Exercise asthma, or not?

Triathlon Forum
1

I know the internet is not the best place for diagnosis, but I have been seeking treatment and am just looking for any similar experiences here. There are some old threads in the archives about exercise asthma, but my symptoms do not really match that. I have no wheezing, chest pain, shortness of breath. My problem and single symptom is this:

When I do longer workouts (don’t really notice it swimming, probably >3-4hrs biking, >80min running), I experience the insidious onset of a sensation that causes me to reflexively cough when I inhale too deeply. Towards the end of the workouts, I have to be sure to keep my breath a tad shallow, or else if I take a deep inhale then there is an irritation along and behind the sternum that causes me to cough as a reflex once I reach a certain inspiratory volume. It is very annoying, I’m not sure if it’s a performance limiter, I do feel like I’m getting the air I need, just not in the most comfortable manner.

An allergy doc did a bronchodilator/spirometry test, and called my airways “reactive, but not asthmatic”. My FEV1 improved a few percent, not to diagnostic significance, and my FEV25-75 improved somewhat substantially post-bronchodilator.

I have tried taking puffs of albuterol and xopenex before, during, and after workouts and it doesn’t really seem to help. If I really OD on the stuff, like 6 puffs, it seems to help just a little bit. I was on Symbicort and Singulair at the same time prior to an Ironman this summer, AND took the short-acting stuff during the race, and still experienced the problem despite that triple-pronged attack. I can detect no correlation that causes it other than that it is almost linearly correlated with total breaths taken during a workout (ok maybe it is sigmoidal). It has happened on 90deg rides, on 40deg rides, in Texas, all over California, etc. Higher training volume seems to make it worse too. It’s as if my lungs don’t have enough recovery time. If I did no workouts except a weekly 5hr bike, I’d probably be fine, but the volume seems to lower the time threshold per workout beyond which I feel the problem.

Anyone ever experience this or have a suggestion about what I ought to do besides seek additional medical opinions?

Thanks!

Edit: I am on a daily PPI, and it seems to really be helping! I did 5 hours on the bike today, normally the last 2ish my symptoms would be full on - this time I only barely felt some slight irritation behind my sternum after 4 hours or so, but it didn’t really limit my inhalation or cause me to cough at all. I was convinced my problem was pulmonary, but if reflux can cause coughing and exercise can cause reflex, I guess it makes sense… Hope this helps someone else.

2

I’ve experienced something like it. There have been times when, after a certain time into the workout, I have a hard time taking deep breaths. It happened a lot more often when I was younger and especially when swimming. In fact, it hasn’t happened recently at all. But I can remember times where I had leave swim practice early, and it took a couple hours before my breathing returned to normal. Never did anything about it or went to a doctor. I always thought, however, that it was a combination of some mild asthma and smog (or pool chemicals when swimming).

3

I have experienced the same symptoms related to duration and intensity of rides/runs. A persistant, dry cough without much in the way of mucus that lasts for a couple hours after the workout. I’ve also been termed “reactive” and prescribed an inhaler that doesn’t seem to have much/any affect.

Will be watching this thread with some interest.

4

My exercise induced asthma always gets better the longer I go. Could you be aspirating spit?

5

I have experienced the same symptoms related to duration and intensity of rides/runs. A persistant, dry cough without much in the way of mucus that lasts for a couple hours after the workout. I’ve also been termed “reactive” and prescribed an inhaler that doesn’t seem to have much/any affect.

Will be watching this thread with some interest.

Yes my “deep inhalation-induced cough”, and accompanying odd sub-sternal irritation, while beginning during a long workout, still persists after I stop like you. It is a couple hours until back to normal, maybe even the next day for the one IM I’ve done with this issue.

6

My exercise induced asthma always gets better the longer I go. Could you be aspirating spit?

I do generate a decent amount of mucus/spit when I workout - I’m always blowing my nose into my shirt, wiping my glove under my nose, spitting to the side. Is that a potential cause?

