Commentary
Childhood asthma and exercise
Daniel Hughes MD FRCPC
C hildren with asthma, similar to most children, enjoy being
physically active, participating in school physical education
activities, sports, or even just after-school and weekend games.
Some of these activities provoke respiratory symptoms in the asth-
matic child, a complaint not infrequently heard in the offices of
primary care physicians and paediatricians. Occasionally, this is
the initial presenting symptom in a child not previously known to
have asthma. When physical activity causes symptoms in an asth-
matic child, cough and dyspnea are the most common complaints,
with chest tightness being a close second. Wheezing is mentioned
less often, even when specific inquiries are made.
Exercise is likely the second most common trigger of asthma
(after viral respiratory infections); however, it is often overlooked
unless carefully sought. Symptoms may first appear when the child
participates in gym activities in school. After establishing that the
school-age child participates in gym classes, the best question
directed to the child from the physician is, “What happens when
you run fast around the gym?”. The parents often express surprise
when the child answers, “I cough”. The child may mention short-
ness of breath, chest tightness or difficulty “breathing air in”, which
limits their activity. Tightness in the throat may suggest vocal cord
dysfunction (VCD). Parents are typically not aware of the child’s
respiratory symptoms in the school gym. Further inquiry may reveal
symptoms associated with activities at home or with sports.
For the older child, the association between exercise and res-
piratory symptoms becomes clearer. The activities that provoke
these symptoms are, quite predictably, those causing prolonged,
rapid breathing. Typical examples are distance running and soccer.
For some children, figure skating, ice hockey, cross-country skiing,
paddling, cycling and dancing can be problematic. Activities that
rarely cause symptoms include volleyball, downhill skiing, softball,
baseball and taekwondo. These activities do not require pro-
longed, rapid breathing. Be aware that running laps around the
field before a ball game or the gym before taekwondo may provoke
asthma symptoms. Certain activities have a variable effect, such as
basketball – which is usually not a problem for the younger asth-
matic child, but which may be troublesome for the older, more
competitive player (especially when, as one of the better players,
the score is close and the coach leaves them in the game).
Gymnastics can occasionally cause symptoms, but only if the
activity requires prolonged, rapid breathing. Swimming has often
been recommended for asthmatic children because the activity is
conducted in the warm, moist environment of an indoor pool. The
author has seen many competitive swimmers with asthma and,
although they may have no symptoms with practices, races can be
troublesome. In some cases, the symptoms may be more bother-
some with a particular stroke (eg, butterfly). The asthmatic child
whose symptoms are worse in a particular pool may be reacting to
the organic chlorine chemicals (trichloramines) (1).
The hockey player presents a special case. Some experience no
symptoms of asthma and enjoy skating in cold, dry air, but others
do not. Hockey players typically play in many different arenas, and
Correspondence and reprints: Dr Daniel Hughes, Pediatric Respiratory Medicine, IWK Health Centre, 5850 University Avenue, PO Box 9700,
Halifax, Nova Scotia B3K 6R8. Telephone 902-470-8218, e-mail dan.hughes@iwk.nshealth.ca
Accepted for publication August 13, 2014
Paediatr Child Health Vol 19 No 9 November 2014
it may be educational to ask the symptomatic hockey player to
name their ‘best’ rink and their ‘worst’ rink. This author has
observed that rinks that are colder and have low roofs tend to be
worse than those that are warmer and have high roofs. Nitrogen
dioxide and particulate matter from fossil-fuelled ice resurfacing
machines (ie, Zambonis) may be closer to the ice surface in rinks
with low roofs (2,3). It should also be noted that asthmatic goalies
do not experience symptoms during the hockey game, but invari-
ably do experience symptoms during practices when skating
around the ice causes prolonged, rapid breathing.
