Wheezing on the Run

An Endurance Athlete's Guide to Exercise Induced Asthma

An elite female being tested for EIA

Ever come off the bike, feeling great at the start of the run, to only, after a few minutes, finding yourself puffing and wheezing like an old steam train barely making it up an incline?

If you've experienced excessive shortness of breath, wheezing, or even a cough that just won't quit during or after exercise, you may be flirting with a not always recognised companion of the endurance world: exercise-induced asthma (EIA), also known as exercise-induced bronchoconstriction (EIB). This respiratory twist is surprisingly common, even among those in peak physical shape. Let’s look at what EIA is, how it’s diagnosed, what else it might be, and what can be done to manage it.

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Symptoms: It’s Not Just Being Out of Shape

Unlike the usual heavy breathing that comes with pushing hard on the trails or track, EIA symptoms can make even a steady jog feel like running up Everest without oxygen. You might recognise some of the following:

• Wheezing or whistling sound while breathing, especially when breathing out.

• Shortness of breath that seems a bit much, even for a tough workout.

• Coughing, particularly after stopping exercise or while cooling down.

• Chest tightness that makes every breath feel like it’s coming through a straw.

• A feeling of fatigue that’s not simply “I should have trained more” but a proper energy-sapping struggle.

These symptoms can start during exercise but are just as likely to appear five to 20 minutes after you've stopped. Sometimes, they seem worse in cold weather or particularly dry, pollen-heavy air. If you’re reaching for your imaginary air pump mid-run, it might not be your imagination; EIA could indeed be at work.

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Diagnosis: More Than Just a Case of Fitness FOMO

Diagnosing EIA requires a bit of investigation and a good sports or respiratory physician. Here’s what the process might look like:

1. The Screening Chat: First off, you’ll discuss your symptoms, their timing, and triggers. Often, the history gives a clear clue, and, in that case, your doctor might initially prescribe you an inhaler to try just before exercising to see how you respond. A positive response, when your breathing feels no longer restricted, indicates a likelihood of the EIA. You can then go away and experiment with the timing and dosage of the inhaler to get the best response before reporting back to your doctor. Your doctor will always ask you if there is asthma in the family, as that can be a helpful clue.

2. Spirometry Test: The most common diagnostic tool for asthma is a peak flow meter. It measures how much air you can blow out in one big push. This will establish your lung function at rest and see if there’s any hint of restricted airflow. Peak flow meters are hand-held and can be bought over the counter in pharmacies in most countries. They give a reliable first-off indication if there is a problem. The normal range depends on age, height and sex. Peak flow numbers are usually higher in younger, taller people and males. A normal range for adults is 400-700 L/min and 150-450 L/min for children. Your peak flow in rest before a workout should be the same as your peak flow rate immediately after exercise. Often, it can even be a bit higher after a training session as your lungs will have ‘opened up’. A peak flow rate, which is lower after exercise than at rest, indicates that all is not well and that EIA is a likely possibility. If this simple field test does not give a clear indication, a skilled technician can do more complex spirometry in a clinical setting.

3. The Exercise Challenge: Because EIA is, by nature, exercise-induced, your doctor might put you on a treadmill or stationary bike and monitor your breathing during and after exercise. Sometimes, you may have to jog along while inhaling dry air (not as pleasant as it sounds) to see if the symptoms match those in real life.

4. Methacholine Challenge: Doctors might try a methacholine test if you’re still a bit of a mystery. This involves inhaling a substance that triggers bronchoconstriction. If you’re prone to EIA, this test can reveal whether your airways are indeed more sensitive than most.

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Differential Diagnosis: Just in Case It’s Something Else

Endurance athletes are a hardy breed, but respiratory complaints can come from various sources, not just EIA. Here are a few conditions to rule out:

• Vocal Cord Dysfunction (VCD): This often mimics EIA, causing wheezing or breathlessness, but it’s due to the vocal cords closing at the wrong times. It won’t respond to asthma treatments, and it’s usually diagnosed with a laryngoscopy by an ENT specialist. It is a diagnosis which can be pursued when EIA is excluded, as EIA is much more common.

• Chronic Asthma: This is less specific to exercise and may involve a variety of triggers, including cold air, smoke, or pet dander. Chronic asthma will have similar symptoms, but you might be short of breath even when you're not exercising. Many asthmatics have symptoms of EIA, which might initially require additional medication. On the other hand, asthmatics report generally improved control over their symptoms once they are fit, so regular exercise should become part of the treatment routine.

• Allergic Rhinitis: An itchy nose, runny eyes, and other allergy symptoms sometimes overlap with EIA. Although allergies don't directly cause bronchoconstriction, they can irritate your airways and make EIA more likely.

• Heart Conditions: While rarer in young, fit athletes, it’s wise to rule out heart problems if symptoms include chest pain or a concerning level of breathlessness. Testing for this is usually more thorough but well worth it for peace of mind.

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Treatment: Breathing Easier

The good news? EIA can be managed, often effectively, so that you can get back to the business of breaking personal records rather than worrying about breathing issues. Treatment options generally include:

• Inhalers: The most common go-to is a short-acting bronchodilator inhaler, such as albuterol (salbutamol). Taken 15 to 20 minutes before exercise, it opens the airways and often reduces symptoms.

• Daily Control Medication: For those who experience symptoms frequently or severely, a daily inhaler with corticosteroids or a leukotriene modifier might be prescribed to reduce the underlying inflammation of the lungs' lining.

• Warm-Up Routine: A solid, structured warm-up with gradual increases in intensity has been shown to reduce the chance of symptoms by giving the airways time to adjust. Known as the “refractory period,” some athletes find that after an initial round of exercise, they experience fewer symptoms for up to an hour.

• Adjusting Training Conditions: Avoiding outdoor workouts during high-pollen days, reducing exertion in cold or dry air, or wearing a mask or scarf in extreme temperatures can help.

• Non-Medicated Aids: Staying hydrated, managing allergies, and even breathing techniques (try pursed-lip breathing) can make a difference for some athletes.

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When to Consult Your Doctor Again

If you’re on treatment but still struggling, it’s worth checking back in with your physician. They might adjust your dosage, suggest new techniques, or re-evaluate your diagnosis. The aim, after all, is for you to run, cycle, or swim free from distraction. Because while you might want to be remembered for your endurance, being known for your audible wheeze isn’t quite as alluring.

So next time you're out there chasing a new PB, and you feel like you've run into an invisible wall, don’t ignore it. It could be EIA, and the right treatment might be all you need to get back on track—minus the wheeze.

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