Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Exercise-induced bronchoconstriction in elite athletes

  Exercise-induced bronchoconstriction (EIB) is a temporary narrowing of the airways that occurs during or after intense physical activity. It can affect athletes with diagnosed asthma, but it also appears in competitors who have no persistent respiratory symptoms at rest. Because elite athletes regularly train at high workloads, even a modest reduction in airflow can affect pace, power, recovery, and confidence.

  Respiratory symptoms in sport are easy to misinterpret. Cough, chest tightness, wheezing, and breathlessness may reflect airway hyperresponsiveness, but they can also result from poor conditioning, respiratory infection, vocal cord dysfunction, allergy, or environmental exposure. A careful assessment is therefore more reliable than symptoms alone.

  For sports physicians, pulmonologists, coaches, and athletes, the goal is to identify the cause, confirm it objectively, and create a plan that supports both health and performance. Discussions of respiratory medicine at professional congresses such as APSR 2022 and KATRD are valuable because they connect clinical evidence with real-world care.

  Why intense exercise can narrow the airways

  During vigorous exercise, ventilation rises sharply. Athletes often breathe rapidly through the mouth, allowing large volumes of cool or dry air to reach the lower respiratory tract. This increases water loss from the airway surface and can trigger inflammatory and vascular changes around the bronchial muscles. The result is transient airway narrowing, usually developing shortly after exercise stops.

  EIB is especially relevant in sports involving sustained ventilation, including distance running, cycling, swimming, rowing, and winter competition. Chlorinated pool air, cold weather, indoor pollutants, pollen, and particulate matter may intensify symptoms. Some athletes are also exposed to repeated training loads that reveal airway reactivity even when ordinary daily activity causes no difficulty.

  Symptoms and performance effects

  Typical symptoms include cough, wheezing, chest tightness, unusual shortness of breath, and a feeling that recovery is taking too long. Symptoms often peak five to 15 minutes after exercise rather than at the moment of maximum effort. In some athletes, the main sign is a decline in performance or an inability to sustain a familiar pace.

  A normal resting examination does not exclude EIB. Elite competitors may compensate efficiently and describe their symptoms as fatigue or reduced fitness. Repeated episodes can lead to altered breathing patterns, anxiety about high-intensity work, or avoidance of key training sessions. Any sudden, severe, or atypical breathing problem requires prompt medical evaluation because cardiac and other pulmonary conditions can present similarly.

  Distinguishing EIB from other causes

  A reliable diagnosis separates bronchoconstriction from conditions that imitate it. Exercise-induced laryngeal obstruction, for example, often causes noisy inhalation and throat tightness during peak effort, with rapid improvement after stopping. Dysfunctional breathing may produce breathlessness without the characteristic fall in expiratory airflow. Infection, anemia, overtraining, and cardiac disease also need consideration when symptoms do not follow a predictable pattern.

  Feature	Exercise-induced bronchoconstriction	Exercise-induced laryngeal obstruction	Poor conditioning or other systemic cause
  Usual timing	Often peaks after exercise	Usually strongest during maximum effort	Variable
  Main sound	Expiratory wheeze or cough	Inspiratory noise or throat sound	Usually no wheeze
  Main sensation	Chest tightness and difficult exhalation	Throat tightness and difficult inhalation	General fatigue or disproportionate breathlessness
  Recovery	Commonly improves within 30–60 minutes	Often improves quickly after stopping	Depends on the underlying cause
  Useful assessment	Exercise challenge with spirometry	Laryngoscopy during exercise	Blood tests, cardiac review, or broader testing

  Symptoms should not be used as the sole basis for prescribing asthma medication. Objective testing helps prevent both underdiagnosis and unnecessary treatment, while also supporting appropriate documentation for athletes subject to anti-doping regulations.

  How clinicians confirm the diagnosis

  Assessment usually begins with a detailed history covering symptom timing, training environment, seasonal patterns, allergies, previous asthma, medication use, and family history. Baseline spirometry can identify resting airflow limitation, but normal spirometry does not rule out exercise-related airway narrowing.

  When EIB is suspected, clinicians may use an exercise challenge, eucapnic voluntary hyperpnea, or another bronchial provocation test. Spirometry is measured before and at intervals after the challenge. A clinically meaningful reduction in forced expiratory volume in one second supports the diagnosis. The selected test should reflect the athlete’s sport and available clinical expertise.

  Testing should be performed under controlled conditions when possible. Recent respiratory infections, inadequate effort, medication timing, humidity, and the type of exercise stimulus can influence results. A multidisciplinary team may include a respiratory physician, sports physician, physiologist, physiotherapist, and coach.

  Treatment and prevention strategies

  Management begins with an individualized plan. A gradual warm-up with repeated short bursts of higher-intensity effort may reduce the severity of airway narrowing for some athletes. Breathing through the nose when practical, using a mask or heat-and-moisture exchanger in cold conditions, and limiting exposure to smoke, pollution, or irritant pool environments may also help.

  Short-acting inhaled bronchodilators are commonly used before exercise when clinically appropriate, while inhaled corticosteroids may be considered when asthma or persistent airway inflammation is present. Medication choice and frequency should be reviewed by a qualified clinician. Frequent reliance on a reliever can indicate poor control and should prompt reassessment rather than automatic escalation.

  Athletes must also check current anti-doping rules and therapeutic-use requirements. Inhaled medicines can have specific permitted doses and documentation standards, so records should be maintained well before competition. Treatment should support safe participation without masking a condition that requires broader investigation.

  Practical recommendations for athletes and teams

  A consistent plan makes respiratory symptoms easier to recognize and manage across training and competition. Athletes should record when symptoms occur, the environmental conditions, warm-up pattern, medication use, and recovery time. This information can reveal links that are missed during a single clinic visit.

  Teams should ensure that coaches understand the difference between expected exertional discomfort and warning signs of airway or cardiopulmonary disease. Emergency procedures, inhaler access, and referral pathways should be established before major events.

  • Arrange objective respiratory testing when symptoms recur with exercise.
  • Track cough, wheeze, chest tightness, recovery time, and environmental triggers.
  • Build a progressive warm-up and protect airways from cold, dry, or polluted air.
  • Review inhaler technique, adherence, side effects, and competition regulations.
  • Reassess the diagnosis if symptoms occur at rest, worsen suddenly, or fail to respond as expected.

  Better recognition of exercise-induced bronchoconstriction can protect performance while reducing unnecessary anxiety about breathlessness. Clinical teams can use the evidence discussed in respiratory medicine forums and congress programs, including the professional resources associated with APSR and KATRD, to align diagnosis, treatment, and athlete education. Reviewing the available program and speaker materials is a practical way to follow current perspectives on airway disease in sport.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)