| Clinical problem | Intervention | Comments |
| All patients with EIB | Educate about features of exercise that are likely to provoke EIB (eg, effect of temperature, dry air, intensity of exertion, allergens, pollution) and measures for mitigation | |
| Educate about use of SABA to treat EIB symptoms (eg, albuterol two puffs) | ||
| Educate about use of SABA or other agent to prevent EIB | ||
| Advise caution about vigorous exercise when asthma is poorly-controlled | ||
| Patients intolerant of SABA | Try one puff of albuterol instead of two | May not provide adequate prevention of EIB symptoms. |
| Review inhaler technique and consider use of spacer/chamber | ||
| Improve general control of asthma (eg, with inhaled glucocorticoid) to reduce need for prophylaxis | If asthma not well-controlled (based on frequency/severity of symptoms or need for rescue inhaler, low peak flow or FEV1), add inhaled glucocorticoid. If asthma is otherwise well-controlled, try alternate preventive agents. | |
| Try alternate SABA (eg, levalbuterol)* | Try levalbuterol if above interventions are unsuccessful and levalbuterol is available. Levalbuterol can also be used for breakthrough symptoms. May not completely eliminate adverse effects of SABA. | |
| Try regular use of LTRA*¶Δ | LTRA may be more effective in children than adults. | |
| Try ipratropium two puffs, 20 to 30 minutes prior to exercise*Δ | ||
| Substitute cromolyn or nedocromil (where available) for SABA for prophylaxis*Δ | ||
| EIB refractory to SABA | Add regular use of LTRA | |
| Improve general control of asthma (eg, with inhaled glucocorticoid) | ||
| Use cromoglycate with SABA as prophylaxis (where available) | ||
| Reassess diagnosis | ||
| Patients who exercise for more than three hours or more than once per day | Avoid LABA monotherapy or daily use of SABA | Tachyphylaxis may occur with daily SABA or LABA. |
| Try LTRA | May be more effective for prevention of EIB in children than adults. | |
| Improve general control of asthma (eg, with inhaled glucocorticoid) | ||
| Patients who exercise in extreme conditions (eg, high intensity or in dry cold air) | Try methods for mitigation (eg, warm-up, scarf or face mask), depending on setting | |
| Empiric trial of combination albuterol-ipratropium 20 to 30 minutes prior to exercise |
