Diagnosis
➤ SS6: Use an indirect graded challenge (eg, mannitol, if available) for
assessing EIB in recreational or elite athletes who have normal to
near-normal lung function and who might currently require treatment
for the prevention of EIB or asthma. (S-D)
➤ SS7: Perform an indirect challenge (eg, exercise challenge or surrogate
testing, such as with eucapnic voluntary hyperpnea [EVH] or mannitol,
where available) instead of a direct challenge (eg, methacholine) for
assessing EIB, recognizing that an indirect challenge is more sensitive
for detection of EIB than a direct (eg, methacholine) challenge. (S-B)
➤ SS8: Ensure the ventilation reached and sustained during exercise
challenge testing is at least 60% of the maximum voluntary ventilation
by using dry medical grade air to achieve an adequate challenge. If
ventilation cannot be measured, ensure the heart rate as a percentage
of maximum heart rate (HRmax) that is reached and sustained is ≥85%
in adults and ≥95% in children and elite athletes. (S-B)
➤ SS9: Perform EVH as the preferred surrogate challenge for the athlete
without a current history of asthma participating in competitive sports
in whom the diagnosis of EIB is suspected. (S-D)
➤ SS10: If an indirect graded challenge (eg, mannitol) result is
negative and EIB is still suspected, an ungraded challenge should
be considered. (W-B)
➤ SS11: To differentiate between EIB and exercise-induced laryngeal
dysfunction (EILD), perform appropriate challenge tests (eg, exercise,
EVH, and mannitol for EIB) and potentially flexible laryngoscopy during
exercise for diagnosis of EILD. (S-B)
➤ SS12: To determine whether exercise-induced dyspnea and
hyperventilation are masquerading as asthma, especially in children
and adolescents, perform cardiopulmonary exercise testing. (M-C)
➤ SS13: Perform spirometry, as well as detailed pulmonary examination,
to determine whether shortness of breath with exercise is associated
with underlying conditions, such as COPD, or restrictive lung
conditions, such as obesity, skeletal defects (eg, pectus excavatum),
diaphragmatic paralysis, or interstitial fibrosis, rather than EIB. (M-C)
➤ SS14: Consider a diagnosis of exercise-induced anaphylaxis (EIAna)
instead of EIB based on a history of shortness of breath or other
respiratory tract symptoms accompanied by systemic symptoms (eg,
pruritus, urticaria, and hypotension). (M-C)
