What are the treatment options for a cough that occurs during exercise?

Treatment Options for Exercise-Induced Cough

For exercise-induced cough, treatment should be directed at the underlying cause, with asthma, exercise-induced bronchoconstriction (EIB), upper airway cough syndrome, and environmental exposures being the most common etiologies requiring targeted interventions. 1

Common Causes and Diagnostic Approach

Before initiating treatment, it's essential to identify the underlying cause of exercise-induced cough:

• Asthma and Exercise-Induced Bronchoconstriction (EIB): Most common causes of exercise-induced cough, requiring pulmonary function tests and bronchoprovocation challenges for diagnosis 1
• Upper Airway Cough Syndrome (UACS): Often from rhinitis, requiring assessment of allergy to common airborne allergens 1
• Respiratory Tract Infections (RTIs): May exacerbate exercise-induced cough 1
• Exercise-Induced Vocal Cord Dysfunction: Less common but important cause to consider 1
• Environmental Exposures: Particularly relevant in cold/dry air or polluted environments 1, 2

Treatment Algorithm Based on Etiology

For Asthma and Exercise-Induced Bronchoconstriction:

• Pharmacologic options:

  • Beta-adrenergic agonists: First-line treatment, taken 15-30 minutes before exercise 3
  • Cromolyn sodium: Preventive medication taken before exercise 3
  • Inhaled corticosteroids: For persistent symptoms, helps restore normal cough reflex sensitivity during exercise 4
  • Theophylline: Can block exercise-induced decreases in flow rates and eliminate chronic cough 5
  • Leukotriene modifiers: May be beneficial for some patients 3

• Non-pharmacologic approaches:

  • Early vigorous warm-up: Can reduce EIB severity 3
  • Mask for rebreathing warmed air: Particularly useful in cold environments 3
  • Physical training program: To increase anaerobic fitness 3

For Upper Airway Cough Syndrome:

• Antihistamines: Terfenadine has been shown to effectively block EIB 3
• Nasal corticosteroids: For underlying rhinitis 1
• Nasal saline irrigation: To clear irritants 1

For Exercise-Induced Vocal Cord Dysfunction:

• Speech therapy: Can be effective in treating chronic cough related to laryngeal issues 6
• Breathing exercises: To improve control during exercise 2

For Environmental Exposure-Related Cough:

• Avoiding trigger environments: When possible 2
• Face masks: To filter pollutants or warm inspired air 3
• Pre-treatment with bronchodilators: Before exposure to known triggers 2

Special Considerations for Athletes

• Anti-doping regulations: Always check that medications comply with World Anti-Doping Agency (WADA) regulations 1
• Performance impact: Consider potential side effects of medications that might affect training performance 1
• Sport-specific factors: Treatment should account for the specific sport and training environment 1

Pitfalls and Caveats

• Misdiagnosis: Exercise-induced cough is often misattributed solely to asthma when other causes may be present 1
• GERD consideration: Despite being common in athletes, gastroesophageal reflux has not been well-documented as a cause of cough in athletes specifically, but should be considered in persistent cases 2
• Inadequate evaluation: Failure to perform proper diagnostic tests (pulmonary function tests, bronchoprovocation challenges) may lead to inappropriate treatment 1
• Overlooking environmental factors: The specific training environment plays a crucial role in exercise-induced cough 1
• Medication timing: Improper timing of pre-exercise medications can reduce their effectiveness 3

Evidence Quality Considerations

The evidence guiding treatment of exercise-induced cough is generally of low quality, with most recommendations being consensus-based rather than from high-quality clinical trials 1. Until more specific management studies are performed in athletes, current guidelines for the general population should be applied, with appropriate modifications for the athletic context 1.