Physical examination is rarely helpful when the asymptomatic
child is seen in the office or clinic, and spirometry is normal unless
the child has mild or moderate persistent asthma. Occasionally, a
child with a low normal forced expiratory volume in 1 s will have
a significant response to a bronchodilator in the pulmonary func-
tion laboratory. Studies involving athletes have shown that the
typical symptoms associated with asthma are neither sensitive nor
specific for identifying individuals with exercise-induced asthma
(EIA) (4). It has been recommended that exercise testing with
bike or treadmill, or even a sports-specific exercise challenge that
simulates the training and competition environment, be per-
formed (5,6). This may be appropriate in some situations when the
facilities are available, but is not very practical in the typical office
setting. The controlled laboratory environment may not always
reproduce the child’s symptoms and a negative test does not rule
out exercise as a trigger of asthma (6). Similarly, methacholine
challenge tests may be normal in the child with EIA.
Other causes of exercise-associated symptoms, such as VCD,
need to be considered as well as symptoms arising from poor
physical fitness, occasionally related to obesity. The clue to VCD
is inspiratory stridor from partial vocal cord closure and normal
oxygen saturations during exercise and, in the obese child, dyspnea
without coughing. The author prefers the term EIA as long as it is
understood that exercise is a trigger of pre-existing asthma and not
a cause of asthma. The term ‘exercise-induced bronchoconstric-
tion’ is preferred by others, particularly when used to describe
individuals not known to have asthma but with bronchoconstric-
tion associated with exercise (7). It has been suggested that
repeated environmental exposure, such as cold air in cross-country
skiers, nitrogen oxides from ice resurfacing machines and tri-
chloramines in swimming pools, may cause asthma-like symptoms
in previously healthy individuals (5).
Several theories have been proposed to explain EIA, which is
reported to occur in 80% to 90% of asthmatics (5). Inspired air is
normally heated to 37°C and fully saturated with water vapour by
the airways. The first theory proposed is that rapid breathing dur-
ing exercise causes heat and water loss. This is compounded by
breathing air that is dry and cold. Airway cooling causes reflex
bronchoconstriction and, at the end of exercise, rebound vasodila-
tation occurs, causing mucosal edema, which leads to airway nar-
rowing. The second theory suggests that hyperventilation causes
airway drying, which eventually leads to the release of mediators
©2014 Pulsus Group Inc. All rights reserved 467
Commentary
that cause bronchoconstriction. Others have shown that exercise-
induced deep inspirations mechanically stretch the airway smooth
muscle bronchodilating the lower airways. Bronchoconstriction
occurs following exercise when the airways rewarm, leading to
engorgement of the vascular bed. For years, it was taught that the
symptoms of EIA occur following exercise. We now know that this
is not necessarily the case, particularly in children (8). Children
with EIA experience a shorter period of bronchodilatation, and
the bronchoconstrictor response starts during exercise. This is
consistent with the clinical history when the child reports symp-
toms commencing during, not following, the activity.
The management of EIA should begin with a brief explanation to
the child and parents about the mechanisms causing EIA and that
symptoms are invariably associated with any activity that causes pro-
longed rapid breathing. Having the child list the activities that cause
symptoms and those that do not will usually make the point. A cold,
dry environment can certainly be a triggering factor, but many asth-
matic children experience symptoms in a warm school gymnasium.
For symptoms occurring at school, the parents should meet with
the child’s teacher and the gym instructor or coach. Modifications to
the activity or sport, if possible, can be helpful when the symptoms
are limiting the child’s participation. Avoiding running during
warm-ups before ball games, volleyball and taekwondo may be help-
ful. Shorter distances of track and field, long jump or high jump do
not require prolonged rapid breathing and allow the child to partici-
pate. The author has seen many discouraged cross-country runners
limited solely by their EIA. Becoming a fullback in soccer or
engaging in shorter distances in paddling may be helpful. The
author is aware of several asthmatic children who excelled as goal-
keepers in soccer and could play the entire game without symptoms,
something they otherwise would not have been able to do.
Predictably, they experience their symptoms during practices when
they are required to run laps around the field with the other players.
If the child reports that they are goalkeepers in hockey, soccer,
lacrosse or field hockey, do not miss the opportunity to ask them
why they chose that particular position. The asthmatic child may
have already learned that they can more fully participate and experi-
ence fewer symptoms. Ice hockey can be a problem. One never tells
a competitive forward to become a goalie. The children themselves
learn to expect more symptoms when, having contracted a respira-
tory virus, their weekend game is going to be in their ‘worst’ rink.