7

My exercise induced asthma always gets better the longer I go. Could you be aspirating spit?

I do generate a decent amount of mucus/spit when I workout - I’m always blowing my nose into my shirt, wiping my glove under my nose, spitting to the side. Is that a potential cause?That’s normal. Everyone does that especially when it’s cold out. Sounds like ‘track hack’ or pursuiters cough. Do you have a powermeter? Does your power drop at the end of a 4 hr ride?

8

My exercise induced asthma always gets better the longer I go. Could you be aspirating spit?

I do generate a decent amount of mucus/spit when I workout - I’m always blowing my nose into my shirt, wiping my glove under my nose, spitting to the side. Is that a potential cause?

Your airways are irritated, probably inflamed and swollen. Singulair should have helped.
Do you use a spacer with the inhaler?

9

My exercise induced asthma always gets better the longer I go. Could you be aspirating spit?

I do generate a decent amount of mucus/spit when I workout - I’m always blowing my nose into my shirt, wiping my glove under my nose, spitting to the side. Is that a potential cause?

Your airways are irritated, probably inflamed and swollen. Singulair should have helped.
Do you use a spacer with the inhaler?

Had to look that up. No, no spacer. It was a sample the allergist just gave me. Used it for something like 1.5-2 weeks prior to that IM.

10

My exercise induced asthma always gets better the longer I go. Could you be aspirating spit?

I do generate a decent amount of mucus/spit when I workout - I’m always blowing my nose into my shirt, wiping my glove under my nose, spitting to the side. Is that a potential cause?That’s normal. Everyone does that especially when it’s cold out. Sounds like ‘track hack’ or pursuiters cough. Do you have a powermeter? Does your power drop at the end of a 4 hr ride?

I mean, sometimes I guess, not much though. Nothing precipitous. Yes I have a power meter. I post today because I am starting to ride long this season and the problem is happening again. Here is my ride today: http://imgur.com/howgotk.

Pretty crowded, cold, and windy at the start, I think that’s why I overcooked it there, otherwise not bad I think. Lots of stoplights at the end. My symptoms started about halfway, and built to a peak with 20miles/~1 hour to go.

11

Just accept that your exercise-induced asthma symptoms are mild and delayed. Use a spacer with the inhaler before long workouts. It helps to deliver up to 75% more of the drug into the smaller airways. Go to Am Lung Assoc web site.

12

Go look up, “vocal cord dysfunction” and see if this fits the bill. An ENT would be able to work through the diagnosis. I was given the name of a specialist by my allergist. I have had exercise induced asthma for over 10 years, only partially controlled by inhalers, and am only now finding out about this condition…

13

I mean, sometimes I guess, not much though. Nothing precipitous. Yes I have a power meter. I post today because I am starting to ride long this season and the problem is happening again. Here is my ride today: http://imgur.com/howgotk.

Pretty crowded, cold, and windy at the start, I think that’s why I overcooked it there, otherwise not bad I think. Lots of stoplights at the end. My symptoms started about halfway, and built to a peak with 20miles/~1 hour to go.Sorry, no help on your cough but it looks like you have a nice area for riding. I don’t know how you can keep your power so smooth with stoplights. I have a lot more spikes in my power graphs.

14

Get tested for allergies. If you have them, start shots. The coughing goes away.

15

I have a nearly identical story as you. I started having a debilitating cough on bike rides when I started triathlon in 2005. I couldn’t tell if it was reflux (I was having reflux symptoms and the cough appeared after eating on the bike) or cough-variant asthma. The cough was much worse on windy days. I could run without a problem except on windy days when I would get a mild cough. My symptoms were even worse for 10-15 minutes after stopping then would abate. I, too, could not take a deep breath. It was really painful.

