When most people think of exercise-induced asthma (EIA), the vision of an athlete gasping for breath at the beginning of a workout or after hard efforts comes to mind. Unfortunately, these are not the only symptoms of EIA problems.
I don't remember the first time it happened, but early on in my experiences as an endurance athlete, I noticed I would cough after interval workouts and races. At the time I just assumed it was physical proof I had pushed my body to the limit.
As time went on I noticed that not only did I cough, but I also produced "lung stuff" that looked similar to what I produced when I had my annual bouts of bronchitis or a sinus infection. After mentioning this to my coach, he told me it was likely from being out of shape for early-season racing.
As the season progressed and the problem continued, my coach blamed the coughing on lengthy, high-intensity efforts. He shrugged them off so I did, too.
In the fall of 2003, I attended a U.S. Olympic Committee seminar for staff supporting the 2004 Olympic team. The session addressed the heat, humidity and air quality concerns in Athens. One of the talks, "Air Pollution: Special Concerns for Athletes with Allergies, Asthma and EIA" delivered by Dr. William Storms, was a trigger for me to learn more about asthma.
Asthma is defined as "an intermittent narrowing of the airways, accompanied by a decrease in some measure of airflow that the individual experiences as wheezing, chest tightness, coughing and/or dyspnea (discomfort associated with breathing) with the presence of lung inflammation."
Exercise-induced asthma is defined as "an intermittent narrowing of the airways, accompanied by a decrease in some measure of airflow that the individual experiences as wheezing, chest tightness, coughing and/or dyspnea that is triggered by exercise."
People who have asthma or EIA fall into one of three categories:
- Those with both chronic asthma and EIA
- Those with chronic asthma but not EIA
- Those with EIA, but not chronic asthma or allergies
Typical Symptoms of EIA
The typical symptoms associated with EIA include shortness of breath, wheezing, chest tightness, coughing, excess mucous, and a mismatch between fitness levels and state of fatigue.
Not every individual will experience all symptoms, and the symptoms may not be bad enough to cease an exercise session. Most often, EIA's transient narrowing of the airways resolves itself within one to two hours after the cessation of exercise.
At the seminar, I specifically asked about the coughing issue after hard efforts. It is common for some athletes to cough after difficult workout sessions or races, but typically this coughing is very short-lived, less than 30 minutes and intermittent.
Sometimes, athletes will display this kind of coughing when exerting themselves in dry or cold conditions and/or when exerting themselves at altitude or in polluted conditions. An occasional bout of coughing is nothing to be worried about.
I had to probe more. I asked, "What if the coughing lasts for 24 to 36 hours and the athlete is coughing up more than clear, thin mucous? What if the athlete is coughing up lung stuff, similar to a bout with bronchitis?"
Dr. Storms replied, "People that are still coughing up to 24 hours after an event need to be tested, as they likely have undiagnosed EIA."
I considered that I might have an issue with asthma. I was "that athlete" and I did have some of the symptoms, but my symptoms weren't that bad. I could manage. Heck, I was managing.
Several coughing bouts and nearly six months later, I was sitting in Dr. Storms's office. Still not convinced I had a problem with asthma, I hoped a visit to the doc would rule it out.
Before visiting the office, I filled out a couple of questionnaires relating to my general health and my medical history related to breathing and allergy issues. This information is the first step in determining if asthma issues exist.
The second step is a physical examination to rule out issues that mimic asthma. Possibilities include things such as pneumonia, bronchitis, pulmonary embolism, panic disorder, chronic obstructive pulmonary disease (COPD) and heart failure.
The third step in diagnosis is a lung function test. The preferred test is the non-invasive spirometry test, which looks at three values and compares them to normal values for a person your age:
- The maximum amount of air you can inhale and exhale
- The maximum flow you can generate during a forced exhalation
- The maximum amount of air you can exhale in one second
If the test values are below expected values, it may be a sign that airways are obstructed. The doctor may ask you to inhale a bronchodilator drug used in asthma treatment to open obstructed air passages, then retake the spirometry test. If your measurements improve significantly, it's likely you have asthma.
Based on my history, the physical examination and the spirometry test, he told me I had EIA as well as regular asthma. He suggested a daily medication for asthma management in addition to using an inhaler before exercising for EIA. This was not the news I was expecting and I still had questions.
Admitting There's a Problem
At first, asthma didn't seem to be a big problem. Sure, I coughed a little after exercise, but that's really just a slight inconvenience. I had managed to do endurance sports for 17 years before this appointment and was a competitive swimmer before that--asthma never stopped me during a workout or competition. Surely I could continue my sports life sans daily medications, right?
I asked Dr. Storms, "What if I don't take any medications and just continue as I've done in the past?"
He explained that if I was in a sport with low-asthmogenic activity, taking the path of non-medication for some time would likely cause minimal health problems. As I age, the asthma could cause me to need medication later on.
However, because I participate in sports that are high-asthmogenic activities (triathlon, trail running, road cycling, mountain biking and cross-country skiing), and I do at least one of these sports nearly every day, I run a higher risk for long-term damage. If my lungs are in an almost daily state of inflammation, this constant irritation could cause even more decrease--permanent decrease--in lung function over time.
I didn't want to admit something was wrong with me, or want a lifetime of medication. Dr. Storms explained that it's not unusual for athletes to resist taking medication. However, since I didn't intend to quit endurance sports and I did not want to continually decrease my lung function over time, I had to admit I have a problem and would have to adhere to the treatment plan.
It has been four years since I was diagnosed with asthma and EIA. In most circumstances, my asthma is easily managed. I do change my protocol for special situations, such as ultra-distance races at high altitudes. These events combine many of the issues that aggravate asthma, including long exposure to altitude, dust, cold air, dry air and high exertion levels.
As I began to manage my asthma, I realized I had learned to ignore the low-level coughing. Although I once considered 24- to 36-hour post-race coughing to be a sign of great effort, I now know it's really a signal of a problem.
Exercise-induced asthma exhibits itself differently in different athletes. If you have any of the symptoms listed earlier in the column, I suggest you consult an asthma and allergy expert. My diagnosis was straightforward; however, some cases require the administration of more specialized tests to find an EIA problem.
Coughing or other breathing problems are not signs of athletic accomplishment or toughness and should not be shrugged off. If you have any of the symptoms, don't be like me and wait for 17 years to seek the advice of an expert.