Shortness of Breath in Exercise Not Always Asthma

Please feel free to discuss this with me. MIAMI BEACH -- Researchers suggested here that many people who are diagnosed with exercise-induced shortness of breath and asthma frequently may be misdiagnosed. In this study, patients exercised and the combination of symptom assessment, physical examination, and pulmonary function testing was used to make a diagnosis. "We found that of the 785 patients who were being treated for shortness of breath in our clinic, 362 of them -- about 46.2% -- were simply overexerting themselves," said Tim Stewart, a physician assistant at the Colorado Allergy and Asthma Centers in Denver. Another 168 people (21.4%) were suffering shortness of breath because they were not fit for the level of exercise they attempted, Stewart reported in a poster presentation at the annual meeting of the American College of Allergy, Asthma & Immunology here. Of the total, 20.9% or 164 of the patients were experiencing exercise-induced bronchospasm -- defined as a 15% drop in forced expiratory volume at one second (FEV1) in relation to exercise or drop of 10 to 15% with pulmonary symptoms. "Many people come to us with shortness of breath during exercise," Stewart said. "We try to replicate as much as possible what happened during exercise that caused their breathing problems, and what we found was that quite often these people were being treated for asthma yet they had some other problem." The researchers found, for example, that in 59 cases, patients had vocal cord dysfunction -- a syndrome that causes asthma-like symptoms as a result of abnormal closure of the vocal cords. "Exercise-induced bronchospasm by self-reported symptoms and/or clinical history without confirmation by an exercise challenge are often incorrect," Stewart said. "This may lead to the inappropriate use of asthma therapy." Stewart and colleagues reviewed findings in 328 males and 457 females, ranging in age from 3 to 68. Often symptoms appeared when patients were engaged in more than one activity, but most occurred during free runs. He said 588 individuals (75%) described symptoms while exercising outdoors; 197 people complained of symptoms that occurred while exercising indoors. In the vast majority of patients, symptoms occurred while they were running, but 22 people said they had symptoms while using a treadmill; 12 experienced shortness of breath on a stationary bicycle; three had symptoms while swimming; and two while using an elliptical device. When they presented to the clinic, Stewart said, 549 (70%) had been diagnosed with dyspnea; 261 (33%) with seasonal or perennial rhinitis; 112 (14%) with asthma, and 104 (13%) with cough. Many of the subjects had multiple diagnoses. Stewart said that among adolescents, many developed shortness of breath when they attempted to move from recreational leagues to varsity athletics, and overexerted themselves while trying to perform at a higher level than they were ready to achieve. "A lot of these individuals came to us because they were not responding to their medication for asthma," said Jerald Koepke, MD, clinical professor of medicine at the University of Colorado Health Science Center in Denver and a founder of the clinic. "Of course, they weren't responding because they didn't have asthma. In 85% of the cases we were able to decrease medication in these patients." Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

Is Swimming Pool Chlorine Fueling the Allergy Epidemic?

Only this morning, I saw a patient who had wheezing after swimming both indoors and outdoors.  This is a timely article.

Is swimming pool chlorine fueling the allergy epidemic?

By Megan Brooks Mon Sep 14, 10:15 am ET

NEW YORK (Reuters Health) – Swimming in a chlorinated pool may boost the odds that a child susceptible to asthma and allergies will develop these problems, a study released today indicates.

"These new data clearly show that by irritating the airways of swimmers chlorination products in water and air of swimming pools exert a strong additive effect on the development of asthma and respiratory allergies such as hay fever and allergic rhinitis," Dr. Alfred Bernard, a toxicologist at the Catholic University of Louvain in Brussels, Belgium, noted in an email to Reuters Health.

"The impact of these chemicals on the respiratory health of children and adolescents appears to be much more important -- at least by a factor of five -- than that associated with secondhand smoke," Bernard noted.

Taken together with his team's prior studies, he added, "There is little doubt that pool chlorine is an important factor implicated in the epidemic of allergic diseases affecting the westernized world."

In the current study, Bernard and colleagues compared the health of 733 adolescents, 13 to 18 years old, who swam in chlorinated outdoor and indoor pools for various amounts of time with that of 114 "control" adolescents who swam mostly in pools sanitized with a concentration of copper and silver.

In children with allergic sensitivities, swimming in chlorinated pools significantly increased the likelihood of asthma and respiratory allergies, the researchers report in the journal Pediatrics.

Among "sensitive" adolescents, the odds for hay fever were between 3.3- and 6.6-fold higher in those who swam in chlorinated pools for greater than 100 hours and the odds of allergic rhinitis were increased 2.2- to 3.5-fold among those who logged more than 1000 hours of chlorinated pool time.

For example, among children and teens who swam in chlorinated pools for 100-500 lifetime hours, 22 children out of 369 (6.0%) had current asthma, compared with those who had spent less than 100 hours (2 of 144, 1.8%). The proportions with asthma rose with longer exposure, to 14 out of 221 (6.4%) who had been swimming for 500-1000 hours, and 17 out of 143 (11.9%) who swam for more than 1000 hours.

The risk of asthma and allergy was not influenced by swimming in copper-silver sanitized pools and children without allergic tendencies were not at increased risk of developing allergies.

"The only plausible explanation" for these observations, the researchers argue, is that the chlorine-based toxic chemicals in the water or hovering in the air at the pool surface cause changes in the airway and promote the development of allergic diseases.

"It is probably not by chance," Bernard told Reuters Health, "that countries with the highest prevalence of asthma and respiratory allergies are also those where swimming pools are the most popular."

The current findings, he and colleagues conclude, "reinforce" the need for further study on the issue and to enforce regulations concerning the levels of these chemicals in water and air of swimming pools.

SOURCE: Pediatrics, October 2009.