Original Article
Diagnosing Exercise-Induced Bronchoconstriction With Eucapnic Voluntary Hyperpnea: Is One Test Enough?

https://doi.org/10.1016/j.jaip.2014.10.012Get rights and content

Background

In athletic individuals, a secure diagnosis of exercise-induced bronchoconstriction (EIB) is dependent on objective testing. Indirect bronchoprovocation testing is often used in this context and eucapnic voluntary hyperpnea (EVH) testing is recommended for this purpose, yet the short-term reproducibility of EVH is yet to be appropriately established.

Objective

The aim of this study was to evaluate the reproducibility of EVH in a cohort of recreational athletes.

Methods

A cohort of recreational athletes (n = 32) attended the laboratory on two occasions to complete an EVH challenge, separated by a period of 14 or 21 days. Spirometry and impulse oscillometry was performed before and after EVH. Training load was maintained between visits.

Results

Prechallenge lung function was similar at both visits (P > .05). No significant difference was observed in maximum change in FEV1 (ΔFEV1max) after EVH between visits (P > .05), and test-retest ΔFEV1max was correlated (intraclass correlation coefficient = 0.81; r2 = 0.66; P = .001). Poor diagnostic reliability was observed between tests; 11 athletes were diagnosed with EIB (on the basis of ΔFEV1max ≥10%) at visit 1 and at visit 2. However, only 7 athletes were positive at both visits. Although there was a small mean difference in ΔFEV1max between tests (−0.6%), there were wide limits of agreement (−10.7% to 9.5%). Likewise, similar results were observed for impulse oscillometry between visits.

Conclusions

In a cohort of recreational athletes, EVH demonstrated poor clinical reproducibility for the diagnosis of EIB. These findings highlight a need for caution when confirming or refuting EIB on the basis of a single indirect bronchoprovocation challenge. When encountering patients with mild or borderline EIB, we recommend that more than one EVH test is performed to exclude or confirm a diagnosis.

Section snippets

Study population

Thirty-six recreational athletes (training 6 ± 1 h/wk; men: n = 31) from various sporting disciplines—endurance (n = 22; runners, cyclists, and triathletes), intermittent high-intensity (n = 11; soccer, rugby, and hockey), and nonendurance (n = 3; weightlifters)—were recruited to take part in the study. All subjects were nonsmokers, free from respiratory, cardiovascular, metabolic, and psychiatric disease, and any other significant medical condition except mild asthma. Six subjects had a

Results

Thirty-two athletes (men: n = 28) completed the study. One athlete was excluded at the initial visit on the basis of resting airway obstruction, and three athletes were excluded because of illness. Subjects' characteristics are presented in Table I.

Discussion

In a cohort of recreational athletes, EVH demonstrates poor diagnostic test-retest reproducibility over a short-term period of assessment. This finding has implications for the clinical utility and application of EVH as a bronchoprovocation challenge in the diagnosis of EIB, specifically when it is used in a population of recreational athletes with mild reductions in lung function after a challenge. Moreover, it highlights the need for caution when EVH is used as a screening tool for EIB in a

Conclusions

EVH is currently recommended as a key bronchoprovation challenge for the diagnosis of EIB in athletes. This study demonstrates poor diagnostic reproducibility over a short-term period of assessment in recreational athletes, when a cutoff value of 10% or more fall in FEV1 is employed. Accordingly, the findings indicate the need for caution when clinicians make a diagnosis on the basis of a solitary EVH assessment and suggest that further assessment and/or surveillance be considered. Therefore,

References (45)

  • O.J. Price et al.

    Airway dysfunction in elite athletes–an occupational lung disease?

    Allergy

    (2013)
  • O.J. Price et al.

    The impact of exercise-induced bronchoconstriction on athletic performance: a systematic review

    Sports Med

    (2014)
  • L. Ansley et al.

    Misdiagnosis of exercise-induced bronchoconstriction in professional soccer players

    Allergy

    (2012)
  • L. Ansley et al.

    Practical approach to exercise-induced bronchoconstriction in athletes

    Prim Care Respir J

    (2013)
  • K.W. Rundell et al.

    Self-reported symptoms and exercise-induced asthma in the elite athlete

    Med Sci Sports Exerc

    (2001)
  • J.P. Parsons et al.

    An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction

    Am J Respir Crit Care Med

    (2013)
  • J.M. Weiler et al.

    Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter

    Ann Allergy Asthma Immunol

    (2010)
  • O.J. Price et al.

    Advances in the diagnosis of exercise-induced bronchoconstriction

    Expert Rev Respir Med

    (2014)
  • S.D. Anderson et al.

    Reproducibility of the airway response to an exercise protocol standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma

    Respir Res

    (2010)
  • International Olympic Committee - Medical Commission. Beta2 adrenoceptor agonists and the Olympic Games in Beijing....
  • J.P. Parsons et al.

    Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes

    Med Sci Sports Exerc

    (2007)
  • J. Dickinson et al.

    Diagnosis of exercise-induced bronchoconstriction: eucapnic voluntary hyperpnoea challenges identify previously undiagnosed elite athletes with exercise-induced bronchoconstriction

    Br J Sports Med

    (2011)
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    No funding was received for this work.

    Conflicts of interest: The authors declare that they have no relevant conflicts of interest.

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