Respiratory Care

Diagnosis and Assessment

Asthma diagnosis should be confirmed with objective evidence, including history of recurrent episodes of coughing or wheezing, symptoms related to typical triggers, response to beta-adrenergic agents, and pulmonary function tests showing reversible obstruction, as recommended by Environmental Health Perspectives 1

The American Thoracic Society recommends avoiding any inhaler or respiratory product containing rifamycins, as rifampin and rifabutin significantly decrease bictegravir levels 2
Short-acting beta-agonists (SABAs) like albuterol can prevent exercise-induced bronchospasm (EIB) in more than 80% of patients, and albuterol is the preferred SABA due to its established safety profile, according to the Journal of Allergy and Clinical Immunology 3
The recommended albuterol dosing is 2 puffs (180 mcg) administered 15-20 minutes before exercise, as suggested by the American College of Allergy, Asthma, and Immunology and the American Thoracic Society 4, 5
Symbicort (budesonide/formoterol) can be used as a single dose of 1-2 inhalations taken 15-30 minutes before exercise for exercise-induced asthma (EIA) management, but not as daily maintenance therapy unless the patient also has persistent asthma requiring controller medication, as recommended by the American Academy of Allergy, Asthma, and Immunology 4
Alternative medications such as leukotriene receptor antagonists (LTRAs) like montelukast, which reduces EIA by approximately 10.7% compared to placebo, and inhaled corticosteroids (ICS) can be considered, as they can provide protection in approximately 50% of patients and decrease frequency and severity of EIB, respectively, according to the American College of Allergy, Asthma, and Immunology 4, 5

Daily use of formoterol (the LABA component in Symbicort) can lead to tolerance, which manifests as reduced duration and magnitude of protection against EIA, and can develop within 12-24 hours after the first dose 4
To minimize tolerance development, allow 48-72 hours between uses if using Symbicort more than 3-4 times per week 4
SABA use should be less than daily on average to prevent tolerance, according to the American Thoracic Society 5
Implementing a proper warm-up period of 15-30 minutes before main exercise can help prevent EIB, as suggested by the Journal of Allergy and Clinical Immunology and the American College of Allergy, Asthma, and Immunology 3, 4
Using a mask or scarf over the mouth during cold weather exercise and choosing warm, humid environments for exercise when possible can also help reduce the risk of EIB, according to the Journal of Allergy and Clinical Immunology and the American College of Allergy, Asthma, and Immunology 3, 4

Schedule regular office visits to assess medication effectiveness and monitor for signs of tolerance (diminished protection against EIA) 4
If requiring Symbicort or albuterol more than twice weekly for exercise, consider adding a controller medication 4
Regular follow-up visits are necessary to assess medication effectiveness and monitor frequency of albuterol use, considering adding controller medication if needed, as stated by the American College of Allergy, Asthma, and Immunology and Environmental Health Perspectives 4, 1
A written asthma action plan should be provided to the patient, parents, and coaches, including when to use the rescue inhaler and when to seek help 5
The American Thoracic Society recommends that patients with asthma carry their albuterol inhaler at all times during sports activities, and that coaches and athletic staff be informed about the asthma diagnosis 5