I wound up on a PPI (protonix) and an inhaled steroid (Advair high dose) and albuterol. My symptoms never went away completely. I finished 2 Ironmans with great difficulty. I gave up biking for the most part because of this. I can run a marathon without a big problem without meds. I had a methacholine challenge that was not definitive for EIA. I am getting ready to start biking again this year after a few year hiatus and am already worried about this damn cough. It is worse than the worst bonk I have ever had.

I have not had allergy testing, but I am not convinced that would make a difference given my ability to run. The aero position on the bike and the fact that it happens after I eat makes sense from a reflux standpoint. The windy day correlation and the fact that it doesn’t bother me that much on the run unless its windy makes sense from the EIA standpoint. I understand treating it empirically, which is what I am likely to do again, but knowing what the hell I am treating would be nice so I am not taking meds unnecessarily.

If there are any pulmonologists out there who can offer their 2 cents, that would be great.

16

I have a nearly identical story as you. I started having a debilitating cough on bike rides when I started triathlon in 2005. I couldn’t tell if it was reflux (I was having reflux symptoms and the cough appeared after eating on the bike) or cough-variant asthma. The cough was much worse on windy days. I could run without a problem except on windy days when I would get a mild cough. My symptoms were even worse for 10-15 minutes after stopping then would abate. I, too, could not take a deep breath. It was really painful.

I wound up on a PPI (protonix) and an inhaled steroid (Advair high dose) and albuterol. My symptoms never went away completely. I finished 2 Ironmans with great difficulty. I gave up biking for the most part because of this. I can run a marathon without a big problem without meds. I had a methacholine challenge that was not definitive for EIA. I am getting ready to start biking again this year after a few year hiatus and am already worried about this damn cough. It is worse than the worst bonk I have ever had.

I have not had allergy testing, but I am not convinced that would make a difference given my ability to run. The aero position on the bike and the fact that it happens after I eat makes sense from a reflux standpoint. The windy day correlation and the fact that it doesn’t bother me that much on the run unless its windy makes sense from the EIA standpoint. I understand treating it empirically, which is what I am likely to do again, but knowing what the hell I am treating would be nice so I am not taking meds unnecessarily.

If there are any pulmonologists out there who can offer their 2 cents, that would be great.

Now that you mention it, my allergist did float reflux as a differential diagnosis. I didn’t believe that could be it so haven’t pursued it, but maybe worth a shot. It doesn’t seem to be correlated to when I eat or anything I eat, having done rides on minimal nutrition and with liquid/solid/multiple types of fuel. Also don’t think its correlated to body position as it has happened with running, road, tri bikes. And I can’t even say I know what reflux is because I’m pretty sure I’ve never felt it before. But thanks for reminding me, I’ll look into.

Thank you also for the suggestions re: allergy testing, spacer, etc.

To the poster about my power profile on that ride - the data is pretty smoothed and it was an organized century so some desolate roads and traffic control meant not too much stopping except at the end with stoplights.

17

… The aero position on the bike and the fact that it happens after I eat makes sense from a reflux standpoint. The windy day correlation and the fact that it doesn’t bother me that much on the run unless its windy makes sense from the EIA standpoint.

Have you tried doing a shot of Pepto Bismol before biking. I have reflux issues, and that can work wonders on bad days.

18

I know the internet is not the best place for diagnosis, but I have been seeking treatment and am just looking for any similar experiences here. There are some old threads in the archives about exercise asthma, but my symptoms do not really match that. I have no wheezing, chest pain, shortness of breath. My problem and single symptom is this:

When I do longer workouts (don’t really notice it swimming, probably >3-4hrs biking, >80min running), I experience the insidious onset of a sensation that causes me to reflexively cough when I inhale too deeply. Towards the end of the workouts, I have to be sure to keep my breath a tad shallow, or else if I take a deep inhale then there is an irritation along and behind the sternum that causes me to cough as a reflex once I reach a certain inspiratory volume. It is very annoying, I’m not sure if it’s a performance limiter, I do feel like I’m getting the air I need, just not in the most comfortable manner.

