Treatment
➤ SS15: Refer to appropriate specialists (eg, cardiologist or pulmonologist)
to perform cardiopulmonary testing when breathlessness with exercise,
with or without chest pain, might be caused by heart disease or other
conditions in the absence of EIB. (M-C)
➤ SS16: Refer patients for psychological evaluation when the symptoms (eg,
hyperventilation and anxiety disorders) are in the differential diagnosis of
EIB. (W-D)
➤ SS17: Schedule regular office visits with patients because medications
can differ in effectiveness over time because of variability of asthma,
environmental conditions, intensity of the exercise stimulus, and
tachyphylaxis. (S-A)
β
2
-Adrenergic Receptor Agonists
➤ SS18: Prescribe inhaled short-acting β
2
-adrenergic receptor agonists for
protection against EIB and for accelerating recovery of pulmonary function
when given after a decrease in pulmonary function after exercise. (S-A)
➤ SS19: Prescribe a single dose of SABA, LABA, or both on an intermittent
basis (ie, <4 times per week) before exercise because this might protect
against or attenuate EIB. (S-A)
➤ SS20: Be cautious in daily use of β
2
-adrenergic agents alone or in
combination with ICSs because this can lead to tolerance manifested as a
reduction in duration, magnitude, or both of protection against EIB and a
prolongation of recovery in response to SABAs after exercise. (S-A)
Leukotriene Inhibitors
➤ SS21: Consider prescribing daily therapy with leukotriene inhibitors
because this does not lead to tolerance and has been shown to
attenuate EIB in 50% of patients. It can also be used for intermittent or
maintenance prophylaxis. However, it provides incomplete protection and
is not effective for reversing airway obstruction. (S-A)
Mast Cell Stabilizers
➤ SS22: Consider prescribing inhaled cromolyn sodium and nedocromil
sodium (currently not available in the United States as a metered-dose
inhaler or dry powder inhaler) shortly before exercise; this attenuates
EIB but can have a short duration of action. There is no bronchodilator
activity. They might be effective alone or as added therapy with other
drugs for EIB. (S-A)
