You're out on a run, or cycling up one of the many steep hills that Ithaca has to offer, and after a minute or so of high-intensity exercise, you start to feel the familiar symptoms such as wheezing and shortness of breath. Here goes my asthma again, you might think.?
However, according to Andrew Getzin, MD, it’s likely not asthma.?
“Asthma is a problem that classically occurs at the end of exercise, or after exercise,” says Getzin, director of the Shortness of Breath Clinic at Cayuga Medical Center. “If the individual has symptoms in the first five minutes, it’s not asthma.”?
Many of the patients that come to see Dr. Getzin have been diagnosed as asthmatic. And for those those that do suffer from exercise-induced asthma (asthmatic symptoms in reaction to exercise), it is primarily expiratory, and occurs either at the end of, or after, exercise. It takes place in the chest, and the associated symptoms — which include wheezing and shortness of breath — gradually manifest, often lasting for hours. If an asthmatic is exercising outside during the winter, the symptoms worsen, as the high ventilatory rate as a result of exercise coupled with the cold, dry environment exacerbates the asthma.?
Nonetheless, “controlled asthma can let you be an Olympic athlete,” Getzin reassures.? Despite the challenges that asthmatics face, there are ways in which asthmatics can ease the discomfort that exercise-induced asthma causes. “If people warm up more gradually, they can develop what’s called a refractory period, where it might prevent an asthmatic response, or decrease the severity of it. But not everybody has a refractory period,” Getzin warns.?
Exercise, he said, relies on the path of oxygen from the air we inhale, all the way to the working muscle. This is a multifaceted process that, due to its complexity, can make it difficult to discern without proper testing what the exact cause of a shortness of breath would be.?
“Anywhere on that chain can be broken, so it’s a complicated problem,” Getzin explains. “Is it [shortness of breath] a normal response, or is it abnormal? It’s very difficult to tell. And so these people struggle.”
In order to determine whether the cause of a patient’s dyspnea — shortness of breath that is disproportionate to the level of exercise — is related to asthma or another condition, Getzin stresses the importance of objective testing. Many people have symptoms such as dyspnea, but aren’t aware of the cause of it. “If someone has trouble with exercise, we do an exercise test to see whether that exercise provocation resulted in an asthmatic response.” He and others also prefer to use a test called spirometry, a test to measure the amount of air a patient has in their lungs and how rapidly the lungs can expand.?
When Getzin’s patients leave, the majority of them do so without a diagnosis of asthma. A common condition that patients might assume is asthma before receiving a proper objective assessment is exercise-induced laryngeal obstruction (EILO). EILO, which usually takes place during peak exercise intensity, is a paradoxical closure of the vocal cords, so is an upper airway problem. It has a rapid onset, like a light switch, Getzin says. It is primarily inspiratory, meaning it affects one’s ability to inhale. EILO occurs in the neck and patients – who commonly are adolescents – typically experience wheeze-like symptoms called stridors, as well as many of the same symptoms as asthmatics. The method of diagnosis for EILO is continuous laryngoscopy with exercise (CLE). The process for CLE involves placing a small laryngoscope through the patient’s nose, and into the upper airway. This laryngoscope is then worn during exercise so a doctor such as Getzin can visualize what is truly occurring inside the patient’s upper airway during exercise.
The mainstay of treatment for exercise-induced laryngeal obstruction is speech therapy. Michele Chisholm, a speech therapist at Cayuga Medical Center, assesses patients by first studying how the patient’s vocal cords and larynx are performing. Then she examines muscle tension and muscle phonation time, which allows for her to assess breath support. After this assessment, Chisholm will go over the results with the patient, informing them of what is happening. A lot of her assessment focuses on education, she says.?
The next step of her work with a patient is counseling. “This is a big part of treatment for patients,” she says, because “a lot of them are stressed, and have anxiety.” During counseling, Chisholm emphasizes the importance of developing a rapport and trusting relationship with the patient. After counseling, Chisholm instructs the patient how to identify and relax tension within their body that would aggravate the difficulty in breathing caused by EILO. And then to accommodate this, she provides the patient with breathing techniques.
If a patient’s dyspnea is not a result of asthma, or EILO, Getzin says that other potential causes could include: a lack of fitness or obesity, overtraining syndrome, unreasonable expectations, expiratory flow limitation, or swimming induced pulmonary edema. It could even be a cardiac problem, he says. But if a patient wants to know the exact cause of their dyspnea, it is important to receive the appropriate knowledge and testing.?
“If you want to know the cause,” Getzin said, “you need to have objective evidence.”?