Breathlessness with Exercise: Time to Figure Out the Cause

By Andrew Getzin | June 15, 2018, 12:14 p.m. (ET)

You are at the track doing mile repeats but every time you pick up your speed you can’t breathe. You notice the same breathing difficulties occur episodically on the bike. You know you could be faster if only you could get more air.  It makes you a little bit nervous; maybe there is something wrong with your body that needs treatment.

If you are experiencing shortness of breath with exercise, you are not alone. A respiratory survey given to elite-level Quebec athletes found that 40 percent of the athletes currently were experiencing breathlessness with exercise and 50 percent had symptoms over the past few years (1). Breathlessness, or the medical term dyspnea, means out of breath disproportionate to the given workload. It is the pulmonary equivalent of the palpitation — an uncomfortable sensation of the heart beating. Both may be normal sensations. However, both can be signs of underlying bad pathology. 

Historically, athletes with breathing difficulties were often incorrectly diagnosed with asthma based on a history of breathing difficulties alone. They were and still are treated with inhalers, which often do not help. A history of breathing difficulty with exercise is insufficient data by itself to diagnose the cause of the problem.  Exercise physiologist, Ken Rundell, Ph.D., surveyed elite level winter athletes at U.S. Olympic Training Center in Lake Placid, New York. He then measured their lung function before and after international competitions. A history of shortness of breath with exercise or a previous diagnosis of asthma did not correlate with a positive exercise-induced asthma test.

Determining the cause requires obtaining objective medical information from testing. Some of the possible causes for dyspnea include anemia, exercise-induced asthma, exercise-induced laryngeal obstruction (EILO) — an inspiratory problem that occurs at maximum exertion where the upper airway narrows (we will go into more detail in next month’s column), cardiac problems, pulmonary problems or unreasonable expectations of performance based on fitness level.

If you are struggling with dyspnea, I encourage you to be evaluated by a physician who understands triathletes. At our Shortness of breath in athlete clinic, in Ithaca, New York (www.cayugamed.org/SOB)we initially perform bloodwork to look for anemia (or low oxygen carrying capacity) and obtain a chest X-ray to look at the lungs radiographically. We perform an ECG to evaluate the resting electrical activity of the heart and measure our clients’ lung function before and after treatment for asthma to see if medication results in an improvement which would be consistent with baseline untreated asthma.  

The most important part of the evaluation involves performing a cardiopulmonary exercise test. If the problem usually occurs during exercise, it is essential to exercise the patient and evaluate. A basic cardiopulmonary exercise test can give information on how the lungs and heart respond to exercise as well as determine over all fitness level. Asthma provocation testing may be indicated. This testing involves measuring pre-exercise lung function with a breathing test called spirometry, exercise provocation at a given workload and in cold, dry conditions (such as an air-conditioned room) and post exercise lung function to see if the exercise provocation resulted in deterioration of lung function as we would expect to see in patients with exercise-induced asthma. At our center, we are one of the two places in the country that performs continuous laryngoscopy with exercise (CLE) to evaluate the upper airway with exercise. CLE involves placing a small scope with the camera on the end that is affixed to a headgear with running. It allows proper visualization of the upper airway during exercise to look for EILO.

Unfortunately, too often athletes who are experiencing dyspnea are given the stamp of asthma and put on potentially unnecessary medication. Asthma medication is expensive, can result in side effects, and can actual make the problem worse in non-asthmatics. Because the solution to the breathing problem is dependent on the cause, treatment can range from training modification for individuals who are short of breath due to unreasonable expectation about their fitness, to speech therapy for individuals with EILO, to cardiac surgery for those who have coronary artery disease that is presenting with breathing problems.

In summary, if you are having symptoms of breathlessness that are hindering your ability to train or compete, get evaluated by a physician to find the root cause of your problem so that a treatment can be tailored to your specific needs. 

  1. Turcotte H, Langdeau JB, Thibault G, Boulet LP, Prevalence of respiratory symptoms in an athlete population, Respir Med 2003 Aug;97(8):955-63
  2. Rundell KW, Im J, Mayers LB, et al, Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc  2001 Feb;33(2):208-12
  3. Christensen PM, Heimdal JH, Christopher KL, et al, ERS/ES/ACCP 2013 international consensus conference on inducible laryngeal obstructions. Eur Respir Rev 2015;24:445-450

Andrew Getzin, MD is the head team physician for USA triathlon. He is a USA Triathlon level I coach, multiple-time USA Triathlon All-American and has competed in Kona. He is a fellow of the American College of Sports Medicine.  Dr. Getzin is the medical director of Cayuga Medical Center Sports Medicine and Athletic Performance in Ithaca, NY, www.cayugamed.org/sportsmedicine and the director of their shortness of breath in the athlete clinic, www.cayugamed.org/sob.