutes with a goal of reaching 50% to 60% of maximum heart rate (Weiler et al, 2007). The EPR-3 Guidelines also recommend the use of SABAs as the therapy of choice for the prevention of EIB. These agents are recommended because they relax airway smooth muscle and produce an increase in air flow within 3 to 5 minutes of administration (EPR-3 Guidelines). Although effective, the frequent or chronic use of long-acting beta2-agonists (LABAs) is discouraged for the prevention of EIB because they have the potential to disguise poorly controlled persistent asthma (EPR-3 Guidelines). In addition, the duration of protection against EIB with LABAs decreases with regular use (EPR-3 Guidelines).
The EIB Landmark Survey was conducted by the national public opinion research organization Abt SRBI Inc, in partnership with Strategic Pharma Solutions, LLC, and was sponsored by Teva Respiratory, LLC. The authors wish to acknowledge the technical and editorial support provided by ApotheCom.
1. Carlsen, K H, Anderson, S D, Bjermer, L, et al; European Respiratory Society; European Academy of Allergy and Clinical Immunology. (2008) Treatment of exercise-induced asthma, respiratory and allergic disorders in sports and the relationship to doping: Part II of the report from the Joint Task Force of European Respiratory Society (ERS) and European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN. Allergy. 63(4), 387-403.
2. Crapo, R O, Caaburi, R, Coates, A L, et al. (2000) Guidelines for Methacoline and Exercise Challenge Testing – 1999. This official statement of the American Thoracic Society was adopted by the ATS board of directors July 2, 1999. Am J Respir Crit Care Med. 161, 309-329.
3. Di Marco, F, Verga, M, Santus, P, et al. (2010) Close correlation between anxiety, depression, and asthma control. Respir Med. 104, 22-28.
4. Hallstrand, T S, Curtis, J R, Aitken, M L, et al. (2003) Quality of life in adolescents with mild asthma. Pediatr Pulmonol. 36, 536-543.
5. McFadden, E R Jr, Gilbert, I A. (1994) Exercise induced asthma. N Engl J Med. 330, 1362-1367.
6. Rimington, L D, Davies, D H, Lowe, D, Pearson, M G. (2001) Relationship between anxiety, depression, and morbidity in adult asthma patients. Thorax. 56, 266-271.
7. Strategic Pharma Solutions LLC with Abt SRBi Inc. (2009) Exercise-induced bronchospasm (EIB): a landmark survey of asthma patients, general public and healthcare providers. Available at www.eiblandmarksurvey.com. Accessed June 24, 2009.
8. US Department of Health and Human Services. (2007) Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, Maryland: NHLBI Health Information Center; 28 August.
9. Weiler, J M, Bonini, S, Coifman, R, et al. (2007) American Academy of Allergy, Asthma & Immunology Work Group Report: exercise-induced asthma. J Allergy Clin Immunol. 119, 1349-1358.
Supported by Teva Respiratory, LLC
Colice: Research/consultant, Teva
Craig: Speaker, Teva
Eid: Speaker/consultant, Teva
Stoloff: Research/consultant, Teva
Hayden: No relationships to report
Parsons: Consultant, Teva