An allergy doc did a bronchodilator/spirometry test, and called my airways “reactive, but not asthmatic”. My FEV1 improved a few percent, not to diagnostic significance, and my FEV25-75 improved somewhat substantially post-bronchodilator.

I have tried taking puffs of albuterol and xopenex before, during, and after workouts and it doesn’t really seem to help. If I really OD on the stuff, like 6 puffs, it seems to help just a little bit. I was on Symbicort and Singulair at the same time prior to an Ironman this summer, AND took the short-acting stuff during the race, and still experienced the problem despite that triple-pronged attack. I can detect no correlation that causes it other than that it is almost linearly correlated with total breaths taken during a workout (ok maybe it is sigmoidal). It has happened on 90deg rides, on 40deg rides, in Texas, all over California, etc. Higher training volume seems to make it worse too. It’s as if my lungs don’t have enough recovery time. If I did no workouts except a weekly 5hr bike, I’d probably be fine, but the volume seems to lower the time threshold per workout beyond which I feel the problem.

Anyone ever experience this or have a suggestion about what I ought to do besides seek additional medical opinions?

Thanks!

I’m not a pulmonologist, but I have a few comments.

With minimal relief from bronchodilators and the fact that it occurs later into the workout is against exercise induced bronchospasm (the correct term). It might suggest reflux, which can be made worse with exercise. EIB tends to occur early into a workout and get better with time. Not everyone with EIB has asthma, however and not all asthmatics have EIB. Testing an hour into a long trainer workout might be interesting. Also, you might have a bit of both.

Formoderol (in Symbicort) does work quite a bit longer than salmeterol (in Advair), especially in prevention of EIB. It also has much quicker onset 5-10 minutes vs. 30-60 minutes.)

FEF 25-75 is generally considered a more sensitive test than FEV 1. I thought that interesting in your case.

I wonder if a trial of a PPI (like prilosec) might help. If the problem is GERD, it should. It takes several days to start working, however. H2 blockers like Pepcid (famotidine) can help some, but are less effective. However, they begin to work in less than an hour. H2 blockers plus a little bit of antacid might work as well as a PPI and would only have to be taken right beforehand. Also, low dose erythromycin is a promotility agent. Taking it before a long workout might help. It does not work as well as metoclopramide, but it also doesn’t have the central nervous system side effects of metoclopramide, either.

Anyway, something to talk to your doc about.

19

Anyway, something to talk to your doc about.

Awesome, thank you. Will do.

20

I’m not a pulmonologist, but I have a few comments.

With minimal relief from bronchodilators and the fact that it occurs later into the workout is against exercise induced bronchospasm (the correct term). It might suggest reflux, which can be made worse with exercise. EIB tends to occur early into a workout and get better with time. Not everyone with EIB has asthma, however and not all asthmatics have EIB. Testing an hour into a long trainer workout might be interesting. Also, you might have a bit of both.

Formoderol (in Symbicort) does work quite a bit longer than salmeterol (in Advair), especially in prevention of EIB. It also has much quicker onset 5-10 minutes vs. 30-60 minutes.)

FEF 25-75 is generally considered a more sensitive test than FEV 1. I thought that interesting in your case.

I wonder if a trial of a PPI (like prilosec) might help. If the problem is GERD, it should. It takes several days to start working, however. H2 blockers like Pepcid (famotidine) can help some, but are less effective. However, they begin to work in less than an hour. H2 blockers plus a little bit of antacid might work as well as a PPI and would only have to be taken right beforehand. Also, low dose erythromycin is a promotility agent. Taking it before a long workout might help. It does not work as well as metoclopramide, but it also doesn’t have the central nervous system side effects of metoclopramide, either.

Anyway, something to talk to your doc about.

Any suggestions on heat exacerbation? I also have been diagnosed with EIB, on Singulair (Which I noticed no real effect), and albuterol inhaler. I have much fewer symptoms in workouts when it is cold out, and the hotter it gets the worse it gets.

John