Efficient Use of Simple Exercise-Induced Bronchoconstriction Challenge Testing in Pediatric Exercise-Induced Dyspnea

Abstract

BACKGROUND: A simple exercise test to evaluate for exercise-induced bronchoconstriction (EIB) is routinely ordered in pediatric patients with exercise-induced dyspnea. However, the utility of this test in establishing the cause of exercise-induced dyspnea is not thoroughly examined in the pediatric population. We sought to assess the efficiency of a simple EIB challenge test in finding the cause of exercise-induced dyspnea in pediatric patients referred to our tertiary center in the last 5 y. METHODS: We performed a retrospective chart review for all of these exercise tests done at Akron Children's Hospital from March 2011 to March 2016. Patients with chronic conditions (eg, cystic fibrosis, cardiac abnormality) were excluded. Demographics, clinical diagnosis of asthma, a presumptive diagnosis of exercise-induced asthma or EIB by the referring provider, symptoms with and without exercise, albuterol use, spirometry, and simple EIB challenge test results were collected. The chi-square test of independence was utilized in the examination of potential dependent relationships between categorical variables. A P value < .05 was considered to be statistically significant. RESULTS: Out of 164 enrolled subjects (57 males; age 6-20 y), only 19% showed evidence of EIB. There were no significant associations between EIB status (ie, EIB-positive or EIB-negative) based on exercise testing and gender, typical symptoms of EIB, diagnosis of exerciseinduced asthma or EIB, and albuterol use (P > .05). However, a subject without asthma was 2.8 times more likely to have negative exercise test for EIB (odds ratio 2.8, 95% CI 1.3-6.5); in addition, approximately 85% of tests in subjects without asthma were negative. CONCLUSION: In a majority of subjects without asthma, a simple EIB challenge testing failed to uncover the cause of exercise-induced dyspnea and thus was inefficient. In these subjects, cardiopulmonary exercise testing may be more useful and cost-effective to explore other causes of dyspnea including EIB.

Cardiopulmonary exercise testing for pediatric exercise-induced dyspnea especially in patients whose asthma treatment failed

“…6 Many studies of pediatric patients referred for consultation for EID showed EIB in only 8% to 19%, in line with our findings. [1][2][3] Although most of our patients had been prescribed bronchodilators for suspected EIB, only 10% showed EIB on CPET results. This highlights that self-reported exercise-induced symptoms are poor predictors of EIB.…”

“…1,2 Previous studies show that EIB is present in just 8% to 19% of otherwise healthy children with EID. [1][2][3] In fact, most of these patients have 1 or more problems other than EIB limiting exercise. Cardiopulmonary exercise testing (CPET) can identify clinical entities that mimic EIB.…”

“…1 Paradoxically, aspirin desensitization improves respiratory symptoms in 67% to 78% of patients. 3 However, additional treatments are needed because some patients who fail to improve cannot tolerate aspirin. 3,4 The respiratory tract in AERD is characterized by eosinophilic infiltration, with nasal polyps and bronchial biopsies demonstrating more eosinophils and higher levels of interleukin-5 (IL-5) than in patients with aspirin-tolerant-asthma.…”

“…3 However, additional treatments are needed because some patients who fail to improve cannot tolerate aspirin. 3,4 The respiratory tract in AERD is characterized by eosinophilic infiltration, with nasal polyps and bronchial biopsies demonstrating more eosinophils and higher levels of interleukin-5 (IL-5) than in patients with aspirin-tolerant-asthma. 5,6 Interleukin-5 is an eosinophilic maturation and differentiation factor contributing to tissue and peripheral eosinophilia.…”

2019 Year in Review: Asthma

“…The search was further refined by selecting only those studies that contained one of the following key terms: "respiratory therapy," "protocols," "mechanical ventilation," "exacerbation," "bronchodilation," or "respiratory care." Nine manuscripts were identified from the search and were categorized as asthma diagnosis (1), asthma education (1), pressurized metered-dose inhaler (pMDI) instruction (2), RT-driven asthma protocols/management (2), and asthma treatment (3). These manuscripts and their findings are therefore discussed below.…”