Dyspneic athlete

Abstract

Breathing concerns in athletes are common and can be due to a wide variety of pathology. The most common etiologies are exercise-induced bronchoconstriction (EIB) and paradoxic vocal fold movement disorder (PVFMD). Although some patients may have both, PVFMD is often misdiagnosed as EIB, which can lead to unnecessary treatment. The history and physical exam are important to rule out life threatening pulmonary and cardiac causes as well as common conditions such as gastroesophageal reflux disease, sinusitis, and allergic etiologies. The history and physical exam have been shown to be not as vital in diagnosing EIB and PVFMD. Improvement in diagnostic testing with office base spirometry, bronchoprovocation testing, eucapnic voluntary hyperpnea (EVH) and video laryngoscopy are essential in properly diagnosing these conditions. Accurate diagnosis leads to proper management, which is essential to avoid unnecessary testing and save healthcare costs. Also important to the physician treating dyspnea in athletes is knowing regulations on medications, drug testing, and proper documentation needed for certain organizations. The differential diagnosis of dyspnea is broad and is not limited to EIB and PVFMD. Ruling out life threatening cardiac and pulmonary causes with a proper history, physical, and appropriate testing is essential. The purpose of this review is to highlight recent literature on the diagnosis and management of EIB and PVFMD as well as discuss other potential causes for dyspnea in the athlete.

Dysfunctional breathing and reaching one’s physiological limit as causes of exercise-induced dyspnoea

“…Given this “typical” pattern, the cause of the EIB is unlikely to be bronchoconstriction when individ­uals report that symptoms commence shortly after initiating vigorous activity. It is recognised that some individuals experience EIB associated with chest tightness, cough and wheeze without other interval symptoms of asthma and hence many consider that it can exist independent of “classic” asthma [ 7 , 8 ].…”

“…EIB appears to be common in athletes [ 6 , 8 ], more so in those that: are endurance athletes, have allergic rhinitis, are female, or who exercise in cold weather or in chemical environments such as swimming pools [ 7 – 10 ].…”

“…In some, compensatory breathing strategies can limit breathlessness, but for ­others there is an increased perception of dyspnoea [ 14 , 15 ]. Although objective investigation into the causes of EID is recommended [ 16 ] it would appear that few healthy young adults seeking medical advice for breathlessness undergo diagnostic testing [ 7 , 9 ].…”

“…They were previously known under the banner of “vocal cord dysfunction” but have been renamed to differentiate them from more permanent structural abnormality. pVFMD occurs when there is intermittent, abnormal, paradoxical adduction of the vocal folds with respiration, causing variable upper airway obstruction that is not related to a permanent deficit in vocal cord mobility [ 7 , 29 ]. Likewise, exercise-induced laryngomalacia is intermittent causing obstruction due to collapse of supraglottic tissues during inspiration when a subject is participating in vigorous exercise and generating large negative intrathoracic pressures [ 28 ].…”

“…Likewise, exercise-induced laryngomalacia is intermittent causing obstruction due to collapse of supraglottic tissues during inspiration when a subject is participating in vigorous exercise and generating large negative intrathoracic pressures [ 28 ]. Symptoms for both include EID, variable and/or sudden shortness of breath, inspiratory stridor, choking, throat tightness, voice changes and/or cough [ 7 , 28 , 29 ]. If triggered with exercise, it quickly resolves with exercise cessation.…”