Guidelines regarding EIA usually recommend warm-ups before
planned exercise to take advantage of the induced refractory per-
iod (7). Warm-ups may be beneficial for the elite athlete or those
participating in a scheduled track and field event, but are rarely
helpful for hockey players or for most school-based gym and sports
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attendance, atopy and the risk of asthma during childhood.
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2. Rundell KW. High levels of airborne ultrafine and fine particulate
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3. Thunqvist P, Lilja G, Wickman M, et al. Asthma in children exposed
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4. Rundell KW, Im J, Mayers LB, et al. Self-reported symptoms and
exercise induced asthma in the elite athlete. Med Sci Sports Exerc
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5. Carlsen K-H. The breathless adolescent asthmatic athlete.
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468
activities. It is important to ensure, as much as possible, that the
child’s asthma control is ideal. Improving a child’s technique with
their metered-dose inhaler (puffer) and spacing device occasion-
ally is sufficient. In addition to what the child may be prescribed
for day-to-day asthma control, the primary pharmacological treat-
ment for EIA is a short-acting beta-agonist 10 min to 15 min
before activities that cause symptoms. In the school setting, this
requires the medication to be readily available. A suitable plan
needs to be established with school staff because the parent is not
going to be present. It is imperative that the child knows how to
properly self-administer the medication and that the technique be
reviewed in the physician’s office.
Outside the school setting, parents or surrogates can supervise
medication use and, importantly, take note of whether the medica-
tion is working. It is rare for a couple of puffs of a beta-agonist to
completely prevent all symptoms of EIA, but they can help.
Success depends on the particular sport, the level of activity and
the severity of the child’s asthma. The author allows additional
doses of the beta-agonist to be used when the activity is prolonged,
eg, hockey and soccer.
Optimizing asthma control is essential. Regular daily use of
inhaled corticosteroids may be required for the child with more
troublesome asthma, and add-on therapy with a long-acting beta-
agonist or leukotriene receptor antagonist may occasionally be
necessary. Some guidelines suggest that the presence of EIA
reflects asthma that is poorly controlled, and the solution is to
increase the inhaled corticosteroids or provide additional therapy
(9). The author has seen many children whose overall asthma
control is excellent but who experience breakthrough symptoms
during sport. In an attempt to bring these symptoms under control,
the inhaled corticosteroids have been increased to excessive levels,
risking side effects including adrenal suppression. Caution is
required. The administration of an inhaled corticosteroid just
before the activity is not beneficial and should be discouraged.
Children with EIA and allergies may benefit from an allergy con-
sultation and the use of an antihistamine (7). Elite athletes com-
peting at high levels and physicians should be aware of the
guidelines provided by the World Anti-Doping Agency (10).
Physical training, exercise and participation in sports should be
encouraged in all children including those with asthma. Asthmatic
children should not simply be told to limit their physical activities.
Such activities will not improve lung function in the asthmatic
but can improve physical fitness, allow participation with peers
and lead to improved quality of life (11). The asthmatic child and
parents will benefit from the advice of a physician knowledgeable
about EIA, its presentation and management.
7. Parsons JP, Hollstrand TS, Mastronarde JG, et al. An official
American Thoracic Society clinical practice guideline:
Exercise-induced bronchoconstriction. Am J Respir Crit Care Med
2013;187:1016-27.
8. van Leeuwen JC, Driessen JMM, de Jongh FHC, et al. Monitoring
pulmonary function during exercise in children with asthma.
Arch Dis Child 2011;96:664-8.
9. National Asthma Council Australia. Asthma Management
Handbook 2006. Melbourne, 2006.
10. World Anti-Doping Agency. <www.wada-ama.org/> (Accessed
October 3, 2014).
11. Basaran S, Guler-Uysal F, Ergen N, et al. Effects of physical exercise
on quality of life, exercise capacity and pulmonary function in
children with asthma. J Rehabil Med 2006;38:130-5.
Paediatr Child Health Vol 19 No 9 November 2014